Lipomas are among the most common tumors of the human body. However, they are uncommon in the oral cavity and are observed as slow growing, painless, and asymptomatic yellowish submucosal masses. Surgical excision is the treatment of choice and recurrence is not expected. The case of a 30-year-old woman with a huge lipoma on the tip of her tongue since 3 years, is presented. She had difficulty with speech and mastication because the tongue tumor was filling the oral cavity. Clinical examination revealed a yellowish lesion, measuring 8 cm in maximum diameter, protruding from the lingual surface. The tumor was surgically excised with restoration of normal tongue function and histopathological examination of the tumor confirmed that it was a lipoma.Tongue lipoma is rarely seen and can be a cause of macroglossia. Surgical excision for lipoma is indicated for symptomatic relief and exclusion of associated malignancy. Lipomas are the most common benign soft tissue mesenchymal neoplasm; however, they are not common in the oral cavity ,2 and arCase Report A 30-year-old female was presented to the head and neck clinic with a slow-growing mass on the tip of her tongue, which had been present for 3 years. Her speech was not clear due to the bulkiness of the mass and she also had difficulties swallowing. Clinical examination revealed a yellowish lesion measuring 8 cm in diameter protruding from the lingual surface and covered by a mucosa that was rich in vessels. During palpation, the lesion was observed to be rubbery and compressible .Although the tongue movement was limited, there was no ankyloglossia. Taste and somatic sensation were intact.Under general anesthesia, through a longitudinal incision along the edge of the tongue, the tumor was removed .The tumor was yellowish in color and well-encapsulated . The mucHistological examination revealed mature adipocytes without cellular atypia. Lipoblast, which is pathognomonic for malignant liposarcoma, was not present.The majority of tongue tumors are malignant in nature. Lingual lipoma, which accounts for 0.3% of tongue neoplasms, is a benign condition. Similarly, the occurrence in the oral cavity is rare and reported as 2% to 4% of all lipomas ,12. It iIn this study the patient was a 30-year-old female with a slow growing mass present since the last 3 years, which measured 8 cm in diameter. The mass was painless but she had difficulties swallowing and tongue movement was impaired; however, taste and somatic sensation was intact. In other studies: Chunkitchung reported a 62-year-old man with a 6cm mass in his tongue that was slow growing for 2 years. He had difficulties swallowing large food items. Moreover, his speech was not very clear due to the bulkiness of the mass .Magadum reported a 60-year-old man with a 3cm mass in his tongue, which he had first noticed about 10 years earlier. Because of the absence of pain and bleeding, he was not initially alarmed, but later he complained of masticatory problems .Chidzonga reported a 58-year-old female with an 11cm mass that had been present for 3 years. She had a large “anterior open bite” and slurred speech with the tumor bobbing up and down and in and out of the mouth when speaking. Despite the feeding and breathing difficulties, she was well nourished and not in any particular distress . ChandakFinally Colella reported a 75-year-old man with a 10 cm mass in his tongue from 30 years ago. His speech was not very clear due to the bulkiness of the mass and he had difficulties swallowing .These studies are generally without gender predilection ,10,19-21Their clinical course is usually asymptomatic until they grow to large sizes ,22. In tThe differential diagnosis includes well-differentiated liposarcoma, ranula, dermoid cyst, thyroglossal duct cyst, ectopic thyroid tissue, pleomorphic adenoma, and mucoepidemoid carcinoma angiolipoma, fibrolipoma, and malignant lymphoma ,23-26. TSurgical excision is the most common form of treatment ,21. RecuTongue lipoma is rarely seen and can be a cause of macroglossia. Surgical excision for lipoma is indicated for symptomatic relief and exclusion of associated malignancy


This case report exhibits a rare biliary tumor within the liver of a 53-year-old Caucasian woman. This exophytic, multicystic, 6.5 × 5.0 cm mass was composed of complex tubulocystic structures lined by nonmucin-secreting, biliary epithelium embedded in fibrous stroma, consistent with biliary adenofibroma. This is the seventh case described in the literature. Multiple foci of high-grade dysplasia/carcinoma in situ were found with a microscopic focus of invasive carcinoma in review of the pathology, making this only the second case reporting malignant transformation. It is presented to illustrate the premalignant potential in a biliary epithelial tumor currently categorized as benign. Benign biliary tumors are uncommon entities and include bile duct adenomas, von Meyenburg complexes, biliary cystadenomas, and biliary cysts that lie on a spectrum of ductal plate malformations . BiliaryFirst described by Tsui et al., BAF is characterized by a proliferation of nonmucin-secreting, tubulocystic structures variably embedded in a fibrous stroma. It likely originates from interlobular or larger bile ducts based on immunohistochemistry. Though it is categorized as a benign tumor with indolent behavior, there is a concern of malignant potential –9. Tsui This case report represents the 2nd case known with evidence of high-grade dysplasia/carcinoma in situ out of seven biliary adenofibromas now reported in the current medical literature.The significance of this case is to show biliary adenofibroma as a premalignant condition, differentiated from a benign biliary neoplasm. Despite its rarity, BAF proves to have malignant transformation in two of the seven cases now reported and warrants greater acknowledgement for this propensity.Our patient is a 53-year-old Caucasian female with a past medical history of Hashimoto thyroiditis, osteopenia, and uterine fibroids. Her surgical history was significant for a thyroid biopsy but otherwise, she was a healthy woman requiring no medicines. She denied any history of alcohol use, blood transfusions, intravenous drug use, tattoos, or body piercings. Her family history consisted of breast cancer and cardiac disease in her mother and a history of aortic dissection in her father. She is without any previous personal or family history of hepatobiliary disease. During her laparoscopic total abdominal hysterectomy for uterine fibroids, she was incidentally found to have a left hepatic complex cystic mass. An ultrasound of the liver revealed a 5.3 × 5.5 × 6 cm complex cystic mass concerning a neoplasm, which prompted an MRI study. MRI revealed a 6.6 × 5 cm multiseptated mass within the inferior portion of the medial segment of the left lobe, segment 4b . It was The patient was taken to an operating room for an exploratory laparotomy, adhesiolysis, cholecystectomy, and segmental resection of Couinaud's segments 3 and 4.Her postoperative course was uneventful, and the patient was discharged on postoperative day 3. Histology of her hepatic mass was then found to be biliary adenofibroma with a microscopic focus of invasive carcinoma. Considering that only 6 cases have been reported in the literature, with only one reporting malignant transformation, clinical management for this disease process has yet to be delineated , 9. WithThe hepatic specimen consisted of a 6.5 × 5 × 3.5 cm exophytic multicystic mass located 3 mm from the closest parenchymal margin of resection. The surrounding liver appeared normal. The cysts were filled with nonmucinous fluid. The cystic lesion itself originated from Couinaud's segments 3 and 4, 3 mm from the closest parenchymal margin of resection. Microscopic findings of the mass were composed of proliferation of variably sized tubulocystic structures lined by cuboidal epithelium, embedded in a fibrous stroma . Many arBiliary adenofibroma has been described in 5 women and 2 men, including this publication. This report describes the first female patient to have malignant transformation of her BAF, the second overall. There are two cases previously reported of malignant transformation , 9, thouRegardless, BAF is currently described as a benign entity , though


Colonic lipomas are a rare type of gastrointestinal benign tumor. Those that are <2 cm are generally asymptomatic and do not require any treatment. However, those that are >2 cm may be symptomatic, resulting in abdominal pain, changes in bowel habits, intestinal obstruction and rectal bleeding. A 39-year-old male patient presented with a mass prolapse through the anal canal, which was causing anal pain and rectal bleeding. The patient was admitted to hospital via the emergency services and directed to the Department of General Surgery with the preliminary diagnosis of a rectal prolapse. A pedunculated polyp  was detected at the 35th cm of the anal canal. Due to the large size of the polyp, an endoscopic polypectomy could not be performed. Therefore, the prolapsed lipoma was excised externally and the patient was discharged on the first postoperative day on which no complications were experienced. A colonic lipoma must be considered during the differential diagnosis of anorectal diseases, such as hemorrhoids and rectal prolapses. Local excision, hemicolectomy, and segmental and external resection should be considered in addition to an endoscopic polypectomy for the diagnosis and treatment of colonic lipomas. Colonic lipomas are an uncommon type of benign gastrointestinal tumor. Although colonic lipomas are generally asymptomatic, when the colonic lipoma measures >2 cm, certain symptoms, such as abdominal pain, change in bowel habits, bleeding and a mass that presents as a rectal prolapse may be observed ,2. WhileA 39-year-old male patient was admitted to our emergency clinic with a mass protruding from the anal canal. Other symptoms included anal pain and rectal bleeding. During the physical examination, the prolapsed mass was spontaneously reduced through the rectum. The mass was initially diagnosed as a rectal prolapse and the patient was transferred to the Department of General Surgery, Buyukcekmece State Hospital  in June 2012. During the physical examination, the mass was forced out from the anal canal while the patient performed the Valsalva maneuver under light sedation. The mass  had a shiny surface and hyperemia was detected during the physical inspection . A smootColonic lipomas are rarely observed, and are an asymptomatic, benign, submucosal and nonepithelial type of gastrointestinal tumor. In general, this type of lipoma is <2 cm, sessile or pedunculated and often located in the right colon. These lesions are more common in women, observed in the fifth and sixth decades of life and are usually detected during an autopsy, colonoscopy or surgery ,5. The cColonic lipomas are generally submucosal lesions with a smooth mucosal surface, which are composed of lobular adipose tissues . The colImaging techniques facilitate diagnosis; however, as the results are not definitive, the final diagnosis may only be obtained following excision of the tissue ,2,6,8. Aet al . Although, the risk of bleeding and perforation is high when performing an endoscopic polypectomy on polyps >2 cm ,9. Kim eet al  demonstr cm. Althl (et al . In the In conclusion, colonic lipoma should be considered in the differential diagnosis of anorectal diseases, such as hemorrhoids and rectal prolapse. An external excision may be performed for the treatment of a prolapsed colonic lipoma, as this procedure is considered to be safe and reliable. Furthermore, it may be performed as an alternative to major surgery in certain patients.


Peripheral giant cell granuloma and peripheral ossifying fibroma are clinicopathologically distinct gingival lesions. Both are included in clinical differential diagnoses of common benign and reactive gingival epulides in humans. It is often impossible to make a clinical distinction between the two entities, thereby making definitive diagnosis dependent on histopathologic features. While our search of the English literature revealed several reports of peripheral giant cell granuloma with ‘bone formation’, we were unable to identify any reports of hybrid peripheral ossifying fibroma-peripheral giant cell granulomas.We report a case of a 44-year-old Caucasian man presenting with a three-month history of swelling of his right posterior mandible, related to an area of previous dental implant restoration. A clinical examination revealed modest extraoral facial swelling of his right posterior mandible, while an intraoral examination showed a 45×25×15mm sessile, lobular soft tissue mass of the right posterior mandibular gingiva. The mucosal covering of the lesion exhibited focal surface ulceration. A panoramic radiograph showed two implants at the vicinity of the lesion with no other significant findings. An excisional biopsy of the lesion followed by histopathologic examination of the biopsy specimen revealed salient and distinctive features of peripheral giant cell granuloma and of peripheral ossifying fibroma, estimated at near equal proportions. This raises the possibility of a hybrid odontogenic lesion.The presentation of this lesion, with areas of peripheral giant cell granuloma along with a distinct area of extensive osseous formation and stroma reminiscent of a peripheral ossifying fibroma, justifies consideration of this as a possible hybrid lesion. Although the biologic behavior of a combined lesion is not anticipated to deviate significantly from that of either of the single entities, this case resurrects an enduring debate as to whether peripheral giant cell granuloma and peripheral ossifying fibroma are simply parts of a disease spectrum, or whether some of these lesions represent true hybrid lesions. It is therefore recommended that more cases with histopathologic features similar to the lesion in our case be reported in the literature to further elucidate the histogenesis of these lesions. Peripheral ossifying fibroma (POsF) was first reported and described by Shepherd as ‘alveolar exostosis’ in 1844 , 3. The POsF and PGCG are site-specific lesions arising exclusively from the periodontal ligament. This makes both, by definition, lesions of the gingiva or alveolar ridge , 10. Theet al. [et al. [Cases of both POsF and of PGCG are occasionally seen with isolated foci of the diagnostic histopathologic feature of the other, but the preferred diagnosis of one over the other is usually based on the predominant morphologic features present in any specific case. Thus, cases with predominantly stromal cells with numerous osteoclast-like multinucleated giant cells with only focal areas of calcified bone and/or cementum deposits are diagnosed as PGCG. Those with a stroma comprising aggregates of primitive oval and bipolar mesenchymal cells, where a trabecular of woven and lamella bone with cementum-like deposit often dominates, receive a POsF diagnosis . Archivaet al.  and simi [et al.  highlighA 44-year-old Caucasian man presented to our Urgent Care clinic with a complaint of swelling in his right posterior mandibular molar teeth area that started about three months previously. There was no associated pain except for occasional interference of the swelling with occlusion and mastication. His vital signs were within normal ranges; his medical history included a family history of diabetes, cardiovascular disease, and cancers. His previous dental treatment included two right posterior quadrant dental implants, proximate to the lesion area, placed three months prior to presentation.On clinical examination, he had slight extraoral facial swelling of his right posterior mandible, but his regional lymph nodes were not palpable. An intraoral examination showed a 45×25×15mm sessile, lobular soft tissue mass of his right posterior mandibular gingiva related to his first and second premolars  lesion that eroded to the surface and into the overlying gingival soft tissue, or an originally soft tissue lesion that burrowed its way into bone . In our et al. [Dayan et al.  emphasizet al. . Furtheret al. .de novo. Cases of PGCG associated with dental implant therapies have been reported [Both POsF and PGCG are reactive inflammatory hyperplasias arising from the pluripotent cells of the periodontal ligaments . It is treported –21. In mreported , 21.We report a case of PGCG with a distinct area of extensive osseous formation and stromal area, reminiscent of that characteristic of POsF. The combined classic histopathologic features of both lesions represented in similar proportions justify the diagnosis of a combined PGCG-POsF. The biologic behavior of the combined lesion is not anticipated to deviate significantly from that of either of the lesions in their commonly single entity presentations. We recommend that more cases with histopathologic features similar to our case be reported in the literature to further elucidate the histogenesis of these lesions.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Patients with hereditary retinoblastoma have a heightened risk of developing subsequent bone and soft tissue sarcomas, exacerbated by radiation and alkylating chemotherapy. Secondary leiomyosarcomas are rare. A 29-year-old patient with bilateral retinoblastoma history presented with concurrent, independent malignancies found to be Rb-suppressed uterine and Rb-positive bladder leiomyosarcomas. She had undergone both ifosfamide chemotherapy and radiation therapy but demonstrated rare simultaneous primary leiomyosarcomas not previously described in association with ifosfamide. This rare case underlines the protean genetic predisposition to malignancy in this patient population, heightening awareness of lifelong malignancy potential, and the necessity for continuous periodic screening. Although a rare neoplasm, retinoblastoma is the most common eye tumor in children. It is frequently caused by mutations in the Rb-1 tumor suppressor gene located at band q14 of chromosome 13 and is hereditary in 30–40% of patients. When hereditary, the disease is more likely to be bilateral and multicentric.Patients with a history of hereditary retinoblastoma are more likely to develop soft tissue sarcomas, bone sarcomas, and malignant melanomas , 2. LeioA 29-year-old female presented with nausea, vomiting, diarrhea, and abdominal pain. Her past medical history was significant for bilateral retinoblastoma. Her right eye was enucleated at four months, and one year later retinoblastoma was identified in the contralateral eye. She underwent external beam radiation and chemotherapy with vincristine and cyclophosphamide for three years. At age 12 she developed osteosarcoma of the right femur for which she received adriamycin, ifosphamide, and methotrexate for one year, with subsequent limb salvage surgery with allograft. At age 29, she presented to our hospital and underwent imaging that demonstrated a vascular mass in the posterior bladder with incidental findings of fibroid uterus and right ovarian cyst. Exploratory laparoscopy, cystoscopy with biopsy, and pelvic washing revealed a bladder neoplasm consistent with high-grade leiomyosarcoma. Gynecologic evaluation showed an endometrial polyp with simple hyperplasia without atypia in the curettage specimen and rare atypical malignant cells suggestive of either an adenocarcinoma or a spindle cell neoplasm. Further radiological surveys of the chest, abdomen, and pelvis did not reveal any metastatic disease, although a bone scan showed a moderate focus of activity in the right proximal humerus; this was subsequently consistent with enchondroma.The patient underwent a radical cystectomy with ileal conduit and simple hysterectomy. The cystectomy specimen showed a tan, partially necrotic papillary tumor with edematous and focally hemorrhagic surrounding mucosa. The tumor did not extend throughout the bladder wall, and there was no connection between the posterior wall of the bladder and the anterior aspect of the uterus. The hysterectomy specimen revealed multiple leiomyomatous lesions in the anterior and posterior uterine walls and cervix that varied from small microscopic lesions to up to 3.2 cm in largest diameter.Histopathological analysis demonstrated two distinct leiomyosarcomas: one arising from the urinary bladder, the other from the uterus. These were established to be unrelated, representing two independent primary sarcomas. The bladder leiomyosarcoma was high-grade with mitotic figures averaging 80/10 high power fields. The tumor was positive for Rb, p53 (1-2%) and negative for estrogen receptor (ER) and progesterone receptor (PR) and had a higher MIB-1 (Ki-67) proliferation marker count (50%) Figures . In contAll other specimens including pelvic lymph nodes received were without malignancy, and all resection margins were free of tumor. The patient has undergone follow-up for seven years and remains cancer-free.The Rb gene acts as a tumor suppressor gene in all cells of the body as it does in the cells of the immature retina. When Rb is mutated in a germline fashion, patients with hereditary retinoblastoma are at high risk of developing a second nonocular malignancy, with an estimated cumulative incidence of approximately 1% for each subsequent year of life . The mosSoft tissue sarcomas are another group of secondary malignancies that have been reported –3, 6–12.Leiomyosarcoma of the urinary bladder represents less than 1% of all bladder cancers . There hUterine leiomyosarcoma as a secondary malignancy after hereditary retinoblastoma has also been evidenced in a few retrospective studies, although no case reports have been specifically described. Loss of heterozygosity of Rb gene has been reported in uterine leiomyosarcomas  which is


Traumatic injuries to the primary dentition are quite common. When primary teeth are subjected to trauma, force transmission and/or invasion of the underlying tooth germs lying in close proximity can result in a variety of disturbances in the permanent successors. Few of these disturbances include hypoplasia, dilaceration, or alteration in the eruption sequence and pattern. Dilaceration is defined as an angulation or sharp bend or curve in the linear relationship of the crown of a tooth to its root. A rare case of maxillary left central incisor having crown dilaceration and Vertucci's type II canal configuration with symptomatic periapical periodontitis is reported. Cone beam computed tomography was used for better understanding of the anomaly and complicated root canal morphology. The tooth was successfully managed by nonsurgical root canal therapy and restoration with resin composite to restore esthetics. Trauma resulting in oral hard and soft tissue injuries is quite common in children especially in the anterior region. The reported prevalence of traumatic injuries in primary teeth is quite high and has shown to range from 11 to 30% , 3. The Dilaceration is a rare disturbance in traumatized permanent teeth and constitutes about 3% of the total injuries to the developing teeth , 4, 5. IFor determining the normal as well as abnormal external and internal morphology of a tooth, intraoral periapical radiographs are an essential diagnostic tool in endodontics. However, a radiograph is a 2-dimensional view of a 3-dimensional structure, and hence, the ability to clearly view complex tooth morphology especially in the buccolingual plane is an inherent limitation of the radiograph. To overcome these limitations, cone beam computed tomography (CBCT) is popularly being used nowadays in endodontics to aid in preoperative diagnosis, optimal treatment planning, and posttreatment assessment. It provides a great deal of information on unexpected and complex anatomy, degree of calcification, direction, number and curvature of canals, aberrant root canal configurations, root resorption, root fractures, perforations, and periapical pathology. Use of CBCT greatly benefits over multiple radiographs by providing detailed information on three dimensional images thereby enhancing accurate assessment while reducing radiation exposure in complex endodontic cases .Maxillary central incisors are teeth mostly known to have a single root and a single canal. The presence of additional canals in these teeth is extremely rare with a reported incidence of only 0.6% . Most reThe purpose of this paper is to present and describe the endodontic management of a maxillary central incisor having crown dilaceration and Vertucci type II canal configuration, diagnosed using radiographic and cone beam computed tomography examination.A 17-year-old boy reported to the department of Conservative Dentistry and Endodontics with the complaint of pain and discoloration in the maxillary anterior region. The patient's medical history was noncontributory. Dental history indicated trauma to the anterior maxilla at 2-3 years of age due to fall from stairs, following which he had lost his left primary incisors. No dental treatment was undertaken for the same until the patient visited the dental clinic with the complaint of pain in relation to left upper front tooth. His parents confirmed that the permanent successors had erupted with alterations in color and shape and though they were dissatisfied with the esthetics, they had never visited a dentist earlier.On clinical examination, it was seen that the maxillary right and left central incisors, left lateral incisor, and left canine were the affected teeth. Maxillary left central incisor appeared to have a short clinical crown length with alteration in the incisal and middle thirds of the crown. The affected part of the crown was distinctly hypoplastic with yellowish brown discoloration Figures . On closIntraoral radiographic examination revealed the presence of a radiopaque line in the cervical area of tooth number 9 and also revealed a periapical radiolucency surrounding its root apex. Additionally, tooth number 9 appeared to have two root outlines which led us to suspect the presence of two canals Figures . AngulatThe exact tooth anatomy of tooth number 9 could not be verified on radiographic examination, and hence, to ascertain the variations in tooth anatomy and its root canal system, dental imaging with CBCT  for the affected region was undertaken using a limited field of view with exposure parameters of 120 kV, 5.0 mA, and 0.25 mm voxel size. The images were reconstructed at 0.25 mm thickness increments. Cross sectional CBCT images confirmed the presence of a well-defined periapical radiolucency and the presence of a structure which was composed of enamel and dentin in relation to the crown of tooth number 9 . The tooBased on these clinical and radiographic findings, a diagnosis of crown dilaceration of left central incisor having symptomatic periapical periodontitis was made. Lateral incisor was seen to be affected with Type IV hypoplasia and asymptomatic periapical periodontitis. It was decided to perform root canal treatment on tooth number 9 and extract tooth number 10 followed by interdisciplinary management for repositioning and esthetic correction of the affected teeth.After complete explanation of the treatment procedure, risks, and prognosis, an informed consent was obtained. Impressions and study models were made and nonsurgical root canal therapy was initiated in tooth number 9. Access cavity was prepared using Endo Access Kit (Dentsply) under rubber dam isolation, and both buccal and palatal canals were located under magnification using dental loupes . The pulp chamber when opened was found to be greatly diminished in size either due to calcification or due to the developmental anomaly. The root canals were also highly calcified with extremely narrow openings posing great difficulty in locating them. The canals were initially instrumented with K flex number 6, 8, and 10 files using 17% EDTA . WorkingTooth number 10 was extracted under local anesthesia. The patient was recalled after 3 months for evaluation of periapical healing with respect to tooth number 9. At 3 months, resolution of periapical radiolucency was seen in tooth number 9, and hence the patient was referred to the department of Orthodontics for orthodontic correction of teeth. The patient however failed to report on his scheduled appointment. On contacting him, it was learnt that he had left for his native place without having started any further treatment. He reported again to the department after 8 months. It was observed on clinical examination that spontaneous eruption of tooth number 11 had taken place and was now more vertically placed and only a little short of the occlusal plane Figures . OrthodoTraumatic injuries during the primary dentition stage are quite common. Primary tooth trauma resulting in developmental disturbances in permanent successors has shown to have a prevalence that ranges from 12% to 74% . The dirDilaceration can occur anywhere along the length of the tooth, that is, the crown, cementoenamel junction, length of the root, or root apex. Crown dilaceration has usually shown to have a greater occurrence following intrusion or avulsion of primary teeth, and the most affected age group seen is between 1.5 and 3.5 years at the time of injury. Normally, at the age of 2-3 years, the tooth germs of permanent maxillary incisors are located above and palatal to the root apices of primary teeth. When a force is applied to the labial surface of a primary maxillary central incisor crown, the root moves labially, with less chance of disturbing the permanent tooth germ, whereas when a force is applied to the palatal surface of the primary maxillary incisor crown as in the case of traumatic avulsion, the root moves palatally, thereby causing trauma to the underlying tooth germ . AffectePathology of crown dilaceration can be explained by the theory of displacement of the mineralized portion of the tooth in relation to the dental papilla, inner and outer enamel epithelium, and cervical loops . FaciallIn the present clinical case, traumatic force resulting from the avulsion injury at 2-3 years seemed to affect the left central and lateral incisors the most, with a lighter impact on the right central incisor. The tooth germ of canine was also possibly displaced mesioangularly. The impact appeared to be directed at the incisolabial surface of the left central incisor tooth germ resulting in its palatal displacement. The characteristic hook like appearance of the dilacerated crown was well discernible in the CBCT cross-sectional axial slices. The tooth also erupted in slight labioversion. Additionally, CBCT images revealed a single root in left central incisor with an abnormally greater buccolingual width in the cervical and middle thirds and Type II Vertucci canal configuration. Here, maxillary right central incisor showed a normal Vertucci Type I canal configuration, strongly indicating that localized trauma was the probable etiology for the occurrence of additional canal in the left maxillary central incisor.Aberrations in root canal anatomy could possibly be attributed to the stretching apart of the facial and lingual cervical loops resulting in the involution of the hertwigs epithelial root sheath on the proximal sides. This could also possibly explain the greater buccolingual width of the root with deep developmental grooves on the proximal surface which was visible on the radiograph as two root outlines. The presence of dilacerated crown with hypoplastic enamel and dentin would have predisposed to pulpal and periapical involvement as it served as a nidus area for microorganisms and their easier penetration into the open dentinal tubules.In the current case, traumatic injury also affected the left lateral incisor tooth germ resulting in Type IV hypoplasia  and arrested development of the crown , 20. TheCircular enamel hypoplasia is a disturbance of the enamel resulting in a line defect surrounding the crown of the injured tooth and most frequently occurs as a result of trauma in children around the age of two years , 22. SinRadiographic examination is an integral part of diagnosis, treatment planning, and management in endodontics. Angulated radiographs and digital radiography compared to single radiographs greatly improve the ability to identify variations in tooth anatomy ; yet theIn this specific case, the presence of crown dilaceration, additional root canal, and diminished pulp chamber size in left central incisor were confirmed on CBCT. It was essential to avoid perforating the root while locating and negotiating the canals. Endodontic success was achieved despite the difficult internal anatomy of the canal system emphasizing the need for correct diagnosis and determination of morphological variations before treatment onset. The presence of a periapical pathology with a labial perforation defect in relation to the root of the left lateral incisor was additionally detected on the CBCT images only. This information was otherwise missed on the conventional radiographs because of the overlapping mesioangularly placed canine.Disturbances in the permanent dentition subsequent to trauma of primary teeth often dictate an interdisciplinary management depending on severity and extent. The case presented here showed multiple teeth affected by crown dilaceration, hypoplasia, and improper eruption. Orthodontic repositioning for correction was not considered necessary. It was possible to treat the case by endodontic treatment followed by alignment and leveling with esthetic restorative treatment.Cone beam computed tomography has greatly facilitated safe and effective endodontic treatment by serving as an important tool for assessment of complex internal and external anatomy of the tooth. By establishing a correct diagnosis and adhering to the basic principles of endodontic treatment, it is possible to achieve endodontic success in teeth with variations in tooth anatomy.


Abdominal pain is a common symptom in the ER, covering 10% of the assists. The delay in diagnosis and treatment adversely affects the patient's prognosis.Transabdominal ultrasonography is most commonly used to obtain images of hepatobiliary, urogenital, and pelvic structures. However, improvements in ultrasound technology and increasing familiarity with ultrasonographic findings in a variety of gastrointestinal disorders, as Crohn's disease (CD), are broadening its applications, and it is an aspect to be considered by EP in patients with recurrent abdominal painwe present a case of CD, diagnosed at ER, through the use of US scanning used by EPa patient with abdominal pain, with a final diagnosis of an CD36 year old male, was admitted to the ER for the third time by abdominal pain. Emergency analytical were unremarkable, as in the preceding cases. Because of the pain the emergency physician underwent an ultrasound scan observing area terminal ileum same transmural thickening with luminal narrowing and decreased peristalsis, involvement of the mesenteric lymph nodes and multiple underlying fat, suspecting CD. We entered the patient performing CT abdomen and ileo-colonoscopy confirmed the diagnosis.Bedside ultrasound of the patient by the EP could be an useful tool in cases with abdominial pain whose clinical data and laboratory are unclear. Suspicion of CD, the sensitivity of ultrasound is nearly 90%, especially if ileal location, as in the case presented; being the specific data and the transmural segment thickening, and the presence of fistulae or abscesses. Stenosis exists ultrasound specificity is greater than 95%. Due to its great advantages such as low cost, accessibility, not irradiated and non-invasive ultrasound should be considered in the diagnosis and monitoring of all CD, therefore EP must be trained to diagnose sonographically acute complications of this disease.The study was conducted in accordance with the ethical standards dictated by applicable law. Informed consent was obtained from each owner to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.


Acute spontaneous neck haematoma is rare in children. This rare type of hematoma occurs abruptly without any preceding trauma or iatrogenic damage, making it very difficult to determine the cause precisely. We report here the first two cases of acute spontaneous neck haematoma presenting with neck swelling, and discuss in this article the diagnosis and treatment strategy in our patients.We report a 19-month-old girl and a 30 month-old boy with neck swelling for 10 days. There was no history of trauma, cough, excessive muscular strain or iatrogenic injury, and both patients were not on any anticoagulants or antiplatelet drugs. On initial examination, the swelling was tender, firm and not mobile on palpation. A definite diagnosis was made by hematoma puncture. Both of the haematoma resolved spontaneously in two weeks without any complications or sequelae.Acute spontaneous neck hematoma in children is a rare disorder without any etiology or precipitating factors. The difficulty in making an early diagnosis is mainly due to the nonspecific presenting symptoms. Conservative management and follow-up is recommended as a choice of treatment. Acute spontaneous neck haematoma is rare in children. This rare type of hematoma occurs abruptly without any preceding trauma or iatrogenic damage. Presenting symptoms are usually nonspecific, making it difficult to get a definite diagnosis. A MEDLIINE literature search did not reveal any reported cases of spontaneous haematoma in the neck without any precipitating factor in children. We report herein two cases of spontaneous neck haematoma in a 19-month-old girl and a 30-month-old boy who initially presented with neck swelling.Case 1. A 19-month-old girl presented with post left-sided neck swelling, fever and pain for 7 days. She started with fever at home and the swelling appeared spontaneously after 24 h, and gradual increase in 4 days. There was no history of trauma, cough, excessive muscular strain or iatrogenic injury. She was not on any anticoagulants or antiplatelet drugs. The general examination was normal. A 4.5 × 3.5 cm spherical swelling was seen on the trapezius in the posterior triangle of the left side of the neck and the skin over the swelling was normal  scan with contrast of the neck was reported as resolving haematoma 4.3 cm deep to the left occipitalia at the level of lobulus auriculae in case 1 Figure , and magA CT scan of the neck was reported as resolving haematoma 4.9 cm deep to the left sternocleidomastoid at the level of above the hyoid bone in case 2 (Figure A definite diagnosis of acute spontaneous neck haematoma was made by hematoma puncture in the two children. During this procedure, the aspiration was performed with 5 ml syringe, and the diagnosis was achieved by the successful aspiration of bleeding liquid.In case 1, the patient was treated with analgesics. No hemostatic was used. Both patient received treatment of fine needle aspiration of bleeding liquid form, but the hematoma expanded rapidly in a few hours. Thus, we decided to wait for a time for spontaneous resolution. The lesion resolved spontaneously two weeks later, without any complications or sequelae.It is rare to see spontaneous haematoma in the neck without any comorbidity. To the best of our knowledge, this is the first report of acute spontaneous neck haematoma presenting as swelling in children. In reported cases, haematoma was associated with trauma, bleeding diathesis, invasive procedure or surgery ,2. They Variety of intrinsic factors such as prolonged coughing, sneezing and vomiting are implicated in the cause . The necMRI and CT with contrast are the choice of imaging modality and plays an important role in diagnosis and evaluation of spontaneous haematoma ,6. ImagiNo standardized treatment and follow-up is established for patients with acute spontaneous neck hematomas in children. No recurrent cases have been reported. In our document the patients after evaluation of radiologic examinations, no certain diagnosis could be made; we thought that the patient might be experiencing spontaneous neck hematomas with unknown etiology. The patients herein were treated with analgesics and diagnostic fine needle tap bleeding liquid form haematoma. But the size of the lesion had enlarged day by day as the surgery before. Despite no experience in acute spontaneous neck hematomas in children, we decided to wait for a time for spontaneous resolution because excision of the lesion might result in permanent surgical scars in the neck. As expected, the lesion resolved spontaneously in two weeks by natural absorption, without any complications or sequelae.Acute spontaneous neck hematoma in children is a rare disorder without any etiology or precipitating factors. The difficulty in making an early diagnosis is mainly due to the nonspecific presenting symptoms. In such conditions, MRI or CT imaging scan should be considered to make a differential diagnosis. Conservative management and follow-up is recommended as a choice of treatment.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Clear cell chondrosarcoma is a rare bone neoplasm with low-grade clinical course and the potential to metastasize to the skeleton and lungs. The aim of this report is to present a case that is extremely rare, but in accordance with the literature where the clear cell chondrosarcoma reportedly has a tendency for late metastases. In our patient the primary surgery was intralesional, since it was mistakenly interpreted as a benign tumour in the early 80s. The local recurrence and lung metastases occurred, however, 29 years after the initial treatment. The local recurrence was resected with wide margins, no additional surgery or oncological treatments were given, and two and half years postoperatively patient is doing well and there is no progression in the disease. In conclusion, it is important to have a long follow-up to the clear cell chondrosarcoma patients even for decades or lifelong, because the malignancy tends to metastasize or recur after an extended period. The course of metastasized disease may be unusually slow, so relatively aggressive treatment in metastasized and recurring cases is justified. Clear cell chondrosarcoma (CCCS) is a rare low-grade malignant tumour of the bone comprising about 1.6%–5.4% of all chondrosarcomas . It is aWe report an extremely unusual case of CCCS where the local recurrence and nonsymptomatic lung metastases occurred 29 years after the primary surgery. We also reviewed 41 articles written in English of which 22 were case reports –29 and 1In 1982, a 33-year-old male patient presented with a pathological fracture of the left proximal femur. X-ray images of the proximal femur showed a large lytic lesion involving the whole intertrochanteric area. The lesion was expansive and bubby . An openHe was followed-up for ten years with local X-rays as well as lung X-rays and no evidence of local recurrence or distant metastasis was found. The latest X-ray from the operated femur was taken in 1993 and from the lung in 1994.In November 2011, 29 years after the primary surgery, the patient was referred to our institution because of symptoms suggestive of prosthesis loosening. He had symptoms such as pain and uncertainty in every step, but otherwise his overall health status was excellent. Because of locally increasing symptoms he had taken one cane for support, but otherwise he was able to walk unlimited distances. X-ray showed a typical aseptic loosening of the prosthesis with substantial subsidence. On the lateral X-ray some ectopic ossification could be observed at the prosthesis-bone junction . Magneti en bloc with wide margins. The recurrent tumour was solitary and well circumscribed and there were no satellite tumour clusters to be found. Tissue samples were taken intramedullarily from distal femur as well as from acetabulum and they both revealed to be free from tumour. The reconstruction was made with new modular tumour prosthesis. No further treatment was given.The local recurrence located in soft tissue area adjacent to the prosthesis-bone junction . Bony stTwo and a half years later there is no recurrence in the femur and all nodules in lungs have remained exactly the same in size and number Figures . The patClear cell chondrosarcoma is known to be a low-grade malignant tumour. To date, about 200 cases with clinical data have been reported in the literature. The prediagnosed symptoms are known to last long and delay to definitive diagnosis has been reported to vary from a few months to many years , 33, 41.The rarity and slow growing potential of this tumour quite often leads to prolonged symptoms and also to initial misdiagnosis. The proportion of intralesional surgery has diminished over time, since awareness of this tumour has increased. However, the number of intralesional surgeries is still quite high and leads to a huge risk of local recurrence. The risk of recurrence varies between 40% and 100%, increasing with prolonged follow-up. The risk of local recurrence is markedly decreased by wide resection, but recurrences are still frequent with reported rates between 0 and 33%. Local recurrence may be extremely late, no matter whether treated intralesionally or with wide resection , 41. LocThe progression of the disease seems to be slow even after local recurrence. Multiple resections due to numerous recurrences can be done and survival may still be many years or even decades , 39, 41.CCCS is a low-grade tumour with greatly elevated risk of recurrence after intralesional surgery and therefore wide resection is the suggested adequate surgical method. Metastases mostly occur in bony skeleton or lungs and skeletal metastases seem to be less aggressive in the clinical course. Local recurrence and metastases may also occur after an extended period of time and follow-up is necessary for decades or lifelong. Aggressive treatment of local recurrences and possibly also metastases could be acceptable.


Intraosseous ganglia are benign cystic lesions located in the subchondral bone. Intraosseous ganglion cysts of the ankle are relatively uncommon. We present a case of recurrent intraosseous ganglion in the ankle of a 41-year-old female who had recurrence after initial surgery. She was treated effectively by curettage and autogenous cancellous bone grafting. At the final follow-up, satisfactory results were obtained with no recurrence or complications. Ganglia are common and usually occur near joints, tendons, and tendon sheaths. However, the occurrence of intraosseous ganglions is rare , 2. IntrIntraosseous ganglia occur in the mature skeletons of patients of all ages and have a peak incidence in the fourth and fifth decades of life . The femThis paper presents a case of recurrent intraosseous ganglion in the ankle of a 41-year-old female who was treated effectively by curettage and autogenous cancellous bone grafting.A 41-year-old woman presented with a 2-year history of right ankle pain and limping which had deteriorated in the past 6 months. There was no history of trauma. On examination, there was no effusion swelling or tenderness of the right ankle. The patient had full range of motion in her ankle, and there was no vascular or neurological abnormality. Inflammatory blood markers were elevated. Plain radiographs demonstrated a cystic lesion of the lower tibia extending into the medial malleolus , the patient had no pain or limitation of movement and there was no further local recurrence.An intraosseous ganglion cyst is an uncommon, benign cystic lesion of the bone occurring in close relationship to an articular surface . The conThese patients may present with persistent pain that worsens with the use of the affected region. Physical examination may reveal swelling with tenderness; however there are often no abnormal findings . The aetOn radiographs, the intraosseous ganglia appear as well defined, lytic, oval, or round lesions located in the juxta-articular  region with or without cortical expansion and soft-tissue extension. Most of the lesions are small, at 1-2 cm . The preGrossly, the intact cyst is usually seen as smooth or slightly lobulated and bulging, with a white, fibrous outer surface. The external surface might appear gray-blue if the wall is thinned . The micThe differential diagnosis of intraosseous ganglion includes unicameral bone cyst, chondromyxoid fibroma, Brodie's abscess, giant cell tumour, fibrous dysplasia, and pigmented villonodular synovitis , 15. In Generally, the ideal treatment of symptomatic intraosseous ganglion is surgical excision by curettage followed by bone grafting to prevent recurrence and the risk of collapsing fracture , 5.Our patient had recurrence after the initial surgical management. The current literature reveals that recurrence after surgical curettage is rare (recurrence rate 6.1%). However, recurrence is not always related to inadequate excision or curettage. It can be caused by the occurrence of connective tissue metaplasia either at the operative site or in the tissue immediately adjacent to it .An Intraosseous ganglion is an uncommon lesion. Nevertheless, it is a possible cause of ankle pain and should be included in the differential diagnosis of benign osteolytic lesions in the ankle joint. Imaging in the form of an MRI is essential to aid in diagnosis and operative planning, accompanied with histopathology to confirm the diagnosis. Surgical curettage followed by bone grafting is the treatment of choice.


This heterogeneous group of vascular anomalies, which includes arterial, venous, capillary, and lymphatic lesions, used to be frequently referred to as “angiomas”. They have been since 1992 subdivided in two groups: vascular malformations (or “angiodysplasias”) and the rare true vascular tumours, which include immature angiomas.They are classified according to the type of vascular tissue affected. They may be capillary, capillovenous, venous, arterial, or lymphatic.Capillary angiomas include telangiectasias , angiokeratomas , and flat angiomas (the classic “port wine” stain), located mostly on the face and limbs. These are very difficult to treat because surgical excision leaves a significant cosmetic sequela and laser treatment may have side effects, such as pigmentation and keloid scarring.Capillovenous angiomas produce a bluish subcutaneous swelling, covered by a normal skin, which may progressively increase in size. Although congenital by nature, they can develop at any age in life. On physical examination, there is neither a palpable thrill nor a murmur. Their size is variable, from a few mm3 to a large lesion involving several fingers.Imaging may be necessary in the case of large lesions. Arteriogram has been supplanted by angio-MRI (or MRA), which has become an important diagnostic and therapeutic tool. Small lesions can be excised surgically. The treatment of large lesions is difficult in the hand: embolization carries a risk of digital necrosis, and surgical excision, made difficult by the lack of a plane of dissection and the number of affected pedicles, is only recommended in the localized forms.angiokeratomas, the associated skin involvement may produce dramatic cosmetic impairment. Surgical treatment is challenging in large lesions, involving skin resection and coverage by means of various plastic procedures.In Venous angiomas include cavernous angioma, which is a simple ectasia arising from a vein and can be easily removed or ligated, and dilatation of large veins, which is much more difficult to treat.Arterial angiomas include two different entities: arterial aneurysm and arteriovenous angioma.- Arterial aneurysms can be “false” when they arise from an hematoma resulting from arterial laceration. The lesion is saccular and histologically has neither elastic nor muscular fibres. “True” aneurysms, more commonly found in the hand, are due to a dilation of the arterial lumen. The lesion is fusiform, and its wall contains elastic and muscular fibres. In both cases, the lesion is pulsatile with a systolic thrill. The distal vascular status is assessed clinically by the pulse, and Allen’s test; and radiologically by ultrasound Doppler or an occasional MRI study. Surgical treatment consists of excision of the lesion. If there is a satisfactory collateral blood supply, microsurgical reconstruction may not be required.- Arteriovenous malformations are abnormal communications, or shunts, between an artery and a vein which may be of traumatic or congenital origin. They may remain latent until a second injury. A venous dilation in the hand is suggestive of the diagnosis. There is a characteristic thrill, a bruit, and an increase in local temperature. Angio-MRI reveals the site of the communicating vessels and the marked, excessively rapid venous return.Surgery must be decided on cautiously in the congenital forms of arteriovenous malformations because of the large number of shunting vessels and the possibility of other latent shunts.Lymphangiomas are relatively rare. They may be superficial and circumscribed or deep. Surgery involves a risk of postoperative lymph fistula.Immature angiomas are by far the most common vascular tumour. They appear during the first months of life. Their natural history includes a growing phase until the sixth month of life, a static phase until the twentieth month, and a slow regression phase, which may last until the sixth or seventh year and evolves to complete regression in about 90% of children. Surgery should only be undertaken at the end of the regression phase for the very rare sequelae.Other vascular tumors are extremely rare. They include hemangioendothelioma, hemangiopericytoma, angioleiomyoma, and malignant tumors (angiosarcoma and lymphangiosarcoma).The first two types (hemangioendothelioma and hemangiopericytoma) usually behave aggressively, and histologic differentiation with a malignant tumor is often uneasy. They require careful and frequent follow-up after surgical excision.


CT and MRI findings are presented and role of DWI is outlined. Noninvasive diagnosis of a solid organizing hepatic abscess is possible in the appropriate clinical setting; percutaneous or surgical biopsy may be indicated in equivocal cases.Solid organizing hepatic abscess is a rare form of focal infection, which needs differentiation from benign and malignant solid masses. We report a case of a 30-year-old man with a solid organizing hepatic abscess, diagnosed by imaging and  Cross-sectional imaging is a reliable tool for diagnosing hepatic abscesses in the appropriate clinical setting, but because of nonspecific radiological features percutaneous biopsy may be required for a definitive diagnosis in patients with equivocal clinical symptoms , 2 espec Brucella or parasites [Among solid infected lesions of the liver, usually due to pyogenic pathogens,arasites –7, organarasites . ex juvantibus criteria; features and role of diffusion weighted imaging (DWI) are also described.We here present a case of an organizing hepatic abscess diagnosed on the basis of cross-sectional imaging and9/L with 78% neutrophils), increased C-reactive protein level , and mild increase of transaminases . Urinalysis was normal. Sera IgA, IgG, and IgM and tumor markers were within normal limits. Repeated blood culture was negative as well as serological test for viruses , parasites (Entamoeba histolytica), and bacteria . Autoantibody tests (antinuclear antibodies and antineutrophil cytoplasmic antibody) for systemic autoimmune disease were negative. After admission he was treated with piperacillin-tazobactam  for 2 weeks and then p.o. with levofloxacin and amoxicillin-clavulanate for further 2 weeks; no steroids were administered. Fever definitely resolved on the third day after admission.A 30-year-old man with an unremarkable past clinical history was hospitalized for intermittent fever lasting for three weeks and a hypoechoic mass in the hepatic segment IV detected by an abdominal ultrasonography performed in an ambulatory diagnostic clinic. He was treated at home with ciprofloxacin and amoxicillin-clavulanate without clinical benefit. Laboratory tests at admission revealed neutrophil granulocytosis  before and after intravenous injection of 120 mL of iopromide 370 mg/mL at the rate of 4 mL/sec . Nonenhanced CT scans showed a hypoattenuating lesion measuring 6.5 × 4 cm in the hepatic segment IV. The lesion exhibited a target appearance on dynamic multiphasic CT scans, the main central component showing an enhancement similar to normal hepatic parenchyma. This component was circumscribed by a rim which was conversely hypoattenuating on arterial and venous phases and hyperattenuating on late venous phase. The lesion contained a tiny colliquative core . b-values , and nonenhanced and contrast-enhanced dynamic spoiled 3D GE sequence before and after i.v. injection of gadobenate dimeglumine ; the biliary phase was not acquired.One week later, during i.v. antibiotic therapy, a MRI of the liver was performed with a 1.5T magnet  and a 16-channel phased-array body surface coil using the following sequences protocol: axial in-phase and out-of-phase GE T1, coronal and axial HASTE T2-weighted imaging, axial fat suppressed HASTE T2-weighted sequence, DWI at three different−3 mm2/s, 1080 × 10−3 mm2/s, 1930 × 10−3 mm2/s, and 870 × 10−3 mm2/s, respectively . ex juvantibus criteria.Patient recovered completely during the hospitalization and all laboratory tests were normal at the time of discharge. No liver abnormalities were appreciable on 2-month MRI follow-up. Final diagnosis of an organizing hepatic abscess was made on the basis of diagnostic imaging andOrganizing solid abscesses of the liver are lesions with unknown incidence and gender predilection, pathologically characterized by a prominent chronic inflammatory reaction circumscribed by a fibrous rim and centered on a tiny necrotic suppurative core, not always recognizable on diagnostic imaging; biliary stone disease and recurrent pyogenic cholangitis are considered predisposing factors . HistoloKim et al. described CT and MRI findings of solid organizing hepatic abscesses, which characteristically exhibit a target appearance, more conspicuous on T2-weighted MRI and dynamic imaging . The pro Klebsiella pneumoniae infection versus 36% of cases of polymicrobial infections, with a 90% positive pus culture rate for both groups; these abscesses are however “predominantly” solid and are not circumscribed by a rim [Pyogenic hepatic abscesses may be solid on diagnostic imaging , 10. Alsby a rim , in whicHepatic abscesses may present as solid or target-like lesion in patients with chronic granulomatous disease, an inherited immunodeficiency of childhood characterized by primary phagocyte defect . These aOrganizing solid hepatic abscesses should be also differentiated from solid masses. Hepatic inflammatory pseudotumors are characterized by a large spectrum of CT and MRI findings, sometimes with a multilayer feature , 14. The b-value DWI, and low ADC values. Hypervascular primary and metastatic tumors enhance more than the normal hepatic parenchyma on arterial images whereas cholangiocarcinoma and hypovascular metastases enhance during the late phases [Primary and metastatic hepatic tumors should also be included in differential diagnosis. Neoplasms have high signal intensity on T2-weighted MRI, highe phases . Moreovee phases .In conclusion, the diagnosis of solid organizing hepatic abscess may be suggested by specific CT and MRI findings in the appropriate clinical setting. Nevertheless, percutaneous biopsy is mandatory for a definitive diagnosis in equivocal cases.


Oncocytic tumors, composed of eosinophilic, mitochondria-rich cells, can occur in several locations throughout the body. These tumors can occur in the adrenal cortex and are rarely malignant. We report a case of a patient presenting with an incidental adrenal mass which was later diagnosed as a oncocytic adrenocortical neoplasm (OAN). The patient is a 53-year-old man found to have a 7.2 cm right adrenal mass, incidentally found by computed tomography (CT). After metabolic workup was negative, a right robotic adrenalectomy (RA) was performed. Pathologic analysis revealed clusters of large cells with abundant eosinophilic and granular cytoplasm, consistent with OAN. This pathology is rare, with only about 150 cases described in the literature. It occurs in females 2.5 times more frequently and more commonly on the left side. Diagnosis is usually made by imaging criteria, typically with CT or magnetic resonance imaging (MRI). Treatment is generally surgical, since OAN can be malignant in some cases. Differentiation between benign and malignant OAN is done based on the Lin-Weiss-Bisceglia criteria and can be difficult. If malignancy is diagnosed, recurrence is common and close surveillance should be performed. Oncocytic tumors are composed of eosinophilic cells (oncocytes) containing a high number of mitochondria. They are not specific to any organ and can occur in several locations, such as salivary glands, kidney, thyroid, parathyroid, and pituitary. Tumors occurring within these locations are for the most part benign (oncocytomas). Oncocytic neoplasms have been rarely reported in the respiratory tract and choroid plexus and are sometimes malignant . The terThe patient is a 53-year-old man originally diagnosed with an incidental finding of a large right adrenal mass. He presented with abdominal pain, for which a computed tomography (CT) of the abdomen and pelvis was performed, showing a 7.2 cm right adrenal mass. A CT scan 3 months prior demonstrated the mass to be 6.8 cm. Magnetic resonance imaging (MRI) was also performed, revealing a 7.3 cm mass with heterogeneous T2 signal and low T1 signal .Serum chemistries were normal; there was no increase in cortisol or catecholamines. The patient had a prior history of prostate cancer treated with radical prostatectomy, but no other cancer history. Since the mass had a heterogeneous T2 signal on MRI and angiomyolipoma could be ruled out by the absence of fat on CT, suspicion for malignancy was high. The decision was made to perform a right robotic adrenalectomy (RA).Grossly the mass was found to be a 10.5 cm, pale red-brown variegated mass with areas of hemorrhage and central scarring. Microscopic examination showed clusters of large cells with abundant eosinophilic and granular cytoplasm, consistent with an OAN. The mitotic rare was low (4 per 50 high-power fields) and no atypical mitoses were seen. It was found to invade the capsule (but not beyond) Figures  and 3, aOAN has been described in only 150 cases in the literature. It typically presents between the ages of 27–72, with a relatively broad age distribution. It occurs in females 2.5 times more frequently and occurs more frequently on the left side .Most cases present as an incidental finding on CT or magnetic resonance imaging (MRI), and only approximately 17% of OAN are functional masses , 4. WhenIn addition to size, presence of necrosis , absenceIt is also important to rule out a functional adenoma, since surgery may be indicated regardless of size . AlthougWhile biopsy and fine-needle aspiration are possible, distinguishing OAN from other adrenal masses using this method can be difficult . Since OOn gross pathologic analysis, these masses tend to be large, encapsulated, and well circumscribed. The average diameter is about 8 cm . These tDifferentiation between benign and malignant forms of OAN can be difficult. The Lin-Weiss-Bisceglia criteria define malignancy by the presence of any one of the following microscopic features: (1) mitotic rate greater than 5 mitotic figures per 50 high-power fields, (2) atypical mitoses, or (3) invasion of venous structures. If no criteria of frank malignancy are present, the minor criteria for borderline malignancy must be assessed. The criteria for tumors of borderline malignant potential include the following: (1) increased size (>10 cm and/or >200 g), (2) necrosis, (3) capsular invasion or (4) sinusoidal invasion. A diagnosis of a benign tumor (oncocytoma) can only be given in the absence of all of the aforementioned criteria for frank or borderline malignancy .In the case of benign OAN, prognosis after surgical resection is considered to be good . If adreWe present a case of a 7.2 cm adrenal incidentaloma eventually diagnosed as OAN after surgical removal. OAN is a rare tumor with roughly only 150 cases described in the literature. Routine imagining techniques cannot reliably differentiate OAN from other adrenal adenomas, so the diagnosis is histologic. Microscopically OAN is composed entirely of large cells with abundant eosinophilic and densely granular cytoplasm and indistinct cell borders. Surgical resection is generally curative, except in the case of malignancy, where recurrence is common.


Papillary tumor of the pineal region (PTPR) was first described as a distinct tumor entity in 2003 and was introduced into the World Health Organization classification of central nervous system tumors in 2007. This tumor is rare and, to the best of our knowledge, only 7 cases have been reported in children <16 years of age, while the youngest documented patient was a 15-month-old boy. The present study reported a case of PTPR in a 10-year-old girl who underwent magnetic resonance imaging and surgical resection of tumors. Histological and immunohistochemical staining results were presented. Patients with PTPR require long-term follow-up, and the patient of the present study has continued to do well, with no recurrence of the tumor at the 15-month follow-up examination. In addition, a review of the literature on this unusual neoplasm was performed, along with discussion of their differential diagnosis. In 2007 in 2003 . Tumors  in 2003 . PTPR ha in 2003 ,7, which in 2003 . The nat in 2003  and Kapl in 2003 . The preA 10-year-old girl presented with one-year history of right eye strabismus accompanied by diplopia, with no apparent cause. The patient was treated with traditional Chinese medicine in a local hospital and the diplopia symptoms were alleviated, while the strabismus symptoms persisted. One month prior to presentation, the patient suffered from an irregular intermittent headache, particularly in the lateral and top areas of the forehead. During this period, the patient additionally experienced intermittent nausea and vomiting. For further evaluation, the patient was admitted to the Affiliated Hospital of Qingdao University  in March 2014. The results of a physical examination conducted at the point of patient admission to the hospital were unremarkable with the exception of the right eye strabismus. Further MRI scans demonstrated a heterogeneously-enhanced and well-defined space-occupying lesion with limited cystic components in the pineal region . The patThe tumor was removed via a suboccipital transtentorial approach . During Microscopic examination revealed that parts of the tumor exhibited papillary structures and a palisade arrangement surrounding the vascular pseudostratified columnar epithelium was observed. Examination of hematoxylin and eosin-stained sections showed that the cells demonstrated papillary growth patterns. The cytoplasm was hyperchromatic and the nuclei were slightly irregular . In addiThe term ‘PTPR’ is based on the histopathological description of a tumor characterized by a papillary pattern, rosettes and pseudorosettes . Other tet al in 2011 (PTPR is an uncommon type of neoplasm and, to the best of our knowledge, only 93 cases have been reported thus far –25. Tabl in 2011  and 19 c in 2011 –25. The  in 2011  and the  in 2011 . In addi in 2011 . The pre in 2011 . By cont in 2011 . Almost  in 2011 . In the Clinical data concerning PTPR is limited and its pathogenesis is unknown. PTPR is frequently misdiagnosed as ependymoma or choroids plexus papilloma. However, the diagnostic criteria of certain postulated papillary-like tumors have been revised, and a more complete understanding of this tumor may be obtained. The present study reported a case of PTPR in a 10 year-old girl who suffered from an irregular intermittent headache, particularly in the lateral and top areas of the forehead. The patient were treated with Chinese medicine which alleviated the diplopia symptoms. Similarly to previous reports they underwent magnetic resonance imaging and surgical tumor resection, and continues to have a positive postoperative outcome. These results along with the data from previous studies indicate that total tumor resection is the optimal treatment guideline.


Osteoma is a benign osteogenic lesion which is composed of well differentiated mature compact and/or cancellous bone that proliferates continuously. Its prevalence is 4%. Its pathogenesis is still controversial. Solitary peripheral osteoma of craniofacial region is a rare finding. We report a case of 30-year-old female having solitary peripheral osteoma present on the lingual cortex of the left posterior mandible which was initially asymptomatic but now is causing discomfort while chewing and not associated with Gardner's syndrome. We also laid emphasis on its clinical, differential diagnosis, radiological, surgical, and histopathological features. The aim of this paper is to present an uncommon case of solitary peripheral osteoma in the mandible along with analysis of literature for peripheral osteomas of jaws and to contribute to the knowledge concerning the pathogenesis, differential diagnosis, and management of these lesions. Osteomas are uncommon, slow-growing, benign osteogenic neoplasms that arise most frequently in the craniofacial skeleton , 2. OsteAim of this paper is to present an uncommon case of solitary peripheral osteoma in the mandible along with analysis of literature for peripheral osteomas of jaws and to contribute to the knowledge concerning the pathogenesis, differential diagnosis, and management of these lesions.A 30-year-old female had reported to our department with a chief complaint of a swelling on the inner side of lower left posterior region of the mandible since 8 years. Her history revealed that 8 years back she developed a small swelling measuring around 5 mm in diameter which slowly progressed to current size. The swelling was asymptomatic, but, as the swelling had increased in its size, now the patient experiences discomfort while chewing food and wants to have it removed. The patient did not have any significant medical and family history and also gave no history of trauma. Physical examination did not reveal any kind of similar swelling in any other region of the whole body and also patient did not have any significant family and medical history of such swellings so Gardner's syndrome was ruled out.Intraorally a solitary oval shaped well defined pedunculated swelling was present on the lingual aspect of teeth 36 and 37 which measured 1 cm in diameter . The oveMandibular occlusal cross-sectional radiograph showed a well defined irregular shaped radiopacity attached to the lingual cortex of 37 with a stalk . Its radThe histopathological evaluation of the excised specimen showed that the lesional tissue was composed of dense compact bone tissue exhibiting concentric lamellae and osteocytes within osteocyte lacunae . These mOsteoma is defined by World Health Organization (WHO) as a benign lesion consisting of well differentiated mature bone tissue with a predominantly laminar structure and showing very slow growth . It is nHistologically they can be divided into three types: compact or ivory or eburnated osteoma , cancellous or trabecular or mature osteoma or osteoma spongiosum , and mixed-type osteomas , 17, 18.Solitary peripheral osteomas (PO) of the jaws are rare, commonly occurring in young adults  with no  APC (adenomatous polyposis coli) tumor suppressor gene [Multiple osteomas of the jaws along with other pathologies like colorectal polyps with high malignity, cutaneous fibromas, congenital retinal pigment hypertrophies, and multiple impacted or supernumerary teeth, enostoses, or epidermal cysts, are characteristic findings in Gardner's syndrome  which is an autosomal dominant disease caused by a mutation in thesor gene , 15, 27.sor gene .Radiologically PO appear as well defined radiopaque mushroom or oval shaped masses with a narrow contact area near vestibule with density similar to normal bone . They caThe differential diagnosis of osteomas includes exostoses, osteochondroma, osteoid osteoma, periosteal osteoblastoma, parosteal osteosarcoma, peripheral ossifying fibroma, Paget's disease, fibrous dysplasia, and odontoma , 20. ExoParosteal osteosarcoma is commonly seen in posterior mandible, homogeneous or heterogeneous, ill defined lobulated sclerotic mass. At periphery it can have either sun burst appearance or formation of Codman's triangle .Peripheral ossifying fibroma is found exclusively on gingiva and is a reactive lesion commonly occurring in the maxillary anterior region which is firm in consistency . Paget'sPatient with osteoma should be evaluated properly clinically and their family and medical history should be recorded thoroughly to rule out Gardner's syndrome . Asympto


Medulla oblongata (MO) tumors are uncommon in adults. Controversies about their treatment arise regarding the need for histological diagnosis in this eloquent area of the brain, weighing benefits of a reliable diagnosis, and the potential disadvantages of invasive procedures. As a broader variety of pathological findings could be found in this localization, the accurate histopathological definition could not only allow an adequate therapy but also can prevent the disastrous consequences of empiric treatments. There are few publications about their surgical management and all belongs to small retrospective cohorts. In this scenario, we are reporting two patients with exophytic or focal lesions in the inferior half of the medulla, who underwent surgery by suboccipital midline subtonsillar approach. This approach was not specifically described to reach MO before, and we found that the lesions produced a mild elevation of the tonsils providing a wide surgical view from the medulla to the foramen of Luchska laterally, and up to the middle cerebellar peduncle, offering a wide and safe access. Brainstem tumors are infrequent in adult patients. Median age of presentation is the fourth decade of life, and overall survival is about 54–64 months. They represent <2% of all brain tumors in epidemiological data . Those lThere are isolated reports of small surgical experiences dealing with direct surgery in this particular CNS region. Although most of them reported satisfactory results, others described that postoperative neurological deterioration was common and suggested that surgery is of questionable benefit –18.Regarding the type of mass lesions that can be found in adults, a diversity of histopathological findings has been reported, such as high-grade and low-grade astrocytomas, anaplastic and low-grade oligodendrogliomas, ependymomas, gangliogliomas, DNT’s, metastases, granulomas, lymphomas, infection, inflammatory diseases, and pseudotumoral lesions as tumefactive demyelinating diseases , 19, 20.Therefore, controversies arise regarding the need for histological diagnosis in this eloquent area of the brain, weighing benefits of a reliable diagnosis and the potential disadvantages of invasive procedures. In this scenario, recommendation of the surgical management in adult patients cannot be defined with an appropriate level of evidence. Meanwhile, the contribution of our two cases experience dealing with uncommon tumors of the MO can provide more information for the surgical decision making process.A 41-year-old woman had a 6-month history of headache, vertigo, unsteadiness, and persistent cough. At admission, she had 90 points Karnofsky performance status (KPS). The patient did not have a relevant medical history and her clinical work up was normal. Funduscopy was normal. T1-weighted MRI scans showed an exophytic hypointense and homogenous mass in the left MO without gadolinium enhancement. Complete MRI scans of the entire neuroaxis were unremarkable. The suspected preoperative diagnosis was low-grade glioma or ependymoma, according to the more common lesions with its radiographic features in this CNS localization. The intraoperative biopsy demonstrated a tumor composed of cells like ependymoma and astrocytes. This finding supported the complete excision of the lesion. The definitive diagnosis was subependymoma.Postoperatively, the patient presented transient dysphagia, which recovered after a few months rehabilitation period. Neurological symptoms relieved significantly in the long-term follow-up in comparison to preoperative status; however, dizziness episodes still appear occasionally. The subependymoma is a low-grade glioma, with a well-known good survival prognosis, and low chances of recurrence when complete resection is accomplished; therefore, the patient did not required additional therapy after surgery Figures A,B.A 30-year-old man had a 2-month history of headaches, vomiting, gait ataxia, dysphonia, dysphagia, and urinary incontinence presenting a 60 KPS. T1-weighted cerebral MRI scans showed a wider medulla due to a hypointense heterogeneous mass with necrosis or polimicrocysts. Gadolinium-enhanced T1-weighted MRI scans demonstrated a heterogeneously enhancing mass. MRI scans of the complete neuroaxis were unremarkable. The patient had had a suprasellar germ cell tumor in childhood that was treated with radiotherapy. He did well in the long-term follow-up, without evidence of recurrence during the last 20 years. Blood markers as alfa-fetoprotein (AFP), β-human chorionic growth factor (BHCG), and embryonic-carcinoid antigen (ECA) levels were within the normal range. Lumbar puncture to obtain CSF biochemical markers  or pathological cells was inadvisable because of the tumor extension and the presence of intracranial hypertension.A direct approach was performed with the presumptive diagnosis of a new CNS lesion or a progression of the previous disease. The intraoperative finding demonstrated a germ cell tumor and, as this type of tumor is very sensitive to oncological treatment, only a subtotal resection was performed, No surgical complications were observed. The neurological status dramatically improved postoperatively to 90 KPS; it could probably be related to the evacuation of the cyst component of the tumor and the posterior fossa decompression. Then, he received chemotherapy and radiation therapy Figures A,B.We describe the surgical technique, supporting description of approach with some anatomical specimens performed in laboratory Figures A–D.The patient is positioned prone with the head placed in a neutral position whereas the cervical spine is slightly anteriorly flexed. Bilateral somatosensory evoked potential and VIII, XI and XII cranial nerves monitoring are performed. A midline vertical skin incision is made from the inion to the second vertebra. A suboccipital midline craniotomy extended to the posterior rim of the foramen magnum is performed. The posterior arch of C1 is removed, but preserving the atlantooccipital joints.The dura is opened in Y-like fashion. Cerebellomedullary arachnoid is sharply and meticulous dissected unilaterally to allow mobilization of cerebellum’s tonsils off the dorsal surface of the medulla. Opening of the tonsillovermian fissure further increased the exposure. This maneuver allows the access to the inferior end of the IV ventricle and the MO. The medulla enlarged by the intrinsic lesion, is displacing the tonsils upwards. The bulging neural lesion is displacing the posterior inferior cerebellar arteries (PICAs), and the vascular structures are identified and preserved. Regarding veins, the cerebellomedullary fissure vein drains the superior and ventral surfaces of the tonsils and portions of the inferior vermis. It passes laterally within the fissure to empty into the tributaries of the superior petrosal sinus. At its medial origin, the cerebellomedullary fissure veins may communicate by means of the lateral uvular vein with the inferior vermian vein. The posterior aspect of the medulla can be exposed without sacrificing neural tissue. A minimal neural opening is performed in the midline, in the area of less tissular vascularization, known as safe entry zone of the inferior half of the medulla. Removal of small piece of tissue for histopathological study is performed in real time to define the extent of resection. Then, the duramater is closed in watertight fashion. Muscles and superficial tissues are closed in the usual manner Figures A,B.Two patients with masses located in the inferior half of MO are reported. One was a focal lesion and the other was an exophytic one. The suboocipital subtonsillar midline approach used in these two cases provided a wide surgical view to the foramen of Luschka laterally and up to the middle cerebellar peduncle. It was found that the tumors had produced a mild elevation of the tonsils making the access easier, and there was no need to use retractors. The approach provided enough decompression and simultaneously allowed to obtain histological samples. The extent of resection depended to the intraoperative histopathological findings. Good neurological results were achieved without complications related to the procedure.Lesions located in the MO represent undoubtedly a difficult challenge, since the expected high risk of surgical exploration of this eloquent area. Moreover, their low incidence in adults combined with little worldwide experience has provided scarce information about surgical results and prognosis. This has probably discouraged the treatment of tumors in this localization for many years.Although modern neurological imaging techniques provide well-defined images, the histological diagnosis cannot be certainly confirmed. It has been reported that neurorradiological assessment varied from histopathological diagnosis in approximately 40% of brain stem cases –23. DespAlthough stereotactic biopsy is usually safely implemented in other areas of BS such midbrain or pons, pure MO lesions are seldom biopsied . For insRegarding the subtonsillary approach, it was originally described to reach the fourth ventricle, and anatomical details have previously reported , 28, 29.The broader variety of pathological findings that could be found in the MO supports the benefit of getting an accurate histological diagnosis. Regarding the role of intraoperative pathology reviewed in real time, although it can not always confirm the definitive histopathological diagnosis in the operating room, usually provides enough information to determine the extent of resection.In conclusion, direct surgery via subtonsillar approach assisted by intraoperative neurophysiological monitoring provides a safe surgical way to this critical area of the brain. The awareness of the histopathology is decisive to define the course of treatment and could avoid the disastrous consequences of empiric treatments in cases appropriately selected.All subjects gave written informed consent according to the requirements of the Institute of Medical Research A. Lanari, University of Buenos Aires.AR: design of the research, writing of the article, revision of the literature. DH: participation in the design of the research and critical review of the paper. AC: work in the Anatomical Research Laboratory.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Acute appendicitis with appendicial endometriosis is a very infrequently encountered condition during pregnancy. Decidualization is the hypertrophy of endometrial stromal cells by the effect of progesterone. Similarly, in pregnancy, ectopic stromal endometrial cells in endometriosis can also be transformed by the same mechanism and ectopic decidua (deciduosis) may occur.Case: Here we report a 30 year old pregnant woman presenting twice with acute abdominal symptoms requiring surgery for appendicial and ovarian endometriosis and deciduosis. We emphasize that deciudualized endometriosis may first present during pregnancy with acute abdomen necessitating emergency laparotomy and complicating the course of gestation.Conclusion: To our knowledge only 9 cases in which decidualized endometriotic tissue causing acute abdomen necessitating surgery during pregnancy were reported in the literature. What makes our case special is that the patient needed two laparotomies during the pregnancy period which was a very stressful situation for both the patient and the physicians. Acute appendicitis with appendicial endometriosis is a very infrequently encountered condition during pregnancy which ranges between 3-8 deliveries per 10,000 . Here we report a 30 year old pregnant woman presenting twice with acute abdominal symptoms requiring surgery for appendicial and ovarian endometriosis and deciduosis.oC and 104/min, respectively. Abdominal examination revealed tenderness, guarding, and rebound tenderness at the right side of the uterus. White blood cell count was 19,500 cells/mm3 with 92.8% neutrophils. A 30-year old, gravida 1, para 0, woman at 24th week of pregnancy presented with right lower quadrant pain, fever and nausea. Axillary body temperature and pulse rate were 37.3The sonographic examination did not reveal any findings consistent with acute appendicitis exception for periceaceal fluid and it showed a normal intrauterine pregnancy. With a preoperative diagnosis of acute appendicitis, a laparotomy was done via a paramedian incision in the right side of the abdomen. Appendix was erythematous and appendicectomy was performed. The histopathological examination of the appendix revealed acute appendicitis with extensive deciduosis of the appendiceal wall of all the three layers. There were also glandular structures among the decidua which were positive with cytokeratin 7, while the adjacent appendicial mucosa was negative. The diagnosis was endometriosis and decidiosis of appendix and acute appendicitis. The patient was discharged with antibioteraphy without further complaints. oC and 110/min, respectively. At physical examination, the patient had 7 months of pregnant uterus and acute abdominal findings consisting of mainly left lower quadrant tenderness. Laboratory results showed a white blood cell count of 23, 800 cells/mm3. A pelvic sonogram revealed a normal intrauterine pregnancy at 28 weeks and free fluid between the intestinal structures and a 5 cm complicated left ovarian cystic mass compatible with tubo-ovarian abscess. At laparotomy with a median subumbilical incision, a small amount of purulent free fluid and extensive pelvic deciduosis covering all the pelvic peritoneal surfaces with left tuboovarian abscess was observed. The abscess was drained and left salpingectomy was performed. One month later, at 28 weeks’ pregnancy, the patient came again with left lower quadrant pain, high fever and vomiting. Her temperature and pulse rate were 38.5th postoperative day the patient had uterine contractions and tocolytic therapy was initiated with nifedipine. She gave birth to a 1400 gr healthy male baby with spontaneous vaginal delivery. Papillary excrescences were observed protruding into the lumen of the mass and ovarian biopsies were obtained. The abdominal cavity was washed with warm saline solution and a drain was placed in the Douglas pouch for drainage which was removed 3 days later. Early postoperative recovery was uneventful but on the 5Histo-pathological examination revealed ovarian endometriosis with marked decidual changes and hemosiderin-laden macrophages as well as moderate amount of polynuclear leukocytosis in cyst wall. The final pathological report confirmed infected endometrioma with deciduosis. Postoperatively patient received tazocin antibiotherapy for 3 weeks and discharged from the hospital without further complications. At the second postpartum month she was completely recovered and her baby was doing well without any complications related to prematurity.Endometriosis of appendix is a rarely encountered condition, occurring with the rate of 0.2-0.3% in appendectomies . There wTherefore, endometriosis of the appendix is often an incidental finding during abdominal operations. Deciduosis appendix is encountered during pregnancy and it is frequently identified at the serosal region of the appendix. At this localization the decidualisation was attributed to the physiological reaction of the pluripotential submesothelial stromal cells to hormonal influences of the pregnancy . In someAdnexal masses complicating pregnancy have been reported to occur in average 1 in 600 of live births and approximately 11% of these are endometriomas . These dIn conclusion, we emphasize that deciudualized endometriosis may first present during pregnancy with acute abdomen necessitating emergency laparotomy and complicating the course of gestation. To our knowledge only 9 cases in which decidualized endometriotic tissue causing acute abdomen necessitating surgery during pregnancy were reported in the literature . What makes our case special is that the patient needed two laparotomies during the pregnancy period which was a very stressful situation for both the patient and the physicians.


The Wunderlich syndrome found after the rupture of primitive renal Ewing's sarcoma is not a situation that we find often in everyday practice. The clinical findings are not specific, which is why the differential diagnosis must be made with a multitude of benign and malignant renal masses until the correct diagnosis can be made by the pathologist. The CT and MRI images are not characteristic. One treatment option is the multidisciplinary approach; however, the prognosis remains poor for patients with metastatic disease. A Wunderlich syndrome caused by the rupture of Ewing's sarcoma of the kidney is a rare entity and represents a life-threatening emergency. In the beginning, PNET  and Ewing's sarcoma were considered different but today, because of their similar histologic and cytogenetic characteristics, they are included in the same family with Ewing's sarcoma.A 40-year-old woman presented to the emergency room for left flank pain lasting for 2 hours and irradiating to the groin. Her medical and surgical history included aortic regurgitation, left kidney stones, stress urinary incontinence surgically treated, and obesity (BMI = 40.8). On physical examination, the patient was found to be afebrile and in good clinical status except for a positive Giordano's sign. Her blood haemoglobin was 12.7 g/dL with a normal coagulation profile and normal renal function. She was first treated with anti-inflammatory agents, which lead to a decrease of the clinical symptoms. A computed tomography scan showed a large solid heterogeneous mass measuring 7 × 6.7 cm, without calcifications, located in the left kidney, as well as a perinephric hematoma . No otheEwing's sarcoma is a rare primary malignant renal tumor and it is characterized by an aggressive biological behaviour. The first Ewing's sarcoma was reported by Mor and colleagues. Later, John Ewing presented this type of tumor in the diaphysis of long bones . The cliThe Wunderlich syndrome was described for the first time in 1856 as a spontaneous renal bleeding confined to the perinephric or subcapsular space . It is aEwing's sarcomas have obvious metastases at the time of diagnosis in 20–25% of the cases, being the main indicator of prognosis. Furthermore, after local therapy, 80–90% of the cases develop in time systemic relapse, suggesting that the metastases had been present subclinically at the moment of diagnosis . The mosWunderlich syndrome after the rupture of a renal Ewing's sarcoma is a rare entity, which represents a diagnostic challenge and already aggressive tumor. The CT and MRI images are not specific that is why the true diagnosis will be made by the anatomopathologist after molecular, immunohistochemistry, and histologic tests. It is important to have a definite diagnosis in order to choose a good multimodal treatment, due to the tumor's poor prognosis and to the young age of most of the patients.


Mature teratoma of the pituitary-hypothalamic region is rarely reported in the literature. In this article, we present a 13-year-old girl with clinical and radiological findings that were initially considered as germinoma. However, histological examinations disclosed a mature teratoma. This case highlights that the radiation-induced cerebral edema caused acute hydrocephalus. The mature teratoma is not radiosensitive, and the most appropriate treatment is direct surgery. Primary intracranial germ cell tumors (GCTs) are relatively rare neoplasms, and account for 0.5% of central nervous system (CNS) tumors . The WorA 13-year-old girl was admitted to our hospital with a 3-year history of polyuria (approximately 3 L of urine every 24 h), polydipsia and amenorrhea. During the 2 months preceding investigation, she complained of blurred vision. In addition, she also had a 1-month history of progressive migraine-like headache. The patient with short stature (height 112 cm) had a weight of 18.5 kg and a bone age of 6 years. Past medical history included myocarditis for 1 year. Physical examination revealed bitemporal hemianopsia, which was more prominent on the right side. The rest of neurological examination was within normal limits. Laboratory evaluation was notable for a urinary specific gravity of 1.003 : 1.010 - 1.025), thyroid-stimulating hormone of 6.830 mU/L (N: 0.27 - 4.2), thyroxine of 38.69 nmol/L (N: 62 - 164), and prolactin of 50 ng/mL (N: 6.0 - 29.9). Seric human chorionic gonadotrophin (HCG-β) and alpha-fetoprotein (AFP) levels were 20 mIU/mL (N < 3.81 mIU/mL) and 50 ng/mL (N < 8 ng/mL), respectively. Growth hormone (GH) level was 1.69 ng/mL (N < 10 ng/mL). Cranial MRI demonstrated a large, sellar and suprasellar, cystic and solid mass extending to the optic chiasm and the right optic nerve . On T1-wThree days after the RT, however, the patient suffered severe headache, vomiting and visual field defects. Subsequent computed tomography (CT) revealed a mass lesion within the third ventricle accompanied by moderate dilation of the lateral ventricles . Slight The patient underwent a total resection of the mass in the operating room via a right pterional approach. In the operative observation, the tumor consisted of two components, cystic and solid areas. The cystic portion was dark yellow fluid; the solid portion was hair and whitish fat material . The bonPostoperatively, the patient remained stable, although she had transient diabetes insipidus, which resolved by the time of discharge from the hospital. Hormonal replacement was administered. The patient vision improved significantly and she has useful vision in both eyes although the visual field is restricted. No evidence of tumor recurrence was detected on repeat MRI 1 year after surgery , and theMature teratoma is regarded as a benign GCT. The tumor derives from embryonal cells, and has the presence of fully differentiated neuroectodermal, mesodermal and endodermal elements. To our knowledge, there were three cases of primary sellar teratomas in the previous reports . AlthougThe most frequently presenting complaints of suprasellar lesions were hypothalamic-pituitary axis dysfunction such as diabetes insipidus, menstrual irregularities, delayed growth or precocious puberty . GCT, liOur patient experienced sudden onset of hydrocephalus 3 days after irradiation. CT revealed a large mass of the sellar region with obstructive hydrocephalus . The matMRI plays the most important role in detecting CNS GCTs. Generally, the solid parts of GCTs are isointense with or slightly lower signal than gray matter on T1-weighted imaging, and isotense on T2-weighted imaging . But in The histological findings are essential for both craniopharyngioma and GCT diagnosis. In our case, a histopathological verification is made via surgical removal of the lesion. Serum tumoral markers are elevated (HCG-β and AFP), but there was no evidence of secreting cells on immunohistochemical testing. They might have already disappeared after RT.The best treatment of GCT remains controversial, and includes surgery, RT and chemotherapy. Germinomas are extremely radiosensitive, and the 10-year survival rate of treatment with RT alone is about 90-100% . In the Many kinds of neoplasms including pure germinoma could be treated with irradiation, without surgical resection of the main part of the tumor, but our case underwent open surgery. Surgery brings more benefit than harm to our patient. It could resolve the compressive effect and hydrocephalus, gaining the definite diagnosis. Neurosurgeons should weigh the risks and benefits of surgery to determine the most appropriate plans for each patient. If it is not safe to conduct a surgical removal for patients with sellar masses, when the ventricle is enlarged, endoscopic biopsy of the tumor extending to the third ventricle is rather recommended. Stereotactic biopsy without direct vision for the lesions around the sellar region should be hazardous, because major vessels are located in close proximity to the course of needle insertion. Our study shows that the mature teratoma is not radiosensitive, and the optimum management is direct surgery.In conclusion, mature teratomas of the pituitary-hypothalamic region are rare. The radiation-induced cerebral edema caused acute hydrocephalus, which is not described in all the previous reports. This should draw attention to the neurosurgeon after irradiation. The clinical features and radiological findings of sellar tumors may be similar in both craniopharyngioma and mature teratoma. Our case suggests that the mature teratoma is not radiosensitive, and the most appropriate treatment is direct surgery.