Odontogenic myxoma (OM) is a rare and locally benign neoplasm of high aggressive behavior found exclusively in the jaws. OM commonly occurs in the second and third decade, its quite rare to find in maxilla that to invading the maxillary sinus completely. The lesion often grows without symptoms and presents as a painless swelling. The radiographic features are variable, and the diagnosis is therefore not easy. This article presents a case of OM of maxilla in a 13-year-old boy, which was previously diagnosed as fibrosseous lesion with the help of CT. The odontogenic myxoma is a rare, benign tumor which does not show metastasis but local agressiveness and involves the maxilla and mandible. When involving the maxilla, odontogenic myxomas can invade the maxillary sinus, and are then diagnosed later stages only after having grown to huge mass.A 13-year-old male was referred to the Dental Department at Krishna Devaraya College of Dental Health Sciences Center for definitive management of a right-sided maxillary lesion. Which was previously diagnosed as fibrosseous lesion with the help of CT 2 years back. A three-year history of a slow growing mass causing intermittent pain in the right midface was reported. The patient denied any visual disturbance. Physical examination revealed fullness of the right midface which was mildly tender to palpation. The overlying skin was not erythematous and he demonstrated no lymphadenopathy or trismus . IntraorThe occlusal radiograph showed a large multilocular radiolucent area with a well-defined sclerotic margin extending from the right lateral incisor to the distal aspect of the right second molar, with ’spider web’ and ‘tennis racket’ pattern appearance, with which a preliminary diagnosis of OM was made . A compuAn incisional biopsy confirmed the diagnosis of odontogenic myxoma. The surgical management involved a combined intra- and extraoral approach. The tumor was resected with a margin of normal tissue. This involved a maxillary ostectomy . Macrosc34 Myxoma is defined as a true neoplasm composed of rounded, angular, stellate and sometimes spindle-shaped cells set in a myxoid stroma containing mucopolysaccharide through which course very delicate reticulin fibers in various directions.5 According to the WHO’s classification of odontogenic tumors, in 1992, the Myxoma is considered a tumor of the odontogenic mesenchyme with or without the presence of odontogenic epithelium.6 Usually, when it involves bony tissue, it affects the facial bones.7 Odontogenic myxoma is believed to originate from the dental papilla or follicular mesenchyme. The evidence for its odontogenic origin arises from its location in the tooth bearing areas of the jaws, its occasional association with missing or unerupted teeth and the presence of odontogenic epithelium.8Myxoma is a benign, mesenchymal-stemed, slowly prolif-erative, local aggressiveness and high rate of recurrence. Virchow coined this term in 1863, which was subsequently defined by him as “Schleimgesch-wulste” (myxomata) in 1871, because he thought of only soft tissue myxoma, as it happens with the umbilical cord, and had mucin. Myxomas may involve both hard and soft tissues.910 The present case reported here can be of unusual variant because, the patient’s history of 3 years duration of lesion, which might have started in early age and site of lesion also, i.e. maxillary posterior segment with involvement of antrum. OM clinically present as an asymptomatic lesion discovered during routine dental or radiological examinations in the initial stages of lesion or as a lesion associated with painless jaw expansion in later stages. Lesions with more advanced stages may be associated with pain, paresthesia, facial asymmetry, ulceration, teeth displacement and root resorption1112 our case showed only facial asymmetry and displacement of teeth. So, the clinical differential diagnosis should include ameloblas-toma, odontogenic keratocyst, radicular cyst, dentigerous cyst lateral periodontal cyst, intraosseous hemangioma, simple bone cyst, giant cell granuloma, aneurismal bone cyst and metastasis of malignant tumors which shows the slow growth pattern.13Odontogenic maxillary myxoma was first mentioned in the literature by Thoma and Goldman in 1947. OM usually affect adolescents and young adults, between the second and third decades of life, very rarely affects people below 10 years of age or above 50 years. With equal gender predilection, mandibular tooth bearing area is favored over the maxilla.14 Recent ultrastructural studies have showed that myxoma is a tumor of fibroblasts, modified in such a way to form a matrix composed of glycosaminoglycans and do not form collagen fibrils-designated as ‘myxoblasts’. Histological differential diagnosis should be made with rhabdomyosarcoma, myxoid liposarcoma, neurogenic sarcoma, neurofibroma, lipoma, fibroma, chondromyxoid and nodular faciitis.1510 Conventional radiography  and CT are useful in the detection of OM and also helpful to estimate the size, extent and margins of the tumor. Because of wide variation of radiographic presentation of OM, apart from most specific radiographic patterns, CT must be used to confirm conventional radiographic findings. Literature studies have described this tumor as both a unilocular or multilocular radiolucency and as having a distinct or diffuse margin.16 Barros in 1969, proposed two stages of radiologic patterns, first stage osteoporotic appearance, with more prominent medullary spaces separated by thin septa of bone. During this stage, the lesion acquires its classic radiographic appearance, consisting of multilocular radiolucency with well-developed locules, composed of trabeculae tending to intersect at right angles, forming locules straight, thin, elongated and lacy, Eversole called this as ‘Lichen planus of jaw bone’. It has varied radiographic presentations: Soap-bubble or honeycomb, spider web, tennis racket appearances. Other shapes include small or large triangles, diamonds, squares, rectangles, and X,Y and V figures. Second stage consists of the breakout or destructive phase consisting of loss of internal locules, significant expansion and perforation of the cortex with invasion into surrounding soft tissues. in maxilla there is extension into the antrum. Sometimes the peripheral margin of the septa may be arranged at right angles to the margin, giving a ‘hair brush’ or ’sun burst’ appearance.17 Due to its varied radiographic feature, the present case was misdiagnosed as fibroseous (fibrous dysplasia) lesion based on CT findings which led to delay in accurate treatment leading to vast anatomic destruction, leading to facial disfigurement. OM should be considered in the differential diagnosis of both radiolucent and mixed radiolucent-radiopaque lesions of both jaws in all age groups.1 Radiographic differential diagnosis of odontogenic Myxoma should include: Intraosseous heman-gioma, cherubism, aneurismal bony cyst, fibrous dysplasia, ameloblastoma, central giant cells lesion, traumatic bony cyst and odontogenic cysts .18 The current treatment for OM includes resection with bony margins of at least 1.0 to 1.5 cm and leaving behind one uninvolved anatomic boundary. Maxillectomy and sometimes resection of the orbital floor are required for OM in the upper jaw.19 Treatment for the present case was same. Enucleation, curettage and peripheral ostectomy are inadequate because of its gelatinous and nonencapsulated nature which makes the lesion to recur. Period of the greatest recurrence rate is seen in the first 2 years.20 Defects resulting from maxillary resection can be replaced by prosthetic obturator or tissue reconstruction procedures.21Macroscopically, the lesion appears to be a soft gelatinous yellowish grey mass which is often nonencapsulated. Cut surface of the lesion exhibits characteristic slimy appearance. Histopathologically, OM consists of triangular stellate cells with long processes intermeshing with each other. The intercellular matrix is mucoid, and the cytoplasm is slightly basophilic, finely granular and with a well-defined nucleus, mitotic figures are few. Cells may show pleomorphism. Bone may be rarely present with islands of inactive odontogenic epithelium.Due to varied radiographic presentation it makes difficult to diagnose lesion based on radiographic features alone. Proper diagnosis requires clinical, histological and radiographic correlation. Because of its high rate of recurrence, especially due to its gelatinous, nonencapsulated and mucous aspect, surgical treatment through bone resection is the most indicated treatment modality, and the patient must be followed up closely for years.


We report a case of a 56-year-old male under investigation for large lytic lesion at clivus. After lesion resection, patient was referred to abdominal computed tomography scan for metastasis screening. The lesion was posteriorly characterized as chondroid chordoma at histopathology examination.On non-enhanced computed tomography, multiple hypottenuating nodules of different sizes were seen; the largest nodule had 3.2cm. On post-contrast phases lesions had similar enhancement to adjacent liver parenchyma. However, no significant mass effect or invasiveness were seen, once vascular structures  crossed such nodules without dislocation or invasion. Our findings, although not pathognomonic, suggested the hypothesis of multifocal nodular steatosis.In order to confim the diagnosis, patient underwent a magnetic resonance imaging (MRI) that further characterized lipid within the lesions. On MRI this characteristic can be explored by chemical shift technique in which there is signal drop on out-of-phase sequence compared to in-phase sequence.,2 Nodular patterns are uncommon, and can be mistaken for metastasis, which is particularly problematic in oncologic patients. In our case, patient had a chordoma, a rare tumor that can present with metastasis in 3 to 48% of cases – and about one fifth of them are located in the liver. Fat deposits in liver parenchyma are frequent and have a prevalence of 15% in general population.,4-7Imaging findings such as lack of invasion or displacement of vascular structures, enhancement similar to normal liver parenchyma and stability over time corroborate the diagnosis. Magnetic resonance imaging is very helpful to confirm this diagnosis with signal drop on out-of-phase sequence compared to in-phase sequence, confirming intracellular lipid content.


Background. Angiofibroma is a benign tumor, consisting of fibrous tissue with varying degrees of vascularity, characterized by proliferation of stellate and spindle cells around the blood vessels. It most commonly arises from the nasopharynx, although it may rarely arise in extranasopharyngeal sites. Case Report. A 46-year-old male presented with left side nasal obstruction and epistaxis for one month. Clinical nasal examination revealed left sided polypoidal mass arising from the vestibular region of the lateral nasal wall. Results. CT scan and MRI showed highly vascular soft tissue mass occupying the anterior part of the left nostril. Preoperative selective embolization followed by transnasal excision was performed. Histopathological examination confirmed the diagnoses of nasal vestibular angiofibroma. Conclusion. Extranasopharyngeal angiofibroma is a very rare pathology. It should be kept in mind as a differential diagnosis with any unilateral nasal vestibular mass causing nasal obstruction and epistaxis. A biopsy without further investigation can cause life threatening bleeding in the patient. Angiofibroma is a benign tumor, consisting of fibrous tissue with varying degrees of vascularity, characterized by a proliferation of stellate and spindle cells around the blood vessels. It is originating from the pterygoid plate and the region of the sphenopalatine foramen. There are many theories trying to explain the pathology underlying this tumor, like genetic, hormonal, and developmental ones, but none of them had general acceptance. It has been hypothesized that angiofibroma is a testosterone-dependent tumor that arises from a fibrovascular nidus in the nasopharynx that lies dormant until the onset of puberty; hence the incidence is more in males with peak incidence between the ages of 14 and 18 years . It is t3/mm3, hemoglobin (Hb) level 12.5 g/100 mL, and platelets count (Plt) 278 × 103/mm3. Liver and kidney function tests were normal. CT scan of paranasal sinuses showed 3.4 × 2.5 × 1.9 cm mass localized to the anterior part of the left side of the nasal cavity with no extension to the choana or to the paranasal sinuses  was 8.8 × 10 Figures . MRI  are essential for evaluating the extension and vascularity of the lesion. However, signs of suspected hypervascularity, upon CT scan or MRI, indicate the need for angiography with selective embolization prior to any surgical intervention, to reduce the risk of bleeding during the surgery. The use of angiography and selective embolization should have a high threshold, that is, only if there is radiological evidence of diffuse, large, and hypervascular lesion, as these procedures come with their own complications. There are three cases of nasal vestibule angiofibroma previously reported in the literature with no preoperative embolization; all had different amount of intraoperative bleeding varying from minimal to profuse . PerhapsAlthough extranasopharyngeal angiofibroma is very rare diagnosis, it should be kept in mind as a differential diagnosis with any unilateral nasal vestibular mass causing nasal obstruction and epistaxis.CT scan and MRI are essential in the preoperative evaluation of a vestibular mass to assess for hypervascularity.The use of angiography and selective embolization should have a high threshold, that is, only if there is radiological evidence of diffuse, large, and hypervascular lesions which are predictive factors of intraoperative profuse bleeding.


Brunner's gland hamartoma, also called hyperplasia, adenoma, and Brunneroma, is an extremely rare benign proliferative lesion of Brunner's glands in the duodenum. While being mostly small and asymptomatic, they can result in gastrointestinal bleeding and obstruction. We report the case of a 54-year-old man presenting with melena and severe anemia requiring blood transfusion. CT scans showed a large mass of 8 cm in diameter, presumably arising in the duodenum. Endoscopic biopsies were not conclusive. As we were unable to determine the nature of the mass preoperatively and due to the severe symptoms, its size, and the uncertain malignant potential, a classic Whipple procedure was performed. The resected specimen showed extensive proliferation of Brunner's glands without signs of malignancy. Brunner's glands were first described in 1688 by Johann Brunner, a Swiss anatomist. Brunner's glands are localized in the submucosal layer of the duodenum, predominantly in the most proximal part, and decrease in prevalence in the second and third parts of the duodenum. Brunner's glands secrete an alkaline fluid that protects the epithelial lining of the duodenum from the acid chime of the stomach . BrunnerA 54-year-old Caucasian man presented with melena since four days. A single episode of melena had occurred a year before but had not warranted further investigation. Presently, the melena did not resolve and the patient started to develop symptoms of nausea, vomiting (no hematemesis), and lack of appetite. Moreover, the patient had an increasing sense of lightheadedness and fatigue. Four days after the start of these symptoms, the patient experienced severe fatigue and the continued sensation of near-fainting. The patient then contacted the hospital where he was admitted. Physical examination showed an anemic man in weakened condition, tachycardia (pulse 110 beats/minute), low normal blood pressure of 116/61 mmHg, and otherwise normal vital signs . Except confirmation of the melena during rectal examination, no further abnormalities were found during physical examination. Hematological investigations showed a severe normocytic anemia with 2.6 mmol/L hemoglobin . The patient received a total of 5 transfusions of erythrocyte concentrates, after which the hemoglobin level remained stable at 6.0 mmol/L. Computed tomography analysis showed a lobular mass of around 8 cm near the proximal duodenum. Ultrasound investigation showed a solid mass with smooth borders, partly vascularized. It was difficult to identify whether or not the mass originated from the intestine itself. Endoscopic investigation revealed a large swelling immediately distal to the pylorus, covered with apparently normal mucosa. It was not possible to see the entirety of the mass due to its size. An origin of the intestinal bleeding was not observed. However, during biopsies, the mass showed a quick inclination to bleed. Biopsies were not conclusive.During multidisciplinary discussion, it was decided that the most likely diagnosis was a gastrointestinal stromal cell tumor (GIST). Given the severe anemia, risk of acute bleeding, the tumor's size, and uncertain malignant potential, urgent surgical intervention was deemed necessary. The patient was then transferred to our hospital for further examination and presurgical workup for a possible Whipple procedure. The CT scan was repeated, which confirmed a large (8 cm diameter) hypervascular exophytic mass Figures  and 2. IAn uncomplicated classical Whipple procedure was performed. Gross macroscopic examination of the resection specimen showed an 8 × 4 × 8 cm submucosal polypoid tumor located in the proximal duodenum. A cut section showed a firm tan tumor with a small lobular pattern. The polypoid tumor was located 5 cm from the pancreas. Microscopically, the lesion showed marked proliferation of Brunner's glands, extending up towards the antrum of the stomach Figures . MoreoveSeveral days into the postoperative period, the intra-abdominal drain near the wound bed showed chylous fluid drainage. The patient was placed on a medium-chain triglyceride diet but was switched to total parenteral nutrition when his oral intake was determined to be insufficient. The abdominal drain was removed on day 13 after surgery. The patient's oral intake increased and the total parenteral nutrition was stopped. The patient was discharged on day 17. The patient recovered well and had no recurring symptoms the following year. To our knowledge, never before has a Brunner's gland hamartoma been described presenting with such severe anemia and this size, requiring blood transfusions and a Whipple procedure. A previously documented case of severe anemia due to Brunner's gland hamartoma was reported to present with similar symptoms of lightheadedness and melena and a hemoglobin level of 61 g/L (3.8 mmol/L). This case also required erythrocyte concentrate transfusions and as the size was relatively small (3 cm) a segmental duodenal resection was performed [The nomenclature surrounding this lesion has been a point of discussion over the years. The terms Brunner's gland hamartoma, Brunner's gland hyperplasia, Brunner's gland proliferative lesion, and Brunneroma have been used interchangeably. In general, they all refer to a benign hamartomatous proliferating lesion of Brunner's glands. Kim et al. distinguish between hyperplasia and hamartoma . They deThe prevalence of Brunner's gland hamartoma remains unclear since they are generally discovered incidentally and their rarity does not allow for definitive studies. Brunner's gland hamartomas usually present in the fifth or sixth decades of life and appear to have no gender or race preference. Benign lesions of the small intestine in themselves are a rarity and Brunner's gland hamartoma constitutes a small part of these lesions –3. BotsfMost often, at discovery, this type of lesion presents as a single pedunculated polyp reaching an average size of 1-2 cm. Extremely rare are the so-called giant Brunner's gland hamartomas, reportedly reaching sizes of around 10 cm , 6, 12.  Helicobacter pylori infection has been proposed to play a pathogenic role as several reports have observed their coexistence while others could find no significant correlation. The fact that H. pylori infection is so highly prevalent in the general population and Brunner's gland hamartomas are extremely rare also does not support this as the main pathogenic cause [The etiology and pathogenesis of Brunner's gland hamartoma remains unclear. Since Brunner's gland secretions are proposed to provide antiacid protection, it has been proposed that hyperacidic conditions could stimulate the formation of Brunner's gland hyperplasia. However, this seems unlikely since the use of antiacid inhibitors appears to have no effect on the lesions . Furtheric cause , 25, 26.ic cause . They foic cause . The foric cause . Our resic cause . Our patOur patient presented with melena and severe anemia, requiring blood transfusion. To our knowledge, a Brunneroma resulting in such a severe anemia has not been described before. After analysis showed a large mass in presumably the duodenum and we were unable to determine its nature with biopsies, a classic Whipple procedure was performed. The resected specimen showed a large Brunner's gland hamartoma of 8 × 4 × 8 cm. Histopathologic examination also showed ectopic gastric mucosa in the duodenum as well as gastric metaplasia, a sign of possible peptic duodenitis. While the etiology of Brunner's gland hamartoma remains unclear, damage to the duodenal mucosa has been suggested as a possible pathologic mechanism. In our patient's case, the presence of ectopic gastric mucosa most likely resulted in increased acidity and peptic duodenitis, causing duodenal mucosa damage that likely leads to the proliferation of Brunner's glands.


Dear Editor,A seven-year-old female patient with acute appendicitis underwent an emergencyappendectomy. During the procedure, as incidental findings, a bulky bladder and aprobable collection adhered to the wall were observed. Cystoscopy revealed an enlargedbladder with diffuse thickening of its walls. Subsequently, computed tomography of theabdomen showed a well-defined, hypointense collection, with cystic attenuation, withregular contours, showing no enhancement and in contact with the right lateral wall ofthe bladder . An inve. The clinicalsymptoms are non-specific and therefore do not facilitate the differential diagnosiswith other diseases of the bladder. The most common forms of presentation are irritativeurinary symptoms, a palpable mass in the abdomen, and hematuria-4. Among the cases published in the literature, that the mean age atonset is approximately 46 years, with no gender predominance, and the preferentiallocation is in the dome of the bladder,4,5. However, the case presented here was in a seven-year-old(pediatric) patient, in whom the lesion was located in the right lateral wall, thusruling out any association with the urachus.Xanthogranulomatous cystitis is a rare chronic inflammatory disease, only approximately30 cases having been documented in the literature. It has a benign course and its originremains obscure. However, previous reports have suggested possible associations with aremnant of the urachus, chronic infection, malignant bladder tumor, and immunedisorders-5.Xanthogranulomatous lesions can occur at sites other than the bladder, typically thekidneys or, less frequently, the gall bladder, pancreas, appendix, colon, ovary,endometrium, and brain, usually mimicking malignancy-4.In individuals with xanthogranulomatous cystitis, conservative treatment is noteffective. Such individuals require surgical resection by partial cystectomy, which iscurrently the gold standard treatment fore the diseaseXanthogranulomatous cystitis is an extremely rare disease and continues to be the subjectof many studies, because little is known about its true cause and behavior over the longterm. This case highlights the importance of recognizing an unusual lesion that canpresent in individuals of any age and can impede the final diagnosis.


Tumors arising in the spermatic cord are very rare. The common benign tumors of the spermatic cord include adenomatoid tumor, lipoma, neurofibroma, and leiomyoma. We report a rare case of fibrous pseudotumor of the spermatic cord presenting clinically as a hydrocele. A 28-year-old male presented with the complaint of swelling in the left scrotum, which gradually progressed in size over four years. Clinically, the swelling was soft and fluctuant. The left testis was not separately made out and a diagnosis of left hydrocele was made. On scrotal exploration, a large 12 x 7 cm fleshy mass was seen in the left hemiscrotum with the left testis adherent to the upper pole of the mass. The mass was dissected out from the testis, and the histology showed features of fibrous pseudotumor of the spermatic cord. Fibrous pseudotumor of the spermatic cord is a very rare entity and can pose a diagnostic challenge. Preoperative scrotal ultrasound and intraoperative frozen section assessment can prevent unnecessary orchiectomies in young patients with paratesticular fibrous pseudotumors. Paratesticular fibrous pseudotumors are rare lesions involving the testicular tunics and the paratesticular soft tissues. The etiology is not known, though they are thought to be a reactive condition following trauma or infection. They typically present as painless multinodular scrotal masses that are usually firm to hard in consistency. Clinically, they may mimic a malignancy, but they are composed of dense fibrous tissue with interspersed bland fibroblasts and myofibroblasts and mixed inflammatory cells. Herein, we describe a rare case of a diffuse fibrous pseudotumor that presented clinically as a soft, fluctuant scrotal swelling mimicking a hydrocele. This case report highlights the importance of clinical examination and preoperative ultrasonography in patients presenting clinically with a hydrocele, especially in high volume government hospitals in developing countries.A 28-year-old male presented to the surgery outpatient department with the complaint of swelling in the scrotum for a period of four years. The swelling gradually progressed in size over four years and was not associated with pain or fever. There was no history of prior surgery or trauma to the scrotum. On examination, a 12 x 7 cm non-tender swelling was noted in the left hemiscrotum, and it was soft and fluctuant. The left testis was not separately palpable and we could get above the swelling. The testis on the right side was normal. A diagnosis of left hydrocele was made, and a left-sided eversion of sac under local anesthesia was planned.On scrotal exploration under the spermatic cord block, a large 12 x 7 cm pink fleshy mass was seen in the left hemiscrotum with the left testis densely adherent to the upper pole of the mass  showed focal positivity Figure  and withBased on the histology and immunohistochemistry features, the tumor was reported as a fibrous pseudotumor of the spermatic cord.Paratesticular fibromatous lesions were recognized by Sir Astley Cooper in 1830. Numerous terminologies are used to describe this condition based on the variation in the gross and microscopic appearance, differences in the opinion on cell of origin, their location, and the benign or malignant nature of these lesions. The terminologies include chronic proliferative periorchitis, inflammatory pseudotumor, nodular and diffuse fibrous proliferation, proliferative funiculitis, fibromatous periorchitis, fibroma, benign fibrous paratesticular tumor, fibrous mesothelioma, and pseudofibromatous periorchitis [Paratesticular fibrous pseudotumors were first reported in detail by Balloch in 1904. Paratesticular tumors are very rare and fibrous pseudotumors constitute about 6% of these paratesticular tumors . These tThey usually present as a unilateral painless mass and are more common on the left side. The size ranges from 0.5 to 8 cm, though tumors as large as 25 cm have been reported .Grossly, the fibrous pseudotumors are well-circumscribed, firm, uniform gray-white or yellow lesions. Cystic changes, areas of necrosis, hemorrhage, and calcifications are rare. On microscopy, these lesions are characterized by the presence of myofibroblast and fibroblast spindle cells in a collagenous or myxoid matrix. A compact proliferation of spindle cells arranged in storiform or fascicular growth pattern are present in a few cases. Inflammatory infiltrate comprising of plasma cells, lymphocytes, and occasional eosinophils can be seen. Immunohistochemical staining is positive for vimentin, smooth muscle-specific actin, and common muscle actin and is negative for S-100, keratin, and desmin .Paratesticular fibrous pseudotumors may be associated with IgG4-related diseases like retroperitoneal fibrosis, sclerosing pancreatitis and cholangitis, Riedel thyroiditis, and sclerosing sialadenitis. An elevated level of intralesional IgG4-expressing plasma cells is seen in some of these tumors . HoweverScrotal ultrasonography is the initial investigation modality in patients with paratesticular tumors. Ultrasound differentiates between an intratesticular or extratesticular lesion and if the lesion is solid or cystic. Fibrous pseudotumors are usually uniformly hypoechoic but can be hyperechoic depending on the amount of collagen and the presence of calcification. Magnetic resonance imaging (MRI) can give additional information when an ultrasound is inconclusive and can provide better tissue characterization and tumor delineation. These lesions typically appear as low intensity lesions in T1 and T2 weighted images due of the presence of fibrosis . The disSurgical excision is the treatment of choice for paratesticular fibrous pseudotumors. Radical orchiectomy may be needed in cases where the lesion is diffuse and encasing the testis. Intraoperative frozen section biopsy can prevent orchiectomy in a young patient and is recommended when the testis is involved by the tumor . The proFibrous pseudotumors are a rare cause of scrotal swellings and they can mimic testicular tumors. Preoperative diagnosis is challenging and a high index of suspicion is needed especially in young patients with hard scrotal swellings. This patient presented with a soft fluctuant mass, which was probably due to the high fat content of the tumor in this case, the finding being termed pseudofluctuation. In developing countries where the surgery outpatient attendance is too high in government hospitals, scrotal ultrasound is not routinely done in a clinically diagnosed case of hydrocele. Preoperative scrotal ultrasound and intraoperative frozen section assessment can prevent unnecessary orchiectomies in young patients with paratesticular fibrous pseudotumors.


Detection of iatrogenic root perforation during post-space preparation especially in labiolingual plane can be challenging due to the two-dimensional nature of conventional radiography; this can be even more challenging if the cemented post is radiolucent. Cone-beam computed tomography (CBCT) scans were shown to be a valuable diagnostic aid in diagnosis of such cases. However, in this case, the application of CBCT did not help in diagnosis of a labial fiber post perforation in a maxillary central incisor which was finally detected through exploratory surgery. Root perforation refers to creation of an artificial and unwanted communication between the root canal system and the periodontal ligament (PDL); at the site of root perforation, an inflammatory reaction in PDL occurs and leads to the formation of a primary endodontic lesion . PerforaAccidental and unnoticed lateral root perforations during post-space preparation, show lateral bone defects on radiographies and cause formation of a sinus tract or periodontal pocket . OccasioHappening for any reason, this unwanted communication leads to destruction of the adjacent periodontal tissues . The surCalcium-enriched mixture (CEM) cement is a tooth-colored cement with clinical applications similar to MTA. It offers proper sealing ability, biocompatibility, antimicrobial properties, hard tissue induction properties and shorter setting time, greater flowability and lower film thickness than MTA -13.The pA young women in her early twenties was referred by a dentist, complaining of localized discomfort in the anterior maxillary vestibule subsequent to endodontic treatment and restoration of the left maxillary central incisor. Her medical history was noncontributory. Upon clinical assessment the buccal gingiva of the maxillary left central incisor had a sinus tract in the mid root area which according to the patient was occasionally formed after RCT. In the referral letter, the dentist had mentioned RCT was indicated after detection of pulp necrosis of the incisor which had a class three cavity. The tooth was not sensitive to percussion. A parallel periapical radiography was taken that indicated perfect RCT and restoration . Due to As the CBCT findings were not suggestive of the lesion origin , exploraInterestingly, after curettage of the granular tissue surrounding the fenestration, a fiber-reinforced lucent prefabricated post became visible that had perforated the root and bone just under the gingival soft tissues . That seThe present report reviewed successful surgical management of a mid-root perforation during post space preparation in an upper left central incisor that was left undetected by the dentist. The post lucency prevented its emergence in radiographies and contrary to our perception, CBCT was not much helpful in detection of the lesion origin. Thus, exploratory surgery was indicated which uncovered the cause of patient’s problem; labial mid-root perforation during post space preparation where the radiolucent fiber post was cemented. The perforation site was prepared/sealed using CEM cement. After one year, the tooth was symptomless and functional.et al. observed that more than half of the perforations in their cases of root perforation occurred during post-preparation procedures [Root perforation often happens iatrogenically as a result of misaligned application of burs during endodontic access preparation and search for root canal orifices, and during efforts to negotiate calcified and curved canals , 4. Inapocedures . In some cases of endodontic practice, conventional intraoral radiography does not provide adequate information on pathologic conditions and positional relationships. Three-dimensional images have become possible with introduction of CBCT technology to dentistry. The imaged area can be arbitrarily sliced and observed from three different directions . Althouget al. [Many important factors that are all related to infection control at the perforation site, influence the survival prognosis of the tooth , 20: theet al.  perforatCEM cement has been recommended as an appropriate endodontic biomaterial for repair of lateral root perforations , 9, 11. In conclusion, the present case report showed that a surgical approach may be effective for treating a combined endodontic-periodontal lesion originating from a root perforation in the middle third of a maxillary central incisor with a cement lucent post, which was treated with a surgical approach using CEM cement. The presented case demonstrates that CBCT imaging technology is not always useful in detection of lesions that are not clinically and radiographically diagnosable. Endodontic surgical flaps for diagnostic purposes and management of complex endodontic problems cannot be overlooked.


Medulloblastoma is a malignant brain tumor that is typically seen in children. It is classified as an embryonal tumor, classically located within the posterior fossa. When it involves the fourth ventricle, the patient commonly presents with signs and symptoms of raised intracranial pressure secondary to obstructive hydrocephalus. It is exceedingly rare for Medulloblastoma to occur in middle and late adulthood. In this paper, we present a case of a 51-year-old man who presented with a posterior fossa mass that was diagnosed later as Medulloblastoma. Medulloblastoma is a malignant brain tumor (WHO grade IV) that is thought to arise from stem cells located in the subependymal matrix or the external granular layer (EGL) of the cerebellum . It typiA 51-year-old male, known case of DM type II on insulin therapy, presented with history of repeated vomiting associated with progressive gait imbalance over one-month period.Neurological examination was normal apart from positive Romberg sign and ataxic gait. General physical examination and review of systems were essentially unremarkable.The initial laboratory and radiological work-up were not helpful. Brain CT scan at the emergency department showed abnormality of the 4th ventricle with a suspicious right middle cerebellar peduncle mass that warranted further assessment by MRI. An additional metastatic work-up to find a primary malignancy source was also negative.Brain MRI before and after contrast Figures  revealedThe histological features seen in our case did not show the classical architectural pattern of Medulloblastoma. On the contrary, there were angiocentric arrangement and peculiar perivascular accentuation  commonlyβ-catenin, and Filamin A are reliable tools in subclassifying Medulloblastoma. β-catenin (nuclear pattern), YAP1, and Filamin A immunoreactivity characterize the WNT subtype, while GAB1 immunoreactivity indicates an SHH subtype. The non-SHH/non-WNT subgroup only shows cytoplasmic β-catenin staining while the remaining markers are nonimmunoreactive. In our case the tumor showed cytoplasmic β-catenin without nuclear immunoreactivity and GAB1 positivity. It was negative for YAP1. These results were compatible with a SHH molecular subtype. P53 immunohistochemical antibodies were our method to assess P53 mutation; the neoplastic cells were nonimmunoreactive, indicating that this tumor is TP53 wild type.Immunohistochemical studies showed focal GFAP positivity, diffuse weak positive staining for synaptophysin, and strong positivity for INI-1 and CD56. NSE and neurofilament protein immunohistochemical markers showed strong cytoplasmic staining in the majority of the tumor cells. Retinal S antigen was not available in our laboratory to perform. We did other immunohistochemical stains such as LCA (CD45) which was negative excluding the diagnosis of lymphoma. Pancytokeratin stain was nonimmunoreactive excluding a metastatic carcinoma. Immunohistochemical surrogate markers such as GAB1, YAP1, The clinical stage of the disease and the status of the patient precluded any further surgical intervention. The patient then received a combination of chemotherapy and radiotherapy. Vincristine was the choice of chemotherapy, while radiotherapy with 15 fractions and total dose of 27 Gy was also given. The patient, however, continued to deteriorate and eventually passed away 2 months later.Medulloblastoma (WHO grade IV) is the second most common brain tumor in children after pilocytic astrocytoma . AlthougCurrently, the WHO tumor classification recognizes four distinct histological subtypes . Furthermore, the new WHO tumor classification 2016 has classified Medulloblastoma according to its molecular properties. Four subgroups are now identified, the Wingless (WNT), Sonic Hedgehog (SHH), group 3, and group 4 , 8.Several case reports have been published of patients diagnosed with Medulloblastoma in middle-to-late adulthood. Cervoni and colleagues reported two cases of Medulloblastoma aged 71 and 67 with one of them surviving up to 42 months after surgical resection and radiotherapy with no evidence of recurrence . The oldDissemination of Medulloblastoma within CSF pathways is a defining pathobiologic characteristic of this tumor; when present it signifies a decimal prognosis. Treatment options include complete total surgical resection plus craniospinal irradiation. Chemotherapy is another treatment modality, though its effectiveness in the management of Medulloblastoma is still controversial. Subtotal surgical resection and evidence of disease dissemination are considered poor prognostic factors . Five-yeIn conclusion, although Medulloblastoma is a pediatric tumor and far less common than metastasis or lymphoma in a posterior fossa mass in an adult, it should be considered in the differential diagnoses.


Cutaneous angioleiomyomas (ALMs)  are unusual benign tumors of the skin deriving from the muscle layer of dermal blood vessels. They usually manifest as tender subcutaneous nodules, mostly encountered on the legs of adult women in their fifth or sixth life decade. ALMs rarely develop on the head/neck area, and even more rarely  on the auricle. Head/neck (including ear) ALMs differ from their more usual leg counterparts in that they are usually painless and do not show a female predominance. The diagnosis is clinically difficult, and most cases are diagnosed by histopathologic examination. A new case of an auricular ALM in a 40-year-old Caucasian man is reported herein, and a brief literature review on this unusual tumor is presented. Cutaneous angioleiomyomas (ALMs) are a subset of leiomyomas, that is, benign tumors originating from smooth muscle cells present in the skin. ALMs  derive from the muscle layer of dermal blood vessels. They manifest typically as solitary, deep dermal, or subcutaneous flesh-colored, well-circumscribed nodules usually located on the lower legs of adult women . They maA 40-year-old man of North African descent noted the progressive development, since one year, of a nodule on the rim of the helix of his right ear. The lesion had developed spontaneously and was asymptomatic, but its size was somewhat fluctuating according to the patient. Physical examination showed a ca. 1 cm firm nodule of the posterior aspect of the ear with a slightly bluish hue. The patient was otherwise in good condition, and his family history was unremarkable. The lesion was excised under local anesthesia and submitted for pathological examination, with the probable clinical diagnoses of follicular cyst or angioma. Microscopic examination showed a roundish, well-demarcated nodular tumor invading the mid- and deep-dermis, sparing the underlying ear cartilage Figures . It was Cutaneous ALMs are uncommon tumors. A review of the files of our dermatopathology laboratory revealed 36 cases diagnosed during 16 years 1999–2015). In this series, the mean age of patients was 59 years , and there was a clear female predominance (77.8%). The location of ALMs (mentioned in 35/36 cases) was on the lower limbs (57%), including the leg/shin (34%), the ankle/heel/foot (23%), the knee (14%), and the thigh (2.85%). The remaining cases were located on the forearm and elbow (23%), the palm (2.85%), and the ears . These data are in agreement with those of the literature, namely, a large study of 562 cases [015. In tThe clinical appearance of ALMs of the ears is not very specific. The lesion manifests in adults as a single nodular growth with occasionally a bluish red hue that may fluctuate in size, as in our patient. Auricular ALMs may be located on the helix , 15, theAlthough ALMs only rarely develop on the ear, they should be included in the clinical differential diagnosis of tumors developing in this anatomic zone. The definite diagnosis requires histopathological examination of a biopsy (or excision) specimen.


A para1 woman aged 27 years presented with a 5-month history of heaviness and abdominal distension. The distension had gradually increased over time. There was no history of fever or weight loss. Bowel and urinary habits were normal. Her menstrual cycles were regular. She underwent a cesarean delivery 1 year previously. Intraoperative notes showed an 11x9x8-cm fundal fibroid, her ovaries were normal. The cesarean section was uneventful and myomectomy was not attempted at that time. The post-operative period was uneventful.3, and markers for ovarian tumor such as Ca-125 were negative. The MRI films are shown in When she visited our outpatient department, she was carrying ultrasonography (USG) and magnetic resonance imaging (MRI) reports, which were suggestive of a dermoid cyst or mucinous ovarian tumor. Her hemoglobin was 9.3 gm/dL, the total leukocyte count (TLC) was 6000 cells/mmOn general physical examination, the patient was maintaining good health. Her vitals were stable. In her abdominal examination, a healed cesarean Pfannenstiel scar was seen, there was a cystic mass filling the whole abdomen, the lower limit could not be reached, and mobility was restricted. The abdomen was not tender. In the vaginal examination, the uterus was bulky and the same mass was felt through the anterior fornix.The plan was unilateral ovariotomy and staging if the mass appeared malignant because imaging showed tumor confined to one ovary and the patient was P1L1. The possibility of malignancy and the treatment plan of optimal cytoreduction in the event of extra-ovarian disease was explained to the patient and husband prior to surgery. On opening the abdomen, a thick-walled cyst extending up to xiphisternum was encountered. There were flimsy adhesions with the omentum. The content of the cyst (pus) was aspirated with a 21-gauge needle. A stab incision was made and 5 liters of pus was drained. The incision was increased and a whole sponge was found and removed from inside . FurtherRetrospectively, when we took the history again, the patient recalled that she had fever during the post-cesarean period, which settled after a course of antibiotics. Reviewing the MRI images, the strand-like structure was actually the sponge in the abscess. Probably a simpler investigation such as X-ray of the abdomen would have picked up the diagnosis. We did not suspect a retained surgical item because the patient did not initially report a history of fever in the postoperative period.Retained surgical items (RSI) are a preventable cause of patient morbidity and sometimes mortality. It is included in the 27 “never events” released by the National Quality Forum in the United States of America . In a sySponges are the most common RSI 68%) . Retaine8% . RetaIn a series of 8 cases by Chopra et al. , five paPalpable masses in the abdomen/pelvis may be confused with soft tissue tumors based in that location . PatientOften misdiagnosed preoperatively, a high index of suspicion and imaging studies can help in making the diagnosis. Abdominal X-ray is the first-line investigation and CT is the confirmatory imaging test. MRI has no diagnostic use in such cases because the radiopaque marker is neither magnetic nor paramagnetic, hence not visible on MRI .The usual treatment of an RSI is surgical removal through an open or laparoscopic approach .To emphasize, prevention is always better than cure. To decrease the incidence of RSI, a few new technologies have been developed such as radio-frequency chip identification by barcode scanner , compute


The solitary fibrous tumors (SFT) are rare tumors in the head and neck region and there have been only 5 cases reported in the literature in the soft palate. The current paper presents a unique case of a 62-year-old male with TFS arising in the soft palate. The tumor was highly cellular, composed of bland looking haphazardly arranged spindle cells. The signal transducer and activator of transcription (STAT)-6 and nuclear β-catenin were reactive by immunohistochemistry (IHC). The current case highlights the importance of the STAT-6 and the β-catenin as IHC markers to make a differential diagnosis with other entities. In summary, the paper presents the first reported case of a SFT of the soft palate in a male patient with nuclear expression of STAT-6 and β-catenin. Originally described in the pleural cavity 1931 by Klemperer and Rabin as a spindle cell neoplasia, solitary fibrous tumor (SFT) is an uncommon, CD34 positive fibroblastic neoplasia described in virtually any anatomic location . To the A 62-year-old male, presented with a 2-year history of dysphonia, nasal voice, and dyspnea. No history of prior surgery or trauma affecting the region was reported. On physical examination, a painless, mobile, non-ulcerated mass was detected in the soft palate that was excised. Macroscopically, the tumor weighed 9.1 g, was ovoid and well demarcated, and measured 3.2x3x2.4 cm. The outer surface was smooth and showed a focal linear pedicle with 2.7 cm in length.. Positive immunoreactivity was demonstrated in the tumor cells for CD34, Bcl-2, factor XIIIa, cytoplasmic CD99, focal reactivity for epithelial membrane antigen (EMA), and strong signal transducer and activator of transcription (STAT)-6 and β-catenin nuclear staining pattern. Ki 67 index was 5%. The neoplastic cells were uniformly negative for D240, S-100 protein, cytokeratin AE1-AE3, actin (HHF35), transducin-like enhancer protein (TLE)-1, and activin receptor-like kinase (ALK)-1. Based on the histological and immunohistochemical findings, a diagnosis of solitary fibrous tumor was rendered  was performed  signaling pathway. Mutation in the proteins involved with WNT signaling and β-catenin lead to the expression persistence of the protein, which promotes the translocation to the nucleus, activating genes associated with cell proliferation, and inhibition of apoptosis .7. The pleural SFT presents a higher index (10%-20%) of malignancy; however, most of the extrapleural tumors are benign and cured by resection. When the metastasis occurs, it appears in the lung, bone, and liver. Although clinical follow-up of patients with oral SFT is limited, to date all of the intraoral tumors are treated by complete local excision and no additional treatment is necessary for any of the patients . Recurrence or metastasis develops in 5% -10% of patientsndex 10%-0% of malThe elected treatment is surgery resection, with no adjuvant therapy, on head and neck tumors; the recurrence is rarely reported .In summary, the current paper presented the first reported case of a SFT of the soft palate in a male patient with nuclear expression of STAT-6 and β-catenin.


Presented herein is a case of mediastinal mature teratoma with adenocarcinomatous transformation predominantly composed of mucinous adenocarcinoma in a 25-year-old man. Disease progressed despite application of surgical removal, adjuvant radio- and chemotherapy. Further immunohistochemical stains indicated a gastrointestinal origin of the tumor. Consequently chemotherapy according to the FOLFIRI regimen was applied that resulted in good response. To our knowledge, this is the first report of a clinical remission from chemotherapy with the FOLFIRI regimen after comprehensive initial treatment with surgery, radio- and chemotherapy for a patient with teratoma with malignant transformation, highlighting the importance of choosing an appropriate chemotherapy regimen. Germ cell tumors (GCTs) account for approximately 15% of mediastinal tumors in adults . OccasioA previously healthy 25-year-old Chinese man presented to local hospital with complaint of gradually progressive heaviness of chest for three months. There were no associated signs of superior vena cava syndrome, no lymphadenopathy, and no abnormalities on genital examination. His routine hemogram, urine and blood biochemical analyses were within normal ranges. Contrast-enhanced computed tomography (CT) scan Figure  of the cOn September 24, 2014, a median sternotomy was performed for complete resection of the mediastinal mass, including a portion of inferior lobe of right lung and thymus. Macroscopically, the mediastinal tumor measured 8 × 6 × 5 cm. On section, it revealed a large multilocular cystic tumor containing brown fluid and sebaceous debris. The cyst lining was thickened with a yellow, gritty surface. From part of the cyst wall, a few grayish-yellow nodular areas were noted, the largest of which measured 2 × 1.5 cm. The cyst did not contain hairs or osteocartilaginous structures and was relatively well demarcated. Microscopically, the tumor contained a mature cystic teratoma component with extensive necroses and regressive calcifications. The cyst wall consisted of keratinizing squamous epithelium and sebaceous glands of ectodermal origin Figure , and end2) and radiotherapy . Even so, he exhibited peritoneal effusion with multiple peritoneal and mesenteric metastasis nodules on contrast-enhanced abdomen CT scan  was applied. After a total of 8 cycles of that regimen, the patient achieved clinical response and radiologically stable disease  matched with the specific mutation of stomach cancer, colon cancer, lung adenocarcinoma, esophageal cancer and leiomyoma Table , which hIn conclusion, thorough postoperative pathological examinations of TMT are crucial for tailoring subsequent treatment. Presently, complete resection in conjunction with histologically adapted chemotherapy seems to be suitable and targeted therapy may emerge as an alternative approach.


This case study describes a young man with symptoms suggestive of the presence of a space-occupying lesion within the cranial cavity. Imaging studies confirmed a lesion in the suprasellar region and surgical intervention to remove the tumor yielded an unexpected diagnosis. Neuroimaging characteristics and histopathology including immunohistochemistry are described. Gangliogliomas are uncommon CNS neoplasms and are most commonly found in the temporal and frontal lobes of young, male adults. They are rarely seen in the suprasellar region and only a handful of cases have been reported to date. The differential diagnoses associated with these suprasellar region lesions can be dependent on the age of the patient and neuroimaging characteristics. The present report highlights the importance of histopathological examination and the need to consider a wide range of diagnostic entities in the differential diagnosis of lesions in this topographic distribution, including rarely encountered tumors such as gangliogliomas. He was confused and combative. CT head without contrast at an outside facility was reported as hydrocephalous with possible aqueduct stenosis. He was intubated for airway protection. He was transferred to this medical center for higher level of care. On arrival, he was sedated, pupils 2 mm sluggishly reactive to light, and oculocephalic, corneal, cough, and gag reflex were present. He withdrew each extremity on application of pain stimulus. Deep tendon reflexes were recorded as 2+. At admission axial CT of the head without contrast demonstrated an extra axial mass at the level of the suprasellar cistern, with mixed cystic and solid components and some peripheral calcification (black arrows) .An emergent external ventricular drain was placed for CSF diversion and the patient was admitted to Neuro-ICU. Axial T2 weighted MR image showed the extra axial mass within the suprasellar cistern with internal cysts and solid components that are near isointense to gray matter . MR imagDuring the patient's ICU admission, endocrinology was consulted to evaluate pituitary function. Prolactin, cortisol, LH, FSH, and IGF-1 levels were normal, while testosterone levels were decreased (35 ng/dl). ACTH stimulation test was performed and reported as normal. On day 4 of hospitalization, he underwent a right pterional craniotomy with image guidance for resection of tumor. The tumor was only partially resected primarily due to its adherence to optic tracts and the internal carotid artery. Postoperatively he was treated for aspiration pneumonia and subsequently extubated on postoperative day 5. At this point his headache had improved significantly and neurological exam revealed a partial right 3rd cranial nerve palsy and bilateral papilledema. The extraventricular drain was removed on postoperative day 10 and the patient was discharged home on day 14.Microscopic sections revealed a tumor that had a predominantly glial background. There was a well-defined fibrillary glial proliferation, with occasional fragments of Rosenthal fibers similar to that seen in a pilocytic astrocytoma . MultiplGangliogliomas are defined in the WHO Classification of Tumors of the Central Nervous System as “a well-differentiated, slow growing, glioneuronal neoplasm composed of dysplastic ganglion cells  in combination with neoplastic glial cells” . These tGangliogliomas are most commonly found in the temporal and frontal lobes of young, male adults . Their pCT scan imaging of gangliogliomas has been reported to show a hypodense lesion with calcifications, and these lesions may enhance with contrast in fewer than 40% of patients . Some caThe histopathology of gangliogliomas is typically quite characteristic and is usually easily distinguishable from other diagnostic considerations. The unusual location of this tumor notwithstanding, the pathologic diagnosis was readily apparent. The presence of a diffuse neoplastic fibrillary glial background with eosinophilic granular bodies, combined with dysplastic ganglion cells, is quite characteristic. Binucleate neurons, often arranged in clusters with apparent disregard for normal configuration, are confirmatory. Additionally, immunohistochemistry for GFAP defined the glial component. Multiple dysplastic neurons immunoexpressed CD34: this marker is not expressed in normal neurons but is frequently seen in abnormal neurons in gangliogliomas .The overall characteristics of gangliogliomas suggest that they are often well defined, which makes complete surgical excision a promising possibility for treatment with good prognosis , 10. HowIn summary this report presents a rare case of suprasellar ganglioglioma in a young male. The vast majority of gangliogliomas are found in the temporal and frontal lobes with only a few reports of occurrence in the suprasellar region. The differential diagnosis of lesions encountered in this region often does not include these tumors by either radiology or pathology. Increased awareness of the possibility of this rare lesion in a highly uncommon location is therefore important in the management of these tumors.


Metastatic cardiac tumors are far more common than primary tumors. Although the hematogenous spread of osteosarcoma is well known, the imaging findings of cardiovascular involvement by osteosarcoma are seldom reported and can be difficult to recognize.A 21-year-old man of African descent presented to our center complaining of shortness of breath, awareness of heart beats, easy fatigability, swelling of lower limbs, and left-side chest discomfort for the past 6 months getting worse for the last 3 months prior to his third readmission. In 2004 he was admitted with the diagnosis of osteosarcoma of his left calcaneus bone confirmed by bone biopsy and treated at an oncology center with several cycles of radiotherapy and chemotherapy; he was declared cured after 5 years of annual clinical and radiological skeletal survey follow-ups. In the current admission, a physical examination revealed bilateral lower limb swelling, pansystolic murmur on the left side of his sternum at fourth intercostal space (tricuspid area) grade three, hepatomegaly with a liver span of 17 cm, and a positive fluid test and shifting dullness.This case report presents a 21-year-old man with relapsed osteosarcoma manifesting as metastatic lesions to his right ventricle encroaching on his interventricular septum, which was identified by transthoracic/transesophageal echocardiography computed tomography scan and cardiac magnetic resonance imaging. Although hematogenous spread of osteosarcoma is well known, the imaging findings of cardiovascular involvement by osteosarcoma are seldom reported and can be difficult to recognize. The enhanced resolution of modern computed tomography (CT) and magnetic resonance imaging (MRI) scanners may lead to better detection of cardiovascular involvement .The antemortem diagnosis of cardiac metastases in osteogenic sarcoma has been rarely documented whereas a prevalence as high as 20% is seen at autopsy, suggesting that cardiac involvement is a late stage complication. As the survival times for primary osteosarcoma continue to improve, late stage complications will undoubtedly become more prevalent in the future .A 21-year-old man of African descent presented to our center complaining of shortness of breath, awareness of heart beats, easy fatigability, swelling of lower limbs, and left-side chest discomfort for the past 6 months getting worse the last 3 months prior to this third readmission. Such symptoms started gradually from 2015, approximately 6 years after he had received a declaration that his osteosarcoma had been cured. In 2004 he was admitted with the diagnosis of osteosarcoma of his left calcaneus bone, confirmed by bone biopsy, and treated at an oncology center with several cycles of radiotherapy and chemotherapy; he was declared cured after 5 years of annual clinical and radiological skeletal survey follow-ups. In the current admission, a physical examination revealed bilateral lower limb swelling, pansystolic murmur on the left side of his sternum at fourth intercostal space (tricuspid area) grade three, hepatomegaly with a liver span of 17 cm, and a positive fluid test and shifting dullness. Biochemical investigations noted elevated levels of brain natriuretic peptide. An electrocardiogram demonstrated an abnormal analysis. A chest X-ray showed cardiomegaly with increased interstitial pulmonary markings and pleural effusion  class III heart failure which he presented on admission. He was discharged on 15 December 2016 in a fair condition with NYHA class II and booked in a follow-up clinic by the time of drafting this manuscript.Noncardiac tumors may invade the heart by means of lymphatic or hematogenous dissemination, local extension, or a transvenous route. However, catheter-based biopsy is not suitable for cardiac tumors. Therefore, it is extremely important to accurately determine the nature of the cardiac mass before considering surgical options . Our pat18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT which could have revealed the morphological features of the cardiac tumor and glucose uptake; these could have been significant indicators of tumor malignancy and the whole body metastasizes [A limitation is that our center does not perform stasizes . MetastaThis report presents a 21-year-old man with relapsed osteosarcoma manifesting as metastatic lesions to his RV encroaching on his interventricular septum, which was identified by transthoracic/transesophageal echocardiography CT scan and cardiac MRI.


Incidentally discovered adrenal masses are very common given the increased number of imaging studies performed in recent years. We here report a clinical case of a 20-year-old woman who presented with left flank pain. Ultrasound examination revealed a contralateral adrenal mass, which was confirmed at computed tomography (CT) scan. Hormonal hypersecretion was excluded. Given the size (11 × 10 × 7 cm) and the uncertain nature of the mass, it was surgically removed and sent for pathological analyses. Conclusive diagnosis was ganglioneuroblastoma. Ganglioneuroblastoma is an uncommon malignant tumor, extremely rare in adults, particularly in females. This neoplasm is frequently localized in adrenal gland. One of the most common unexpected findings revealed by imaging studies is an adrenal mass, called incidentaloma, which occurs in about 2–4% of the radiological studies performed for other reasons . The preGanglioneuroblastoma (GNB) represents a rare cause of adrenal tumor in adults. Preoperative suspicion is challenging and the final diagnosis is often made by the pathologist after surgical removal.A 20-year-old Caucasian woman was admitted through the Emergency Department for right flank pain. Abdominal ultrasound examination was performed and a contralateral adrenal mass was incidentally found. Subsequently, the patient underwent computed tomography (CT) to confirm the finding. The mass in left adrenal lodge was solid and measured 11 × 10 × 7 cm, showing heterogeneous density (varying 17–40 HU) and calcifications . DynamicThe patient was addressed to the Endocrine Unit for biochemical evaluation of the adrenal mass.2), blood pressure was 110/70 mmHg, pulse rate 64 beats/min, and SpO2 99% (room air). There was no family history of relevant morbidities. She was active smoker and suffered from patent foramen ovale of the heart and focal nodular hyperplasia of the liver.She was in good clinical conditions and the complete physical examination was negative; in particular, no Cushing stigmata or hirsutism was present. Her height was 153 cm, weight 48.5 kg , aldosterone 457.2 pg/ml (37–150), renin 1.5 ng/ml/h (1.0–2.4), aldosterone-renin ratio 30.48, basal cortisol, and 17-OH-progesterone were normal both in basal condition and after stimulation with ACTH 250 mcg. Regrettably the patient was on contraceptive estroprogestinic therapy at the time of hormonal evaluation.Considering the size and the undetermined radiological features, the adrenal mass met the criteria for surgical removal according the most recent international guidelines .The patient was admitted to the Department of Urology where she underwent transabdominal adrenalectomy. The adrenal mass incorporated the renal hilum, aorta, and superior mesenteric arteria; therefore intraoperative decision to perform additional left nephrectomy was taken. There were no complications after surgery.The surgical sample sent for pathological examination included left kidney, left adrenal gland, and two lymph nodes (celiac and paraaortic). The tumor grossly was grey and multilobulated, replaced the entire adrenal gland, measured 11 × 10 × 7 cm, weighed 195 g, and incorporated arterial and venous vessels of renal hilum and sparing renal parenchyma. The histological report described a spindle cell stroma in a fibrillary matrix interspersed with scattered nests of primitive neuroblasts and high proportion of differentiating elements (ganglion cells) , placingIncidentally discovered adrenal masses are becoming more common with the imaging technological advances and the increased number of imaging studies performed. Nowadays the prevalence of adrenal incidentalomas in radiological studies has come close to the autoptic data: approximately 2–4% in adult age, increasing up to 10% in elderly population. Their differential diagnosis must consider a wide range of pathologies . The prePeripheral neuroblastic tumors (PNTs) are a group of tumors arising from sympathetic ganglion cells. In two-thirds of the cases, PNTs arise in the adrenal gland or the retroperitoneal paravertebral ganglia. PNTs represent one of the most frequent solid tumors in children, while the occurrence in adults is very rare. Overall survival in infants is very high 91%) and progressively declines parallel to the increased age at diagnosis. In a study performed on RARECAREnet and involving very few cases, 5-year survival was reported to be 48% in adolescents (15–24 years) and 40% in adults 25–64 years) , 1312, 1No long-term data in adults have been reported due to the small series of patients.There is no evidence about the most appropriate follow-up for adrenal GNB in adults.


Streptococcus constellatus is a microorganism that lives commensally in the oropharyngeal region, urogenital region, and intestinal tract. However, it can cause infection in patients with certain predisposing factors. Rarely, this microorganism can cause a brain abscess. Thalamic localization of brain abscesses is much rarer than abscesses in other locations of the brain. Brain abscess caused by streptococcus constellatus are very rarely been reported in the literature. We present a rare case of a left-sided thalamic abscess caused by streptococcus constellatus in a 25-year-old male patient who was injured by shrapnel pieces in the head and who was malnourished. The patient was successfully treated by stereotactic aspiration and antibiotherapy. Streptococcus constellatus is a member of the Streptococcus family and is part of the normal flora of the oral cavity, urogenital region, and intestinal tract. It can cause purulent infections in patients with cirrhosis, diabetes, malignancy, malnourishment, or conditions that cause immunosuppression [streptococcus constellatus are reported very rarely in the literature [streptococcus constellatus. We present a rare case of a left-sided thalamic abscess that was caused by streptococcus constellatus in a 25-year-old malnourished male patient who was wounded in the head by shrapnel. The patient was successfully treated with stereotactic aspiration and antibiotherapy.pression . Brain aterature , 3. Thalterature , 5. In tstreptococcus constellatus. The s. constellatus was susceptible to meropenem and vancomycin, and appropriate antibiotherapy was started. By the end of the second postoperative week, all symptoms had resolved. Follow-up cranial MRI after 12 weeks of the intravenous antibiotic regimen showed normalization of abnormal lesions and disappearance of the remaining brain abscess  revealed small shrapnel pieces in left frontal bone. Gadolinium-enhanced magnetic resonance imaging (MRI) of the cranium showed a mass lesion measuring 24 x 26 x 22 mm in the region of the left thalamus. There was marked ring enhancement, perilesional edema, and a slightly deviated third ventricle, but no enlargement of the ventricular system . A CT-gu abscess .Thalamic localization of brain abscesses is uncommon . In moststreptococcus constellatus is a member of the normal flora of the mouth, gastrointestinal tract, and genitourinary tract and is often associated with purulent infections. Brain abscess caused by streptococcus constellatus is very rare [streptococcus constellatus abscess, there was either underlying pathology or a history of immunosuppression [streptococcus constellatus. In our case, there is a history of malnutrition and a shrapnel wound in the same side of the head as the thalamic abscess. The history of malnutrition and malnutrition-related immunosuppression was the probable underlying condition related to this cerebral abscess; however, we are not sure about the relationship between the shrapnel wound and the thalamic abscess on the same side of the head because the shrapnel pieces were located subcutaneously over the frontal bone and did not enter either the bone or the brain parenchyma.ery rare , 3, 6, 7pression , 3, 6, 7The best surgical management of thalamic abscesses remains controversial. One of the important goals of thalamic abscess surgery is to prevent intraventricular rupture of the abscess in the operation. Treatment options include stereotactic aspiration, free-hand aspiration through a burr hole, stereo-endoscopic aspiration, ultrasound-guided aspiration, surgical transventricular approach, and medical management , 7, 8. SThalamic abscesses are much rarer than abscesses in other locations of the brain. In the literature, there is no single thalamic abscess caused by Streptococcus constellatus. It may be taken into consideration and is critical that pyhsicians include this condition in differential diagnosis.


Adult extrarenal nephroblastoma is a very rare tumor. Nephroblastoma arising from primary testicular germ cell tumor is exceedingly rare. To our knowledge, only three cases have been reported in the English literature. We report a case of a 19-year-old man who presented with a large right testicle. Image studies showed a large retroperitoneal mass along with liver and lung metastases. Orchiectomy demonstrated a mixed germ cell tumor composed of yolk sac tumor, embryonal carcinoma, and mature and immature teratoma with a significant portion of nephroblastoma. The patient received chemotherapy and no recurrence was noted during six months of followup. WT-1 expression was also studied due to the lack of consistency of its expression in testicular nephroblastoma in the literature. We also present a discussion and review of the literature due to its rarity, which indicate an adverse prognosis for patients with nephroblastoma components receiving standard chemotherapeutical regimes for testicular germ cell tumors. Although nephroblastoma is the most common primary renal malignant tumor in children, its occurrence at extrarenal sites in adults is very rare. The reported extrarenal locations included retroperitoneal, iliac, pelvic, and inguinal regions –4. ThereA 19-year-old, otherwise healthy male presented to the Emergency Department due to a syncopal episode. He was noted to have a recent history of lethargy and profound weight loss. Physical examination revealed a nontender, mobile firm right testicular mass. The patient confirmed a 5-month history of an enlarged swollen right scrotum. Pelvic computed tomography (CT) showed a 9 cm heterogeneous mass in the right testis . AbdominWith the clinical impression of a testicular neoplasm, the patient was taken to the operating room for a right radical orchiectomy. Gross examination of the orchiectomy specimen demonstrated a 10 cm encapsulated solid mass with interspersed cystic areas replacing the entire testicular parenchyma. The cut surface of the tumor was soft and tan-brown to yellow in color . MicroscThe patient's serum hCG and AFP remained elevated until after completing chemotherapy. He received six cycles of VP-16, ifosfamide, and cisplatin (VIP). Postchemotherapy imaging studies showed partial response of the hepatic and pulmonary visceral metastases with persistence of the large retroperitoneal mass.Although nephroblastoma or Wilms tumor is the most common malignant renal tumor of children occurring between 2 and 5 years of age, extrarenal nephroblastomas in adults are very rare and most are reported after chemotherapy.On the other hand, germ cell tumors are the most common tumor in young men. Somatic type malignant components in germ cell tumors are occasionally observed –12. NephAlthough WT-1 mutation was well documented in renal nephroblastoma, the histological origin and molecular mechanisms of testicular nephroblastoma are poorly understood. The potential histology origins include Sertoli cells and rete testis, which have retained WT-1 expression in adult testis. WT-1 expression was observed in two of the three reported cases –15. One


MEN1 gene. Primary hyperparathyroidism affects the majority of MEN1 individuals by age 50 years. Additionally, MEN1 mutations trigger familial isolated hyperparathyroidism. We describe a seemingly unaffected 76-year-old female who presented to our Genetics Clinic with a family history of primary hyperparathyroidism and the identification of a pathogenic MEN1 variant.Multiple endocrine neoplasia type 1 (MEN1) is a hereditary cancer syndrome associated with several endocrine as well as non-endocrine tumors and is caused by mutations in the MEN1 pathogenic variant. Molecular testing for the known MEN1 mutation c.1A > G, as well as, biochemical testing, MRI of the brain and abdomen were all performed using standard methods. Molecular testing revealed our patient possessed the MEN1 pathogenic variant previously identified in her two offspring. Physical exam revealed red facial papules with onset in her seventies, involving her cheeks, nose and upper lip. Formerly, she was diagnosed with rosacea by a dermatologist and noted no improvement with treatment. Clinically, these lesions appeared to be facial angiofibromas. Brain MRI was normal. However, an MRI of her abdomen revealed a 1.5 cm lesion at the tail of the pancreas with normal adrenal glands. Glucagon was mildly elevated and pancreatic polypeptide was nearly seven times the upper limit of the normal range. The patient underwent spleen sparing distal pancreatectomy and subsequent pathology was consistent with a well-differentiated pancreatic neuroendocrine tumor (pNET).The patient was a 76 year-old woman who appeared to be unaffected. She had a family history of a known MEN1 mutation carriers in families that at first blush may appear to have isolated hyperparathyroidism.Age-related penetrance and variable expressivity are well documented in families with MEN1. It is thought that nearly all individuals with MEN1 manifest disease by age 40. We present a case of late-onset MEN1 in the absence of the most common feature, primary hyperparathyroidism, but with the presence of a pNET and cutaneous findings. This family expands the phenotype associated with the c.1A > G pathogenic variant and highlights the importance of providing comprehensive assessment of  MEN1 gene located in the region 11q13.1 [MEN1 is a tumor suppressor gene that encodes for the protein, Menin. This 610 amino acid protein is localized within the nucleus, has two functional nuclear localization signals and represses JunD mediated transcription. It is expressed in a variety of tissues and is conserved across species from Drosophila to Homo sapiens. Menin is proposed to act as a tumor suppressor, as MEN1-associated tumors follow Knudson’s “two-hit hypothesis” [MEN1 gene [Multiple endocrine neoplasia 1 (MEN1) or Wermer’s Syndrome is an autosomal dominant disorder caused by germ line mutations in the othesis” , 3. MEN1EN1 gene . The MENEN1 gene . The cliIn this report we describe a case of MEN1 where diagnosis of hyperparathyroidism in family members prompted the 76 years old asymptomatic proband to seek a genetics referral. The report expands on the phenotype of this syndrome and also highlights the phenotypic variability associated with it.MEN1. She did not have a diagnosis of any of the “three P” tumors classic to MEN1 - parathyroid, pituitary or pancreas. Her past medical history was significant for hypothyroidism and osteoporosis, for which she was being appropriately treated with levothyroxine and intermittent bisphosphate replacement. She also had a history of lymphoma, which was treated with Cyclophosphamide, Hydroxy doxorubicin, Vincristine (Oncovin), and Prednisone (CHOP) regimen. Surgical history was notable for a cholecystectomy. A complete physical examination revealed no other abnormalities, except for the presence of red papules on the cheeks, nose, vermillion border of the upper lip and chin. The patient reported that these papules had been present for the past 4–5 years. On closer examination by the geneticist, these papules were diagnosed as facial angiofibromas . Plasma Ca++, parathyroid hormone levels (PTH), prolactin and Insulin like Growth Factor (IGF-1) levels, as well as fasting gastrointestinal tract hormone profile,  were also performed.A 76 year- old female was referred to our genetics clinic due to a family history of MEN1 in two children and a familial pathogenic variant in mas Fig. . FollowiMEN1 c.1A > G, that results in the loss of the translation initiation codon. The imaging revealed an solitary enhancing, partially cystic pancreatic tail lesion suggestive of a neuroendocrine tumor (Fig. Genetic testing was positive for the familial pathogenic variant mor Fig.  measurinMEN1 c.1A > G pathogenic variant was first reported in 2002 [The  in 2002  in a fam in 2002  of this MEN1, such as c.2 T > A [MEN1 pathogenic variant, which prompted our asymptomatic 76 year-old patient to seek testing. Most patients with MEN1 have shown biochemical manifestations by age 40–50 years [Other reports involving this start codon of .2 T > A , also ex50 years –12. Spec50 years , 12–14. Regarding the patient’s co-existence of MEN1 and lymphoma, there has been a prior case report  demonstrOnce our proband tested positive for the pathogenic variant, she was encouraged to share her results with other family members. Her son also tested positive for the pathogenic variant and was found to have a pancreatic tumor on subsequent screening at age 57 years. This highlights the value of medical genetics consultation in patients with MEN1 so that family members at risk can be regularly screened for the endocrine tumors.This case report brings to attention the variable age of diagnosis for MEN1, the phenotypic heterogeneity of MEN1, even within the same family, and a proband that was asymptomatic until age 76 years, barring facial angiofibromas. The report signifies the importance of medical genetics consultation for diagnosis of MEN1, and, careful screening for MEN1 associated tumors when a pathogenic variant is identified.


A 76-year-old man, with no family history of prostate cancer (PCa), consulted for erectile dysfunction. Digital rectal examination revealed an enlarged prostate with a firm area on the left side. The serum PSA concentration was 17.70 ng/mL. Transrectal ultrasound (TRUS) examination of the prostate showed a hypoechoic area in the left peripheral zone (PZ). TRUS-guided biopsy revealed a Gleason score 9 (4 + 5) adenocarcinoma on the left side and a Gleason score 7 (4 + 3) adenocarcinoma on the right side.For staging purposes, a 3T multiparametric MRI (mpMRI) was performed three weeks after the TRUS-guided biopsy. MRI confirmed a tumor in the midgland anterior and lateral posterior section of the left PZ with extracapsular extension and enlarged iliac lymph nodes.A second smaller nodular lesion was present in the midgland medial posterior section of the right PZ. The lesions had homogeneous low signal intensity on T2-weighted images (WI)  in up to 80 percent of cases. However, the degree of hemorrhage has been shown to be significantly less in areas of PCa than in areas of normal or benign prostatic tissue. This feature has been referred to as the T1 hemorrhage exclusion sign. Although the prevalence of this sign is relatively low (20%), its positive predictive value for PCa is high (95%) and, as such, provides a useful diagnostic adjunct to DWI.Some authors recommend delaying mpMRI for three to eight weeks after biopsy, but there is a large variability in the timing of the disappearance of hemorrhage. Furthermore, if the mpMRI is performed following a negative biopsy, the likelihood of PCa at the site of hemorrhage along a needle trajectory is low. In this situation, a clinically significant PCa should rather be expected in the non-hemorrhagic (non-biopsied) areas.The T1 hemorrhage exclusion sign is an additional aid for localization of larger foci of prostatic cancer on mpMRI performed after biopsy.


Nonspondylolytic lateral clefts of the lumbar neural arch (laminolysis and pediculolysis) are rare pathologies that usually occur consequent to repetitive stress injuries in patients with unilateral spondylolysis. These lesions are different from the usual bilateral spondylolytic defects, and their management depends upon the chronicity and the type of bony defect. We hereby discuss the verdict of current literature on underlying pathomechanics and ideal management guidelines of these rare lesions. Lytic spondylolisthesis typically results from a bilateral defect in the pars interarticularis, which occurs following acute fractures or stress/fatigue failures . Such a The earlier concept of benign nature of unilateral lytic lesions of the pars interarticularis has been controverted by recent literature reports confirming the existence of regional instabilities generated across the vertebral segments with asymmetric pars defects -6. In chClassification of nonspondylolytic clefts of the lumbar vertebral arch can be based on the anatomic location, as described in 1983 by Johansen et al. , who coiThe initial description of unilateral pars lysis was made in 1953 by Stewart , and theAlthough acute injuries can cause such disruptions of the posterior spinal elements, the more common underlying mechanism has been reported to be chronic stress fractures. Recurrent microtrauma following repetitive hyperextension and rotational stresses delivered across a relatively hyperlordotic, hypoplastic, or dysplastic lumbar spine lead to gradual failure of the neural arch . More coThese lateral non-pars clefts can rarely be visualized on plain roentgenograms. Plain stress radiographs can demonstrate intervertebral instability at these affected vertebral levels. However, computed tomography (CT) scans give the most accurate picture regarding the extent of such bony defects, as seen in Figures Chronic stress fractures usually present with rounded, sclerotic margins in contrast to acute failures . In ordeFive major factors that need to be considered in the treatment of these vertebral lesions include: 1) age of the patient; 2) underlying systemic pathology contributing to insufficiency fractures; 3) physical demand (based on the activity level of the patient); 4) chronicity of the lesion (as demonstrated on MRI scan); and 5) degree of intervertebral instability. Acute pediculolysis and laminolysis lesions with hyperintense morphology on MRI are known to respond well to conservative management. The majority of these lesions have been typically described in adolescent  athletes. A trial of conservative treatment for a period of three to six months, including relative rest and abstinence from sports activities, should definitely be considered in these individuals before any option of surgical intervention is conceived. Some authors also advocate lumbar bracing to enhance healing . ConservHowever, in these chronic lesions arising out of repetitive stress injuries, one should understand the existence of inherent instability, which has, in fact, led to the development of fibrous, hypertrophic nonunion. These patients, when symptomatic, definitely need to undergo surgical intervention for healing of bony defects -14. The Most of the literature evidence regarding these nonspondylolytic lesions describes early fractures in adolescent athletes. Since these lesions are extremely uncommon, thorough preoperative evaluation and planning are of utmost relevance to ensure timely diagnosis (when conservative management can be considered) and appropriate treatment. In patients with L5 pediculolysis, who undergo surgical fusion, the need to extend the level of fusion proximally to the L4 pedicle has to be cautiously assessed. Some patients present with a significantly hypertrophied L5 pedicle, where complete decompression of the L5 nerve root may necessitate partial removal of the pedicle itself. As a result, the fixation may need to be extended proximally by one level. We have given a general algorithm below Figure , though Good preoperative planning and careful understanding is of utmost importance in the management of these rare lateral nonspondylolytic lesions. In carefully selected patients, both conservative and surgical management can give good outcomes. A vital part of surgical planning includes the identification of ideal candidates for isolated repair of the defect, or single- or double-level fusions. We believe that the guidelines thus purported can help in making the critical distinction between these different patient groups and aid in providing better results in such rare scenarios.


Obturator hernia is an extremely rare type of abdominal wall hernia occurring mostly in elderly, thin females. It is characterized by the herniation of intra-abdominal contents through the obturator foramen. Symptoms are often nonspecific, and the patient usually presents with an acute or subacute intestinal obstruction. A high index of suspicion is needed in such females presenting with abdominal distention and positive Howship-Romberg signs. Computed tomography of the abdomen and pelvis are often necessary to arrive at a diagnosis, and immediate surgical intervention is recommended. The high postoperative morbidity and mortality are often attributed to a delay in the diagnosis and in initiating treatment. We present a case of a 65-year-old lady with strangulated obturator hernia who underwent emergent, lower midline laparotomy with resection and anastomosis of the small bowel and purse-string repair of the hernial defect. Obturator hernia is one of the unusual varieties of hernias, which is more common among elderly females. Obturator hernia occurs through the obturator foramen, containing obturator nerves and vessels. It poses a diagnostic conundrum due to its infrequent incidence and nonspecific presentation, making its clinical diagnosis delayed as well as difficult. Hence, obturator hernia has among the highest morbidity and mortality of all abdominal hernias 13%-40%) [3%-40% 1. Once diA 65-year-old lady was admitted in the surgical emergency with complaints of acute onset of right-sided groin pain followed by diffuse abdominal pain and distension over a period of one week. She also had a history of obstipation for the past one week. The onset of obstipation was associated with bilious vomiting for the past five days. She had no other significant medical history in the past. On physical examination, she was poorly built and nourished and had signs of dehydration. Her lower abdomen was tense and distended with diffuse tenderness. There were no peritoneal signs but bowel sounds were exaggerated. The digital rectal and vaginal examinations were normal. A local examination revealed a fullness in the right groin region around the pubic tubercle with tenderness along the medial thigh (Howship-Romberg sign). The pain was exacerbated by the adduction of the hip or medial rotation of the thigh.Abdominal radiography showed evidence of dilated small bowel loops with multiple air-fluid levels, suggesting intestinal obstructions. An ultrasonography of the abdomen and pelvis showed dilated small bowel loops with decreased peristalsis, but the cause of obstruction could not be identified. Contrast-enhanced computed tomography (CECT) of the abdomen revealed the ileal loop entering through the right obturator foramen and was found between the pectineus and obturator externus Figure . A diagnObturator hernia is nicknamed “little old lady’s hernia” due to its high prevalence in elderly, thin females . It occuAcute intestinal obstruction is the most common presentation, which is seen in nearly 90% of the patients, and the mean duration of presentation is approximately four to six days . ObturatThe Howship-Romberg sign seen in obturator hernia is because of the compression of the obturator nerve in the obturator canal. This sign is considered to be pathognomonic for obturator hernia but can be elicited in only 15%-50% of the cases. It can be invalidated in the presence of conditions affecting the ipsilateral hip joint, such as osteoarthritis. Hence, the absence of a Howship-Romberg sign does not rule out the diagnosis of obturator hernia. Another sign, the Hannington-Kiff sign, is described as the absence of the thigh adductor reflex in the presence of the patellar reflex. Though the Hannington-Kiff sign is more specific than the previous sign, it is used less frequently. Since the mode of presentation and the signs elicited are usually inadequate for diagnosis, radiological investigations are the cornerstone for diagnosis .The investigations include plain radiographs, contrast studies, herniography, ultrasonography, computed tomography, and magnetic resonance imaging . ComputeThe surgical approaches include lower midline laparotomy (most common), retroperitoneal, obturator, extraperitoneal, laparoscopic, and a combination of these approaches .The repair of a hernial defect can be done using simple peritoneal repair; otherwise, the interposition of surrounding tissues like aponeurosis, periosteum, muscle, costal cartilage, greater omentum, round ligament, uterine fundus, ovary, bladder wall, or prosthetic material such as a mesh can be used for the repair . DespiteObturator hernia has the lowest incidence of all abdominal wall hernias. A high index of clinical suspicion is required for diagnosis, especially in old and emaciated females. It poses a diagnostic conundrum due to its rarity and unusual presentation, which makes its diagnosis difficult clinically. Computed tomography is the best imaging modality, which helps in early and accurate preoperative diagnosis. The prompt identification of the condition and urgent surgical exploration is recommended to reduce the morbidity and mortality.


Sinus pneumatization is a complex variable process that begins in early life and continues for many years. We present a case of a 6-year-old boy with progressive headaches and neurologic symptoms suggestive of intracranial pathology. The presence of enhancing tissue within the sphenoid sinus created a diagnostic dilemma which leads to a transsphenoidal biopsy. Knowledge of imaging characteristics associated with incomplete pneumatization can help differentiate it from more ominous skull base pathology and prevent unnecessary testing. We describe four-year imaging follow-up in a patient with incomplete pneumatization of the sphenoid sinus presenting as an enhancing mass lesion with subsequent follow-up imaging demonstrating gradual regression and increased aeration of the sphenoid sinus. Sinus pneumatization is a prolonged developmental process beginning in utero and extending into early adulthood . Early iA 10-year-old male, who initially presented at age 6 with frontal headaches, complained of increasing headache frequency over the preceding months, occurring up to 3-4 times per week. He also experienced associated photophobia and phonophobia. His family history is notable for migraines. The patients' symptoms are initially managed conservatively.The patient was brought to the emergency department by his father after developing acute loss of vision in his right eye with right upper extremity numbness. He again complained of headache at this time. The patient noted that his vision had returned to normal by the time he had arrived at the hospital. Given the acuity of his symptoms with focal neurological deficits, the patient underwent an MRI and MRA of the head, as well as an MRI of the orbits as part of his diagnostic workup.MR imaging demonstrated an enhancing lobular lesion with T2/FLAIR hyperintensity and T1 isointensity in the sphenoid with extension laterally into the greater wing of the sphenoid bilaterally. These findings were concerning for a neoplastic process which prompted endoscopic transsphenoidal biopsy. Tissue sampling revealed the presence of benign tissue composed of fragments of respiratory epithelium, fibrous tissue with scattered chronic inflammation, and hemorrhage with no neoplastic elements.Over the following few years, his symptoms were treated as a chronic migraine disorder but the patient was unresponsive to most front line migraine treatments. Following additional unremarkable neurological tests, further diagnostic imaging was performed over the course of the following four years. Subsequent imaging demonstrated ongoing gradual decrease in the size of the enhancing tissue in the sphenoid sinus with increasing aeration. The diagnosis of incomplete pneumatization of the sphenoid sinus was then made.Pneumatization of the sphenoid sinus is a complex process, beginning with marrow conversion in the presphenoid before progressing posteriorly to the basisphenoid plate. This progression continues inferiorly and posteriorly adjacent to the clivus . The timThe structural anatomy of the sphenoid sinus is highly variable. There are four main structural configurations of sphenoid sinuses. The sinus may be small or missing (type I); the position of the posterior sphenoid wall may be anterior to the anterior wall of the sella turcica (type II), posterior to the posterior wall of the sella turcica (type IV), or interposed (type III) .There are multiple hypotheses postulating the mechanism of pneumatization. One such theory is the invasive tissue hypothesis. Mucous epithelium invades adjacent osseous structures, allowing mechanical stability of the complex sinus system . TriggerFatty marrow may persist adjacent to a partially pneumatized sinus and may appear mass-like, creating a challenging diagnostic dilemma . DelayedThe clinical picture was further complicated by the presence of postcontrast enhancement within the lesion on MRI . PersistThe differential diagnosis for an enhancing skull base lesion is broad. One notable differential diagnosis is fibrous dysplasia; characteristic CT findings of ground glass marrow can aid with this diagnosis. Other important differential diagnoses include ossifying fibroma, chordoma, and chondrosarcoma. Both ossifying fibroma and arrested pneumatization are well circumscribed; ossifying fibromas tend to be more expansile and do not commonly occur in the skull base. Chordomas and chondrosarcomas also tend to be expansile and destructive while lacking central fat . An intrClinicians and diagnostic radiologists should be aware of the process of paranasal sinus development and its corresponding imaging characteristics. Sinus structure and aeration are highly variable in children creating difficultly in differentiating normal variation from worrisome pathology. Familiarity with the normal patterns of sinus development is therefore crucial in recognizing this entity. Although the differential for enhancing skull based lesions is broad, identifying the characteristic findings associated with ongoing or arrested pneumatization, such as internal fatty components, curvilinear calcifications, and nonexpansile well circumscribed borders, can allow for confident diagnoses and avoid unnecessary intervention.