Pseudosarcomatous myofibroblastic lesions of the urinary bladder are relatively rare entities of an uncertain pathogenesis and benign indolent nature.We present an extremely rare case of an ALK-1-positive pseudosarcomatous myofibroblastic lesion of the urinary bladder, which was initially misinterpreted as a low-grade leiomyosarcoma of myxoid subtype on histologic examination owing to prominent atypia, high mitotic activity, abnormal mitotic figures and infiltration of the bladder wall. Although the histologic features were suggestive of a sarcoma, the correct diagnosis was finally established and radical surgical treatment was subsequently avoided. The patient is currently free of disease without any evidence of tumor recurrence or metastasis at 3 years post-operatively.The key differentiating point rests in distinguishing the aforementioned mass forming lesion from the myxoid subtype of low-grade leiomyosarcoma in order to avoid unnecessary radical therapy. Non-epithelial tumors account for 2%–5% of all primary urinary bladder neoplasms, with the most common types being rhabdomyosarcoma in patients under the age of 10 years and leiomyosarcoma in adults. The latter has 3 distinct histologic variants: the classical spindle cell subtype, the myxoid subtype and the less frequent epithelioid subtype [A 36-year-old, postpartum, white female became increasingly symptomatic with sharp, low abdominal pain with the completion of each urination and gross hematuria. She denied night sweats or fever and any history of urinary tract infection, trauma, instrumentation or other urological problems. An ultrasound study of the kidneys and the urinary bladder revealed a broad-based polypoid mass (2.4 × 2.3 × 2.2 cm), located in the right posterolateral wall of the bladder. The patient subsequently underwent a transurethral resection of the aforementioned lesion.a) positive for vimentin and ALK-1  focally positive for cytokeratins 8/18/19, muscle specific and smooth muscle actins, and desmin; (c) negative for S-100, CD34, c-Kit (CD117), h-caldesmon and MyoD1.Histologic examination of the excised mass displayed infiltration of the bladder wall Fig.  by an atLK-1 Fig ; (b) focin situ urothelial neoplasm and the immunophenotype, this was considered to be more likely a smooth muscle tumor than a spindle cell carcinoma. Consequently, further adequate local excision was recommended. At that point, a staging work-up, including a bone scan, abdominal/pelvic MRIs and an intravaginal ultrasound, disclosed no definite evidence of radiographically residual intravesicular tumor and no evidence of extension or metastasis. Due to negative staging work-up and considering the rarity and complexity of the case, the patient was referred for close clinical follow-up and cystoscopic re-evaluation of the bladder excision site for potential residual lesion.These histologic findings posed a particular diagnostic problem and yielded a differential diagnosis of pseudosarcomatous myofibroblastic lesion versus low-grade leiomyosarcoma of focally myxoid type. Although the possibility of the former was taken into account, the diagnosis of malignancy could not be avoided, given the nuclear pleomorphism, abnormal mitoses and the infiltrative nature of the lesion. Based on the absence of an After five months' interval since the initial transurethral resection, a repeat cystoscopy was performed and disclosed scar tissue without any obvious tumor growth; additional biopsies were obtained from the surgical site. Microscopy revealed no sarcoma, but residual foci that simulated a reactive process.Given that a sarcoma of the bladder would have already shown significant proliferative activity and comparing the initial slides with the re-biopsy slides, we issued a new diagnosis; in particular, we inclined more towards a diagnosis of pseudosarcomatous myofibroblastic lesion instead of a sarcoma. Due to the atypical features encountered and the fact that the biological potential of this entity cannot be accurately assessed, a close follow-up was warranted. The patient did not receive any adjuvant treatment. She is currently free of disease without evidence of tumor recurrence or metastasis by 3-year follow-up.Non-neoplastic reactive, mesenchymal proliferation of the urinary bladder is a rare, but distinctive entity, which has been referred to as inflammatory pseudotumor (IP) or myofibroblastic tumor (IMT), postoperative spindle cell nodule, nodular fasciitis, pseudosarcomatous myofibroblastic proliferation, pseudomalignant spindle cell proliferation, and pseudosarcomatous or atypical fibromyxoid tumor ,4. The ua) the occurrence of cases with deep infiltration of the bladder wall and extension into the perivesical soft tissue and (b) the demonstration of a non-random chromosomal translocation involving 2p23 that results in the expression of anaplastic lymphoma kinase (ALK) [The pathogenesis of IMT is still in doubt ; some rese (ALK) . In addise (ALK) , since bse (ALK) .Pseudosarcomatous myofibroblastic lesions of the bladder may occur at any age (range from childhood to elderly patients), but typically occur in adult males ,8,9; beiIMT contains a mixture of spindle cells showing myofibroblastic differentiation, admixed with variable numbers of inflammatory cells. These display 3 histologic patterns in varying proportions: (a) the myxoid-vascular pattern, characterized by loosely arranged, stellate-to-plump spindle cells in an oedematous, myxoid background with an irregular network of small blood vessels and inflammatory cells, resembling nodular fasciitis or granulation tissue, (b) the compact spindle cell pattern, which consists of a compact interlacing fascicular or storiform spindle cell proliferation with variable myxoid and collagenized regions, accompanied by an inflammatory infiltrate composed largely of plasma cells, resembling fibrous histiocytoma or smooth muscle neoplasms, (c) the hypocellular-fibrous pattern, characterized by platelike collagen, lower cellularity and relatively sparse inflammation with lymphocytes and plasma cells trapped in a dense eosinophilic matrix, resembling a desmoid or scar ,16. MicrOf clinical importance, IMT follows a benign indolent course and conservative management  has been reported ,3,13,17 a) prominent cytological atypia, (b) abnormal mitotic figures, (c) preferential reactivity for high-molecular-weight caldesmon and the lack of (a) a delicate vascular network, (b) interspersed inflammatory and red blood cells, and (c) ALK-1 immunostaining  may be of particular value in the differential diagnosis [a) exhibiting greater cellularity and increased numbers of atypical mitotic figures, (b) the presence of rhabdomyoblasts, a uniform population of small hyperchromatic cells, (c) a "cambium layer"  and (d) positive myogenin (Myf4) and MyoD1 immunostainings [In fact, some leiomyosarcomas of the urinary bladder can express cytokeratin and are partially or extensively myxoid to such a degree that distinction from IMTs may become impossible; albeit, the presence of  declare that they have no competing interests.AL participated in the surgical treatment of the patient and drafted the manuscript. AP participated in the pathologic diagnosis. TP drafted the manuscript. AP drafted the manuscript. MRM participated in the pathologic diagnosis. MC participated in the clinical evaluation and follow-up of the patient. CD participated in the clinical evaluation and follow-up of the patient. AL drafted the manuscript.


Mucosa associated lymphoid tissue (MALT) lymphoma is the third most common non-Hodgkin's lymphoma subtype. Clinical presentation is often insidious as a low-grade lesion and disease tends to remain localised for a long period of time. Ileal involvement is rare and presentation within an area of focal anti-mesenteric ileal wall dilation simulating a large diverticulum has not been reported.A 59-year-old man of Caucasian origin presented to a general surgical outpatients clinic with an 18-month history of intermittent upper abdominal pain following meals. Following normal gastroscopy and abdominal ultrasound, a focally dilated segment of ileum was seen on computed tomography and further clarified by barium investigation. Histology of this segment demonstrated MALT lymphoma of the small bowel.A solitary focally dilated segment of ileal wall may be neoplastic in nature and surgical resection needs to be considered. Mucosa associated lymphoid tissue (MALT) lymphoma otherwise known as extra-nodal marginal zone lymphoma was first described by Isaacson and Wright in 1983. The term MALT lymphoma was originally used to describe lymphoid tissue seen to histologically closely resemble that of the terminal ileum . The gasThis report describes the case of a 59-year-old Caucasian man presenting to a general surgical outpatients clinic with an 18-month history of intermittent upper abdominal pain following meals. Clinical examination, blood tests and an ultrasound examination were all unremarkable and no justification for symptoms was found at upper gastrointestinal endoscopy. A computed tomography (CT) scan of the abdomen following an acute admission with abdominal pain and vomiting demonstrated a 4.6 cm dilated segment of ileum containing both contrast and debris Figure . DiffereAt laparoscopy, a focally dilated anti-mesenteric segment of ileum was found 140 cm from the ileocaecal valve and displaying an abnormal serosa Figure . A segmeA thorough literature review has failed to identify a similar case of MALT lymphoma presenting within an area of focal anti-mesenteric dilation simulating a large diverticulum. Other differentials include MALT within a non-Meckel's diverticulum, ileal duplication or Meckel's diverticulum. Small bowel diverticula (non-Meckel's) most commonly arise in the duodenum and emerge on the mesenteric border where mesenteric vessels penetrate the bowel wall. Intestinal duplication is a rare condition which tends to present in early life and is closely associated with the mesenteric border. Isolated adult cases of ileal duplication, some with malignant change, have however been reported . IntestiMALT lymphoma of the GI tract often presents with non-specific symptoms. Additionally, traditional investigative techniques often miss the early stages of the diseases process making timely clinical diagnosis challenging. In patients with unexplained gastrointestinal symptoms, video capsule endoscopy may need to be considered as it is the diagnostic test with the highest yield for small bowel malignancies .A solitary focally dilated segment of ileal wall may be neoplastic in nature and surgical resection needs to be considered.CT: computed tomography; MALT: mucosa associated lymphoid tissueWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.RS, MG and IB were all involved in the drafting and re-editing of the manuscript. The final manuscript was read and approved by all three authors.


Appendices epiploicae are affected by spontaneous torsion, calcification, primary or secondary inflammation, enlargement by lipomas or metastases and incarceration in hernias.A 20-year-old Asian man was admitted with non-specific abdominal pain, which later evolved to intestinal obstruction. Operative findings showed the small bowel obstruction was due to an omental band adhered to a nodule. Histopathology of the nodule revealed an infarcted appendix epiploica.Heightened suspicion and increased awareness of this entity would have led to an earlier diagnosis. Acute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants. Untreated, peritonitis or intestinal obstruction may result. Use of diagnostic laparoscopy in non-resolving abdominal pain would help to resolve the issue at an earlier stage and prevent additional morbidity. Appendices epiploicae are adipose structures protruding from the serosal surface of the colon. Approximately 50-100 is present normally and is arranged in two separate longitudinal rows extending from the caecum to the rectosigmoid junction. They are thought to have a protective function, similar to that of the greater omentum, containing any intra-abdominal infection. They appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick on abdominal radiography, CT scan or US, if intraperitoneal contrast material, ascites or blood surrounds the colonic wall. The use of intraperitoneal gas as a negative contrast agent is apparently inadequate for radiologic demonstration of the appendage. The radiologic findings  provide useful criteria for preoperative recognition of torsion, infarction and primary inflammation of appendices epiploicae [Appendices epiploicae are affected by spontaneous torsion followed by ischaemic or haemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas  or metasEach epiploic appendage is supplied by one or two small endarteries branching from the vasa recta longa of the colon and drained by a rather tortuous vein passing through its narrow pedicle. Such a limited blood supply, together with their pedunculated shape and excessive mobility, makes appendices epiploicae prone to torsion and ichaemic or haemorrhagic infarct .A 20-year-old Asian man was admitted with a three day history of central abdominal pain and decreased appetite but no history of vomiting or constipation. Examination of his abdomen revealed mild tenderness to the right of the umbilicus and bowel sounds were normal. All blood results including inflammatory markers were normal and an abdominal X-ray did not show anything unusual. He was started on conservative management.The next day, the patient’s abdominal pain increased. He was tender in both the iliac fossae on clinical examination with no rebound tenderness or guarding. He however settled down by evening and was well the next day. The following day (4th day since admission), the pain recurred and he started vomiting. He was passing flatus but no faeces. On examination, he had a slightly distended abdomen and was tender on the right side of his abdomen. There was no guarding or rigidity. Blood tests showed rising inflammatory markers (neutrophil leucocytosis) (White cell count - 12.2 and C - reactive protein 22). An abdominal X-ray showed dilated small bowel loops. He proceeded to have a CT scan of his abdomen which showed evidence of small bowel obstruction with a cut off at the mid ileum .In view of his clinical picture, a decision was taken to perform a diagnostic laparoscopy. This however had to be converted to a laparotomy due to significant dilatation of small bowel loops. Operative findings included dilated small bowel loops till the mid-ileum where an ischaemic stricture with perforation of the small bowel had resulted as a consequence of an omental band. This omental band had encircled the small bowel and was adherent to a nodule arising from one of the appendices epiploicae. The appendix was slightly congested. The band was divided and a wedge resection of the small bowel was carried out. The nodule to which the omental band had stuck to was excised and sent for histology. The appendix was removed.The patient developed a small pelvic collection post -operatively which was managed conservatively with antibiotics. He was discharged from hospital 12 days after surgery and did not have any further complications.The histology of the excised nodule showed an infarcted appendix epiploicae. Small bowel showed acute ischaemic ulceration with focal infarction extending through the bowel wall and the appendix was normal.Acute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants, since the sigmoid colon and caecum are the main sites of involvement. Mild fever and leucocytosis may develop, but symptoms of obstruction, nausea, vomiting and loss of appetite are infrequent. The clinical symptoms experienced by patients during the acute phase of torsion and infarction of appendices epiploicae will subside after several days or weeks. In such cases if the surgery is not performed, the infarcted appendage may undergo aseptic fat necrosis and gradually transform into a fibrotic or calcified mass. It may remain attach to the colonic serosa, or it may detach from it and remain as a mobile, loose body within the peritoneal cavity . IschaemPrimary epiploic appendagitis may occur as an acute primary process localised to one or several adjacent appendages or secondary to inflammatory changes originating in the colon or other neighbouring organs  . DivertiDiagnostic laparoscopy for acute abdominal pain revealed gangrenous torsion in one of the appendices epiploicae in the ascending colon and sigmoid colon, which was excised with harmonic scalpel . We trieAll patients with acute diseases  of the appendices epiploicae should be treated by an emergency operation for removal of the appendices, closure of their beds with double-row interrupted sutures and reinforced with a pedicled omentum graft. Removal of the infarcted appendix results in cure, with no reported cases of recurrence. The disease can be fatal, four deaths having been reported in the literature . UntreatAcute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants. Untreated, peritonitis or intestinal obstruction may result. Heightened suspicion and use of diagnostic laparoscopy  would he


The incidence of mesenteric ischaemia is rising possibly due to increasing awareness and early diagnostic tools available. However it remains a challenging diagnosis especially in the elderly population.We report an unusual case of acute mesenteric ischaemia in an elderly lady occurring in conjunction with acalculous cholecystitis. A 71 year old woman was referred to our hospital with abdominal pain, vomiting, diarrhoea and pyrexia. An initial ultrasound scan of the abdomen revealed acute acalculous cholecystitis.She failed to respond to medical treatment and further investigations revealed concurrent mesenteric ischaemia. Mesenteric ischaemia results from decreased blood flow to the bowel resulting in cellular injury as a result of decreased oxygen and nutrient supply. It can be classified temporally (acute vs. chronic), by location  and by vessel  involved . AlthougA 71 year-old Caucasian lady was referred to our hospital with a one week history of diarrhoea, vomiting, epigastric pain and pyrexia. She was obese with a BMI of 38.3 but no significant past medical history. She had been to Australia a month prior but was clinically well during her stay there. Blood inflammatory markers revealed a normal white cell count but a raised C-reactive protein (CRP) of 54 mg/l. Liver function tests were unremarkable apart from a raised serum alanine transaminase (ALT) of 70 U/l. Stool and blood cultures were negative. Clostridium difficile toxin was not detected. She was treated supportively for infective gastroenteritis and her symptoms resolved spontaneously after 3 days. She was subsequently discharged and an outpatient abdominal ultrasound was arranged to investigate the cause of the mildly raised ALT.9/l, and an increased CRP of 72 mg/l. Liver function tests continued to be unremarkable apart from ALT which remained elevated at 80 U/l. Abdominal and chest X-rays were unremarkable. Arterial blood gases were normal. She was diagnosed with acalculous cholecystitis and treated with intravenous broad spectrum cephalosporins. Unfortunately her condition did not improve and she subsequently developed diarrhoea and bleeding per rectum.A week later, she was developed severe upper abdominal pain, rigors and pyrexia of 39°C and was readmitted to hospital. The abdominal ultrasound showed a thickened and inflamed gall bladder with no calculi seen. Inflammatory markers on this admission showed an elevated white cell count of 11 × 10Further investigations were then carried out including a flexible sigmoidoscopy which was unremarkable apart from diverticular disease in the sigmoid colon. A computed tomography (CT) scan of the abdomen showed moderate small bowel dilatation and some enhancement of the bowel wall, which raised the possibility of bowel ischaemia. Thrombosis of the proximal superior mesenteric vein was also noted.An exploratory laparotomy was then performed and a 17 cm segment of the jejunum was found to be ischaemic and gangrenous. The affected section of small bowel was resected followed by an end to end anastomosis. Histology of the resected specimen confirmed full thickness infarction of the small bowel associated with thrombi in the mesenteric vessels, the overall appearance of which was consistent with acute mesenteric ischaemia. There were several thrombi within the mesenteric vessels, raising the possibility of embolic aetiology.AMI is a potentially fatal abdominal emergency with a mortality rate of 60 – 80% ,5. AlthoAcalculous cholecystitis, i.e. inflammation of the gallbladder without evidence of calculi or sludge, comprises 2 – 15% of all cases of acute cholecystitis . The patThe patient's initial symptoms were vague and did not provide evidence to suggest mesenteric ischaemia which is not uncommon in elderly patients . InitialTo the best of our knowledge, this is the first case of acute acalculous cholecystitis occurring with AMI. It is highly plausible that widespread ischaemia may have contributed to both conditions.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TL, BT and TP collected the data and drafted the initial manuscript. SA operated on the patient with the assistance of TP. NR and RG contributed to the final approval and revision of the manuscript. All authors read and approved the final manuscript.


Non-parasitic hepatic cysts are benign entities, occur rarely (5% of the population), and in the majority of cases, are asymptomatic. Cysts can cause symptoms when they become large and produce bile duct compression or portal hypertension, and also when complications such as rupture, infection or hemorrhage take place.We present the case of a 70-year-old Greek-Caucasian man with a large, asymptomatic and non-parasitic liver cyst that presented as an acute surgical abdominal emergency after spontaneous rupture into the peritoneal cavity.We present an extremely rare complication of simple liver cyst, its rupture in the free abdominal cavity, and its presentation as an acute abdomen. Large simple liver cysts should be treated with intervention at early recognition as conservative management usually results in their recurrence. Recent technical advances, cost reduction and increased use of radiological imaging modalities have resulted to an increased detection of simple or non-parasitic hepatic cysts (NPHC) in approximately 1% to 5% of the general population [Found more frequently in women than in men 3:1), NPHC are usually asymptomatic , NPHC ar. ObstrucIn this report we present the case of a 70-year-old man who was admitted to our hospital with diffuse abdominal pain after the spontaneous rupture of a large non-parasitic hepatic cyst. The patient was treated through surgery wherein a wide unroofing of the cyst was performed.A 70-year-old Greek-Caucasian man was admitted to our hospital with diffuse abdominal pain of sudden onset three hours prior to his admission. The patient did not complain of nausea, vomiting or diarrhea and his temperature and arterial pressure were normal despite an elevated pulse rate (90 ppm.). His latest stool passage was blood-free and a digital rectal examination revealed nothing pathological.During physical examination, the patient's abdomen was mildly distended with diffuse guarding and marked rebound tenderness. Abdominal sounds were diminished during auscultation.Laboratory investigations revealed normal values for his hematocrit, hemoglobin, white blood cell count, and platelets. Renal and hepatic function tests were also normal and his blood glucose was a little elevated at 167.8 mg/dl .The patient's medical history included colonic diverticular disease, an endoscopic excision of benign rectal polyps four years prior to his presentation, and ongoing arterial hypertension and osteoporosis treatment. Ten years prior to presentation in a random ultrasound examination, the patient was found to have several simple liver cysts including two large hepatic cysts and other smaller ones. The largest cyst had a size of 13 cm. At the time, his pancreas, spleen and kidneys were normal Figures . A seconDuring the patient's present admission, there was no free air in his abdomen. An abdominal X-ray examination did not show bowel air-fluid levels. Abdominal ultrasound examination showed a significant quantity of free liquid in his abdominal cavity, around the spleen and liver, as well as in the Douglas pouch. Since the patient's general condition was deteriorating and he was already showing symptoms of paleness, sweating, increased abdominal guarding and marked rebound tenderness in the whole abdominal area, we decided to perform an exploratory laparoscopy.The laparoscopy revealed a vast amount of opaque-yellowish peritoneal fluid occupying majority of his abdominal cavity without any obvious origin, so the operation was converted to laparotomy.Echinococcus and tumor markers, CEA and CA 19-9, all showed negative results.The exploration of the patient's abdominal cavity revealed a ruptured liver cyst that originated from the lower surface of his right liver lobe Figure . UnroofiTwo drains were positioned, one at the patient's cystic cavity area and the other at his Douglas pouch. The postoperative course of the patient was uneventful and three days later the drainages were removed. The patient was discharged in excellent general condition eight days after his admission.Echinococcus granulosis or Echinococcus multilocularis), neoplastic cysts  and biliary duct-related cysts . False liver cysts may be caused by spontaneous intrahepatic hemorrhage, post-traumatic hematoma, or intrahepatic biloma [Depending on the presence of an epithelial lining, liver cysts are classified as true or false. True liver cysts include congenital cysts (simple cysts and polycystic liver disease), parasitic cysts  with IV contrast administration is a suitable imaging modality for cyst detection, localization and sizing. It also offers significant information concerning differential diagnosis . While nOn the other hand, parasitic cysts are less confusing. Compared to their non-parasitic counterparts, parasitic cysts rarely show the same type of homogenous full-of-fluid interior in CT scan, and their lumen contains daughter cysts and a considerable amount of solid debris.Simple non-parasitic hepatic cysts are congenital and are supposedly triggered by chromosome 16 . They arThe vast majority of simple hepatic cysts are asymptomatic. They can produce symptoms due to their size, anatomical localization, or when they become complicated. Most commonly, cyst enlargement can produce a sensation of foreign body, epigastric pain, nausea, vomiting and postprandial bloating . ComplicSimple asymptomatic cysts require no treatment as they can regress spontaneously , especiaPercutaneous (US- or CT-guided) needle aspiration apart from therapeutic application can be used as a good therapeutic test to ascertain whether abdominal symptoms are related to the liver cyst. Although its therapeutic use is associated with high relapse rates (approximately 80% to 100%), the recurrence rate can be decreased by about 20% when percutaneous needle aspiration is combined with alcohol minocycline chloride or tetracycline chloride injection ,15. ThisDeroofing is a definite and safe treatment for liver cysts. With few exceptions, the operation can be performed laparoscopically in 94% of reported cases . CombineRoux-en-Y drainage (cystojejunostomy) has been proposed as treatment for cysts communicating with the bile duct. This operative management is yet to be proven as complications like cholangitis and sepsis that require repeated antibiotic treatment and occasional hepatic resection has been frequently reported .More radical approaches like complete cyst excision and hepatectomy carry a significant morbidity (up to 50%) . These aThe spontaneous rupture of NPHC is an extremely rare complication as only 15 cases have been reported in the English literature . RuptureThis unusual complication of non-parasitic simple liver cysts may not always require surgery and may still be treated conservatively without surgical intervention when its clinical presentation is still mild . This waBecause simple liver cysts normally have no communication with the biliary tree, biliary leakage should not be the case in such spontaneous ruptures. However, this does not explain the frequent development of relapsing cholangitis in patients treated with cystojejunostomy .Spontaneous rupture of simple liver cysts is a rare complication which can mimic acute abdomen. However, it should be included in the differential diagnosis of an acute abdomen in patients with a history of a liver cyst. Best management of ruptured NPHCs seems to be related to good exposure, wide excision of the cyst wall, and omentoplasty as conservative management can lead to reposition of the cyst wall and cyst recurrence. Laparoscopic fenestration offers the best compromise between efficacy and risk, although an open surgical approach is acceptable in difficult cases.NPHC: non-parasitic hepatic cyst; CEA: carcinoembryonic antigen; CA: carbohydrate antigen; CT: computed tomography; US: ultrasonography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.LM and TG analyzed and interpreted the patient's clinical data. GB made a substantial contribution in the analysis and interpretation of the patient's history and imaging data. IT and IDK were the operating surgeons of the patient. They also made substantial contributions in the conception and design of the manuscript. LM and IDK were the major contributors in writing the manuscript. All authors read and approved the final version of the manuscript.


Extraskeletal Ewing's sarcoma is a rare soft tissue tumor that is morphologically indistinguishable from Ewing's sarcoma of bone. We report a case of extraskeletal Ewing's sarcoma with several systemic problems. A 69-year-old man presented with a 5-month history of a rapidly enlarging mass in the right thigh. Because preoperative radiotherapy with sanazole (AK-2123) contributed the tumor mass reduction down to 40% in size, the tumor was successfully resected with clear surgical margins and repaired with a musculocutaneous flap. The high efficacy of pre-operative low-dose radiotherapy with sanazole was histologically confirmed that the resected tumor specimen involved no viable tumor cells and showed 100% necrosis. Based on clinical outcomes in this case, the combined modality of pre-operative low-dose radiotherapy with hypoxic cell radiosensitizer and adequate surgical resection might provide for the useful clinical application of extraskeletal Ewing's sarcoma treatment. Extraskeletal Ewing's sarcoma (EES) is a rare type of Ewing's sarcoma that arises in the soft tissue at any location and is now regarded as a member of a family of small cell neoplasms of bone and soft tissue, including primitive neuroectodermal tumors (PNETs) , 2.MultiEfficacy of RT largely depends on tumor radiosensitivity and the tolerance of normal tissues. To improve therapeutic outcomes, RT is often combined with chemotherapeutic drugs that are themselves cytotoxic and/or radiosensitizing. Sanazole (AK-2123) as a radiosensitizer with irradiation in various tumors showed encouraging results –9. Here,A 69-year-old man presented at our hospital with a 5-month history of a rapidly enlarging mass in the right thigh. His past history was pulmonary tuberculosis treated with thoracoplasty and hepatitis C. Physical examination revealed the presence of a large irregular mass with multiple ulcers and necrotic tissues, measuring approximately 10 × 10 cm in the lateral side of the proximal thigh . AdmissiBased on clinical findings and imaging characteristics, the tumor was diagnosed as a primary soft tissue tumor and an incisional biopsy was performed. Histopathology of the permanent sections showed the nodular or sheets-like proliferation pattern of small round cells with a high nuclear/cytoplasmic ratio in the background of sparse extracellular collagen . Immunoh2  × 10 days), the tumor volume was reduced to approximately 40% of the pre-treatment condition (Considering patient's age, hepatic dysfunction, and patient's disagreement with chemotherapy, we precluded the choice of the neoadjuvant chemotherapy. To define surgical margins especially at subcutaneous tissues and to increase tumor resectability, we determined to treat the patient with pre-operative low-dose RT and additional administration of sanazole before surgery . As a reondition . On thalondition . The hugondition . There wondition . Based oEES is a tumor of unknown mesenchymal origin predominantly affecting men in the second and third decades of life , 11. TheDespite the role of RT in the management of bone sarcoma is limited, its primary application appears to be in Ewing's sarcoma . The impDespite the limitation of this case including its short follow-up period, our clinical outcomes in radiosensitive EES suggested the high efficacy of pre-operative low-dose RT with sanazole. Therefore, the combined modality of pre-operative low-dose RT with hypoxic cell radiosensitizer and adequate surgical resection might provide for the useful clinical application of EES treatment.


Torsion of the vermiform appendix is a rare disorder, which causes abdominal symptoms indistinguishable from acute appendicitis and is found by chance during the laparotomy.We report a case  suffering of torsion of the vermiform appendix with fecalith. It was twisted 540 degrees in an anti-clockwise direction. Appendectomy was done.Appendiceal torsion may be assocated with the presence of fecalith. This case is the oldest one among the patients with appendiceal torsion reported to literature. Torsion of the vermiform appendix is a rare disorder, which causes abdominal symptoms indistinguishable from acute appendicitis. Primary and secondary torsion are recognized in the appendiceal torsion. In primary torsion, specimen examination shows secondary ischemic or necrotic change and luminal dilatation distal to the torsion site without any primary lesion. About 25 cases of primary torsion have been reported to date. Secondary torsion is much rarer and only 7 cases have been reported to date. Secondary torsion is caused by appendiceal abnormality, which includes cystadenoma, mucocele, fecalith impaction, and malformation -11. Preo3 (78% neutrophils). Abdominal X-ray examination revealed small-intestinal dilatation with air-fluid level. Modified Alvarado's score for appendicitis was nine points. Laparotomy was done on the suspected diagnosis of acute appendicitis. The appendix was 10 cm in length and 1.5 cm in diameter, and showed gangrenous change. It was twisted 540 degrees in an anti-clockwise direction at the point of 1 cm distal to its base  was the oldest one among the patients with appendiceal torsion reported to date. In this case, the presence of fecalith may be associated with torsion of the appendix.The authors declare that they have no competing interests.IW was involved in the acquisition of data, compilation of relevant literature and drafted the preliminary and final manuscript.MK was involved with the revision, formatting and proofreading the manuscript.MR carried out the operation of this patient and helped to draft the manuscript.JS prepared the histopathological photographs for the manuscript.GB supervised the project and reviewed the manuscript.MN undertook final revision of manuscript and was done under his supervision.All authors read and approved the final version of manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal


Seborrheic keratoses are very common findings in elderly patients. However, a sudden onset and dramatic increase in the number and size of these benign lesions deserves special attention, since this may represent the Leser Trélat sign, a rare paraneoplastic cutaneous syndrome.A 92-year-old female presented to our clinic with multiple eruptive seborrheic keratoses, which had dramatically increased in size and number over the past two years. A diagnostic work-up revealed an ovarian carcinoma. Hence, cutaneous findings in our patient were consistent with the diagnosis of the Leser-Trélat sign.The Leser-Trélat sign may coincide with the diagnosis of occult cancer or follow or precede it by months or years. Practitioners should take cases of eruptive seborrheic keratoses seriously and perform thorough patient examinations. Seborrheic keratoses are very common findings in elderly patients. Yet, a sudden onset and dramatic increase in the number and size of these benign lesions deserves special attention, since these may represent a rare paraneoplastic syndrome. Seborrheic keratoses may coincide with the diagnosis of occult cancer or follow or precede it by months or years. This complex is referred to as the Leser-Trélat sign.A 92-year-old woman presented to our clinic with multiple, tan to black coloured skin eruptions with rough, warty or greasy surfaces, consistent with the diagnosis of multiple seborrheic keratoses. The lesions had dramatically increased in size and numbers over the past 2 years (Panel 1 A and B). Moreover, the patient reported a 2-month history of abdominal pain and weight loss. Laboratory examinations revealed elevated CA 125 plasma levels of 500 U/ml. Clinical examination showed signs of mild ascites. Additional staging examinations, including diagnostic abdominal ultrasound and computed tomography (CT), revealed a distinctive, partly necrotic tumor (8 cm by 10 cm in diameter), originating from the left ovary and occupying the pelvis. The tumor mass was accompanied by signs of peritoneal carcinomatosis (Panel 1C). A posterior exenteration with double sided ovariectomy, hysterectomy, rectum resection and Hartmann's procedure was performed. Histopathological evaluation revealed a poorly differentiated serous papillary adenocarcinoma of the right (Panel 2A) and left (Panel 2B) ovary, infiltrating the colon, the small intestine, both Fallopian tubes and the uterus .Cutaneous findings in our patient were consistent with the diagnosis of the Leser-Trélat sign. This rare paraneoplastic cutaneous syndrome is defined as the sudden onset and dramatic increase in the number and size of seborrheic keratoses as a result of cancer . Skin lePathogenetically, eruptive cutaneous paraneoplastic disorders are suspected to be induced directly by tumor-secreted growth factors . AccordiWhereas seborrheic keratoses are very common findings in elderly patients, the eruptive appearance of a number of these benign skin tumors requires further examination. Since these lesions may coincide with the diagnosis of occult cancer, or follow or precede it by months or years, practitioners should perform a thorough examination including taking a complete patient history, physical examination, routine blood tests, chest radiography, abdominal ultrasound or computed tomography (CT), as well as mammography and a Papanicolaou smear test in women and prostate-specific antigen testing in men. With regard to the high incidence of gastrointestinal neoplasias, additional endoscopic analyses (esophagogastroduodenoscopy and colonoscopy) should be considered .In our case the patient was treated with surgery and at the time of writing is receiving palliative chemotherapy with carboplatin.EB and PAG analyzed and interpreted the patient data. RE performed the histological examination. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.


Anorectal melanoma represents an unusual but important presentation of rectal malignancy. There have only been a few cases reported and the optimum management for this condition is still undecided, however, prompt diagnosis is essential. We have outlined current treatment options.We report a case of malignant melanoma of the rectum in a 55-year-old Caucasian man presenting as an emergency with rectal bleeding. Biopsies were taken of the fleshy mass found on digital examination, which confirmed malignant melanoma. No distant metastases were found. He underwent an abdominoperineal resection. We report the surgical management of this rare and aggressive malignancy.Treatment options for this condition are divergent. Surgical management varies from wide local excision to abdominoperineal resection. Clinical awareness in both medical and surgical clinics is required for prompt diagnosis and treatment. In this patient, an emergency presentation of rectal bleeding led to an unusual diagnosis. Rectal bleeding is a common presentation of rectal malignancy. An uncommon form of this is malignant melanoma, attributing to only 1% of all rectal malignancies. Due to the aggressive nature of this disease, an early diagnosis and prompt treatment are essential.A 55-year-old Caucasian man, previously fit and well, presented to the accident and emergency department following a massive rectal bleed. On admission, he was haemodynamically stable with haemoglobin at 15 g/dl. His abdomen was soft and non-tender and percussion note and bowel sounds were normal. Rectal examination revealed an anterior fleshy mass at 11-12 o'clock situated 4 cm from the anal verge and just above the anorectal angle.When questioned, the patient said he had been bleeding intermittently for 4 months but without any pain or change in bowel habit. He was a non-smoker with an unremarkable medical history.Rigid sigmoidoscopy demonstrated a polypoid pigmented lesion at the anorectal angle. Biopsy demonstrated malignant cells with pleomorphic nuclei and abundant melanin in the cytoplasm. Completion colonoscopy was otherwise unremarkable. Computed tomography of the thorax, abdomen and pelvis and magnetic resonance imaging of the pelvis showed well-preserved anorectal fat planes and no evidence of metastasis. Dermatological and ophthalmological examinations revealed no evidence of a cutaneous or an ocular primary lesion. His case was discussed at the melanoma and colorectal multi-disciplinary team meetings.Shortly after his diagnosis, the patient underwent an abdominoperineal resection (APR) without neoadjuvant treatment. He made an uncomplicated recovery and was discharged 13 days later. Immunohistochemical confirmation was obtained with cellular positivity for S100 and melan-A antigens. The malignant melanoma was completely excised with clear margins of at least 2 mm. A macroscopic image of the specimen is shown in Figure Primary anorectal melanoma is a rare disorder accounting for 1% of anorectal malignancies ,3. UnlikLesions are most commonly found at the anorectum, followed by the anal canal and anal verge . These lDiagnosis is often delayed and a poor prognosis is compounded by the aggressive nature of the malignancy resulting in a median survival of 24 months and 5-year survival in only 15% of cases. As a consequence, few surgical guidelines are available. Radical abdominoperineal resection may cure patients with <2 mm-wide lesions - based on the hypothesis that the disease spreads proximally via the submucosa to the mesenteric lymph nodes, it has been deemed the treatment of choice . Wide loMalignant melanoma of the anorectum is an uncommon condition. An expeditious diagnosis and care within a mutidisclipinary team can have an important bearing on prognosis.APR: abdominoperineal resection; WLE: wide local excision.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DS analysed and interpreted the data. AS and NH made substantial contributions to conception of the article and oversaw patient care. SL undertook the literature review and drafted the manuscript.


Blind eyes can harbor a choroidal melanoma. We report a case of uveal melanoma presenting as staphyloma and complicated cataract in a 45-year-old female. The left eye was blind for six months. She underwent comprehensive ocular examination but fundus examination was precluded due to total cataract. The ultrasound of the eye showed a large mass filling the superior, nasal and inferonasal vitreous cavity with high surface reflectivity and low to moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed the diagnosis of choroidal melanoma. The patient underwent extended enucleation and histopathology was consistent with uveal melanoma. Uveal melanoma is the most common primary malignant intraocular neoplasm of Caucasian adults. Uveal meA 45-year-old lady presented to us with a history of painless swelling in the left eye associated with decrease in vision since six months. On ophthalmic examination, she had a best corrected visual acuity (BCVA) of 20/20 in the right eye and light perception with inaccurate projection of rays in the left eye. The anterior segment examination in the right eye was within normal limits. In the left eye there was a staphyloma in the superonasal quadrant, close to the limbus measuring 6 × 6 mm. It was irregular in shape, brown in color with overlying scleral thinning and a sentinel vessel temporal to the staphyloma Figs. , b. IrisThe ultrasound examination of the left eye showed a large mass filling the superior, nasal and inferonasal vitreous cavity with high surface reflectivity and low to moderate internal reflectivity. The mass was extending posteriorly and involving the optic nerve head. Secondary retinal detachment was noted over the mass . It was Magnetic resonance imaging (MRI) of the brain and orbit revealed an intraocular enhancing choroidal mass lesion extending from just posterior to the ciliary body along the nasal quadrant up to the optic disc and extending to the temporal side of the optic disc. It displayed hyperintense signal in T1W1 and hypointense in T2W1 with respect to vitreous with fairly homogenous contrast enhancement Figs. , b. A diThe patient underwent a modified extended enucleation under general anesthesia.During enucleation care was taken not to rupture the globe. Meticulous dissection was carried out in the staphylomatous area. The enucleated eyeball showed almost a total loss of scleral fibers in the entire nasal quadrant .The histopathological examination showed a pigmented tumor mass arising from the anterior part of the choroid which was composed of pigment-bearing spindle cells and epithelioid cells. Multiple mitotic figures were seen Figs. , 6. ExtrUveal melanoma is the most common primary malignant intraocular neoplasm of Caucasian adults. Annual incidence in Caucasians is seven to eight new cases per million persons. Choroidaet al., have presented a total of 11 cases including two of their own.[A case of uveal melanoma reporting as panophthalmitis has been described earlier, however, this type of presentation is very rare. In a preheir own. They havheir own.–10 HowevThis case highlights the need to be alert to such a possibility in cases presenting essentially as a blind eye with staphyloma and complicated cataract. Surgical removal of such a staphylomatous eye should be done with care to avoid accidental globe rupture. Liberal canthotomy and meticulous conjunctival dissection near the staphylomatous area helped avoid such a catastrophe.Uveal melanoma should also be suspected in patients with staphyloma and cataract precluding fundus evaluation. An ultrasound should be performed in all cases presenting to us as blind eyes without a known cause.


Diverticulosis coli is the most common disease of the colon in Western countries. Giant colonic diverticulum, defined as a colonic diverticulum measuring 4 cm in size or larger, represents an unusual manifestation of this common clinical entity.A 68-year-old Caucasian British woman with a history of intermittent lower abdominal mass, leg swelling and focal neurological symptoms underwent extensive non-diagnostic investigations over a significant period under a number of disciplines. The reason for a diagnosis being elusive in part related to the fact that the mass was never found on clinical and ultrasound examination. As a result, the patient's validity was questioned. Ultimately, this 'phantom-mass' was diagnosed as a giant colonic diverticulum causing intermittent compression of the iliac vein and obturator nerve.Intermittent compression of the iliac vein and the obturator nerve by a colonic diverticulum has not previously been reported. A giant colonic diverticulum presenting as an intermittent mass is very rare. This case also illustrates two factors. First, the patient is often right. Second, the optimal mode of investigation for any proven or described abdominal mass with referred symptoms is cross-sectional imaging, typically a computed tomography scan, irrespective whether the mass or symptoms are constant or intermittent. Giant colonic diverticulum (GCD) defined as a colonic diverticulum measuring 4 cm in size or larger is a rare disease . It is nSeveral theories have been proposed to explain its aetiology: a unidirectional flap-valve mechanism at the base of the diverticulum allowing bowel gas and debris to enter but not to leave the diverticulum; gas-forming organisms distend a diverticulum after its mouth has become obliterated; an organized abscess that develops around an infected pre-existing pseudodiverticulum; or a true congenital duplication ,2. The eHere we report a patient with GCD who presented with some peculiarities, which we believe will be valuable in further explaining the mechanism behind GCD, and may help in the prompt diagnosis and treatment of future similar cases.A 68-year-old Caucasian British woman presented with a history of an intermittent large painless mass in her lower abdomen. The mass was more pronounced before defecation and was associated with paraesthesia in the medial side of the left thigh and swelling of the left lower limb. Following defecation, the mass disappeared with instant relief of the associated symptoms. She had no other associated complaints and clinical examination was normal.Blood tests and abdominal ultrasound were normal. Colonoscopy showed sigmoid diverticulosis. She was reassured and discharged.The patient's symptoms recurred and she was referred for a second opinion from a gastroenterologist, a urologist, and a neurologist. Clinical and neurological examination was again confirmed to be normal. An upper gastrointestinal series, intravenous pyelogram, cystoscopy, MRI spine and venous duplex scan were all reported as unremarkable, though at the time of these tests, the patient was asymptomatic. The patient was referred to a psychiatrist and subsequently commenced on various sedatives and antidepressants with no improvement.Two years later, she was referred to our team with similar ongoing complaints. Clinical examination remained unremarkable. Barium enema confirmed uncomplicated diverticular disease. Shortly following barium enema she developed severe lower abdominal pain and fever. Computerized tomography demonstrated a thick-walled, air filled cavity closely related to the sigmoid colon, compatible with a GCD Figure .At laparotomy, an 8 cm mass was found to originate from the antimesenteric border of the sigmoid colon. It was adherent to the iliac vessels and lateral pelvic wall. Diverticulosis involving mainly the sigmoid colon was noted. Sigmoid colectomy was performed. She had an uncomplicated recovery. At 12-month follow-up, she remained asymptomatic.Pathology confirmed a GCD with diverticulitis and peritonitis. This diverticulum was 8 cm across with a 5 mm luminal orifice and was filled with air and faecal debris; a flap-valve effect was noted at the opening of the colon. [Uninflamed simple diverticula were also noted.Diverticulosis coli is the most common disease of the colon in Western countries; GCD represents an unusual manifestation of this common clinical entity .Histologically, there are three different types of GCD with similar clinical presentations . The firIf no mucosal remnants are found, the GCD is considered inflammatory (type 2), which is actually a result of a local perforation of the mucosa with an abscess cavity that remains in contact with the lumen of the colon (organized abscess theory). The wall of this diverticulum contains reactive scar tissue only. The third type is a true diverticulum, in which the wall contains all of the layers of normal bowel .In this patient, the diverticulum gradually inflated because of a flap-valve action of the tiny opening from the bowel, allowing gas and debris to enter, but not escape, during periods of straining. The failure of barium to enter the GCD attests to the small size of the opening. The fact that this GCD could expand and shrink indicates that its wall had elastic properties. When fully expanded, it produced compressive symptoms.Symptoms of GCD and their duration are variable; often the patient's complaint can be ascribed to the associated diverticulitis . A palpaSuch a presentation of GCD as a longstanding non-inflammatory intermittent abdominal mass is distinctly unusual. Intermittent compression of the iliac vein or the obturator nerve as a presentation of GCD has not previously been reported.Plain film diagnosis of GCD can be made in the presence of a persistent smooth-walled gas containing structure, 'balloon sign', adjacent to the colon with or without air fluid level .Diagnostic colonoscopy is not considered to be helpful  except iUltrasound examination does not seem to be helpful in detecting a non-complicated GCD . In our This case of GCD which presented initially with a longstanding non-inflammatory intermittent abdominal mass is distinctly unusual. Intermittent compression of the iliac vein or the obturator nerve as a presentation of GCD has not previously been reported.This case also illustrates two factors. First, the patient is often right. Second, a proven or described abdominal mass with or without referred symptoms should prompt cross-sectional imaging, typically a CT scan, irrespective of whether the mass or symptoms are constant or intermittent.CT: computed tomography; GCD: giant colonic diverticulum; MRI: magnetic resonance imagingWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AA and AO identified the association between the GCD and the patient's unique presentation, reviewed the literature and drafted the manuscript. MA and IB contributed to drafting the manuscript and critically revised the discussion and conclusions. All authors have read and approved the manuscript.


Soft tissue tumors of the feet are uncommon and there have been very few reports of large series in the literature. These tumors continue to present the clinician with one of the most difficult problems in medicine.We present a case of a large multilobular noninfiltrating angiolipoma at the plantar surface of the forefoot. Only three cases occurring at the foot have been previously described. We report this new case due to unusual location of the tumor, the long duration (25 years) of its existence and the unique surgical approach for the tumor excision.Surgical excision is the treatment of choice and adjuvant radiotherapy is indicated in select cases. Benign lipomatous lesions involving soft tissue are common musculoskeletal masses  though they are rare in the foot. They are classified into nine distinct diagnoses: lipoma, lipomatosis, lipomatosis of nerve, lipoblastoma or lipoblastomatosis, angiolipoma, myolipoma of soft tissue, chondroid lipoma, spindle cell lipoma and pleomorphic lipoma, and hibernoma .Angiolipomas are benign neoplasms and have been first described by Bowen in 1912 . The preA 47-year-old man was admitted to our department with a soft nodular mass at the plantar surface of the forefoot figure . He compPhysical examination revealed a tender soft-solid nodule. A corn was developed at the overlying skin. No tingling or numbness was present. Neurological consultation was negative. Past medical and familiar history, as well as general examination was negative.Radiographs of the foot and computer tomography (CT) demonstrated a soft-tissue lesion with no osseous involvement. Magnetic resonance imaging (MRI) revealed a well-defined mass located at the plantar forefoot with no apparent bone infiltration, figure . The sagGross pathology: The specimen 7 × 5 × 2 cm. with ill defined margins was yellowish and elastic in consistency. Histologically: the mass was comprised of mature adipose and proliferated vascular tissue in various proportion from field to field with no signs of atypia in either of the two components,  or magnetic resonance imaging (MRI). On contrast-enhanced studies, angiolipomas demonstrate a marked enhancement as a result of their intense vascularity. Noncontrast studies demonstrate the homogenous low attenuation of a typical lipoma . In our The main challenge of these otherwise benign tumors is first to establish a correct diagnosis. They belong to a wider spectrum ranging from benign pure lipomas, composed of adipose tissue, to benign pure angiomas, composed of vascular tissue. They probably lie in the middle of this spectrum and according to the relative percentages of adipose and vascular tissues, can be divided as lipomatous or angiomatous types ,9.Although a presumptive diagnosis is typically made clinically, these tumors with atypical clinical features may require radiological consultation. Difficulty arises when radiographic features are not typical of lipoma. Radiological evaluation is diagnostic in up to 71% of cases. These lesions are identical to subcutaneous fat on computed CT and MRI images .Histopathologically angiolipomas are characterized by mature adipose tissue containing copious vascular elements that vary from sinusoids, thin-walled vessels or thick-walled vessels with proliferation of the smooth muscle layer . MitoticBased on studies by Dionne  and Lin Although angiolipomas are benign lesions sometimes they can be more aggressive and invade the contiguous bone and adjacent soft tissues ,17. ContDifferentiation of angiolipomas from liposarcomas based on imaging features is not possible some times necessitating surgical resection for definitive histological diagnosis . The difBenign lipomatous lesions affecting bone, joint, or tendon sheath include intraosseous lipoma, parosteal lipoma, liposclerosing myxofibrous tumor, discrete lipoma of joint or tendon sheath, and lipoma arborescens. Intraosseous and parosteal lipoma have a pathognomonic CT or MRI appearance, with fat in the marrow space or on the bone surface, respectively. Liposclerosing myxofibrous tumor is a rare intermixed histological lesion commonly located in the medullary canal of the intertrochanteric femur. Benign lipomatous lesions may occur focally in a joint or tendon sheath or with diffuse villonodular proliferation in the synovium (lipoma arborescens) and are diagnosed based on location and identification of fat.The treatment of both infiltrating and noninfiltrating angiolipomas is total surgical excision. The infiltrating type of lesion is associated with more treatment difficulties. These lesions have been reported to recur after surgical excision in 35 to 50% of cases . Wide loThe author(s) declare that they have no competing interests.TBG was the principal investigator of the study, operated upon the patient, conducted the collection of data and involved in drafting the article. ODS involved in drafting the article and involved in collection of the literature, SAP helped in manuscript drafting and in the collection of the literature, the GL performed the pathological examination, wrote the report and involved in drafting the article and GT, IK, PA were involved in collection of the literature and drafting of manuscript. VK made the radiological diagnosis and report. All the authors read and approved the final manuscript.


Late colonic metastasis following curative surgery for renal cell carcinoma has rarely been described. We present the first reported case of solitary colonic renal cell carcinoma metastasis presenting as an intra-abdominal bleed, nine years post-nephrectomy. The worldwide incidence of renal cell carcinoma (RCC) is approximately 209 000 new cases per year with a mortality of 102 000 deaths per year. This accounts for 3% of all adult malignancies. Metastatic disease may be present in up to 25% of patients at the time of diagnosis [Intestinal metastasis from RCC is uncommon. The commonest site of distant metastasis in 1451 autopsy cases with RCC was in the lungs (76%), followed by lymph nodes, bones and liver . RCC verA 65-year-old woman presented to casualty with acute abdominal pain and collapse. The only significant history was of a left nephrectomy for clear cell renal carcinoma nine years previously, from which she had made a full recovery, recently being discharged from further follow-up. The patient recalled that her RCC had been excised with tumour-free margins - no further information was available.Examination revealed generalised abdominal tenderness with a normal haemoglobin of 11.4 g/dL. Portable ultrasound scan excluded an abdominal aortic aneurysm. A few hours later, she became haemodynamically unstable with marked abdominal distension. Repeat bloods showed a drop in haemoglobin to 7.7 g/dL. There had been no sign of haematemesis, melaena or fresh rectal bleeding. At emergency laparotomy, an actively bleeding mass was found attached to the surface of the mid-transverse colon. This was excised locally with the resulting colonic defect closed in 2 layers. No other lesions were noted within the abdominal cavity.Macroscopic examination revealed a 6 × 6 cm soft brown tumour with central necrosis. Histology of the lesion demonstrated a clear cell tumour - a metastasis from the original renal cell carcinoma removed nine years previously. Subsequent computed tomography (CT) of the thorax and abdomen excluded any further metastatic disease. As such, a conservative approach without immunotherapy was adopted and the patient was followed-up with regular clinical examination and CT scans. No evidence of further recurrence has been demonstrated six years following her laparotomy.Uchida et al have stated that if patients with RCC undergo curative nephrectomy and subsequently develop recurrence, this usually occurs within five years post-operatively (i.e. early recurrence) . Out of The biological behaviour of RCC is variable, and the prognosis unpredictable. Despite it being a male-predominant disease 2:1), the predominance of women among patients with late recurrence and their better survival rate may suggest an endocrine influence on the activity of the tumour , the pre,6,9,11. In summary, recurrence of RCC more than five years after nephrectomy is not a rare event, and is one of the particular characteristics of RCC . HoweverWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.AMJ and BAD were responsible for delivering patient care. AMJ and SGT contributed equally towards to drafting of the manuscript while BAD provided overall supervision and edited the final version of the manuscript. All authors read and approved the final manuscript.


There are several types of small bowel pathology that can lead to small bowel obstruction or intussusception. The etiology causing small bowel obstruction varies by age. Benign disease is the typical cause in children and adolescents while malignant or adhesive disease is far more common in older patients. Although cases of adult intussusception caused by benign processes are rare, there are reports of inflammatory fibroid polyps causing adult intussusception of the terminal ileum published in the literature.We present the case of a 70-year-old man with a multiple year history of intermittent episodes of bowel obstruction who was found to have a giant ileal inflammatory fibroid polyp causing intermittent small bowel obstruction. The patient underwent operative intervention and has now been symptom-free for three years.Small bowel lesions include both malignant and benign etiologies. The malignant etiologies include adenocarcinoma, carcinoid or lymphoma while benign lesions are typically lipomas, inflammatory polyps or adenomas. Inflammatory fibroid polyps are rare, benign lesions that can occur anywhere within the gastrointestinal tract. They are typically an incidental finding, but on rare occasions have been presented as the source of intussusception or obstruction. There are several types of small bowel pathology that can lead to small bowel obstruction or intussusception. The etiology causing small bowel obstruction varies by age. Benign disease is the typical cause in children and adolescents while malignant or adhesive disease is far more common in older patients ,2. AlthoA 70-year-old gentleman presented for gastroenterology consultation after multiple episodes of severe abdominal pain that occurred over a period of six years. The patient had a past medical history of hypothyroidism and hypertension. He reported several episodes of nearly identical GI symptoms over this period of time. The episodes would begin with right upper quadrant abdominal pain that would be relatively sudden in onset and 3 out of 10 in severity. Over a matter of hours, the pain would crescendo to 10 out of 10 and would last three to four additional hours. During this period of time, the patient would pass very little flatus and would develop abdominal distention, severe diaphoresis, and nausea. The pain would settle in the right lower quadrant for several hours and then would almost completely resolve. The patient would then remain "sore" for a period of one to two additional days. On a few occasions, he had vomiting. He had two such episodes with vomiting prior to presenting for evaluation.Between the episodes, the patient reported normal bowel habits. He had no history of diarrhea, weight loss, or significant nausea or vomiting. The patient had no history of anemia or GI bleeding. He had never undergone a colonoscopy in the past. The patient did not use aspirin or other non-steroidal anti-inflammatory medications on a regular basis.The patient's physical exam was unremarkable. The patient was afebrile, vital signs were stable. The patient's abdomen was soft, non-tender and non-distended. There were no palpable masses in abdomen. There were no incisional scars on the abdomen.Evaluation included a CT scan of the abdomen and pelvis. The CT scan showed a benign appearing renal cyst and an area of abnormal ileum. An approximately 12 centimeter long portion of ileum demonstrated concentric thickening. The radiologist offered a presumptive diagnosis of Crohn's.Laboratory evaluation demonstrated a normal complete blood count and normal iron studies. The patient underwent colonoscopy to further evaluate the ileal thickening. He tolerated colonoscopy prep without difficulty. Colonoscopy demonstrated left colon diverticula. The terminal ileum was abnormal. The mucosa appeared atrophic and the luminal diameter was narrowed. There was also a mobile, pedunculated 3.5 centimeter frond-like mass. During the endoscopic evaluation, this lesion was seen to move proximally and distally over a span of at least 5 to 7 cm. It was difficult to biopsy given its movement. When the mass moved distally it filled the entire terminal ileal diameter Figure . The masThe patient had two additional episodes of abdominal pain in the months after the colonoscopy. After one of the episodes he underwent a small-bowel follow through which demonstrated 18 cm of abnormal small bowel in the distal ileum with effacement of the small bowel folds Figure . No mentThe patient then agreed to surgical evaluation and underwent laparoscopic assisted right hemicolectomy. Exploratory laparotomy showed a thickened portion of ileum. Pathologic exam showed a 3 cm inflammatory fibroid polyp composed of an edematous stroma containing spindle shaped stromal cells, lymphoid nodules and eosinophils Figure .The patient has been symptom free for more than three years. He has had no further obstructive symptoms and he has no symptoms suggesting Crohn's disease.Bowel obstruction can occur as a result of a mechanical blockage or dysfunction of the small or large intestine. Only 5% of intestinal invaginations or intussusceptions occur in adults. Cases of adult intussusceptions account for only 1–5% of all small bowel obstructions . PatientSixty-five percent of all adult intussusceptions occur due to a malignant or benign lesion usually appearing at the head of the invagination. The probability of malignancy is greater for those cases occurring in the large intestine. Malignant lesions are found in 43% to 80% of intussusceptions located in the colon compared to only about 14% to 47% of cases occurring in the small intestine. Benign tumors as the lead points of an intussusception have been found to include lipomas, leiomyomas, neurofibromas, adenomas, and inflammatory fibroid polyps .The underlying cause of Inflammatory fibroid polyps (IFPs) is still unknown. Many have suggested etiologies possibly related to chemical, physical, or metabolic triggers . IFPs weIn a case series of 75 patients presenting with inflammatory fibroid polyps, Johnstone et al. reported three-fourths of all cases as gastric IFPs . The occCases of intussusception have been reported secondary to Crohn's disease . While tIFP: Inflammatory Fibroid PolypWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SOM was involved in the drafting of the article, critical revision of the article for important intellectual content. SAM was involved in the conception and design. AMR was involved in the conception and design. JAT was involved in the drafting of the article, analysis and interpretation of the data, critical revision of the article for important intellectual content. TMS was involved in the conception and design, drafting of the article, analysis and interpretation of the data, critical revision of the article for important intellectual content. All authors contributed in the final approval of the article.


Angiosarcomas are malignant neoplasias of rapid growth that develop from endothelial cells. They represent 2% of all sarcomas and only 1–4% are located in the aerodigestive tract. Since 1977, only 16 cases have been reported.We present a 33-year-old male with spontaneous epistaxis that was refractory to cauterization. During physical examination, a smooth purplish tumor of 1.5 cm × 1.5 cm was identified. A CT scan showed a nonenhanced tumor in the left nostril on the uncinate process. A biopsy revealed an intermediate-grade angiosarcoma. Surgical removal followed by radiation therapy was performed with good result. Aerodigestive angiosarcomas have a better prognosis than angiosarcomas of other locations due to better cell differentiation and the presence of early symptoms. Recurrence can occur because of tumor tissue left during resection. Our patient continues tumor free after three years. Angiosarcomas are malignant neoplasias of rapid growth that originate from endothelial cells ,2. They They appear during middle age and prognosis depends on location, size and degree of tissue invasion.We present a case of angiosarcoma of the nasal cavityA 33-year-old male came to our clinic with a 5 month history of recurrent epistaxis of the left nostril described as nasal dripping, previously treated in another center on four occasions by cauterization of the left nasal mucosa with persistence of bleeding. During examination of the nose, we identified a smooth purplish tumor 1.5 cm × 1.5 cm attached to the lateral nasal wall between the inferior and middle turbinates  as the treatment of choice. Chemotherapy has a low impact on the disease. Kazuto Fukushima et al. reported favorable results with the use of recombinant interleukin 2, combined with surgery [Free margins are the best prognostic factor for avoiding recurrence ,8Angiosarcoma of the skin or soft tissue of the head and neck is associated with a 50% mortality rate within the first 25 months and a 12% survival rate at 5 years, compared to nasal cavity or paranasal sinus angiosarcoma, which have a 22% survival rate at 5 years according to grade of differentiation and early diagnosis A literature review reported a 20.8 month survival rate. Cervical metastasis occurs in 10–15% of cases and distal metastasis to bone, liver, lungs or skin occurs in 30% of patients during the first 24 months of the disease.Radical surgery followed by radiotherapy is still the treatment of choice. Due to the lack of experience with these tumors, we believe that a better approach should be sought in order to unify criteria and provide patients with better results."Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."The authors declare that they have no competing interests.JT participated in the conception and design of the case, and help to draft the article. RS participated in acquisition of data and analysis and interpretation of patient data. MV participated in analysis of patient data. VV participated in critical revision and analysis of patient data. BG participated in analysis of patient data. EV drafted the article, acquisition of data and assisted in data analysis. All authors read and approved the final manuscript.


Osteomas of ethmoid sinus are rare, especially when they involve anterior skull base and orbit, and lead to ophthalmologic and neurological symptoms.The present case describes a giant ethmoid osteoma. Patient symptoms and signs were exophthalmos and proptosis of the left eye, with progressive visual acuity impairment and visual fields defects. CT/MRI scanning demonstrated a huge osseous lesion of the left ethmoid sinus (6.5 cm × 5 cm × 2.2 cm), extending laterally in to the orbit and cranially up to the anterior skull base. Bilateral extensive polyposis was also found. Endoscopic and external techniques were combined to remove the lesion. Bilateral endoscopic polypectomy, anterior and posterior ethmoidectomy and middle meatus antrostomy were performed. Finally, the remaining part of the tumor was reached and dissected from the surrounding tissue via a minimally invasive Lynch incision around the left middle canthus. During surgery, CSF rhinorrhea was observed and leakage was grafted with fascia lata and coated with bio-glu. Postoperatively, symptoms disappeared. Eighteen months after surgery, the patient is still free of symptoms.Before management of ethmoid osteomas with intraorbital and skull base extension, a thorough neurological, ophthalmological and imaging evaluation is required, in order to define the bounders of the tumor, carefully survey the severity of symptoms and signs, and precisely plan the optimal treatment. The endoscopic procedure can constitute an important part of surgery undertaken for giant ethmoidal osteomas. In addition, surgeons always have to take into account a possible CSF leak and they have to be prepared to resolve it. Osteomas are relatively rare, slow-growing, osteogenic tumors. They are the most frequent benign neoplasm of the paranasal sinuses, usually originating in the frontal sinus and much less in ethmoid, sphenoid and maxillary sinus. As osteomas are usually asymptomatic, they are very often incidental radiographic findings, most authors agree that small lesions do not need surgery suggesting periodic imaging in order to follow the growth and allow intervention before the development of complications . EthmoidSurgery is the treatment of choice for symptomatic ethmoid osteomas, however, the approach is under discussion and depends on the extension and the occurrence of complications . TraditiWe report a case of a bulky ethmoid sinus osteoma, with anterior skull base and intraorbital expand, treated with a combination of endoscopic and external approach.We also report the management of SCF linkage presented in the same patient, performing duraplasty with fascia lata.A 52-year-old man was referred to our department with a 3 year history of exophthalm, proptosis Fig  and progAssessment by means of coronal and axial computed tomography (CT) scan Fig  of the pDue to the size of the tumor, endoscopic removal was not feasible. Moreover, osteoma was broadly attached to the ethmoidal borders which did not allowed sufficient access to these borders using endoscopy. Hence, to create a better exposure, a combination of endoscopic endonasal technique with external approach carried out. The procedure was performed under general anesthesia; it began with a bilateral endoscopic polypectomy, followed by anterior and posterior ethmoidectomy and middle meatus antrostomy, using 0° and 30° endoscopes. Then, the size of the tumor was significantly reduced with the assistance of diamond drill. Afterwards, an external, non extensive "Lynch" frontoethmoidal incision was used around the left medial canthus in order to give access to the residual specimen. The mass was removed piecemeal. Lamina papyracea was in continuity with the osteoma. The orbit was gently shifted laterally, the osteoma was carefully detached from orbital periosteum and a piece of the osteoma was removed. Periosteum of the medial wall of the orbit was intact without any defect, so reconstruction was not necessary. Finally, the small remaining part of the osteoma was separated from the anterior skull base using a curved blunt elevator Fig . After rThree months later, diplopia and proptosis had been resolved Fig  and the Although small frontoethmoidal osteomas are relatively frequent, giant osteomas are particularly rare findings in this region . LesionsA detailed assessment of the margins of the tumor and definition of its relation with the surrounding structures is required in order to choose the most precise approach . A CT scThere are conflicting reports about the ability of an osteoma to recur after incomplete removal ,12. NeveThere are several reports of successful removal of large ethmoid osteomas with intraorbital extension, treated endoscopically. Huang et al have preIt is worth mentioning, that this is not the first time that the coexistence of sinus osteoma with nasal polyps is reported. Since the etiology of the two entities is not fully investigated, it is possible that both of them are under the influence of similar etiological factors. In the past, post-traumatic and infectious causes have been discussed, and more recent studies advocate the role of developmental and genetic factors in the pathogenesis of both, nasal polyposis and sinus osteoma. .Endoscopic surgery meaningfully assists the removal of large osteomas of the ethmoids, minimizing soft tissue dissection and averting facial bony disruption. Surgeons may be faced during operative procedure with a CSF linkage. Therefore, they have to be prepared to repair it.The authors declare that they have no competing interests.IY, LM, and DK performed surgery, follow-up patient and helped in preparation of manuscript. AE prepared the draft of the manuscript. EG and EF helped to draft the manuscript. All authors read and approved the final manuscript.Written informed consent was taken from the patient for publication of this case report.


Acute gastric dilatation is a rare complication of anorexia nervosa binge/purge subtype that results from gastrointestinal abnormalities, including decreased gastric motility and delayed gastric emptying. Early diagnosis and intervention is critical since delay may result in gastric necrosis, perforation, shock, and death. We report a 26-year-old female with anorexia nervosa binge/purge subtype, who presented with abdominal pain and nausea after a binge episode. Abdominal radiography and computed tomography showed a grossly dilated stomach measuring 32 cm × 17.9 cm consistent with acute gastric dilatation. She underwent exploratory laparotomy with gastrotomy and gastric decompression, and recovered uneventfully. Initially, the patient denied the binge episode, as many patients with eating disorders do, but later revealed an extensive history of anorexia nervosa binge/purge subtype. This case stresses the importance of obtaining a thorough history of eating disorders and maintaining a high index of suspicion for acute gastric dilatation in young women who present with abdominal pain and distention. Anorexia nervosa binge/purge subtype is a disorder characterized by a refusal to maintain adequate body weight with intermittent binge/purge episodes. Anorexia nervosa and bulimia nervosa afflict about 0.6–1% of the population of USA. This is A 26-year-old female with a history of anxiety and depression presented to our Emergency Department with sudden onset of diffuse abdominal pain, nausea, and an inability to vomit of 2 hours duration. Her pain was sharp, severe, and worst in the epigastrium. She reported drinking four beers and eating a Cobb salad several hours prior to presentation. She denied diarrhea, constipation, fever, and chills. She reported no similar episodes in the past and denied the consumption of non-food items.Physical examination revealed a thin, uncomfortable appearing young woman. Her weight was 99 pounds and height was 61 inches. Her temperature was 98.6°F, pulse was 100 beats per minute, and blood pressure was 114/77 mm Hg. The abdomen was distended, firm, and diffusely tender to palpation without peritonitis. All other examination findings were non-contributory.Laboratory abnormalities included potassium 3.1 mEq/L, amylase 210 U/L, and lipase 114 U/L. Remaining chemistries and a complete blood count were normal. Abdominal plain film showed a grossly distended stomach filled with extensive food matter . There wThe patient underwent a laparotomy  which revealed a massively distended stomach. Anterior gastrotomy showed that the stomach was filled with nearly 2 gallons of partially and minimally digested food including whole pasta shells and vegetable matter. Due to the large size and thick consistency of the stomach contents, they were removed via a 40-Fr. chest tube secured in the gastrotomy site, with gentle massage of stomach contents through the tube into a basin. Following adequate decompression, the tube was removed, the stomach mobilized out of the wound, the remaining contents emptied, and the gastrotomy closed. No discrete bezoar or mechanical gastric outlet obstruction was identified. Of note, the gastric wall was poorly perfused due to the massive distention, and the site of gastrotomy showed patchy necrosis even after decompression. Thus, a portion of the anterior wall was resected to viable appearing tissues to allow for safe closure of the gastrotomy. Pathology of the excised gastric wall showed gastric mucosal necrosis.The following day, the patient admitted to a massive 1-hour binge prior to presentation, and revealed a history of anorexia nervosa and binge eating. At age 14, she had been diagnosed with anorexia nervosa binge/purge subtype. Although she had not engaged in binge eating for 4 years, she attributed this episode to alcohol intoxication and stress.Postoperatively, a nasogastric tube was left in place for gastric decompression, and a post-pyloric feeding tube in case of gastric ileus after the extreme distension. The nasogastric tube was removed on day 3 and a clear liquid diet started. She advanced to a full liquid diet and was discharged on day 5. She has since resumed a full diet and has reported no problems.Acute gastric dilatation with necrosis is a rare complication of binge/purge subtype anorexia nervosa.5 There a2The pathophysiology of gastric dysfunction in anorexia nervosa binge/purge subtype is poorly understood. Possible mechanisms include gastrointestinal smooth muscle atrophy, diminished release of cholecystokinin, abnormalities in the autonomic nervous system, and gastric rhythm abnormalities.Patients with acute gastric dilatation typically present with sudden onset abdominal pain, distention, and inability to vomit. It is important to elicit any present or remote history of eating disorders, which patients may initially deny. Maintain2O, a decrease in venous outflow may result in ischemia and infarction of the gastric wall which can rupture.[Feared complications of acute gastric dilatation include necrosis, perforation, shock, and death.–5 As the rupture. The mortInitial treatment of acute gastric dilatation includes nasogastric decompression and fluid resuscitation. However,In conclusion, this case report stresses the importance of a thorough history of eating disorders in young women who present with distention and abdominal pain; a high index of suspicion should remain even when the patient denies an eating disorder. If acute gastric dilatation is suspected and non-operative treatment is not viable, early surgical intervention is critical in preventing fatal complications.


Subdural effusion in the setting of dural metastasis is very rare and may be difficult to be distinguished from chronic subdural hematoma.th day depicted fluid re-accumulation and noticeable midline shift, necessitating craniotomy and removing the affected dura.A 44-year old woman with gastric adenocarcinoma was presented with headache and a hypodense subdural collection in right fronto-parietal in brain CT. Burr-hole irrigation was performed with the impression of chronic subdural hematoma, but nonhemorrhagic xantochromic fluid was evacuated without malignant cell. Brain CT on the 11Because the affected dura can be supposed as the main source of subdural effusion, resection of the involved dura is obligatory for the appropriate palliative management of such patients. Subdural effusion may occur following different situations such as bacterial meningitis, head injury and certain surgical procedures such as transventricular approaches or endoscopic third ventriculostomy -4. HowevIn this report, a case of advanced gastric adenocarcinoma with systemic dissemination and metastatic subdural effusion is presented and different aspects regarding diagnosis, treatment and pathophysiology of the lesion, and differentiation from CSH are discussed.A 44-year old woman with a 2-year history of gastric adenocarcinoma and regional lymph nodes involvement was admitted with severe headache, drowsiness, and mild left hemiparesis. She had recently been diagnosed with multiple systemic metastases including bilateral ovarian masses suggestive for Krukenberg tumor, pulmonary lymphangitic carcinomatosis, and multifocal bone involvements. The patient received 3 courses of systemic chemotherapy before the onset of headache. She had neither history of prior head injury, nor anticoagulant consumption. On admission, the patient was conscious but agitated, and the force of the left extremities was of 4/5 according to Louisiana State University Medical Center grading system. Brain computed tomography (CT) revealed a crescent-like hypodense subdural collection in the right fronto-parietal region, 1 centimeter in diameter with a considerable midline shift to the left (Figure Eleven days after surgery, the patient came back with more severe headache and subgaleal collection at the site of previous burr hole. New brain CT scan depicted re-accumulation of the subdural effusion and a noticeable right to left shift Figure . The preBecause of developing dysphasia and worsened hemiparesis during the assessments, re-operation was contemplated and right fronto-parietal craniotomy was performed. A gray-reddish thickened and hyperemic dura was disclosed. The affected dura was resected, and the borders of the dura in the vicinity of the involved region were coagulated carefully.Histopathological examination revealed a thickened dura containing the nests of metastatic adenocarcinomatous and inflammatory cells Figure .The patient's headache and other symptoms partially improved post-operatively. During 5 months follow up, serial images showed no evidence of recurrent effusion, nor did the patient experience any other episode of headache. However, the systemic metastatic disease progressed continuously, and the patient died from pulmonary insufficiency.Dural metastases account for about 3–13% of all intracranial metastatic involvements , with thThe differentiation between CSH and subdural effusion due to metastasis in CT scan images is difficult, as the subdural collection may mask the underlying dural involvement . Based oConsidering the poor prognosis due to tumor dissemination in most cases, the patients usually undergo palliative treatment. Bur hole irrigation alone is inadequate and may lead to fluid re-accumulation necessitating craniotomy to evacuate the subdural fluid and dura exploration for removing the metastatic tumor . Post-opThree theories can be postulated concerning the mechanism of subdural fluid accumulation in this case:1- The fluid extravasation into subdural space may be caused by increased hydrostatic pressure which can be explained by venous or arterial mechanisms. Obstruction of the dural veins by tumor cells would cause dilation of the capillaries in the inner areolar layer ,10, foll2- It has been shown that hyperplasia of the inner areolar layer occurs as an angiodesmoplastic response to the tumor invasion . The flu3- Considering the elevated protein content and negative cytology of the fluid, it can be suggested that the mucine producing adenocarcinomatous cells may have potential secretory capability themselves, and the fluid would be originated directly from metastatic malignant cells.In accordance with all mentioned mechanisms, the involved dura can be supposed as the main source of creating subdural effusion. Consequently, resection of the affected dura can control the effusion.In conclusion, dural metastasis should be considered in patients with malignant neoplasm and subdural collection. Because the affected dura itself is presumably responsible for fluid production, resection of the involved dura is obligatory for the appropriate palliative management of the metastatic dural effusion.Written informed consent was obtained from the patient's children for publication of this case report and accompanying images after her death. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SMHM made contribution to conception and analyzed the patient data. ZH made contribution in collecting data and drafting the manuscript. KTM was contributor in drafting the manuscript. FN was contributor in revising the manuscript critically. SAFT has given the final approval for the version to be submitted.


Cerebral venous sinus thrombosis is a rare but dangerous condition, occurring with an incidence of 3-4 cases/million/year. Cerebral venous sinus thrombosis presents a diagnostic challenge due to its varied presentation patterns. We report a case of a 42 year old Nepali man diagnosed with cerebral venous sinus thrombosis after presenting with a week long history of continuous headache. He improved rapidly following prompt anticoagulation. Despite thorough investigation no discernable underlying cause could be found. Our report highlights the value of prompt diagnosis of cerebral venous sinus thrombosis through neuroimaging and the importance of immediate anticoagulation as part of patient management. Cerebral venous sinus thrombosis (CVST) is an uncommon condition affecting 3-4 cases/million/year with a mean age of 37 to 38, though any age may be affected ,2. WomenIn this article we report a patient who developed a superior sagittal sinus thrombosis with no discernable underlying cause. It is hoped that the presentation of this case will draw attention to this rare and potentially devastating disease; helping increase clinicians' awareness of the clinical characteristics, methods of diagnosis and management of CVST.2O with normal constituents. D-dimer and fibrinogen degradation product (FDP) were marginally raised; all other parameters were within normal ranges. Magnetic resonance venography (MRV) confirmed the presence of a superior sagittal sinus thrombosis with a small venous infarct  scan appeared normal and lumbar puncture showed an opening pressure of 30 cm HVenous drainage of the brain involves blood flow through cerebral veins into the dural sinuses that then drain into the internal jugular vein. As in our reported case, the superior sagittal sinus is the main cerebral venous sinus affected by thrombus and is involved in 62% of cases . The undPredisposing risk factors are found in 80% . This maThe variation in which CVST presents makes it a diagnostic challenge. Our reported patient presented with a primary complaint of continuous headache which occurs in over 90% of cases . SymptomInvestigations are used in this condition in confirming the diagnosis, and establishing any predisposing causes. Initially, conventional CT scanning is usually performed to exclude other possible diagnoses such as subarachnoid haemorrhage. In 35% of published cases, CT scanning with contrast enhancement may demonstrate an 'empty delta sign' which is a useful radiological sign for the diagnosis of superior sagittal sinus thrombosis . FurtherInitial management of patients with confirmed CVST should include stabilization and the prevention of cerebral herniation. This may involve the use of Mannitol or surgery . DespiteThe prognosis of CVST is usually favourable but is worse in extremes of age, those with underlying conditions such as malignancy and sepsis, and in the presence of coma or deep cortical venous thrombosis . More thCVST is a challenging condition due to its wide range of clinical presentations. Clinicians should have a high index of suspicion, even in the absence of predisposing conditions, in order to facilitate a prompt diagnosis through neuroimaging. Expedited standard management for the CVST should be employed to help ensure the best possible outcome for patients.CSF: cerebrospinal fluid; CT: computed tomography; CVST: cerebral venous sinus thrombosis; FDP: fibrinogen degradation product; GCS: Glasgow Coma Scale; MRV: magnetic resonance venography; TCCS: transcranial color-coded duplex sonography.The authors declare that they have no competing interests.RKG helped gather information regarding the patient and complete the manuscript. AABJ helped gather information regarding the patient and complete the manuscript. UPD supervised the case report and reviewed the final manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.