Epidermal cysts are common skin lesions but they occur very rarely in the oral cavity, especially in the salivary glands. Very few cases have been reported in the literature and, here, we present one such rare case of epidermal cyst in the right parotid gland in a 62-year-old female patient. Epidermal/epidermoid cysts are common lesions occurring in the skin . Only 1.The diagnosis of an epidermal cyst in the parotid gland becomes very essential and it is a very rare entity and it could be easily mistaken for a salivary gland abscess, neoplasm, and other cysts . TherefoA 62-year-old female patient presented to our outpatient department with a complaint of swelling on the right side of the face in front of the ear for two years. The swelling was insidious in onset and gradually progressed to reach the present size. There was no history of pain, fever, difficulty in swallowing, or any discharge from the swelling. There were no other swellings present anywhere else in the body. There was also no history of trauma or any previous surgeries reported in the facial region.On examination, there was a localized ovoid swelling in the right preauricular region. The swelling was 6 × 8 cm in size and extended around 2 cm below the lobule of the right ear. There was no lifting of the ear lobe and the colour over the swelling was of normal skin colour with no surface discharge Figures  and 2. OUltrasound was carried out and it showed hyperechoic cystic lesion in the right parotid region measuring 4.2 × 6.1 cm. There was no vascularity in the lesion and no evidence of calculi in the duct or glands. So a benign parotic cystic salivary gland lesion was given as a diagnosis.Patient underwent surgical intervention and superficial parotidectomy was carried out. The cyst was removed in toto and gross examination revealed a globular mass measuring 4.5 × 6 cm in size and cut surface yields a pultaceous material . SectionEpidermal cysts are common skin lesions that consist of epithelial lined cavities which are filled with viscous or semisolid epithelial degradation products . EpidermEpidermal cyst of parotid gland is a very rare benign cystic lesion and is seen in young to middle age adults . The exaThe different causes of swelling in the parotid region may include branchial cleft cyst which is “congenital”, or may be “acquired” due to inflammation, obstruction, neoplasm, calculi and trauma . Also ifHistopathological examination of the cyst is required for confirmation of diagnosis. Histologically, epidermal cyst has stratified squamous epithelial lining and is usually filled with cheesy material or keratin. But a dermoid or epidermoid cyst contains skin adnexa or other epidermal structures like sebaceous gland or hair follicle. Implantation dermoid is not derived from epidermal appendages and may contain foreign body  even thoEpidermal cysts of the parotid gland origin are extremely rare and a diagnostic challenge, but still, epidermal cysts should be considered as a differential diagnosis in cases of painless long standing enlargement of parotid gland which is soft in consistency.


Incarcerated abdominal wall hernias may contain a variety of contents, but very rarely contains the gallbladder. This rare diagnosis is often not considered and, when diagnosed, has a different management approach. The experience of the small number of case reports have yet to be collected and summarised.We report a presentation and management of an 85 year old Caucasian female with a gallbladder hernia into a parastomal defect, and outline the operative management.Incarcerated gallbladder hernia is an extremely unusual condition, best diagnosed by CT scan. Management should involve operative reduction, cholecystectomy and consideration of repair of the defect. A hernia is a protrusion of a viscus, or part of a viscus, through the walls of its containing cavity . A varieAn 85 year old Caucasian female was admitted with a four day history of increasing abdominal pain at her ileal conduit site with nausea but no vomiting. Five years prior, she was diagnosed with a high grade urothelial carcinoma, and underwent a total cystectomy with formation of a right iliac fossa ileal conduit. There was no evidence of tumour recurrence after 5 years of follow up. She did not have any other previous abdominal surgery and no significant past medical history.At the time of her presentation, she had mild fever but did not have vomiting. She had normal bowel function and her urine output via the ileostomy was normal. Physical examination revealed a firm, irreducible mass lateral to her stomal site with overlying erythema. The stoma was healthy in appearance. There was also a reducible midline abdominal hernia. Her white cell count was elevated but all other blood tests including electrolytes, renal function, bilirubin and liver function tests were normal. A CT scan with oral gastrograffin contrast showed a midline abdominal hernia with small bowel loops, and a parastomal hernia containing an enlarged, thick-walled mass which did not contain oral contrast Fig. . With clAt operation on the same day, a urinary catheter was placed in the stoma, and a midline laparotomy was performed. Following dissection and reduction of the midline abdominal hernia, the parastomal defect was defined Fig. . A 14 gaA gallbladder hernia is a rare event with only a small number of published case reports. The gallbladder has been reported to herniate spontaneously through a ventral defect in the abdominal wall , 4, or tAs the majority of reported patients were of older age, the mechanism for herniation may be related to the elongation of the gallbladder mesentery with age . This alThe presentation of this condition involves an acute or subacute irreducible and often tender abdominal lump. Fever and erythema over the lump may be present with a white cell rise, suggestive of an inflammatory process. Of note, jaundice or abnormal liver function tests are not associated features as there is no biliary obstruction. In addition, vomiting and bowel symptoms are also absent as there is often no associated bowel obstruction.CT is the imaging modality of choice for diagnosis. A gallbladder hernia may be suspected where there is the absence of the gallbladder from its anatomical position, and a defined, thick walled lesion within the hernia is present which does not contain oral contrast. The gallbladder is often strangulated at its narrow neck, and thus develops cholecystitis and noted to be thick-walled. One case report commented that if gallbladder herniation is suspected, the lump should not be reduced as there may be acute cholecystitis which may result in intra-abdominal contamination .Operative management via a midline laparotomy is preferred. This allows adequate exposure to identify the hernia sac and neck which then permits hernia reduction, cholecystectomy and repair of the defect (where possible). To aid reduction of the gallbladder from its herniated position, decompression may be performed with a wide bore needle. If bile is aspirated, the diagnosis is also confirmed and the decompression may also drain intraluminal infection to prevent contamination.In the majority of cases, a cholecystectomy was performed to prevent future herniation. In one case, a cholecystectomy was not performed as there was a short time period of presentation, and a non-inflamed gallbladder was observed . In addiUniversally, an uncomplicated post-operative recovery was reported. Only one case reported long term follow up, where re-herniation of small bowel through the parastomal defect occurred after 3 years .In summary, gallbladder herniation is a rare event which may be considered in an elderly patient where there is an acutely tender abdominal lump and CT evidence of the absence of the gallbladder from its anatomical position. The recommended management is an operative approach via a midline laparotomy. Reduction of the hernia may be aided by drainage of the contents. A cholecystectomy should be performed as there is often cholecystitis due to gallbladder incarceration. Repair of the defect should also be performed, unless, in a parastomal herniation, there is risk of compromise the blood supply to the stoma. Laparoscopic repair has been described and may be attempted if access can be gained. There is usually an uneventful post-operative recovery.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


An atypically large, free-floating thrombus extending from primary pulmonary malignancy into the left atrium (LA) is a rare phenomenon. Here, we report a 61-year-old man presenting with a large mass in the lower lobe of the left lung, extending to LA via the left inferior pulmonary vein.The thrombus remained clinically silent and was detected by computed tomography (CT) and transthoracic echocardiography. To prevent life-threatening complications including systemic embolism and sudden death, the patient underwent surgical excision of the mass under cardiopulmonary bypass. Pathology of the tumor and the embolus was confirmed as moderately differentiated squamous cell carcinoma. Furthermore, immunohistochemical studies demonstrated consistency of the tumor cells in this pathological category.The patient tolerated the surgery well and his condition began to improve gradually after the operation. Though there are no standard treatments available for this particular patient, surgery should be chosen as first line of intervention for large embolus formation in the LA.Incidence of cardiac metastases has increased over the last 30 years. Perhaps owing to increased life expectancy of oncology patients benefitting from advances in cancer diagnosis and management.A 61-year-old man presented with a low-density, round-shaped mass with well-defined margins measuring 5.5 cm on his preoperative chest radiograph  metastasis. It has been found that the frequency of cardiac metastases varies from 12% to 25% in postmortem patients who have died of malignancies and lung tumors show the most cardiac metastatic potential in the common tumors.6 In patients such as the 1 described in this study who are completely asymptomatic, an early diagnosis of the lung tumor with the embolus extending into the LA can be challenging. CT scan and pathological examination of the lung mass would be additional tools used for cardiac imaging during the differential diagnosis of the LA mass taking into consideration that 36% to 49% of cardiac metastasis may occur in NSCLC patients.8 In contrast to CT imaging, TTE is more accurate in the diagnostic process of the patient because this technique may display moving images of the heart particularly for the evaluation of a cardiac mass.Though tumor emboli extending into LA are not uncommon,9 left anterolateral thoracotomy was selected in this case. Since the removal of the embolus could associate with severe bleeding in the presence of dense adhesions, cardiopulmonary bypass was applied to ensure hemodynamic stability during surgery. Embolectomy was successfully performed despite the atypical size. This was facilitated by performing an inverted T-shaped atrial incision by which a line of cleavage was identified between the embolus and left atrial wall. Additionally, disconnection of the left inferior pulmonary vein was required when the whole embolus was completely removed in the surgical process. This not only shortened surgical time but also reduced risk of embolic event due to incomplete resection of the embolus extension. The presence of dense adhesions and absence of cleavage plane may make embolus removal difficult and the residual organized material of the embolus can be left under these circumstances. In such cases, autologous pericardial patch may be used to cover these areas to avoid future embolus formation.10 It is necessary to emphasize that a scheduled surgery should be executed as early as possible because any delay in treatment can be fatal and increase difficulty of the operation. Although safe resection of the large embolus depends largely on the degree of cardiac involvement, this patient tolerated the given surgical therapy well and his condition began to improve gradually after the operation.As the patient was considered to be at risk of systemic embolism and sudden cardiac dysfunction due to the intracardiac embolus,11 P63, a well-known marker of SCC differentiation,12 was over-expressed in both specimens, indicating consistency of these tumor cells in pathological category.Pathological examination of the postoperative patient revealed that the tumor consists of fascicular proliferation with nuclear palisading and a structureless array. Immunoreactivities of the mass and the embolus were all positive for AE1/AE3 (+++) and p63 (+++), which are consistent with a diagnosis of SCC. Postoperative examination of specific CK expression was used to gain valuable information as to the primary site of the tumor embolus. The result of pooled CKAE1/AE3 antibody demonstrated the embolus originated from epithelial carcinoma as the CK cocktail AE1/AE3 distinguishes epithelial carcinoma from nonepithelial malignancies and is often used to characterize the source of various neoplasms.13 It has been reported that some embolic symptoms can constitute the first manifestation of cancer-associated thrombosis.14 However, this patient never experienced these clinical events, suggesting that application of prophylactic anticoagulants was not required for him as necessary in preoperative and postoperative treatment because cancer patients may also have a higher risk of bleeding with the anticoagulant therapy.The size of the embolus was unusually large in comparison to previously reported cases despite the fact that the size of LA in our patient was normal. The exact etiology is not fully understood. It is likely that the hypercoagulable state of oncology patients is a contributing factor to formation of emboli in this size.16 This patient did not receive the adjuvant treatment with reasons including the type of the tumor, the patient's age, and overall health. Since NSCLC respond very poorly to chemotherapy drugs and the therapy itself may also cause unpleasant side effects,17 clinicians should individualize their treatment approach to the patient's specific needs.Better understanding of postoperative patients who will benefit from adjuvant chemotherapy is a field of active investigation.


Synovial chondromatosis is a rare disease of unknown etiology. It usually occurs unilaterally in the large joints like the knee, but may occur in the shoulder, elbow, hip, ankle and temporomandibular joints. The disease is usually intracapsular, but can also be extracapsular on rare occasions. The diagnosis of synovial chondromatosis is given after an anamnesis, physical examination and radiographic examination. However, the diagnosis is obtained after histological examination of the synovial tissue. We report an unusual presentation of bilateral synovial chondromatosis in the knee joint, with both intra and extracapsular localization. never described in the literature. Although synovial chondromatosis is described as a benign disease, it can be very destructive and debilitating. These lesions can mimic a malignant tumor and present a diagnostic problem. A synovial chondromatosis is a rare benign neoplasm that is caused by metaplasia of the synovium into chondrocytes . The aetA 38-year-old man presented with a seven month history of progressively worsening bilateral knees pain with associated swelling. The pain was present when the patient was at rest, and worsened when the legs was bearing weight, thus restricting his walking to short distances. His knees had become increasingly swollen. He was otherwise fit and well. His medical history was unremarkable and he was only taking a paracetamol, codeine and anti-inflammatory drugs for the pain. Upon examination, the patient was seen to have visibly swollen popliteal fossa and marked quadriceps wasting of his right lower limb. On palpation, the masses was hard, mobile, well defined, and measured 0.5 - 04 cm. The swelling was non-tender and there were no associated skin changes. He could fully extend his knee, but flexion was restricted to only 110 degrees. There was a McMurray test proved equivocal and no ligamentous instability. An examination of the patient's hip revealed no abnormality. A plain radiograph of the patient's knees revealed multiple calcific densities within the soft tissues surrounding it on the right one . AlthougThe patient's blood tests were normal: C-reactive protein 5 mg/l and the phosphate calcium balance without errors. A two-stage procedure was planned following the findings of the MRI scan. The first stage was arthroscopy , which wSynovial chondromatosis is a rare benign condition characterized by the presence of cartilaginous nodules in the synovium of joints, tendon sheaths, and bursae which often occur without trauma or inflammation . With diIt is generally agreed that the exact aetiology of synovial chondromatosis is unknown and controversy exists surrounding proposed hypotheses. Milgram, in 1977, categorized the disease process into 3 distinct phases . In phasConversely, individuals may have no signs or symptoms and it is an incidental finding secondary to another complaint. According to Milgram, this is related to the stage of the lesion . AccordiThis case is reported because of its rarity. No other cases of bilateral knee synovial chondromatosis with intra and extra capsular localisation, have been reported. Highlights the importance of careful clinical assessment, appropriate use of investigation, and careful pre-operative planning.


Vascular lesions have been classified in two broad categories, hemangiomas and malformations. Encapsulated vascular lesions have not been reported in the oral cavity, but they were described in other sites, mainly in the orbit. Herein, we present a case of an oral encapsulated vascular lesion located in the right buccal mucosa of a 69-year-old male, including histological and immunohistochemical description and a literature review. Key words:Buccal mucosa, hemangioma, vascular malformation, oral cavity. Classification of benign vascular lesions/tumors is complex and confusing, and they have been grouped in two broad categories, hemangiomas and vascular malformations ,2. HemanVascular hemangiomas/malformations of the mouth are relatively frequent, but encapsulated vascular lesions in general are uncommon and, for the best of our knowledge, not yet reported in the oral cavity. We report a case of an encapsulated vascular malformation of the right buccal mucosa of an adult male patient.A 69-year man was referred to our service with a swelling in the right cheek, of unknown time of evolution. Medical history was not contributory. Physical examination revealed a bluish soft asymptomatic nodule in the right buccal mucosa Fig. .An excisional biopsy was performed and microscopic examination revealed a well-encapsulated lesion rich in plethoric blood vessels lined by a single layer of flattened endothelial cells, presenting a lobular arrangement. The lesion was mainly composed by a venous component, and enlarged and tortuous vessels, with diameters ranging from 80 µm up to 1.5 mm. Some vessels showed a thin muscular wall, but more often large vessels presented thick walls. The stroma was collagenized and some areas displayed dense bundles of smooth muscle. Adipose tissue was also observed, mostly adjacent to the fibrous capsule Fig. . Masson Antibodies used for immunohistochemistry are listed in Nomenclature of reactive/benign vascular lesions is not clear, but in general they can be considered either as hemangiomas or vascular malformations -3,9,10. et al. (2013), orbital EVL, affect predominantly adults, with a mean age of 48 years; with a slight predilection for men, while orbital hemangiomas appear shortly after birth, therefore patient’s age seems to be critical for diagnosis. Histopathological features of orbital EVL are similar to those found in the current case, such as a well-circumscribed and encapsulated lesion showing an evident fibrous capsule of variable thickness, rich in vascular channels, mostly plethoric of blood (Encapsulated vascular lesions (EVL) are uncommon and, for the best of our knowledge, this is an undescribed feature that vascular malformations can present in the oral cavity. According to Osaki t al. 201, orbitalt al. 201, orbitalIn the differential diagnosis of the present case, a few rare well-defined vascular intraoral lesions can be considered, as sinusoidal hemangioma and spindle cell hemangioma. The first was described as a well-circumscribed lesion, located in the submucosa, and composed of multiple lobules of greatly dilated, thin-walled, ramifying and anastomosing vascular channels, demonstrating a sinusoidal appearance. In deeper areas it is observed intercommunicating cavernous vessels filled with blood and lined by a single layer of flattened endothelial cells . Howeveret al. (2013) named the orbital lesion as Adult Encapsulated Venous Lesion (AEVL), presenting similar microscopic aspects  . Ven. (2013) ,20. It i. Ven. (2


There are few reported cases of colorectal metastasis from cancers of other organs, particularly other segments of the colon. Here we describe the long-term survival of a 68-year-old male patient with metachronous rectal metastasis from cecal cancer who underwent repetitive resection and chemotherapy. The patient underwent ileocecal resection and hepatectomy for cecal cancer with liver metastasis  in 2006. The patient subsequently underwent splenectomy for splenic metastasis in 2007. In August 2008, barium enema revealed compression of the rectal wall, and abdominal computed tomography (CT) detected a mass along the rectum extending into the pelvis. Rectal metastasis from cecal cancer was suspected and Hartmann’s operation with bilateral seminal vesicle dissection was performed. Histological examination of the excised tumor revealed moderately differentiated adenocarcinoma formed in the muscularis propria of the rectum and infiltrating the connective tissue between the seminal vesicle and rectum. However, no tumor was detected in the rectal mucosa or submucosa. These histological findings supported the diagnosis of rectal metastasis from cecal cancer. The patient has been monitored at our clinic for 60 months after surgical removal of the rectal metastasis. The findings from this case should alert oncologists to the potential danger of rectal metastasis from primary colon cancer and the benefits of timely complete resection in terms of improved patient outcomes. Timely detection and improved treatment of metastatic disease have dramatically increased the long-term survival of many cancer patients. Although colorectal cancer is one of the most common neoplasias, it rarely arises as metastasis from cancer in other segments of the colon. There is no consensus regarding the most effective treatment strategy for such cases. Here we report the long-term survival of a 68-year-old male patient with metachronous rectal metastasis from cecal cancer who underwent repetitive resection and chemotherapy.A 68-year-old male patient presented at the Department of Gastrointestinal Surgery  with progressive abdominal distention and narrowing of the feces for 2 months. The patient’s medical history revealed that he had undergone ileocecal resection for cecal cancer with solitary liver metastasis in September 2006. Light microscopy of the resected specimen revealed moderately differentiated adenocarcinoma infiltrating the deep layers through the muscularis propria of the cecum and metastases in 1 of 14 lymph nodes. The tumor was diagnosed as stage IVA  according to the International Union Against Cancer tumor, node, and metastasis (TNM) classification (7th edition) [The findings of subsequent physical examination were unremarkable except for slight pallor in the palpebral conjunctiva. Hematological investigation revealed anemia , while other laboratory test results and serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. Barium enema revealed compression of the rectal wall with a partially uneven mucosal surface Figure . We suspThe mass had penetrated the anterior wall of the rectum below the peritoneal reflection. There were no intraoperative findings of disseminated tumor in the abdominal cavity, findings inconsistent with disseminated peritoneal metastasis. The resected tumor measured 5.5 × 4.0 × 3.5 cm and had an uneven surface (Figure Abdominal CT performed 6 months later in April 2009 revealed liver metastases, and the patient was treated with fluorouracil, leucovorin, and oxaliplatin + bevacizumab combination therapy. The patient exhibited complete initial clinical response; however, follow-up abdominal CT revealed growth of the liver metastases. The patient refused continued chemotherapy because of peripheral neuropathy caused by oxaliplatin and subsequently underwent partial hepatectomy in October 2011, pneumonectomy for lung metastasis in April 2012, and partial hepatectomy for liver metastasis in September 2012. Following the surgery to remove the rectal metastasis, the patient has been monitored at our outpatient clinic for 60 months.et al. [et al. [Cases of colorectal metastasis from cancers of other organs have occasionally been reported -5, but cet al.  and Kala [et al.  reportedet al. [The survival of patients with metastatic colorectal cancer has improved with combined therapies, including chemotherapy . Howeveret al.  reportedet al. . In the The patient’s tumor metastasized to the liver and lung after Hartmann’s operation. Fluorouracil, leucovorin, and irinotecan + bevacizumab combination therapy was an option for second-line therapy against the metastases ,11; howeColorectal metastasis from other sites of primary colon cancer is extremely rare, and complete resection of these metastatic lesions may significantly improve outcome. The findings from this case should alert oncologists to the potential danger of rectal metastasis from primary colon cancer and the benefits of timely complete resection.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.CT: Computed tomography; H & E: Hematoxylin and eosin; TNM: Tumor node, and metastasis.The authors declare no competing interests or competing financial interests with respect to the authorship and/or publication of this article.JS wrote the manuscript. TN and TT performed surgery. HU and TT drafted the manuscript. All authors read and approved the final manuscript.


The lingual localization of an enteric duplication is extremely rare but may present with respiratory and feeding problems that require emergency intervention. A 7-month-old boy was brought to our clinic with feeding difficulties and tongue swelling. Physical examination showed a cystic lesion located near the left side of the tongue base that caused tongue protrusion to the contralateral side. During surgery, a 3-cm diameter opaque thick-walled cyst was found to be very closely adherent to the base of tongue, which was excised in its entirety. Following surgery, the patient fed during the early postoperative period and no complications were observed other than hypersalivation. On histological examination, a cystic lesion lined with intestinal mucosa and goblet cells was found. We present the rare case of a duplication cyst of the posterior tongue, with a literature review. Enteric duplication describes heterotopy of the gastrointestinal mucosa, which is a rare congenital malformation that may vary greatly in presentation, size, location, and symptoms. Duplication cysts can occur anywhere in the gastrointestinal tracts from the mouth to the anus . The sizA 7-month-old boy was brought to our clinic with feeding difficulties and swelling of the tongue. On physical examination; we noticed a cystic lesion located near the left side of the tongue base which was causing protrusion of the tongue to the contralateral side. The child did not have any other anomalies on physical examination and his medical history was otherwise unremarkable. The patient was admitted for surgery, during which a 3-cm diameter opaque thick-walled cyst was identified to be very closely adherent to the base of the tongue. The total excision of the cyst via bipolar diathermy was performed under general anesthesia Figures  and 2. Wμm thick sections, and stained with hematoxylin and eosin (H&E) and Alcian blue, before being examined under light microscopy . The gross specimen measured 3 × 2.5 × 2.5 cm and consisted of a unilocular cystic mass that contained mucoid material. Microscopic examination indicated that the cystic lesion was lined with intestinal mucosa accompanied by goblet cells. Stratified squamous epithelium was also present in some areas  are usually considered to be choristomas or histologically normal tissue that is located in an abnormal position . The etiDuring the early postnatal period, respiratory and feeding difficulties may be observed depending on the location and size of the cyst. Larger cysts present with dyspnea or dysphagia and symptoms are generally more acute. Although fine-needle aspiration of the cyst content can give temporary relief during the neonatal period, definitive treatment can only be achieved by total excision of the cyst via laser ablation or bipolar diathermy , 10, 11.Although enteric duplication cysts can be lined by gastric, intestinal, colonic, or respiratory epithelium, the majority consist of gastric-type epithelium. Pathologically, cysts range from having only a mucosal lining, to having a full-thickness duplication that consists of the mucosa, submucosa, and muscularis propria , 13. In Duplication cysts should be considered as part of the differential diagnosis of a lingual cystic mass in an infant. The early surgical excision of such lesions in symptomatic patients is indicated to avoid failure-to-thrive and respiratory distress.


Hypoglycemia secondary to ectopic insulin secretion of non-pancreatic tumors is rare.We describe a middle aged woman with recurrent hypoglycemia. On evaluation, she was detected to have hyperinsulinemic hypoglycemia and right sided renal mass lesion. 68Ga-Dotanoc and 99mTc-HYNICTOC scans confirmed the intrarenal mass to be of neuroendocrine origin. Right nephrectomy was done and it turned out to be an insulin secreting neuroendocrine tumour. Neuroendocrine nature of this tumour was further confirmed by ultra-structural examination. Her hypoglycemia did not recur after resection of this tumour.Few cases of ectopic insulin secretion have been reported though some are not proven convincingly. This case addresses all the issues raised in previous case reports and proves by clinical, laboratory, functional imaging and immunohistochemical analysis that ectopic origin of insulin by non-pancreatic tumors does occur. To our knowledge, this is the first reported case of ectopic insulinoma arising from the kidney. We also extensively reviewed literature for similar cases of ectopic insulin secreting tumours published previously.The most common cause of endogenous hypoglycemia is hyperinsulinemia secondary to islet cell tumours of pancreas. Hypoglycemia due to non-pancreatic tumours is infrequently reported. Most of these non-pancreatic tumours secrete factors with insulin like activity. Ectopic insulin secretion has been reported in few cases but not convincingly proved. We report a case of ectopic insulin secretion by neuroendocrine tumour (NET) of kidney. The ectopic origin of the tumour is demonstrated by functional imaging  5.67 (5.1 – 14.1 mcg/dl), TSH 4.42 (0.27 – 4.2 mIU/ml), Insulin like Growth Factor- I(IGF-1) - 165.90 (62 – 205 ng/ml), growth hormone 1.20 ng/ml and cortisol 15.78 mcg/dl. Samples collected during hypoglycemia showed a serum insulin of 134 (2.6 – 24.9 μU/ml) and C-peptide of 13.35 (1.1 – 4.4) ng/ml. During another symptomatic hypoglycemia, she had plasma glucose of 44 mg/dl while her plasma insulin and C-peptide were 49.81 miu/ml and 9.36 ng/ml respectively confirming endogenous hyperinsulinemic hypoglycemia. She underwent high resolution radiological and functional imaging for localisation of insulinoma.Both multi-phase CT abdomen Figure  and contGross examination: Grossly the kidney measured 10×7×6 cm and weighed 350 gram. A solid well circumscribed yellowish tumour, measuring 7×6×5 cm, was identified in the upper pole of kidney .th post-operative day. The patient is asymptomatic, euglycemic and disease free at last follow-up at 3 months.No metastasis was detected. Our patient got discharged in stable condition on 10Islet cell tumours of pancreas produce insulin which cause hypoglycemia. Hypoglycemia due to non-pancreatic tumours is infrequently reported and poorly understood. Various mechanisms were proposed  are: (a)Ectopic insulin secreting tumours are rare, comprising only 1% to 2% of all insulinomas  and are 68Ga-Dotanoc and 99mTc-HYNICTOC scans for the localisation of insulinoma which unexpectedly revealed increased uptake in the right renal mass lesion itself confirming it to be a NET. To the best of our knowledge, this is the first case of ectopic insulin secretion confirmed in vivo by 68Ga-Dotanoc and 99mTc-HYNICTOC scan. Further, the neuroendocrine and insulin secreting nature of the tumour was confirmed ex vivo by histopathological examination, immunohistochemistry and ultra-structural examination. Paraganglioma and pheochromoctyoma were also reported to cause hyperinsulinemic hypoglycemia and also show tracer uptake by SRS and are immunoreactive for chromogranin A and syanptophysin. Though the mass lesion was arising from upper pole of right kidney, it was intra-renal and hisopathological examination was suggestive of NET.The patient under discussion had presented with right renal mass lesion and hyperinsulinemic hypoglycemia. We initially considered the possibility of incidentally detected right renal cell carcinoma in patient with insulinoma. In our Institute, we have both PET and SPECT imaging agents for octreoscan available for the localisation of insulinoma. Somatostain receptor scintigraphy (SRS) is an established functional imaging method for patients with NETs. The sensitivity of SRS for insulinoma is 50 – 60% . We did NETs are neoplasms that arise from cells of dispersed neuroendocrine system. Although there are many kinds of NETs but they are treated as a group of tumours as these neoplasms share common features such as histology, immunoreactivity for neuroendocrine markers , presence of neurosecretory granules, and secretion of biogenic amines and polypeptide hormones. Neuroendocrine tumours arising from pancreas are classified by the hormone most commonly secreted. Neuroendocrine tumours arising from the intestine, respiratory system and rest of the body were known as carcinoids but under the recent nomenclature they are all know as neuroendocrine neoplasm (NEN) of tumour. Primary carcinoid tumours of kidney are extremely rare and around 90 cases has been reported in literature . None of68Ga-Dotanoc and 99mTc-HYNICTOC was done for the localisation of insulinoma. Both showed uptake in the right renal mass lesion and no uptake in pancreas  RS, JVP, DA, GMA have managed the case clinically with the help of DCJ (radiology), BCS (Nuclear Medicine), SMC (pathology) and SA (Uro-Surgery) for diagnosis and management. DCJ has done and reported the CT scans, BCS has done and reported the Nuclear scans (68Ga-Dotanoc PET/CT and 99mTc-HYNICTOC SPECT/CT scans), SMC has done the ultrastructural examination and immunostaining while SA has performed the definitive surgery which was curative in this case. 2) RS And DA have been involved in drafting the manuscript and JVP in revising it critically for important intellectual content. 3) All authors have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6823/14/36/prepub


Neurothekeomas are uncommon benign neoplasms with a peripheral nerve sheath origin. This tumor usually involves dermis and is described as a small, solitary, slow growing and reddish to flesh-colored nodule or papule. Neurothekeoma preferentially affects the central aspect of the face, the arms or shoulders of women in the second and third decades of life. This is the first case report of neurothekeoma involving the wrist developing from synovial tissue and with uncertain clinical behavior in an adult female. The tumor was completely excised under brachial plexus block. Histopathologically, the examination of the microscopic slides revealed the presence of a 20-mm diameter, well-circumscribed and multilobulated tumor composed of abundant myxoid stroma with cellular elements; with immunohistochemistry there was positivity to vimentin but S100-protein, epithelial membrane antigen, cytokeratin AE1-3, CD99 and CD34 were all negative. This pattern suggested a myxoid tumor form of neurothekeoma, mixed subtype. The patient had an atypical local recurrence and was re-operated after 3 months. After 12 months there was no evidence of clinical recurrences confirmed by magnetic resonance evaluation. Basically, our case report adds an important element in the correct clinical management of neurotecheomas: faced with a histological diagnosis with an unusual localization and mixed or hypercellular type, clinicians must consider the possibility of an early local recurrence, suggesting a close clinical and radiological follow-up. Neurothekeomas, or nerve sheath myxomas, are uncommon benign neoplasms with a peripheral nerve sheath origin , 2. ThisA 30-year-old woman presented with a large dorso-lateral synovial cyst of the right wrist previously ultrasonographically checked (2 months before); at the first examination the wrist was painful and swollen without a specific localization and the overlying skin appeared without local erythema. There was no reported fever, palpitations, irritability, dysphagia, dyspnea, weight loss, or other significant family medical history. The patient did not have a history of smoking but reported a history of recent trauma. The patient was treated with a functional bandage, rest and anti-inflammatory drugs for a week. At the next examination, there was an appreciable reduction of reactive synovitis of the extensor compartment, with evidence of the synovial cyst previously described. Therefore, an excision of the entire cyst was proposed.Under brachial plexus block an S italic skin incision was performed on the dorso-ulnar surface of the wrist; the deep dissection showed a circumscribed and well-cleavable lesion like a tenosynovitis of the extensor carpi ulnaris (ECU) without a pedicle joint that was removed en bloc. Surprisingly, the pathologist found a 20-mm diameter, well-circumscribed and multilobulated tumor: each lobule was composed of abundant myxoid stroma with cellular elements in part fusal, in part epithelial and in part giant; all lobules showed a tendency to confluence but there was no cellular polymorphism or nuclear hyperchromia. Margins were tumor free. With immunohistochemistry there was positivity to vimentin but S100-protein, epithelial membrane antigen (EMA), cytokeratin AE1-3, CD99 and CD34 were all negative. There was a mitotic activity of 7 % (Ki67). This pattern suggested a myxoid tumor form of neurothekeoma, mixed subtype.A close follow-up was performed; at 3 months a new subcutaneous lesion in the dorsal compartment was detected Fig. a, b and There was no recurrence by the 12-month follow-up, according to magnetic resonance evaluation . According to Laskin et al.  cellularBased on these conisdertaions, mixed type and hypercellular type could show unusual local recurrence because of the presence of cells with mitotic activity; nevertheless a complete surgical excision with the tumor margins free, the clinician has to consider this eventuality. Moreover, Laskin et al.  noticed Generally, neurothekeomas are difficult to diagnose prior to performing a biopsy, due to the lack of specific clinical manifestations or imaging characteristics. In fact in our case the diagnosis of wrist mass was oriented towards synovial cyst prior to surgical excision. The differential diagnosis of neurothekeoma should include other neural entities, such as schwannoma, true neuroma and myxoid neurofibroma. The effective treatment of choice is complete surgical excision with clear margins. No malignant transformation or metastases have been reported and local recurrence is extremely uncommon, but possible, especially for the cellular/mixed group , 17. AltBasically, our case report adds an important element in the correct clinical management of neurothekeomas: faced with a histological diagnosis with an unusual localization and mixed or hypercellular type, clinicians must consider the possibility of an early local recurrence, suggesting a close clinical and radiological follow-up.


We propose a Magnetic Resonance Imaging (MRI) guided approach to differential diagnosis of ovarian tumours based on morphological appearance.Characterization of ovarian lesions is of great importance in order to plan adequate therapeutic procedures, and may influence patient’s management. Optimal assessment of adnexal masses requires a multidisciplinary approach, based on physical examination, laboratory tests and imaging techniques. Primary ovarian tumours can be classified into three main categories according to tumour origin: epithelial, germ cell and sex cord-stromal tumours. Ovarian neoplasms may be benign, borderline or malignant. Using an imaging-guided approach based on morphological appearance, we classified adnexal masses into four main groups: unilocular cyst, multilocular cyst, cystic and solid, predominantly solid. We describe MR signal intensity features and enhancement behaviour of ovarian lesions using pathologically proven examples from our institution.MRI is an essential problem-solving tool to determine the site of origin of a pelvic mass, to characterize an adnexal mass, and to detect local invasion. The main advantages of MRI are the high contrast resolution and lack of ionizing radiation exposure. Although different pathological conditions may show similar radiologic manifestations, radiologists should be aware of MRI features of ovarian lesions that may orientate differential diagnosis.Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal masses.• Characterization of an ovarian lesion may influence patient’s management.• Different pathological conditions may have similar radiologic manifestations.• Non-neoplastic lesions should always be taken into consideration.•  Ovarian masses are a common finding in daily clinical practice and may be incidentally detected or identified in symptomatic patients. Characterization of an ovarian lesion represents a diagnostic challenge; it is of great importance in the preoperative setting in order to plan adequate therapeutic procedures and may influence patient’s management.Magnetic resonance (MR) imaging may provide useful information for the characterization of ovarian masses as non-neoplastic or neoplastic, and, in the latter case, as benign or malignant. Therefore, radiologists play an important role in the multidisciplinary approach of ovarian mass, and, though different pathological conditions may have similar radiologic manifestations, they should be aware of MR imaging features of ovarian lesions that may orientate the differential diagnosis.In this article, we review epidemiology, etiopathogenesis, classification, staging and diagnostic approaches to ovarian masses. We propose an MR imaging-guided approach to the differential diagnosis of ovarian tumours based on morphological appearance. We describe MR signal intensity features  and enhancement behaviour of each lesion using pathologically proven examples from our institution. Our MR protocol is also included.Ovarian cancer is currently one of the most common forms of cancer among women worldwide, responsible for 3.6 % of all cases, with a mortality of 4.3 %. In Europe, it is the leading cause of cancer death among gynaecologic malignancies, ranking fifth in incidence  and sixth in mortality among all women’s cancer  . An impoEtiopathogenesis of ovarian tumours is not fully understood; however, it appears to be multifactorial. The leading risk factor is familiarity; namely, history of ovarian cancer in a first-degree relative. However, only 5–10 % of cases are related to hereditary syndromes: the main one is the breast-ovarian cancer syndrome, due to mutations in the BRCA1 and BRCA2 tumour suppressor genes. Approximately 90–95 % of cases are sporadic, with an increasing risk related to nulliparity, early menarche and late menopause, while pregnancy, lactation, early menopause and use of oral contraceptives appear to be protective factors . Epi. Epi3]. There are two staging systems to describe the spread of ovarian tumours: the TNM  and the International Federation of Gynecology and Obstetrics (FIGO). The FIGO system has been recently revised and went into effect on 1 January 2014 -125. In postmenopausal women, CA-125 has high sensitivity as well as high specificity, while in premenopausal women, it has an high sensitivity but low specificity, because it may also be elevated in other conditions . Human epididymis protein 4 (HE4) is a recently added tumour marker and several studies have shown his usefulness in discriminating between benign and malignant adnexal masses in premenopausal women .Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal masses.Ultrasound (US) is often the first imaging study performed in the evaluation of a suspected ovarian lesion because it’s widely available, well accepted by patients, non-invasive and of low cost. A combination of greyscale and colour Doppler features, obtained with transabdominal and/or endovaginal scanning, allow for investigation of both morphological structure and vascular organization of the ovarian mass. Morphological features suggestive of malignancy include thickness (>2–3 mm) and irregularity of walls and septa, the presence of solid areas and papillary projections, as well as other evidence of malignant activity, namely ascites, peritoneal nodules and metastatic lesions. Regarding the vascularization, colour Doppler study is able to demonstrate both the presence and the localization of new tumour blood vessel: a predominantly central blood flow is more often associated with malignancy, while a peripheral one is more typical of a benign lesion  used as second localiser to identify the longitudinal axis of the uterus in the case of laterally deviated uterus;sagittal T2-weighted fast spin-echo (FSE) sequence parallel to the longitudinal axis of the uterus (identified on the previous SSFSE sequence) ;oblique coronal T2-weighted FSE sequence parallel to the longitudinal axis of the uterus ;oblique axial T2-weighted FSE sequence perpendicular to the longitudinal axis of the uterus ;sagittal or axial oblique or coronal oblique fat suppressed T2-weighted FSE sequence ;axial T1-weighted gradient-echo (GRE) sequence in-out  ;2; acquisition time 1 min e 40 s);axial DWI SE EPI  sequence with fat suppression .MR sequencesdynamic sagittal T1-weighted 3D gradient-echo LAVA with fat suppression  acquired at 60 and 120 s after contrast administration;T1-weighted 3D gradient echo LAVA fat-suppressed sequence, in the coronal oblique , axial oblique  and axial planes .After i.v. administration of 0.1 mmol/kg paramagnetic contrast agent  at a flow rate of 2 ml/s, followed by 20 ml of saline solution at the same flow rate, the following sequences are acquired:MR imaging is performed with the patient lying in the supine position (feet first). T2-weighted FSE sequences and DW sequences are acquired with patient breathing freely, T1-weighted 3D gradient echo LAVA fat-suppressed sequence are acquired in breath hold.Standard three-plane scout image;coronal T2-weighted SSFSE with and without fat suppression ;axial T2-weighted SSFSE with and without fat suppression ;fast imaging employing steady-state acquisition (FIESTA) in the coronal, axial and sagittal planes ;2 that represent the best compromise between signal to noise ratio (SNR) and lesion detection sensitivity on our MR system; ASSET 2; acquisition time 27 s];axial DWI SE EPI [TR range/TE range 3000/74; flip angle 90°; section thickness 8 mm; interslice gap 2 mm; field of view 42 cm; matrix 160 × 160; number of signals acquired 2; number of images 15; b-value 0 and 800 s/mmsagittal, axial and coronal T1-weighted 3D gradient echo LAVA fat-suppressed sequence .In case of voluminous ovarian masses that exceed the FOV of the above-mentioned sequences, we use the following MR protocol.sagittal T1-weighted 3D gradient echo LAVA fat-suppressed sequence  acquired at 60 and 120 s after contrast administration;axial T1-weighted 3D gradient echo LAVA fat-suppressed sequence ;coronal T1-weighted 3D gradient echo LAVA fat-suppressed sequence .After i.v. administration of 0.1 mmol/kg paramagnetic contrast agent  at a flow rate of 2 ml/s, followed by 20 ml of saline solution at the same flow rate, the following sequences are acquired:MR imaging is performed with the patient lying in the supine position (feet first). All sequences are acquired in breath hold.unilocular cyst;multilocular cyst;cystic and solid;predominantly solid.Using an imaging guided approach based on morphological appearance, we classified adnexal masses into four main groups Table :Table 3CThen we evaluated signal intensity features  and enhancement behaviour for each lesion Table .Table 4CUnilocular cystic masses in the adnexal region are more likely benign and can have both non-ovarian or ovarian origin. Paraovarian cysts, hydrosalpinx, pyosalpinx and hematosalpinx are the most common extraovarian lesions, whereas ovarian lesions are usually represented by functional cysts and serous cystadenomas; less common unilocular ovarian cystic masses are cystadenofibromas and mucinous cystadenomas (more often multilocular). Most unilocular cystic masses have low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.Paraovarian cysts  arise from mesothelial, paramesonephric or mesonephric remnants. It is important to identify the ipsilateral ovary as a separate structure in order to avoid misinterpretation; however, sometimes a “beak sign” can be found [be found .Hydrosalpinx is a fluid filled fallopian tube; it may assume a cystic appearance on some scans mimicking an ovarian lesion, but multiplanar visualization is usually able to demonstrate its sausage-like C-shape or S-shape tubular structure. Fallopian tubes can also be distended by pus or blood, respectively pyosalpinx  and hematosalpinx  [ images) .Functional cysts are the most commonly encountered cystic masses in women of reproductive age as a normal part of the menstrual cycle, including follicles (diameter <20 mm), dominant follicles (diameter 20–25 mm), follicular cysts (resulting from persistence of an unruptured follicle) and corpus luteum cysts (resulting from a failure of the corpus luteum to regress). The latter one may enlarge because of an internal bleeding, showing high signal on T1-weighted images: follow-up is able to differentiate haemorrhagic corpus luteum cysts from endometrioma considering complete resolution of the functional cyst.Serous cystadenoma is a benign tumour that usually present as an unilocular cyst with a thin regular wall (less than 3 mm); the lining is flat without internal septations, papillary projections or solid components, showing no significative contrast enhancement. Serous fluid shows low signal intensity on T1-weighted and high signal intensity on T2-weighted images  are often multifocal and bilateral, and usually appear as cystic to complex adnexal masses with high signal intensity on T1-weighted and intermediate to low signal intensity on T2-weighted images. Fat saturated T1-weighted sequences are helpful to rule out a fat-containing lesion and to confirm the presence of blood. On T2-weighted sequences, a gradual loss of signal intensity is called “shading sign” and is caused by repeated bleeding within the cyst. It has to be remembered that patients with endometriosis are at risk for developing ovarian malignancy (estimated risk about 2.5 %) [t 2.5 %) . Both enMucinous cystadenoma is a benign mucin-containing tumour, often larger than serous cystadenoma and monolateral rather than bilateral. It usually appears as a multilocular cystic lesion with a thin regular wall and several septations, lacking solid components and showing no significant enhancement after contrast administration  also appears as a complex mass. A germ cell tumour (Yolk sac tumour) and sex cord-stromal tumours (granulosa cell) are also described in this section.Mature cystic teratoma is the most common ovarian neoplasm and affects mostly young patients. It is a benign germ cell tumour consisting of at least two of the three embryogenic germ cell layers, and usually contains ectodermal , mesodermal  and/or endodermal  mature tissue [Struma ovarii is one of the main subtypes of ovarian monodermal teratomas . It is mainly composed of thyroid tissue; thus, it may be associated with symptoms or signs of thyrotoxicosis. MRI demonstrates a complex mass with multiple cystic and solid areas. Cystic spaces may show variable signal intensity demonstrating both high and low signal intensity on T1-weighted and T2-weighted images; in particular, some cystic spaces demonstrate low signal intensity on both T1-weighted and T2-weighted images because of the colloid of the struma  tumours will be described in the next one because of their predominantly solid appearance.Serous cystadenocarcinoma is the most common, and is responsible for about 40 % of malignant ovarian neoplasms, whereas mucinous cystadenocarcinoma is less common and accounts for about 10 % of ovarian malignancies. These tumours are seen as complex multilocular masses, usually with thick and irregular walls, septations, solid components and papillary projections of low signal intensity on T2-weighted images with contrast enhancement after gadolinium administration  as a result of increased vascularity [cularity . It is nGranulosa cell tumours are usually benign; however, they may be malignant as well. Clinically, they can manifest by producing hormones with hyperestrogenism. Granulosa cell tumours can be divided into two main subtypes, adult and juvenile. The adult type is responsible for about 95 % of cases and occurs preferentially in perimenopausal and postmenopausal women, resulting in endometrial hyperplasia and atypical bleeding. The juvenile type is less frequent and affects prepuberal children, leading to pseudoprecocity. Granulosa cell tumours appear mostly as both cystic and solid masses, but they can also have a multilocular cystic or a predominantly solid appearance [pearance , 43.Predominantly solid adnexal masses account for lesions with benign, borderline and malignant behaviour. They include tumours of different origin: epithelial , germ cell (dysgerminoma and Yolk sac tumour), sex cord  and metastatic lesions.Brenner tumour is responsible for about 2 % of ovarian neoplasms; it is also named “transitional cell tumour” because of its histological similarity to the urotelium. It is more often benign. On T2-weighted images, Brenner tumour shows a low signal intensity because of its solid fibrous content. In some cases, areas of calcification within the solid components can be found, best demonstrated on both US and CT, rather than MRI. Brenner tumour can be associated with other cystic tumours, like mucinous cystadenomas, so that MRI demonstrates a lesion with both cystic (cystadenomas) and solid (Brenner) components [mponents . AlthougDysgerminoma usually appears as a solid lobulated lesion with fibrovascular septa, surrounded by a fibrotic capsule. The solid component shows intermediate to high signal intensity on T2-weighted images, whereas the septa appear at low signal intensity, but show a significant contrast enhancement [ancement .Fibromas, thecomas and fibrothecomas are classified as sex cord-stromal tumours and are the most common benign solid lesion of the ovaries. These tumours are usually asymptomatic and there may be an association with ascites and pleural effusion (Meig syndrome). Fibrothecomas consist of both fibrous tissue and theca cells with lipidic content. They present as a well-circumscribed solid mass with low to intermediate signal intensity on T1-weighted and low signal intensity on T2-weighted images, although there may be some scattered areas of cystic degeneration with high signal intensity on T2-weighted scans , complex (cystic and solid) and predominantly solid. It is true that there is a certain overlap between benign and malignant tumours; in particular, it has to be considered that borderline lesions are very difficult to differentiate because they have both benign and malignant features.In 2007, Sohaib et al. showed that from the analysis of the MR imaging features, “the most predictive characteristics of malignancy are vegetations in a cystic lesion, presence of ascites, a maximal diameter greater than 6 cm, and necrosis in a solid lesion” . In 2011non-neoplastic lesions should always be taken into consideration;in a patient with endometriosis, the presence of a complex and rapidly growing mass with contrast enhancement should raise the suspicion of endometrioid or clear cell tumour;a very low signal intensity on T2-weighted images indicates a fibrotic component, suggesting a tumour of the thecoma/fibroma group, a cystadenofibroma or a Brenner tumour;sequences with fat saturation are helpful when facing a mass with high signal intensity on T1-weighted images, because the signal suppression is suggestive of a teratoma; otherwise, an endometrial cysts or other haemorrhagic lesions should be considered;a “stained glass appearance” with cystic loculi of variable signal intensity usually refers to a mucinous tumour, because of the different mucin concentration;metastasis should be considered if a complex enhancing mass is demonstrated in both ovaries ; however, it must be remembered that serous epithelial tumours can be bilateral as well.To conclude this work, we’d like to indicate some key imaging features and general advice that could be of help in the differential diagnosis of adnexal masses:


Magnetic resonance-guided focused ultrasound surgery (MRgFUS) allows for precisethermal ablation of target tissues. While this emerging modality is increasinglyused for the treatment of various types of extracranial soft tissue tumors, ithas only recently been acknowledged as a modality for noninvasive neurosurgery.MRgFUS has been particularly successful for functional neurosurgery, whereas itsclinical application for tumor neurosurgery has been delayed for varioustechnical and procedural reasons. Here, we report the case of a 63-year-oldpatient presenting with a centrally located recurrent glioblastoma who wasincluded in our ongoing clinical phase I study aimed at evaluating thefeasibility and safety of transcranial MRgFUS for brain tumor ablation. Applying25 high-power sonications under MR imaging guidance, partial tumor ablationcould be achieved without provoking neurological deficits or other adverseeffects in the patient. This proves, for the first time, the feasibility ofusing transcranial MR-guided focused ultrasound to safely ablate substantialvolumes of brain tumor tissue. High-intensity focused ultrasound (HIFU) can penetrate soft tissue to producephysiological effects at the target while sparing healthy tissue. Integration withmagnetic resonance (MR) imaging for closed-loop intervention guidance, i.e.,MR-based intra-interventional targeting, continuous temperature monitoring andlesion creation, and finally, lesion assessment, makes HIFU, or in this context,transcranial MR-imaging-guided focused ultrasound (tcMRgFUS), an ideal modality fornoninvasive brain interventions . It doesA 63-year-old patient presented in our clinic with tumor recurrence in the leftthalamic and subthalamic region 5 years after first surgery for a posteromedialtemporal lobe glioblastoma (GBM) Figures  and 2A-CThe tcMRgFUS procedure was performed using a mid-frequency ExAblate Neuro®system  operating at 650 kHz that was interfaced to aclinical 3 T MR system . Thepatient received local anesthesia for the positioning of a stereotactic frame and prophylacticadministration of paracetamol and ondansetron to prevent pain or nausea. Noadditional medication was applied during the intervention. The patient was awake andresponsive during the whole intervention. Repeated neurological assessments before,during, and after the intervention revealed stable neurological conditions and notreatment-related adverse neurological symptoms. Towards the end of the 5-hintervention that included more than 4 h table time in supine position in the MRscanner, the patient was tired and exhausted. He recovered quickly after the end ofthe intervention when he was released from the frame. For post-operative follow-up,the patient spent 1 night in the hospital and left on his own wish the following dayin good condition.The tcMRgFUS intervention process has been described in detail elsewhere . In shorThe case presented in this report is the first successful noninvasive brain tumorthermal ablation performed with MR imaging-guided HIFU. These preliminary resultsconfirm the potential of tcMRgFUS for the noninvasive treatment of patientssuffering from malignant brain tumors, especially in areas not amendable forconventional neurosurgical interventions.The first successful intervention was preceded by two prematurely aborted attempts inanother patient who is included in our ongoing phase I study. Notably, the settingsfound during these unsuccessful trials were more complex. The patient had a catheterwithin a cystic portion of the centrally located tumor, which had to be excludedfrom the sonication pathway. Although the evaluation of preliminary scans wasencouraging, eventually, the intervention had to be terminated because of unreliableMR thermometry data. We suspect that a small ferromagnetic contamination at thecatheter tip induced local inhomogeneity that interfered with thermal measurements.The second attempt in the same patient was planed following a 10-month period aftertumor regrow was asserted. The catheter was removed prior to the intervention.However, due to the clinical condition, physically, the patient could not toleratethe motionless position over the time required for the intervention. Therefore, noablative sonication was performed.First attempts to evaluate the physical phenomenon of HIFU for clinical use inneurosurgery in the 1950s  were hinWhile there is ample evidence to show that tumor tissue can be permanently destroyedusing HIFU, one concern is that tumor mass will indeed be reduced throughcoagulation of tissue, but not completely eliminated—as aimed for withconventional surgery. Although evidence from HIFU therapy for uterine fibroids -which consist histologically of markedly firmer tissue than gliomas - shows that 12months post-thermal ablation, tumor volume reduction can reach over 50% , the lonThe tcMRgFUS technology available today has several shortcomings preventing its broadapplication in brain tumor treatment. One main disadvantage is the current treatmentenvelope determined by the 650 kHz ultrasound transducer system, which limits therange of ablative power to centrally located brain areas. Therefore, our phase Istudy restricts patient selection to cases with centrally located malignant tumorsunsuitable for surgery and patients with larger tumors expanding into the thalamicregion, potentially requiring a hybrid approach including conventional surgery forthe outer part of the tumor and tcMRgFUS for the central region. Various solutionsto widen the treatment envelope are currently being intensively evaluated, such asusing lower ultrasound frequencies, adding ultrasound enhancing microbubbles, orrearranging transducer position and geometry —which prTcMRgFUS is a highly promising technology which has the capacity to improve orreplace present therapies and enable future treatment modalities . Beyond This report on successful brain tumor ablation demonstrates the feasibility ofnoninvasive tcMRgFUS tumor surgery. Further treatments in the context of our ongoingclinical phase I study will be needed to assess the safety and efficacy of tcMRgFUSin patients with malignant brain tumors.Written informed consent was obtained from the patient for publication of this casereport and any accompanying images. A copy of the written consent is available forreview by the editor-in-chief of this journal.The authors declare that they do not have competing interests.DC was responsible for the study submission to the ethics commission, the patientcare and planning and conduction of the treatment, the data analysis, and writing ofthe manuscript. JF was responsible for the patient care and planning and conductionof the treatment, data analysis, and revision of the manuscript. LS participated inthe study coordination and patient care. RO was responsible for the MR setup andintra-interventional imaging. LR was responsible for the pre- andpost-interventional MR imaging and data analysis. JA performed the image workup andwrote the figure description. EM was responsible for the study submission to theethics commission, the planning and conduction of the treatment, and the revision ofthe manuscript. BW was responsible for the planning and conduction of the treatment,the overall technical setup, the data acquisition and analysis, and the writing ofthe manuscript. All authors read and approved the final manuscript.


This report presents an operative case of advanced descending colon cancer in an adult patient with intestinal malrotation. A 63-year-old Japanese male was suffering from left side abdominal pain, abdominal distension, and constipation. An endoscopic examination revealed an advanced tumor in the descending colon. Computed tomography (CT) of the abdomen revealed the thickening of the descending colon wall and superior mesenteric vein rotation. An opaque enema detected severe stenosis of the descending colon. An abdominal X-ray examination revealed the dilation of the colon and small intestine with niveau. At the insertion of an ileus tube, the C-loop of the duodenum was observed to be absent and the small intestine was located on the right side of the abdomen. After the decompression of the bowel contents, laparotomy was performed. Descending colon cancer was observed to have directly invaded the left side of the transverse colon. Left hemicolectomy, lymph node dissection, and appendectomy were performed. The patient had an uneventful recovery and was discharged from the hospital on the 16th day after surgery. This report presents a rare operative case of descending colon cancer in an adult patient with intestinal malrotation. Intestinal malrotation can be defined as any deviation from the normal 270-degree rotation of the midgut in a counterclockwise direction during embryonic development . MalrotaThis report presents a rare case of descending colon cancer in an adult patient with intestinal malrotation.A 63-year-old Japanese male presented with the chief complaints of left side abdominal pain, abdominal distension, and constipation. As the patient's symptoms worsened, he underwent an endoscopic examination, which revealed the presence of an ulcerated tumor of the descending colon. He was referred to the surgical outpatient clinic of our hospital with advanced descending colon cancer.3, a hemoglobin level of 8.7 g/dL, a hematocrit level of 25.3%, and a platelet count of 401,000/mm3. The patient's electrolyte and blood urea nitrogen levels were normal, as was his liver function. His CEA and CA19-9 levels were 1.7 ng/mL and CA19-9 was 21.3 U/mL, respectively. An abdominal X-ray examination revealed a dilated colon and niveau  anywhere along the rotation of the midgut in a counterclockwise direction . Kato etThere are some problems at the operation in the cases of synchronous colon cancer in adult patients with intestinal malrotation. One of these problems is arterial and venous variations. Before the operation, confirm the presence of arterial and venous variations via enhanced CT. In the case of our patient, superior mesenteric vein rotation  and anomWe herein presented a rare operative case of descending colon cancer in a patient with intestinal malrotation.


Inflammatory myofibroblastic tumors are rare, and those located in the extremities without bone involvement are even rarer. We present the case of a 61-year-old Chinese male patient with an inflammatory myofibroblastic tumor of the right thigh. It was excised and a histopathologic examination revealed an inflammatory myofibroblastic tumor. This case is presented by virtue of its rare location. Inflammatory myofibroblastic tumor (IMT) is an uncommon benign neoplasm with partially invasive behavior and a tendency to recur . IMTs arA 61-year-old Chinese male patient was referred to our service with a history of severe pain in his right thigh for the most recent 18 months. There was no history of trauma. A physical examination revealed a moderately hard, immovable, and painful 150 × 100 mm mass of the posterior thigh.A magnetic resonance imaging (MRI) scan revealed a lesion in the right side of the adductor magnus muscle. The lesion was inhomogeneously isointense on the T1-weighted images Figure C, and inSince two cases of spindle benign tumor of lung were reported by Brunn in 1939 , increasExtrapulmonary IMTs are more common in children and young adults with an average age of 10-years-old, and the incidence of men and women is 1 to 1.4 -4, of whPatients suffering from IMTs of the thigh have no systemic symptoms  or laboratory abnormalities. Besides MRI scans, histomorphology and immunohistochemical staining is the most helpful tool in the diagnosis of IMTs. Furthermore, cytogenetic studies have shown clonal rearrangements of the short arm of chromosome 2, involving the ALK receptor tyrosine kinase locus region, in up to 50% of soft tissue IMTs ,11. ALK,In summary, we have reported an additional case of IMT of the lower extremities without bone involvement. This was treated with excision, and clinical and histological features were consistent with a benign lesion.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.ALK: Anaplastic lymphoma kinase; HE: Hematoxylin-eosin; IMT: Inflammatory myofibroblastic tumor; KP-1: Kinesin-like protein-1; MBP: Myelin basic protein; MRI: Magnetic resonance imaging; STIR: Short TI inversion-recovery; SMA: Smooth muscle actin; WHO: World Health Organization.The authors declare that they have no competing interests.JL and HL contributed equally to this work. JL, HL and YZ contributed to the drafting and final revisions of the manuscript. PY, YFZ and YY contributed to the drafting of the manuscript. All of the authors approved the final version of the manuscript.


Spontaneous atraumatic mediastinal hematomas are rare. We present a case of a previously fit and well middle-aged lady who presented with acute breathlessness and an increasing neck swelling and spontaneous neck bruising. On plain chest radiograph, widening of the mediastinum was noted. The bruising was later confirmed to be secondary to mediastinal hematoma. This life-threatening diagnostic conundrum was managed conservatively with a multidisciplinary team approach involving upper gastrointestinal and thoracic surgeons, gastroenterologists, radiologists, intensivists, and hematologists along with a variety of diagnostic modalities. A review of literature is also presented to help surgeons manage such challenging and complicated cases. A 59-year-old woman presented to the emergency department with a 1-day history of acute chest tightness with exertional dyspnea, an increasing neck swelling, and spontaneous neck bruising . The nec9/L, and platelets of 217 × 109/L. Coagulation screen showed prothrombin time of 10.6, activated partial thromboplastin time 24, and international normalized ratio of 1.0.Chest examination revealed extensive bruising extending along both sides of her neck, over the sternum to the upper breasts. A firm neck swelling over the trachea was also palpable. Auscultation confirmed bibasal crepitations. No palpable lymph nodes or any other swelling was noted in her cervical region. Her blood results showed hemoglobin of 12.7 gm/dL, white cell count of 6.8 × 10An initial plain chest radiograph demonstrated a prominent superior mediastinum.An urgent contrast-enhanced computed tomography (CT) scan of her thorax and neck was performed. The CT showed a large prevertebral soft tissue mass extending from the level of the larynx down to below the carina to about the level of T8 vertebral body . The sofFree air along with a fluid level was noted within esophageal mass and posterior mediastinum at the level of the tracheal bifurcation, suggestive of esophageal perforation. A water-soluble contrast swallow was subsequently performed, which did not show esophageal perforation though the upper esophagus was distorted due to soft tissue swelling. An urgent gastroscopy was also performed, which showed a normal esophagus without any intramural mass, ulcers, or growth and normal stomach and duodenum.The case was discussed at the multidisciplinary team meeting, involving upper gastrointestinal surgeons, gastroenterologists, radiologists, intensivists, hematologists, and specialist nurses, since it represented a diagnostic conundrum. After reviewing the case, a conservatively approach was adopted, and the patient was admitted for observation and managed on a surgical ward. The patient remained hemodynamically stable from day 1 to day 4 without any deterioration of her clinical condition or any drop in her hemoglobin level. A repeat CT scan thorax was performed on the fifth postadmission day, which showed a persistent swelling in the mediastinum that had slightly reduced in size.Extensive blood investigations were performed, including von Willebrand factor, antiphospholipid syndrome antibody, myeloma screening, hepatitis profile, and thyroid function tests, as per advice of hematologists but no abnormality was identified.The case was discussed at the specialist upper gastrointestinal multidisciplinary team meeting as well, with a recommendation for further cross-sectional imaging. A magnetic resonance (MR) scan of the neck and endoscopic ultrasound were performed. The MR confirmed a mediastinal hematoma MH; , and endThe patient was discharged home after 10 days and remained stable throughout her stay. Her neck and chest wall bruising had started to disappear. All her symptoms completely resolved within 8 weeks. She has been enjoying a good quality of life after discharge and was kept on a regular follow-up.1 cardiac and great vessel aneurysm, dissection or rupture,2 hypertension,3 or iatrogenic causes including invasive procedures,4 as well as valsalva maneuver5 and iatrogenic causes. However, spontaneous mediastinal hematomas are a rare but very important presentation, which if not dealt with caution can lead to rapid deterioration and death. Shimokawa et al6 have mentioned the 4 clinical settings where spontaneous MH can occur: (a) as a complication of enlarging mediastinal masses, (b) sustained hypertension, (c) hematological conditions, and (d) transient increase in intrathoracic pressure.The review of literature identifies various causes of acute mediastinal hemorrhage, majority of which are life threatening. These include major thoracic trauma,7 It has been shown in the literature that the sensitivity and specificity of combined modalities to detect MH is extremely high.7 Hence, in our case we did use various diagnostic tools to help find the underlying cause. We recommend a multidisciplinary team approach to manage such challenging cases since there is a possibility of rapidly changing scenario as well as multiple aspects of care that need addressing at the same time. However, the treating clinician must bear in mind that sometimes the exact source of the hemorrhage remains unknown despite careful radiological investigations and even thoracotomy.8A high index of suspicion for MH should be kept for any patient who presents with symptoms of acute superior mediastinal compression, chest radiograph showing widened mediastinum, and bruising over the neck and upper chest. Urgent imaging should be performed to confirm the diagnosis. Angiography and surgical exploration used to be the gold standard for diagnosis, but they have been replaced by contrast-enhanced spiral CT of the chest, magnetic resonance imaging scan, or positron emission tomography.9 Endotracheal intubation is performed for airway compromise.9 Based on the patient’s condition and the diagnostic findings, the treatment options include the following: (a) operative intervention (cardiorespiratory compromise), (b) angiography and embolization, or (c) careful watch and wait (for stable patient) as in our patient.5The initial management is fluid resuscitation, transfusion if required, and urgent imaging.Although in our patient a very large hematoma was seen, she was successfully managed conservatively without any intervention and her symptoms improved gradually.Spontaneous mediastinal hematomas are rare. A multidisciplinary team approach should be used to manage these patients conservatively. The exact source of the hemorrhage may remain unknown despite careful radiological investigations and even thoracotomy.


Neurofibroma is a rare benign tumor. The isolated presence of such lesions in the preperitoneal space with no evidence of systemic disease has never been reported in the literature.A 29-year-old white man presented with a 12 months history of progressive abdominal distension. Clinical examination revealed a bulky hypogastric mass. Abdominal computed tomography and pelvic magnetic resonance imaging showed a large, well defined preperitoneal tumor measuring 18 x 17cm extending in the pelvis. A computed tomography guided biopsy was performed which revealed a neurofibroma. Exploratory laparotomy showed a well encapsulated elastic soft tumor in the preperitoneal space which measured 17 x 18cm and weighted 2 Kg. The tumor was completely excised. No recurrence occurred after one year of follow-up.Solitary preperitoneal neurofibroma is an extremely rare benign tumor. Its clinical and radiological signs are nonspecific. Preoperative histology can be useful to guide the surgical approach which is the only curative treatment. Neurofibroma is an uncommon benign tumor arising from the peripheral nerve sheaths. The isolated presence of neurofibromatous lesions in the preperitoneal space , without any other sign of von Recklinghausen’s disease has rarely been reported . AuthorsA 29-year-old white man, with no history of neurofibromatosis or other systemic disease, was complaining of insidious and progressive abdominal distension which appeared 12 months prior to admission. He had hypogastric abdominal pain and pollakiuries in the preceding five months. There were no vomiting or transit disorders, and no neurological symptoms.On clinical examination, the patient was in good general condition with a normal temperature, a body mass index of 24 and no café au-lait spots or dermal neurofibromas on his body. The palpation of the abdomen revealed a well-defined, fixed and painless hypogastric mass, 20 cm in diameter. Digital rectal examination was normal.All the standard hematological and serum biochemical data were normal.An abdomino-pelvic computed tomography (CT) scan Figure  revealedPelvic magnetic resonance imaging Figure  revealedA CT-guided biopsy was performed revealing a conjunctive tissue separated by a fuso-cellular proliferation compound of Schwann cells with regular nuclei immersed in a richly vascularized and myxoid fibrillar background. There was no evidence of malignancy within the tissue obtained. Immunohistochemically, the tumor cells were strongly positive for the S100 and the neurofilament proteins evoking a neurofibroma.Surgical resection was decided by the multidisciplinary meeting for cancer care. Exploratory laparotomy revealed a well encapsulated elastic soft tumor in the preperitoneal space. Upon incision of the linea alba, there was a protrusion of the mass. It was easily cleaved before the opening of the anterior parietal peritoneum. At the end of excision, there was a peritoneal break due to size of the mass Figure .Figure 3The tumor measured 17 × 18 cm and weighted 2 Kg Figure . It was The histological and immuno-histochemical analysis of the surgical specimen confirmed the preoperative diagnosis Figure . Thus, tNeurofibroma is a tumor of neural origin derived from the cells that constitute the nerve sheath. It’s an uncommon benign tumor found as a solitary tumor or as a partial manifestation of neurofibromatosis type I  . The cauThis kind of neoplasms is known to mainly affect the cutaneous nerves of the trunk, neck, and head ,9. Rare Neurofibroma appears to affect adolescents and young adults without a gender preference. It grows along the peripheral nerves as a non-encapsulated focal mass with well-defined margins ,9.The clinical manifestations of solitary neurofibromas are not specific and change according to their locations, their effect on gastrointestinal motility and their possible impingement on contiguous structures, resulting in palpable masses, abdominal pain, and transit disorders due to extra-luminal pressure -15. The Intra pelvic tumors are often diagnosed at a late stage which is source of surgical resection difficulties .Preoperative imaging is usually insufficient to establish the diagnosis with certainty, only the histology can do. In fact, the preoperative histological evidence can influence the treatment modifying the surgical approach, conservative versus aggressive .Surgical removal is the only treatment option. Unlike our case, neurofibromas are difficult to manage surgically as they are extensively infiltrative and highly vascular ,18.Some authors posit that surgical resection is indicated only when the tumor causes pain, neurological deficiencies or when there is a strong suspicion of malignancy .Solitary neurofibromas have a good prognosis, with rare instances of haemorrhage, malignant changes and local recurrences after excision ,20.The solitary preperitoneal neurofibroma is an extremely rare benign tumor arising from nerve sheaths. Its clinical and radiological signs are not specific. Preoperative histological diagnosis can be useful to help choosing the surgical approach, which is the gold-standard treatment option. Unlike other sites, tumor excision in the preperitoneal location remains without difficulties.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.


Salivary gland tumors are a relatively rare and morphologically diverse group of lesions. Pleomorphic adenoma is a benign tumor of the salivary gland that consists of a combination of epithelial and mesenchymal elements. The tumor most commonly arises from the parotid (60-70%) or submandibular glands. It develops less frequently in a minor salivary gland, presenting as an intraoral mass depend on the soft palate. We describe a case of benign pleomorphic adenoma of soft palate in a 45 year old female with computed tomography and histopathological findings. This patient presented in ENT department with history of gradually increasing mass lesion in the palatal region over a period of few months. Pleomorphic adenoma is the most common tumor (60%) of major and minor salivary glands, nearly 70% of the tumors of minor salivary glands are Pleomorphic adenomas, and the most common intraoral site is the palate, followed by upper lip and buccal mucosa . StudiesA 45 year-old unmarried female, presented in the department of otorhinolaryngology with chief compliant of slow growing swelling over palate since last 6 months. The lady also complained of pain over swelling while swallowing along with difficulty in deglutition because of swelling. There was no history of headache, vertigo, ear discharge, trauma or any other associated symptoms. There was no history of fever, weight loss, bleeding, pus discharge or any other type of discharge from the swelling. The personal history of the patient did not reveal any history of smoking, or any other addiction. On past history there was no history of similar illness in past neither there was any past history of significant medical or surgical illness. There was no family history of similar complaints. The patient did not take any treatment for the above complaints and presented for the first time in our hospital for the similar complaints. General examination reveals normal and stable vital parameters. There was no icterus or pallor. The examination of remaining body did not reveal any other swelling. The systemic examination of other systems was within normal limits. On local examination there was a globular mass on right side of palate with normal overlying mucosa was seen. The lesion appeared to arise from mid part of palate, extending up to the posterior border of hard palate . It was Pleomorphic adenoma is the most common tumor of major salivary glands, although approximately 80% of these are found in parotid gland. About 4-5% of pleomorphic adenomas are seen in minor salivary glands, amongst which palate is one of the site . Other sThe differential diagnoses for this case include palatal abscess, odontogenic and non-odontogenic cysts, and other soft tissue tumors. Abscess can be ruled out because of loss of signs and symptoms of inflammation, whereas cysts are not firm in consistency. FNA biopsy should be performed as an adjunct to diagnosis prior to definitive surgical treatment. Computed tomography or magnetic resonance imaging should be considered when assessing for presence of bony erosion or soft tissue and nerve involvement . The hisPleomorphic adenoma, though a common entity, is still a challenging tumor for pathologist, radiologist, and the surgeon. Its diverse histological and topographical property makes the tumor special. The examining clinician and treating surgeon must be aware of its recurrence, longevity, and malignant potential if incorrectly diagnosed or treated.


Angiomyolipoma (AML) is a rare benign renal tumor occurring in about 0.3 to 3% of the general population. Most frequently it takes the form of small single tumors occurring sporadically or accompanying tuberous sclerosis (Bourneville-Pringle disease). In some cases the tumor may reach a very large size and be a cause of various serious complications. This case description concerns a 26-year-old female patient, suffering from hypopituitarism, hypothyroidism and binocular blindness during the course of septo-optic dysplasia, in whom a giant, left renal AML was diagnosed and treated surgically. According to the authors’ knowledge this was the first reported case of a huge size AML in a patient with de Morsier syndrome. Angiomyolipoma (AML) is a rare benign renal tumor histologically containing elements of smooth muscle, adipose tissue and blood vessels in various proportions. It occurs in 0.3 to 3% of the general population, four-fold more frequently in women and the peak of incidence falls between the 30th and 50th years of life . Most fr2. Her blood pressure was 120/70 mmHg, heart rate 70/minute, creatinine levels 66 μmol/l, and her electrolytes, blood count and urinalysis were normal. The lesion had been diagnosed incidentally in another medical centre during investigation of persistent stomach ache with a suspicion of pyelonephritis. During case examination a perceptible mobile pathological resistance was reported on the left side of the stomach from the costal arch up to the iliac fossa. On abdominal ultrasonography (USG) examination, a large, intra-abdominal and left flank heterogeneous tumor with dimensions 170 × 78 mm, mostly hyperechogenic (consisting probably of adipose tissue with little vascularization observed in Doppler color) and probably coming out of the left kidney, was reported. The right kidney was 108 mm long, with no urinary retention and no deposits. The diagnostics were extended by computer tomography (CT) angiography of the abdomen with contrast, in which the following was stated: numerous AMLs in the left kidney, the biggest coming out from its lower part and affecting the whole paranephric space and going down to the level of iliac fossa with dimensions of about 226 × 95 × 104 mm. Except for this the other intra-abdominal organs revealed no abnormalities . Most frequently they are diagnosed by chance during imaging examinations and they do not reach large sizes. They occur multifocally in about 1/3 and bilaterally in about 15% of all cases. They coexist with tuberous sclerosis (Bourneville-Pringle disease) with a frequency of about 20%. In such patients AML is diagnosed in 40 to 80% with a 2 to 3% risk of coexistence of renal cell carcinoma (RCC). AML has a mild nature and it does not produce metastases. Most frequently it proceeds asymptomatically. It may induce hematuria and uncharacteristic pain . Diagnosas girls . So far,We have presented an extremely rare case of the coexistence of congenital defects in the form of septo-optic dysplasia associated with a giant renal AML. The patient required a precise diagnostic work-up and radical surgical treatment.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Wallerian degeneration is the process of progressive demyelination and disintegration of the distal axonal segment following the transection of the axon or damage to the neuron. We report a case of a patient with Wallerian degeneration of the pontocerebellar tracts. She had a history of a pontine infarction 3 months ago. Wallerian degeneration of pontocerebellar tracts is seen bilaterally and symmetrically and is more visible in the middle cerebellar peduncles. Along the middle cerebellar peduncles hyperintense signal was detected on T2 weighted images. Wallerian degeneration of pontocerebellar tracts is a rare entity. It can occur bilaterally after a large pontine infarction. Magnetic resonance imaging seems to be the most effective technique for detection of Wallerian degeneration. In this report we want to mention this rare entity and to prevent wrong diagnosis. Wallerian degeneration represents a uniform answer to injury within the central and peripheral nervous systems. Infarction is the most common event resulting in WD in the central nervous system. Magnetic resonance imaging seems to be the most effective technique for detection of Wallerian degeneration. Along the affected white matter tractus high signal was detected on both T2 weighted images and fluid-attenuated inversion recovery images.A 73-year-old woman was admitted to emergency service with headache, vertigo, speech difficulties, and right-sided weakness. Patient had no history of arterial hypertension, hypercholesterolemia, and diabetes mellitus.A transthoracic echocardiogram was performed and findings were normal for her age.A brain MRI was performed and demonstrated a left, paramedian pontine acute infarct . On T2WIAfter 3 months the patient was admitted to the emergency service again with worsening of her symptoms. Speech difficulties, dysarthria, and right hemiparesis on both upper and lower limbs were depicted.A second brain MRI was performed . On MRI Along the MCPs lesions were hyperintense on both DWI and ADC maps, consistent with T2 shine-through effect Figures .WD represents a uniform answer to injury within the central and peripheral nervous system. In the first days following the injury disintegration of axonal structures occurs, after several weeks infiltration of macrophages and degradation of myelin formed, and finally fibrosis and atrophy of the affected fiber tracts appear .WD is most frequently observed in the corticospinal tract following infarction of the motor cortex or internal capsule .Infarction is the most common event resulting in WD in the central nervous system. Also hemorrhage, necrosis, neoplasm, trauma, focal demyelination, white matter disorders, and multisystem atrophy are reported entities that may cause degeneration .After infarction it usually takes two to four weeks before WD can be detected by conventional MRI . ConventThe main finding is a hyperintensity on T2WI and FLAIR images along the affected tracts.WD of cerebellar peduncles is rarely described. It usually involves the middle ones because they are largest and the main path for pontocerebellar tracts . The MCPWD of the unilateral pontine infarction results in bilateral symmetrical hyperintense lesions secondary to the crossed distribution of the pontocerebellar fibers .Only few reports have described the MR findings of WD in the middle cerebellar peduncles following pontine infarction, hemorrhage, and acute vascular lesions , 8.In our case after a unilateral pontine infarct in the MCPs on T2WI bilateral and symmetrical hyperintense lesions were seen owing to WD.Bilateral symmetric lesions of the MCPs can also be seen in other conditions, such as central pontine myelinolysis, neurodegenerative disorders, multisystem atrophy, and progressive multifocal leukoencephalopathy. However, clinic and biochemical investigations help in differentiation.In conclusion the basic understanding required to diagnose WD in the brain is a detailed knowledge of the course of the association fibers.High signal in the MCPs following a pontine lesion is almost certainly attributable to WD of the pontocerebellar tracts and should not be mistaken for a new infarction.WD is a secondary lesion and should not be mistaken for a primary, independent lesion.