Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with diverse etiologies and varied clinical presentations. Because of variability in clinical presentation and neuroimaging, CVT remains a diagnostic challenge. Recently, some studies have highlighted the value of T2∗-weighted gradient-echo MRI (T2∗WI) in the diagnosis of CVT. We report the case of a 79-year-old woman with CVT due to a hypercoagulable state associated with cancer. On the initial T2-weighted image (T2WI), there was a diffuse high-intensity lesion in the right thalamus, extending into the posterior limb of the internal capsule and midbrain. T2∗WI showed diminished signal and enlargement of the right basilar vein and the vein of Galen. Even though there is a wide range of differential diagnoses in unilateral thalamic lesions, and a single thalamus lesion is a rare entity of CVT, based on T2∗WI findings we could make an early diagnosis and perform treatment. Our case report suggests that T2∗WI could detect thrombosed veins and be a useful method of early diagnosis in CVT. Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with diverse etiologies and varied clinical presentations. The diagnosis of CVT is based on neuroimaging. However, in contrast to arterial strokes, brain imaging by itself is of little positive value for the diagnosis of CVT because it can be normal in up to 25% of patients . BecauseRecently, Selim et al. have highlighted the value of T2*WI, which show the thrombosis as a hypointense signal associated with the magnetic susceptibility effect , 4. TheyHere, we describe a rare case of CVT with unilateral thalamic lesion in which we could detect the thrombosed veins with T2*WI. This finding led us to the early diagnosis of CVT.A 79-year-old woman presented to the emergency department with complaints of weakness and numbness in the left upper and lower extremities. She had been diagnosed with gastric cancer  5 years previously, and chemo- and radiotherapy were performed at that time. However, her cancer was progressive and she had developed stenosis of the cardiac portion of the esophagus.μg/mL; and D dimer, 29.2 μg/mL. The other laboratory parameters, including protein C, S, antinuclear antibody, antiphospholipid antibody, and homocysteine, were within normal limits. Neurological examination revealed left-sided hypoesthesia, and left-sided hemiparesis with a National Institutes of Health Stroke Scale (NIHSS) score of 7. Although the patient did not fulfill the diagnostic criteria of disseminated intravascular coagulation syndrome, she had abnormal coagulation with a fibrinogen level of 191 mg/dL; fibrin/fibrinogen degeneration products, 47.9 On the initial T2WI, there was a diffuse high-intensity lesion in the right thalamus, extending into the posterior limb of the internal capsule and midbrain . The cenThe novel finding in our patient is that T2*WI was a useful tool for the early diagnosis of CVT. Moreover, our case demonstrated that T2*WI could detect thrombosed veins. Recent report has shown that a T2*-weighted gradient-echo MR sequence has more sensitivity than spin-echo T1-weighted image (T1WI), T2WI, and fluid-attenuated inversion recovery images (FLAIR) in detecting CVT, as well as in detecting subarachnoid and intracerebral hemorrhages, both of which can be seen in association with CVT . ThromboThalamic edema is the imaging hallmark of deep venous occlusion, as demonstrated by hypersignal intensity on the T2WI and FLAIR . Deep veAs shown in Previously, it was reported that cancer and tumors accounted for 7.4% of all CVT. Of these, 2.2% were associated with CNS malignancy, 3.2% with solid tumors outside the CNS, and 2.9% with hematological disorders . In our In conclusion, even though a patient presented with a rare case of unilateral thalamic lesions, assessment of T2*WI was a useful method of early diagnosis in CVT. Further studies on the usefulness of T2*WI in the evaluation of CVT are warranted.


Rhabdomyosarcoma is the most common childhood primary malignant tumor of orbit. Most of patients present between the ages of 7 and 8 years. Pure eyelid rhabdomyosarcoma is a very rare tumor with only a few reported cases in the literature. We introduce a pure embryonal rhabdomyosarcoma of upper lid in 15-year-old patient and demonstrate successful management of it. A 15-year-old male patient was referred to oculoplastic service of one of teaching eye hospitals in Mashhad, Iran, due to right upper lid swelling since two months before visit. On external eye exam, the eye had nontender, nonmobile, firm, subcutaneous mass with ecchymosis of right upper lid . MechaniOther part of ophthalmic examination includes visual acuity, pupillary reflex; biomicroscopic and fundoscopic exam were normal. There was no proptosis of right eye. The left eyelids, adnexa, and globe were unremarkable. No limitation of eye movements was found.Due to chronic nature of swelling suspicious to tumoral lesion, orbital CT scan with axial and coronal view was requested, which showed well-defined, homogenous preseptal soft tissue mass without intraorbital extension or adjacent bony erosion .The next step was excisional biopsy of lesion. Under general anesthesia, after preparation, via lid crease incision, complete excision of mass was performed and 3 ∗ 3 ∗ 2.5 cm firm, fleshy mass was excised .Histopathologic examination showed diffuse, spindle-shaped cells proliferation which were entirely rhabdomyoblasts . ImunohiPatient was referred to oncologist for systemic workup. CT scans of abdomen and chest, bone scan demonstrated no evidence of metastasis or lymph node involvement. The patient underwent chemotherapy for eradication of possible residual tumor and completeness of treatment. Six months after completion of therapy, patient had good cosmetic result with no evidence of recurrence .Rhabdomyosarcoma is the most common primary orbital malignancy of childhood . ClassicThe early stages of pure eyelid rhabdomyosarcoma may be diagnosed as a benign lesion such as allergic reaction, insect bite, and hordeolum or appendage tumor. These lesions show spontaneous improvement and/or normal eyelid structure. Malignancy should be suspected whenever chronic, enlarging eyelid mass accompanied with ecchymosis is observed.If rhabdomyosarcoma is suspected, CT and MRI can be used to define the location and extent of the tumor . CT is pIn our patient orbital CT showed uniform, localized mass in preseptal space without extension to orbit which was in favor of a benign lesion, for example, dermoid cyst or hematinic cyst.A biopsy should be undertaken, if malignancy is suspected. It is often possible to completely remove a rhabdomyosarcoma if it had pseudocapsule , 3. If tImmunohistochemical staining helped to confirm the diagnosis. The most useful immunohistochemical marker includes antibodies against muscle-specific actin and desmin, which show the greatest specifity, vimentin shows a positive reaction in most rhabdomyosarcoma but is less specific for this tumor because it can be positive in other malignancy. Other reports have described presentation between range of 3 weeks to 78 years old and retain positive reaction even in poorly differentiated rhabdomyoblasts . VimentiBefore 1926 the standard treatment of orbital rhabdomyosarcoma was orbital exenteration and the survival rate was poor . Since 1These studies have unusually been directed to rhabdomyosarcoma from all locations. Metastasis from orbital rhabdomyosarcoma is relatively uncommon and regional lymph node metastasis is also rare because orbit is largely void of lymphatic . HoweverAlthough the orbit is the most common site of ocular rhabdomyosarcoma and mean age at diagnostics is about 7-8 years old, we report an upper eyelid embryonal rhabdomyosarcoma in 15-year-old man presented as enlarging right upper lid mass accompanied by ecchymosis similar to benign lesion such as subcutaneous hemorrhage. Therefore, ophthalmologists must be suspicious about rhabdomyosarcoma in any patient with eyelid swelling or mass and ecchymosis without history of trauma.


Ocular findings are rarely the initial symptom of leukemia, although up to 90% of all leukemia patients have fundus changes during the course of the disease. Herein we report a relapsing acute lymphoblastic leukemia patient with thesole presentation of sudden visual loss and exudative retinal detachment. An 8-year-old boy with acute lymphoblasticleukemia developed sudden visual loss during his first remission period. Bullous retinal detachment with total afferentpupillary defect was observed. Orbital magnetic resonance imaging revealed an intraocular mass lesion; simultaneouslyobtained bone marrow and cerebrospinal fluid samples showed no evidence of leukemic cells. Following local irradiation,and systemic and intrathecal chemotherapy the mass disappeared. Local irradiation, and systemic and intrathecalchemotherapy effectively controlled the isolated ocular relapse of acute lymphoblastic leukemia and eliminated the needfor enucleation. Ocular symptoms in leukemia patients may be due to the direct effect of leukemic cells on ocular tissues or secondary to such disease-related complications as anemia, thrombocytopenia, and hyperviscosity syndrome . Acute lAn 8-year-old boy diagnosed as pre-B ALL  was treated according to the St. Jude Total XIII high-risk (HR) protocol. Cerebral spinal fluid (CSF) was normal. According to the treatment protocol, due to the risk of central nervous system relapse radiotherapy (RT) was not administered. During the 97th week of treatment (27 months after the diagnosis) the patient developed unilateral sudden visual loss during his first remission period. His best-corrected visual acuity was 10/10 in the right eye, whereas light perception was absent in the left eye. Color vision could not be evaluated in the left eye and was 12/12 in the right eye. There was total afferent pupillary defect in the left eye. Eye movements were full. Intraocular pressure was within normal limits in both eyes. Slit-lamp examination showed bullous exudative retinal detachment in the left eye and a completely normal right eye . Ocular ultrasonographic examination showed total retinal detachment and a mass lesion that completely filled the bulbus oculi. Hyperechoic lesions indicative of calcification were not noted. Orbital magnetic resonance imaging (MRI) showed a 2 x 1.5-cm mass lesion with irregular borders that completely filled the bulbus oculi . Bone maAs soon as ocular relapse was diagnosed, re-induction therapy was initiated according to the St. Jude Total XIII-HR protocol . The patOcular involvement in children with ALL, which is typically bilateral, is usually observed with concomitant central nervous system and/or bone marrow relapse ,8. ImproThe differential diagnosis in leukemic patients with exudative retinal detachment includes central serous choroidopathy, uveal effusion syndrome, choroidal neovascularization, Harada’s syndrome, congenital optic disc pits, choroidal melanoma, and severe intraocular hypotony . All of Primack et al. reported a 3.5-year-old boy with a history of ALL that presented with total retinal detachment during a period of remission. Painful glaucoma that was unresponsive to medical therapy necessitated enucleation. Histopathologic examination showed leukemic infiltration of the retina and optic nerve. The child remained leukemia-free for 3 years following systemic and intrathecal chemotherapy, and craniospinal RT. This was the first reported case of relapsing ALL with retinal detachment as the sole presentation .Schmiegelow et al. reported a 17-year-old female ALL patient with serous retinal detachment and choroidal hemorrhagic infiltration as the presenting signs of relapse, without concurrent bone marrow or central nervous system involvement 1 year after cessation of therapy. No malignant cells were observed in subretinal fluid obtained during choroidal biopsy performed via sclerotomy. She was treated with prednisone, topical corticosteroid, and atropine, which resulted in normalization of vision and clinical findings; however, retinal detachment and choroidal infiltration recurred 5 months later. Pars plana vitrectomy and retinotomy were performed to remove subretinal tissue, which showed that there was leukemic infiltration in the choroid and concurrent bone marrow relapse . The presented patient is the fourth reported case of exudative retinal detachment as the sole presenting sign of relapsing ALL in the absence of concomitant systemic involvement. We did not confirm the presence of leukemic cells in the patient’s bulbus oculi, because we did not obtain a biopsy specimen due to technical difficulties. We did observe a new growing mass in the bulbus oculi via ultrasonography and MRI, and considered the findings as leukemic relapse. As a general rule, newly observed growing mass lesions are regarded as metastasis in cancer patients unless proved otherwise. The mass in the presented patient responded to local irradiation, and systemic and intrathecal chemotherapy. The mass disappeared, leaving behind crescent-shaped fibrotic tissue in the bulbus oculi. This response confirmed the diagnosis of the mass as leukemic infiltration. There are different therapeutic options for leukemic infiltration of the bulbus oculi in ALL patients; evisceration, enucleation, local RT, and systemic chemotherapy are methods that can be combined, according to each patient ,11,13,14In conclusion, local irradiation, and systemic and intrathecal chemotherapy effectively controlled the isolated ocular relapse of ALL in the presented case, and eliminated the necessity for enucleation. Conflict of Interest StatementThe authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included.


The carcinoid tumor of the appendix is one of the most common tumors of the appendix, but one of the rarest anatomic locations of carcinoids. The prognosis is very good, as most tumors are incidentally discovered during surgery for acute or sub-acute appendicitis. The diagnosis is exceptional when combined with pregnancy. We present such a case of a 27-year-old female patient. An emergency appendectomy was performed, and soon after, pregnancy was confirmed. The patient had a tumor smaller than 1 cm in diameter, at the tip of the appendix. The immunochemistry revealed the neuroendocrine profile by positive reaction for chromogranin A and synaptophysin, with a ki-67 profile at an undetectable level. After surgery, the neuroendocrine markers and the octreoscan were negative, consequently indicating a favorable prognosis. Further follow-up is necessary, even though not all the authors recommend it . A short review of the literature is presented, starting with this case report. Neuroendocrine tumors are closer to the last category. The appendix carcinoid tumor has a low aggressive profile. Rarely, there is an associated carcinoid syndrome. The most important step in the diagnosis of the appendix carcinoid is the post-surgical pathological exam, which incidentally reveals the tumor. After surgery, a follow-up of the neuroendocrine markers might be useful. Appendiceal tumors vary from very aggressive adenocarcinomas to benign tumors . In the present case, the tumor was an incidental finding during an appendectomy. In most cases (80%), all the appendiceal carcinoids are incidentally discovered in the removed organ; there are no particular signs before surgery. Sometimes the symptoms mimic a pregnancy. The diagnosis of acute appendicitis is more difficult in pregnant women [4]. The incidence of cancer in pregnancy is of 1 in 1000. The most common cancers associated with pregnancy are cervical, breast and ovarian, while appendiceal tumors are extremely rare [5]. Most of the appendiceal carcinoids are diagnosed in adults. The median age is of 29.8 years [6]. Appendiceal carcinoids account for 1.8% of all intestinal tumors, and for 85% of appendiceal tumors [7]. Females are more affected than males. Carcinoid tumors are found in 0.16 up to 0.7% of all appendectomy specimens [27]. Typically, there is a good long-term prognosis [26]. No risk of a secondary neoplasia was proved in long-term studies [27]. Romanian reports of appendix carcinoid are very limited [28].The first malignant tumor of the appendix was described in 1882, and the first reports about appendiceal tumors and pregnancy date from 1965 [11]. A recent case associates an appendiceal carcinoid to an ectopic pregnancy [12]. The interaction between the carcinoid tumor of the appendix and the pregnancy has not yet been elucidated [10]. The first case diagnosed by transvaginal ultrasound was reported in 2008 [13]. Depending on pregnancy age, appendectomy might be performed [10]. If an aggressive type of tumor is diagnosed, the second surgical step is hemicolectomy, which may be performed after delivery [10]. Sometimes, the tumor is preserved until delivery unless there are signs of local spreading [5]. The few reported cases showed no fetal malformations [14]. There are few cases of appendiceal carcinoids diagnosed during pregnancy, which manifested as appendiceal crises [15].One case with incidental appendiceal carcinoid found during a caesarean section was published in the literature. Generally, this surgical procedure as well as all gynecological surgery should include an appendix check-up [16]. The cut-off is of 2 cm in diameter [17]. Hemicolectomy is indicated in larger tumors, but some doctors avoid it [19]. Increasing tumor size predicts lymph nodes involvement, whereas age, gender, and depth of tumor invasion do not [29]. Regarding the appendix anatomy, 75% of the carcinoids are in the apex, as in our case (with the best prognosis), 20% in the middle portion, and 5% in the base of the appendix [21]. The prognosis of carcinoids depends on several factors including the size and the anatomic location of the tumor, the presence of metastases at diagnosis and the presence of the carcinoid syndrome, the main factor of prognosis in appendiceal carcinoids is the size . In our case, some authors do not recommend a follow-up. The five years survival rate after surgery is of 71 up to 100% [16].In the present case, after surgery, the neuroendocrine markers were normal, thus the full body octreoscan was not necessary. The follow-up included serum markers and an imagistic scan, performed 3 months after the surgery, then every 6 months, for 1 up to 3 years. Only if necessary, blood tests and imagistic studies can be performed annually thereafter [The carcinoid of the appendix is a rare finding in association with pregnancy. The pathological exam reveals the major aspects regarding the biological behavior and the future necessary therapies. Serial tests of the neuroendocrine markers are the most useful tools in follow-up. Generally, the appendiceal carcinoid is not aggressive. The present case highlights the important role of differential diagnosis of acute abdominal pain in women of childbearing age, and also of rare pregnancy-related appendiceal pathology.This case is an argue for performing a pregnancy test in all women of childbearing age presenting with acute abdominal pain and also the importance of considering other diagnoses that may mimic or present concurrently with acute appendicitis.Diagnosis of acute appendicitis is considered more difficult in pregnant than in non-pregnant women. The appendicial carcinoid tumor is a lesion that most frequently is discovered incidentally in the removed organ. There are only few similar cases were found in the literature reporting appendiceal carcinoid tumor during pregnancy.Acknowledgments: none


CL is a 54 year old perimenopausal, nulliparous, morbidly obese Caucasian woman who was referred to gynecologic oncology after discovery of peritoneal implants on CT scan of the abdomen and pelvis, obtained for persistent epigastric pain. She denied history of weight loss, bloating, constipation, pelvic pain, or dysuria. Her history included laparoscopic splenectomy thirteen years prior for idiopathic thrombocytopenic purpura (ITP), and she had no family history of cancer.Abdominal and rectopelvic examinations were normal. Cancer antigen 125 and carcinoembryonic antigen levels were within normal limits. CT review identified multiple small enhancing anterior peritoneal nodular implants without evidence of pelvic mass A. Given As the case was highly suspicious for a malignant process, the patient was consented for exploratory laparotomy and debulking. Intraoperatively, the greater omentum had multiple small maroon nodules under 3 cm in size . ExtensiWe reviewed her splenectomy operative report which described laparosocpic excision with morcellation and removal through an endoscopic bag without spillage. No comment was made of splenic nodules. The patient's platelet count four months prior to splenectomy was 21 K/μL, rising to 383 K/μL the day of splenectomy with medical therapy, then rising to 583 K/μL one month following surgery. Her platelet count was 432 K/μL at the time of consultation thirteen years later.Splenosis is defined as ectopic splenic tissue commonly arising from splenic trauma-induced autotransplantation, or rarely as congenital accessory spleens or polysplenia . Ninety The recurrence risk of ITP secondary to splenosis is unclear. Meta-analysis of 23 reports of ITP relapse following laparoscopic splenenectomy (74% performed for ITP) was 43.6 per 1000 patient years, 1–5 years post-operatively . KhatkouThe majority of splenosis cases are found incidentally, and it has rarely been reported as a primary pathologic process. As concisely reviewed by Fremont et al.; “Pain secondary to infarction, intestinal obstruction due to the adhesive bands of the splenic implants, gastrointestinal hemorrhage, hydronephrosis secondary to a growing mass exerting pressure on the ureter, as well as an enlarging abdominal mass with associated infection have all been reported .”Imaging modalities such as ultrasound, CT, and MRI do not provide confirmatory diagnosis. Splenosis may resemble normal splenic tissue upon these imaging techniques, and none can exclude carcinomatosis . Many raPET scans assist oncologists in treatment planning and malignancy response quantification. Injection of labeled biologically active glucose results in concentration of tracer in many tissues exhibiting increased metabolic activity, a fundamental process in malignant tumors . QuantifA literature review found no reports of splenosis exhibiting PET hypermetabolic activity. In fact, a recent case report of peritoneal splenosis mimicking carcinomatosis used negative PET findings in support of primary laparoscopy instead of laparotomy in a patient with history of cervical cancer . While PDirect visualization and tissue biopsy are the ideal means of characterizing a suspected malignant intra-abdominal process. This patient had normal tumor marker levels and resolution of symptoms, but ominous CT and PET findings. Given this clinical picture, we proceeded with planned laparotomy for debulking surgery. Her surgery and recovery were uncomplicated and the findings provided her with great relief. In retrospect, scintigraphy may have added information to suggest a preoperative diagnosis of splenosis. In this case, visual and tissue confirmation could have been accomplished by laparoscopy. In this patient's clinical scenario we feel that visual and pathologic confirmation is mandatory. The vascular nature of splenic implants may increase the risk for hemorrhage with CT or ultrasound-guided biopsy, and this method would not provide for visual survey of the abdominopelvic cavity.Splenosis is a rare phenomenon that may be mistaken for carcinomatosis upon standard imaging techniques. PET is routinely used to better characterize an abdominopelvic process suspicious for malignancy. In workup of novel carcinomatosis in patients with history of abdominal trauma or splenectomy, splenosis should be part of the differential diagnosis, and consideration of nuclear imaging modalities including PET scan, scintigraphy, and diagnostic laparoscopy should all be considered prior to proceeding with laparotomy.The authors of this manuscript have no conflicts of interests to disclose.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.


Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography.The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy.Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer.The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management. Food-derived bony items swallowed inadvertently can result in large bowel perforation but occasionally dual mechanisms of perforation co-exist and can represent a diagnostic challenge.2An 85-year-old male taking ferrous sulphate for anaemia, with previous peptic ulcer disease and ischaemic heart disease, presented as an emergency with 48 h of progressive of left-sided lower abdominal pain on a background of 2 months of loose stool. Admission physiological parameters were normal. There was tenderness in the left iliac fossa but the abdomen was soft and the rectum empty. Clinical examination was otherwise unremarkable.9 cells/l and 187 mg/l, respectively.Admission blood work confirmed anaemia with a haemoglobin of 98 g/l and elevated leucocyte and C-reactive protein counts of 11.6 × 10Plain abdominal X-rays were reviewed and the patient was admitted to the medical receiving unit for treatment of presumed constipation. The patient clinically decompensated with the development of increasingly severe abdominal pain and sepsis characterised by high fever and a tachycardia of 121 bpm. An erect chest X-ray to exclude a source for sepsis revealed pneumoperitoneum. An urgent surgical consultation identified an incarcerated, erythematous left-sided inguinal hernia and a CT scan of the abdomen and pelvis showed a mid-sigmoid perforation as a result of an ingested bone with a localised collection and free gas tracking through the left inguinal canal to the scrotum. Fluid resuscitation and appropriate antibiotic therapy was commenced and emergency laparotomy undertaken. This confirmed a perforation of the sigmoid colon by a chicken bone and also an immediately distal malignant lesion later characterised pathologically as a T3N1 adenocarcinoma. An anterior resection and colo-rectal anastomosis was performed, but the inguinal hernia was not repaired. The patient made a gradual but uneventful recovery and was discharged on the 15th postoperative day .3Although ingestion of foreign bodies is a commonly encountered clinical scenario thought to account for some 6000 presentations per year in the United Kingdom,It has been suggested that those locations in the gut with tapering or angulation are most susceptible to perforation by foreign bodies.4Perforation of the gastro-intestinal tract by an ingested foreign body is a rare event, where meticulous clinical assessment is required to reduce diagnostic error and delay in surgical management. However, this is made all the more challenging by the typical absence of a corroborative history. Where foreign body perforation of the sigmoid colon has occurred, CT imaging should be carefully scrutinised for occult malignancy, as should a thorough examination of the colon distal to the perforation site. Obviously this finding will have implications for operative strategies.None declared.None.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.J. Terrace: reviewed case, conceived manuscript structure, content and design, performed literature review, wrote manuscript, prepared figures.J. Samuel: reviewed case, contributed to manuscript structure and writing.J. Robertson: reviewed and edited manuscript and figures.R.G. Wilson: management of the clinical case and reviewing the manuscript.D. Anderson: reviewed, edited and co-wrote manuscript.


Although more than 100 cases of hemangioma of the urinary bladder have been reported, capillary-type hemangiomas of the bladder are rare. Pyogenic granulomas, which are common tumor-like vascular lesions of the skin and oral mucous membranes, reveal histopathological findings similar to capillary-type hemangiomas and are differentiated from ordinary hemangiomas by clinical features and etiologic factors. Little is known regarding the occurrence of pyogenic granulomas in the urinary bladder.We present the case of a 78-year-old Japanese man who had developed a hemangiomatous lesion in his bladder which led to acute clot retention. He had a recent history of chemotherapy for pancreatic cancer. A solitary pedunculated mass measuring 1.2 cm was observed in the bladder. Histopathological analysis of the resected mass revealed marked lobular capillary proliferation with surface erosions.Cystoscopic and pathologic findings in addition to possible predisposing factors supported a diagnosis of pyogenic granuloma of the urinary bladder. Although vascular tumors, especially hemangiomas, are relatively common mesenchymal tumors in soft tissue, skin and organs such as the liver, hemangioma of the urinary bladder is a rare tumor that accounts for only 0.6% of all bladder tumors . HemangiPyogenic granuloma is a common tumor-like vascular lesion of the skin and mucous membranes of the oral cavity that has traditionally been considered a reactive hyperplastic lesion rather than a neoplastic process . It usuaA 78-year-old Japanese man was referred for sudden, asymptomatic gross hematuria with pyuria and clot retention that had occurred six days prior to his visit. Upon presentation at our hospital, he was afebrile and denied chills, pain, or weight change. Physical examination revealed no palpable mass or enlarged lymph nodes. The patient had undergone transurethral resection of the prostate for benign prostatic hyperplasia and transurethral lithotripsy for bladder calculi 11 years previously. He had also been diagnosed with pancreatic cancer  seven years previously. Following resection of the pancreatic tumor, he had received chemotherapy for liver and lymph node metastases. Five cycles of gemcitabine therapy proved ineffective; however, stable disease was achieved by second-line chemotherapy (administered until 17 months prior to his being seen for urinary symptoms) using tegafur, gimeracil, oteracil potassium and octreotide. Because of severe adverse events , monotherapy using octreotide and best supportive care had been provided.Cystoscopy revealed a solitary non-papillary, pedunculated mass measuring approximately 1.2 cm located lateral to the left ureteral orifice Figure . The suret al. reported that bladder hemangiomas occur in all age groups, with most being diagnosed in patients less than 30 years of age at a male-to-female ratio of 3.7:1 [Hemangiomas of the urinary bladder are the second most common vascular tumor of the urinary tract, with more than 100 cases reported ,7,8. Hemof 3.7:1 ,3,7,8.On cystoscopy, bladder hemangiomas most commonly appear as elevated sessile blue masses. In our patient, however, we observed a red pedunculated tumor with probable large feeding vessels in the stalk. Similar gross findings have been observed in pyogenic granulomas of the oral cavity, skin, and gastrointestinal lesions -6. AlthoA marked pathological finding of pyogenic granulomas is prominent capillary growth within a hyperplastic granulation reaction, which suggests strong angiogenic activity. Similar histopathology can be seen in capillary hemangiomas and pyogenic granulomas, and there are no differential findings or available diagnostic markers to determine the angiogenic profile and an exact differential diagnosis . ClinicaPyogenic granuloma of the urinary bladder is very rare; there has only been one report of seven cases, which was published as an abstract in 1973 without additional information . In the There are many therapeutic approaches for the management of patients with hemangioma. Partial cystectomy, simple cystectomy with bladder augmentation, and radiation therapy are effective for bulky and multiple tumors. However, endoscopic biopsy and fulguration, and yttrium aluminium garnet laser coagulation have become standard in cases of small tumors -3. In thPyogenic granuloma commonly occurs on the skin and oral mucosa, but is extremely rare in the urinary bladder. We treated a 78-year-old Japanese man with a capillary hemangioma-like lesion of the urinary bladder that resulted in clot retention. Cystoscopic and pathologic findings together with his clinical history led to the conclusion that the lesion was a urinary bladder counterpart of pyogenic granuloma usually found in skin and oral mucosa.Written, informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SM drafted the report, performed the surgical procedure and approved the final version of the manuscript. CO, KY, TG and TK performed examinations, cared for the patient, and approved the final version of the manuscript. HK reviewed the pathological specimens with HT, drafted the report and contributed to the final version of the manuscript. All authors read and approved the final manuscript


Most common sites are limbs, pelvis and head and neck. About 20% of all hemangiopericytomas are seen in head and neck, mostly in adults. Usually it presents in orbit, nasal cavity, oral cavity, jaw, parotid gland, parapharyngeal space, masticator space and jugular foramen. Long term follow up is important because of imprecise nature of the histological criteria for prediction of biologic behavior.Hemangiopericytoma (HPC) is a rare tumor of uncertain malignant potential arising from mesenchymal cells with pericytic differentiation. It accounts for 3-5% of soft tissue sarcomas and 1% of vascular tumors. It usually presents in 5We report herein a case of HPC in 66-year-old man, who presented in our department with headache, nasal obstruction and dysphagia. A neck computer tomography scan and magnetic resonance imaging showed a large left parapharyngeal mass bulging into nasopharynx and oropharynx with extension to pharyngeal mucosal surface and causing narrowing of airways and total obstruction of left posterior nostril. Angiography showed a highly vascular neoplasm. Initially he was managed as a case of schwannoma and embolization was done but with no response. An attempt to do complete surgical resection was made, but due to its critical position, it was not possible. During surgery, highly vascularised tumor was found. The histopathologic examination revealed a vascular tumor consistent with hemangiopericytoma G-II. The patient had normal postoperative course of healing and was given adjuvant radiation. He is on regular follow up without signs of recurrence or metastases.In summary, parapharyngeal space is a rare site of presentation for hemangiopericytoma which is highly vascular tumor, requiring extensive work up including magnetic resonance imaging, computed tomography scan and angiography. Complete surgical excision should be attempted. Postoperative radiation is indicated in cases of incomplete resection. Hemangiopericytoma is a rare tumor type. It originates in a specific cell type called pericytes, identified by Rouget in 1873 and subsequently described by Zimmermann in 1923. Just above 300 cases of HPC have been reported since Stout and Murray described HPCs as "vascular tumors arising from Zimmerman's pericytes" in 1942. These cells are arranged alongside capillary vessels and have smooth muscle characteristics. They are responsible for vessel caliber regulation owing to their contractile capability, modulating both flux and permeability [Hemangiopericytoma constitutes about 3-5% of all soft tissue sarcomas and about 1% of all vascular tumors. The head and neck incidence is 15-30% and it is mostly seen in adults. In the head and neck region it is usually seen in the orbit, nasal cavity, oral cavity, jaw, parotid gland, parapharyngeal space, masticator space and jugular foramen . The patA 66-year old male with known diagnosis of diabetes mellitus, hypertension, cerebrovascular accident and benign prostatic hyperplasia presented in December 2009 with 3 months history of nasal obstruction, headache and difficulty in swallowing. For the past 1 month, he had developed numbness over the right side of face. CT scan head and neck on 27/12/2009 showed well defined heterogeneously enhancing 3.6 × 6.6 × 5.5 cm left parapharyngeal solid mass with multiple small cystic components, bulging into nasopharynx and oropharynx with extension to pharyngeal mucosal surface  in between thin wall blood vessels in some areas with stag horn pattern consistent with hemangiopericytoma G II Figure . Left PaHe was seen in radiation oncology clinic on 08/02/2012. Examination revealed ECOG PS O with left facial nerve palsy. There was well healed scar mark over the left upper neck. After discussing the case in tumor board, it was decided to give him postoperative radiation therapy. He received 60 Gy in 30 fractions, 200 cGy/day, 5 days per week by IMRT technique to tumor bed which started on 2/6/2011 and completed on 2/8/2011. He tolerated radiation treatment quite well developing only G-1 skin reaction in last week of radiation therapy. He is on regular follow up till now and is disease free. His CT scan neck done on 27/11/2011 showed no evidence of recurrence or residual disease.Hemangiopericytoma is uncommon in the head and neck. Stout and Murray described 691 cases of vascular tumors (1942), and only nine of these were hemangiopericytoma. The most frequent anatomic sites for HPC are the extremities, the pelvis, and the head and neck, accounting for 80% of the total cases . Our patDifferential diagnosis of hemangiopericytoma includes juvenile hemangioma, glomus tumor, angiosarcoma, leiomyoma, leiomyosarcoma, schwannoma, mesothelioma, liposarcoma, benign and malignant histiocytoma, synovial sarcoma, chondrosarcoma, neuroblastoma, adenoid cystic carcinoma and mixed cell tumor. Angiographic features may help in differentiating hemangiopericytoma from other hyper vascular lesions. Tomography, radiography and angiography are not specific. Radiographically, the tumor consists of well-circumscribed, radiopaque soft tissue mass often displacing surrounding structures .Characteristically, HPC is a well-circumscribed, brown, spongiform lesion, surrounded by a pseudo-capsule, often with small satellite nodules separate from the main tumor mass . They caPlain radiography is nonspecific, however angiography is recommended for confirmation of diagnosis of vascular neoplasm, preoperative definition of blood supply, and embolization of tumor. Characteristic features on angiography include hypervascularity, radially arranged branching vessels around and inside the tumor, and longstanding, well-demarcated tumor stains. MRI provides useful preoperative information about the extent of the tumor and its relationship to the surrounding structures and distinguishes between intraparotid and extra-parotid neoplasms. Computerized tomography is helpful in the evaluation of bony erosions . The preThe treatment of choice is primary resection with a wide safety margin. Patients undergoing complete resection showed a 100% median survival at 60 months . The useParapharyngeal space hemangiopericytoma is a rare entity found in a rare site. High index of suspicion is required to diagnose these cases. Extensive radiological as well as histological investigations need to be carried out. An attempt should be made for complete surgical resection. Postoperative radiation is indicated in cases of incomplete 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.HPC: Hemangiopericytoma; MRI: Magnetic resonance imaging; CT: Computed tomography; CCA: Common carotid artery; D/D: Differential diagnosis; ECOG: Eastern Cooperative Oncology Group; IMRT: Intensity modulated radiation therapyThe authors declare that they have no competing interests.MMF collaborated between treating surgeon and primary radiation oncologist, collected the data, radiology and pathology slides and wrote manuscript, AAA was the primary radiation oncologist who planned for postoperative radiation, MAA was the primary surgeon who did the maximam possible surgery, YB assisted in radiation oncology treatment planning and execution, MT and RA helped in writing manuscript, while MAA provided valuable guidance in formatting and revising the manuscript. All authors read and approved the final manuscript.


Abnormal cerebral vasculature can be a manifestation of a vascular malformation or a neoplastic process. We report the case of a patient with angiography-negative subarachnoid hemorrhage (SAH) who re-presented 3 years later with a large intraparenchymal hemorrhage. Although imaging following the intraparenchymal hemorrhage was suggestive of arteriovenous malformation, the patient was ultimately found to have an extensive glioblastoma associated with abnormal tumor vasculature. The case emphasizes the need for magnetic resonance imaging to investigate angiography-negative SAH in suspicious cases to rule out occult etiologies, such as neoplasm. We also discuss diagnostic pitfalls when brain tumors are associated with hemorrhage and abnormal vasculature. The patient was ultimately found to have a glioblastoma associated with tumor-related vasculature mimicking an AVM. We discuss challenges in the diagnosis of glioblastoma in the setting of intracranial hemorrhage (ICH) and tumor-associated vascular abnormalities that resemble AVM. We also argue for the use of contrast-enhanced magnetic resonance imaging to investigate the etiology of angiography-negative SAH when warranted based on clinical suspicion.Subarachnoid hemorrhage (SAH) results from both traumatic and non-traumatic etiologies. While vascular malformations such as arteriovenous malformations (AVM) and aneurysms account for the majority of non-traumatic SAH, no specific cause can be found in many cases. Even with catheter-based diagnostic cerebral angiography, no causative etiology is seen in 15–30% of cases . Among nA 53-year-old male anticoagulated with warfarin for stroke prevention  presented with blurry vision and headache that had progressively worsened over the course of 3 days following minor trauma to the head. Computed tomography (CT) demonstrated SAH in the right quadrigeminal and supracerebellar cisterns Figure . CatheteThree years later, following an episode of hemodialysis, the patient developed acute onset of unresponsiveness, lack of right pupillary response to light, and left-sided weakness. CT imaging demonstrated a large right temporal hematoma Figure  that wasThree weeks later, he again became acutely unresponsive with left-sided weakness. A head CT demonstrated new and extensive intraparenchymal hemorrhage centered in the right temporal lobe, extending into the right parietal, and occipital lobes measuring up to 7.8 cm × 3.7 cm Figure . There wHis anticoagulation was reversed emergently and he was stabilized in the intensive care unit. A CT-angiogram demonstrated a large region of abnormal vasculature centered in the right temporal lobe Figure . The rigAutopsy revealed no evidence for a vascular malformation; rather, an extensive glioblastoma involving the right parietal, occipital, and temporal lobes with significant associated hemorrhage and necrosis was found Figure . The tumHistologically, this was a WHO grade IV glioblastoma with extensive infiltration of the white matter centered in the right temporal lobe and involving the parietal and occipital lobes. Classic pseudopalisading necrosis, along with frequent mitotic figures, microvascular proliferation, and reactive gliosis involving the cortex and white matter were noted Figure . There wThis patient first presented with an angiography-negative SAH in the quadrigeminal and supracerebellar cisterns with a history of mild trauma to the head. Although non-aneurysmal SAH has a generally better prognosis than aneurysmal SAH, non-aneurysmal SAH encompasses multiple disease processes, the prognosis for which can vary . Among tAs there was no evidence of neoplasm on CT and the presented patient had a history of mild trauma while on warfarin, it was suspected that the original presentation of SAH 3 years prior had a traumatic etiology exacerbated by coagulopathy. The SAH was not in a classic traumatic location, although a redistribution phenomenon is known to occur when significant time (48–64 h) elapses between trauma and imaging. It is uncertain whether the patient harbored a hemorrhagic tumor 3 years prior to his most recent presentation, although it remains a possibility. There has been one other report of glioblastoma presenting as a suspected traumatic ICH, in which the authors emphasize the importance of workup for possible neoplastic etiology when hemorrhage occurs in an abnormal site . HoweverThree years later, the patient re-presented with an extensive intraparenchymal hemorrhage. Brain tumors represent 0.9–11% of spontaneous ICH, and between 3 and 5% of intracranial neoplasms cause large hemorrhage; the incidence approaches 15% if subclinical and microscopic hemorrhage is considered . The incGlioblastoma-associated hemorrhages are usually located deep within the cerebral hemispheres, corpus callosum, or basal ganglia. Several hypotheses have been proposed to explain the pathological basis of glioma-associated hemorrhage. Hemorrhage within the tumor may be caused by disruption of vessels traversing the necrotic core. Tumor erosion of cerebral vessels at proliferating margins may cause thinning, rupture, distortion, compression, or aneurysm of normal brain vasculature. Tumor capillaries may be structurally deficient and susceptible to bleed , 17. SomGlioblastoma or other intracranial malignancy presenting as ICH poses a diagnostic dilemma, because recognizing the neoplastic lesion is not always possible with CT or CT-angiography. Indeed, in a retrospective study of 50 cases of spontaneous ICH caused by cerebral neoplasms, there was no preoperative radiological suspicion of neoplasm in half of cases . Neverthde novo AVMs are known to occur  that demonstrated slow A-V shunting. The combination of ICH and abnormal vasculature with A-V shunting on angiography was highly suggestive of AVM in this patient. The normal angiogram obtained 3 years prior to his admission was not inconsistent with a diagnosis of AVM, as to occur . In addito occur , 26. Theto occur .The radiographic features that would enable differentiation between AVM and glioblastoma are frequently obfuscated in the setting of acute hemorrhage. For example, a ruptured AVM with hematoma formation can exhibit a mass effect, making it difficult to distinguish from a tumor on CT. In one study, 33 of 60 cases of ruptured AVMs demonstrated significant mass effect .Although rare, there have been a few reports of glioblastoma mimicking or associated with a vascular lesion in which initial imaging does not clearly distinguish between the two. In some cases, initial imaging indicates hemorrhage of uncertain etiology , 29–31; The anatomical coincidence of the first SAH and the large glioblastoma discovered 3 years later suggests that the etiology of the SAH may have been neoplastic. We suspect that a follow-up contrast-enhanced MRI to further investigate the cause of the patient’s SAH may have uncovered a malignant lesion, or at least would have been useful in narrowing our differential for the etiology. Indeed, in one study, MRI following angiogram-negative ICH provided new, valuable diagnostic information in 36% of cases .Additionally, better differentiation between AVM and glioblastoma would have been possible on MRI when the patient re-presented 3 years later. AVMs have characteristic low signal intensity on T1-weighted images and high signal intensity with signal voids on T2-weighted images, and can be enhanced by contrast. Glioblastoma is characterized by poorly circumscribed infiltration associated with significant perilesional edema. In contrast-enhanced MRI, glioblastoma usually shows heterogeneous enhancement. However, even with MRI, early findings of glioblastoma may resemble non-neoplastic lesions .We propose that contrast-enhanced MRI may be useful for investigating the etiology of non-aneurysmal SAH, particularly for distinguishing benign causes like perimesencephalic SAH from more harmful ones, such as neoplasm. Given the known association between glioblastoma and AVM-like angiopathy, we also emphasize the importance of workup for possible neoplastic etiology in the setting of ICH and AVM-like findings on angiography, in which MRI may also play an important role. This case highlights the need for careful consideration of neoplasm in the differential diagnosis of non-aneurysmal SAH, and the potential pitfalls in the diagnosis of glioblastoma associated with abnormal vasculature.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Angiosarcoma (AS) is an aggressive, malignant endothelial cell tumor of vascular or lymphatic origin, the presentation and clinical behavior of which may vary according to its location. This is the case report of a 56-year-old woman with cutaneous angiosarcoma (CAS) of the buttock complicated by severe thrombocytopenia. A review of the literature revealed that only nine cases of CAS with thrombocytopenia have been previously reported. The prognosis of CAS complicated by thrombocytopenia is poor, even after treatment with combined chemotherapy and radiotherapy (RT). The composite karyotype was 46,XX,t[3]/47,X,add(X)(q13),del(6)(q?),add(12)(p13),−21,+2mar[2]/45,XX,der(1)add(1)(p36.3)del(1)(q41),−20[1]/46,XX[13]. Only 13 cytogenetic cases of AS, including the present case, have been reported in the English literature thus far. In this case report, the clinical presentation and cytogenetic findings are described and the relevant literature on AS is reviewed. Angiosarcoma (AS) is an aggressive, malignant endothelial cell tumor of vascular or lymphatic origin . The preA 56-year-old female sought medical assistance due to a 2-month history of dark reddish eruptions and pain in her left buttock. There was no reported history of disease or trauma. Three discrete eruptions without edema were identified on the skin. The surface was smooth with minor inflammation and the borders were poorly defined. The lesions were tender to palpation. The radiological and laboratory findings were normal. A biopsy was performed and sheets of highly atypical, mitotically active, epithelioid endothelial cells were observed under a light microscope, with formation of irregular sinusoidal vascular channels . The les2, ifosfamide 1.5 g/m2 and dacarbazine 300 mg/m2) × 3 days] were administered  . KMS hasOnly a few cases of AS have been cytogenetically investigated –29. The Treatment of CAS is challenging and an optimal treatment protocol has not yet been determined. The treatment usually consists of surgical excision with wide safety margins and postoperative radiation ,30, alth


We present a rare case of osteosarcoma involving the patella. A 30-year-old Japanese woman first consulted our out-patient clinic with a 2-year history of knee pain. Radiographs showed an enlargement of the patella with irregular distribution of both osteolytic and sclerotic lesions. Computed tomography and magnetic resonance imaging demonstrated soft tissue extension at the anterior part of the patella. Incisional biopsy showed abundant osteoid formation by spindle-shaped malignant cells, and the histological diagnosis was conventional osteosarcoma. The patient underwent preoperative chemotherapy, but there was no response. Furthermore, she developed a pathological fracture during chemotherapy. She underwent above-the-knee amputation with postoperative chemotherapy. She developed multiple metastases in the thoracic vertebrae 20 months after the surgery. At the most recent examination, she remains alive with multiple spinal metastases without paralysis 4 years after the surgery. The patella is an uncommon site for primary bone tumor, and benign tumors are more common than malignant tumors . OsteosaIn June 2004, a 30-year-old Japanese female initially consulted a local physician with a 6-month history of right knee pain and was treated with a non-steroidal anti-inflammatory drug. In December 2005, she consulted another local clinic since the knee pain had increased and was referred to our out-patient clinic.On physical examinations, redness and swelling of the anterior aspect of the knee were noted, and flexion of the knee joint was restricted to 120°. She could not raise her lower leg against gravity because of muscle atrophy around the right thigh. On radiographs, the right patella was enlarged, and the cortical shell was irregularly discontinuous. Osteolytic and osteoblastic lesions were irregularly distributed in the patella . ComputeThe patient underwent chemotherapy including high-dose ifosfamide, adriamycin, and cisplatin. However, these were not clinically effective, and the response was estimated as progressive disease. Furthermore, she developed a pathological fracture of the patella during chemotherapy. Therefore, we performed above-the-knee amputation in April 2006. The surgical specimen showed extensive remnant of tumor cells, and the effect of the chemotherapy was evaluated as ‘poor’. High-dose methotrexate, adriamycin, and cisplatin were administrated postoperatively. In December 2007, she developed multiple metastases in the thoracic vertebrae. She again underwent chemotherapy including high-dose ifosfamide, adriamycin, and cisplatin. At the most recent examination in 2010, she remains alive with metastatic disease in the thoracic spine without paralysis.Among primary malignant bone tumors, osteosarcoma is the most frequent. Osteoid and/or bone produced by malignant cells is fundamental to making a diagnosis of osteosarcoma. The metaphyseal parts of the long bone, especially the region of the knee, are common sites. Although osteosarcoma shows a predilection for both the distal femur and proximal tibia, the patella is not a common site. In the Mayo Clinic series, there was only one case showing an osteosarcoma of the patella among 1649 cases of osteosarcoma . Benign To our knowledge, eight cases of osteosarcoma in the patella, including the current case, have been reported in the English literature . CharactOf the eight cases, clinical courses were available in seven. Six of the seven patients presented with pain and swelling of the patella, whereas the current case initially presented with anterior knee pain only. The interval from onset of symptoms to definitive diagnosis ranged from 3 months to 3 years (median 13 months) and tends to be prolonged due to misdiagnosis or failure to consider the potential for malignancy. In only one patient (case 3) was biopsy performed at the initial presentation. The patient subsequently underwent chemotherapy and surgery and has remained well for 120 months to date  . Two casFerguson et al. recommended that a definitive diagnosis should always be obtained before any treatment of the bone lesion is initiated . Case 3,


Spontaneous enterobiliary fistulae are a complication of biliary disease or a disease of adjacent structures. Cholecystocolic fistulae are rare in relation to gallbladder carcinoma (GBC). Previous reports have presented images showing subtle findings suggestive of cholecystocolic fistula. We report the unusual spread and rare images of a case of cholecystocolicfistula,to highlight the aggressive nature of GBC and findings of gross transmural invasion of the colonic wall. The images acquired in all three planes define the anatomical and pathological extent conclusively. There are a higher number of GBC cases across the geographic belt of North India compared to the West. In this case, the patient’s pathology was extensive and unresectable, and therefore palliative and supportive care wasadvised. The cholecystocolonic fistula is an uncommon but pertinent complication of gallbladder disease, occurring in 0.06 to 0.14% of patients with biliary disease . Among tWe discuss the case of a 48-year-old woman who presented with right hypochondrial pain, jaundice and melena. On examination there was severe jaundice and a lump in the right hypochondrium. The patient underwent an abdominal ultrasonography which showed gallbladder fossa mass infiltrating the portahepatis with proximal biliary dilatation. Fine needle aspiration cytology (FNAC) was undertaken and revealed high grade adenocarcinoma. The patient was advised MDCT evaluation. Contrast enhanced multiplanar CT  with IV and oral contrast was performed.Axial sections showedan ill-defined, hypoattenuating infiltrative soft tissue mass lesion in the gallbladder fossa. The lesion showed frank transmural invasion of the colonic wall with a discernible fistulous tract. Multiple air loculi were visible within the mass lesion. Contiguous axial sections demonstrated the fistulous tract and relation of the transverse colon and ascending colon Figure A-C. The Spontaneous enterobiliary fistulae are a complication of biliary disease or a disease of adjacent structures. They are usually associated with gallstones; however, peptic ulcer disease, abdominal trauma, Crohn’s disease, and malignancies of the biliary tract, bowel and head of pancreas, have also been implicated as causes -3. The oGBC has been notorious to have a poor prognosis, with an overall 5-year survival rate reported to be 4% . It is rThe endemic zone of North India comes across aggressive behavior of GBC. Imaging can be definitive and conclusive, and can obviate surgical exploration in appropriately selected cases. A combined approach using noninvasive diagnostic methods and percutaneous aspiration biopsies may reduce the number of explorative laparotomies in advanced cases of GBC. Multidetector scanners are a powerful modality to define the extent, anatomical information and associated complications of GBC.Written informed consent was obtained from the patient for publication of this Case Report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; FNAC: Fine needle aspiration cytology; GBC: Gallbladder carcinoma; MDCT: Multidetector computerized tomography.The authors declare that they have no competing interests.ANDD: Conceived and designed the study. Drafted the manuscript and contributed to the intellectual content and given final approval of the version to be published. SK: Involved in data acquisition and data interpretation and has participated in design of study and intellectual content. SR: Has helped in data acquisition and image analysis and helped in drafting and revising the manuscript. BNM: Participated in data acquisition and data analysis and participated in its design. All authors read and approved the final manuscript.


When obstructive colitis becomes fulminant, it is known as ‘acute necrotizing colitis’. We report a rare case of acute necrotizing colitis due to sigmoid colon cancer, in which shock status occurred within ten hours of onset. A 79-year-old female with acute abdominal pain was transported to our hospital with acute shock. Abdominal enhanced computed tomography revealed thickening of the wall of the sigmoid colon and marked dilation of the proximal colon. Emergency surgery was performed with the intraoperative findings of severe sigmoid colon stenosis and proximal dilation of the colon without perforation, and a large volume of putrid ascitic fluid. The intestine was proximally dilated and black in color, from the sigmoid colon to the ileum 60 cm proximal to the terminal ileum, suggesting acute necrosis. Total colectomy with 80 cm resection of terminal ileum and ileostomy was performed. Whereas acute necrotizing colitis is a rare condition and its etiology remains obscure, the chronic ischemic state must play some role. Our patient was of advanced age and had diabetes mellitus and hypertension. These factors might lead to a chronic ischemic state of the bowel due to arteriosclerosis. In addition to the underlying condition, massive bacterial reflux into the ileum from the colon might cause the capillary vasoconstriction of the bowel that led to her critical state. Obstructive colitis is a condition defined as nonspecific inflammatory lesions of the colon, such as erosion and ulceration, proximal to a completely or partially obstructive lesion -3. ObstrWe experienced a case of acute necrotizing colitis and ileitis due to colon cancer with a rapid clinical course, in which shock status occurred within ten hour of initial symptoms. The patient was saved only after intensive care and two emergency operations, thus emphasizing the importance of these interventions in such cases.2 saturation 100% (with 10 l reservoir mask). Acute shock, abdominal distension and tenderness, and muscular guarding were also noted. Laboratory results showed a mild increase in the inflammatory response: leukocyte count 7.6 × 103/μl, C-reactive protein 2.70 mg/dl, hemoglobin 15.3 mg/dl, and blood urea nitrogen 41 mg/dl, indicative of severe dehydration. Abdominal enhanced computed tomography (CT) revealed thickening of the sigmoid colon and marked dilation of the proximal intestine from the ileum to the sigmoid colon  in the sigmoid colon causing colonic obstruction. The bowel, from the sigmoid colon to 60 cm proximal to the terminal ileum, was totally necrotized (Figure A 79-year-old female with acute, gradually worsening abdominal pain requested emergency services. By the time of their arrival, she had collapsed. She was transported to our tertiary emergency medical center. Physical examination on admission revealed a Glasgow coma scale of E4V5M6, blood pressure 80/50 mmHg, pulse 88/min, respiratory rate 28/minute, temperature 36.9°C, and OAfter surgery, intensive care, including mechanical ventilation, continuous hemodiafiltration, polymyxin B hemoperfusion, and blood transfusion, was continued to address circulatory failure and acute renal failure due to sepsis. The patient’s general condition improved gradually, and catecholamine administration was withdrawn on postoperative day 5. On postoperative day 8, perforation of the small intestine near the stoma occurred. We performed a further emergency surgery to create a new ileostomy. The patient’s general condition improved, and she was then transferred to a rehabilitation hospital on postoperative day 71.The incidence of obstructive colitis is known to be 0.3% to 3.1% of all colorectal carcinomas . The finAmong obstructive colitis cases, few develop fulminating gangrene of the colon, an entity is termed ‘necrotizing colitis’ , the etiSince the present case followed a rapid clinical course and entered shock status within ten hours, we performed emergency surgery. At the tertiary emergency room, rapid 2 l-infusion was initially administered and at that time, the patient was responding to some extent. So, enhanced CT and colonography were examined. With colonography, a transanal drainage tube was inserted to the proximal dilated bowel through the tumor. Because her vital signs deteriorated in spite of these treatments, we performed the emergency operation. In our case, examination of enhanced CT and colonography did not change the final management, and might simply have delayed the operation. Urgent laparotomy might, therefore, be the better choice in septic shock and hemodynamically unstable conditions with clear peritoneal signs on arrival.In this situation, it is vital to resect the entire necrotic intestine, following which the status of the mucosa of the proximal margin and proximal remnant bowel should be checked. If any ischemic change is observed in the proximal remnant bowel mucosa, further colonic tissue should be resected proximally until a healthy mucosal margin is achieved . In the In summary, we report a case of acute necrotizing colitis due to sigmoid colon cancer, in which shock status occurred 10 hours from onset. Emergency surgery and intensive care were essential in saving the patient’s life.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.AJCC: American Joint Committee on Cancer; CT: computed tomography.The authors declare that they have no competing interests.HM, MK and YH collected the data, performed the treatment, and wrote the paper. DS was responsible for writing the paper and for its supervision. All authors read and approved the final manuscript.


We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy. The spleen is a rare location of metastasis from solid tumours. In a recent review of 6,137 patients with metastatic malignant tumours, only 59 (0.96%) involved the spleen. In an earlier series of lung cancer patients, just 12 of 997 consecutive cases had splenic involvement. However, all 12 had other abdominal organ involvement in addition to the spleen at the time of presentation . Due to This case serves as a report of a rare event of metastatic bronchial carcinoid involving the spleen and its successful management with laparoscopic splenectomy.A 51-year-old lady was admitted to our hospital in February 2009 with left-sided pleuritic chest pain. She had a history of left upper lobectomy in December 2000 for a primary carcinoid tumour of the lung . The patient had been discharged from followup in 2005 with no evidence of recurrence. On representing in 2009, a CT scan showed evidence of local recurrence with left-sided pleural lesions and an enlarged left hilar lymph node, as well a solitary 4.7 cm splenic lesion . The patThe patient was placed in the right lateral decubitus position, and 4 ports were placed in the left flank. The colonic attachments were divided, and the short gastric vessels were controlled with the Ligasure vessel sealing system  to allow isolation of the splenic hilum . The splSince discharge the patient has been commenced on Lutetium 177 DOTATATE therapy. Prior to commencement, repeat PET scan in April 2010 showed the formation of several liver metastases. The patient's pleural disease had also increased whilst her bony acetabular lesion was unchanged in appearance. The patient has since completed 3 cycles of Lutetium therapy and her latest Gallium PET scan from October 2010 shows little disease progression. Clinically, the patient has no symptoms of carcinoid syndrome and but suffers from chronic pain at the sights of her left pleural deposits and left acetabular metastasis. She is currently being considered for external beam radiotherapy to her left hip.Carcinoid tumours are uncommon neuroendocrine tumours primarily affecting the gastrointestinal tract and the bronchopulmonary tree , 7. TheySplenic metastasis of solid tumours is rare and is most often seen with extensive multivisceral metastatic disease from breast, lung, ovarian, gastric, and skin melanoma primaries . This caIn view of the rarity of splenic metastasis, splenic lesions in the context of known malignant disease present a diagnostic challenge. It must be assumed that any lesion in this setting is a metastasis, but it is preferable to obtain a tissue diagnosis for confirmation as in the case presented. Despite some concerns of haemorrhagic risk from such highly vascularised tissue, ultrasound guided biopsy has been showed to be safe with comparable complication rates to biopsies of other abdominal organs . Splenectomy for metastatic splenic lesions is generally indicated to prevent further metastatic spread, to improve the efficacy of adjuvant therapy and, therefore, improve survival, or to prevent complications such as splenic vein thrombosis, painful splenomegaly, and splenic rupture. In a review of 13 cases of splenic metastasis from lung carcinoma, Ando et al. report that out of 6 patients who did not undergo splenectomy, 4 (67%) went on to have splenic rupture with associated poor outcomes .Laparoscopic splenectomy (LS) has become the standard treatment for benign and malignant haematological disorders requiring splenectomy . HoweverMakrin et al. report their experience with LS in the treatment of 28 isolated splenic tumours and advocate its use in most cases of splenectomy for solid tumours, except in the case of substantial splenomegaly . All 28 This paper provides a further account of the rare event of metastatic carcinoid involving the spleen and the first application of a successful laparoscopic resection for its treatment. This case offers further evidence that laparoscopic splenectomy is a safe alternative to open resection in the treatment of solid organ tumours involving the spleen.


Composing of less than 1% of all ovarian cancers, immature teratoma is a malignancy that mainly affects the young, and they present with advanced disease. The treatment of immature teratoma is conservative primary surgery usually involving unilateral salpingo-oophorectomy followed by combination chemotherapy.Here we present a case of a 68 year old woman with bilateral ovarian teratoma complicated with carcinosarcoma. The patient was diagnosed as FIGO stage IIIC. She underwent neoadjuvant chemotherapy and interval cytoreduction followed by optimal cytoreduction. The post operative management strategies and gynaecological follow up studies revealed no evidence of regional or distant metastasis.Thus the choice of initial treatment should be decided in a selective fashion depending on various prognostic factors in order to increase the survival of the patients. The term teratoma was derived from the Greek root teratos which means Monster . TeratomA 68 year old lady was referred to oncology outpatients in January 2010, with a month history of severe abdominal pain. Her past clinical history included no tubal ligation or hormone replacement therapy. She had previously given birth to a female child at her age of 21. The patient was fit and well with no significant past medical history apart from hypertension and diabetes. There was no family history of breast or ovarian carcinoma.Physical examination revealed an abdominal pelvic mass with ascites and omental deposits. Blood analysis showed haemoglobin concentration of 11.3 g/dl while the rest of the analysis were normal including the carcinoembryonic antigen (CEA), alphafetoprotein and Cancer Antigen-125 (CA-125) (1.25 U/ml). The cytological examination of the ascitic fluid showed cellular smear composing of mixed inflammatory cells admixed with papillary and acinar clusters of eosinophilic cells with pleomorphic hyperchromatic nuclei thus suggesting a metastatic carcinoma.Pelvic sonogram revealed a large tumour mass with solid and cystic components. Minimal ascites was noted. A subsequent computerized tomography (CT) scan of the abdomen and pelvis revealed heterogeneously enhancing mass lesion measuring 9 × 7.1 cm with solid and cystic areas and calcification in the retrovesical region Figure . The masth week after administration of the 4th cycle of NAC. Standard procedures of ICS consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and maximal debulking of metastatic tumour was adopted. Following the procedure there was no residual macroscopic disease and she was transferred to high dependency.Due to unresectable bulky tumours and poor performance status the patient underwent neoadjuvant chemotherapy (NAC) followed by Interval Cytoreductive Surgery (ICS). Four cycles of combination of paclitaxel and carboplatin were administered every 3 weeks. ICS was performed in the 5The surface of the tumour appeared rough and congested. On cutting, the ovarian mass was full of sebaceous material and hair densely adherent to surrounding structures. Histopathological examination confirmed bilateral teratoma complicated with carcinosarcoma Figure  with hetThe patient recovered well from surgery and was referred for oncological follow up and post- surgical chemotherapy (same regime as NAC). Given her age and performance status a surveillance approach was taken with regular clinical examinations, serial tumour markers and routine CT scans. The follow up studies showed no evidence of recurrence, regional or distant metastasis.The prognosis of immature teratoma heavily depends on the FIGO stage. The other prognostic factors include tumour grade, growth pattern, capsular rupture and vascular invasion ,7. Age aIn spite of the controversial in treatment strategy, in the present study we have presented a rare event of bilateral ovarian teratoma complicated with carcinosarcoma in a 68 year old woman. The FIGO stage was IIIC. The rare event coupled with her age suggests that she was less likely to be treated with standard therapy -16 and sThus in a view point not to worsen the prognosis for patient with such advanced ovarian cancer, neoadjuvant chemotherapy followed by interval cytoreduction was suggested. Thus caring for older women with advanced ovarian cancers presents unique challenges. Even after the achievement of optimal cytoreduction the survival rates are found to be very low. However careful selection of primary cytoreduction versus neoadjuvant chemotherapy can result in higher rates of optimal cytoreduction, low rates of post-operative death. Thus in patients where optimal debulking is not possible at presentation, neoadjuvant chemotherapy will be the best choice of treatment.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SS and NSK designed the study and drafted the MS, SKG managed the treatment strategy, BK carried out the histopathological findings, VN and VK revised the manuscript critically. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/11/218/prepub


Echinococcus granulosus. In this paper, we report a case of liver hydatid cyst. The patient, a 15-year-old boy, presented with a history of intermittent upper abdominal pain of a few-month duration was referred to our hospital for investigation. Computed tomographic scan and laboratory test suggested a hydatid cyst in the right lobe of liver. The adventitia resection of hydatid cyst was smoothly performed as there was a less bloody virtual space between adventitia and outer membrane. Our diagnosis was made using an imaging approach and was confirmed during surgery. We proposed the adventitia resection of hydatid cyst could be safe and easy to perform with low risk of bleeding and bile leakage.Human hydatid disease is a significant health problem in endemic regions caused by the larval form of  Echinococcus granulosus, is a significant health problem in endemic regions, especially in the Mediterranean countries, the Middle and Far East, Europe, Asia, South America, and Australia [Human hydatid disease, caused by the larval form ofustralia . Incidenustralia . Surgeryustralia . To achi3 cystic mass in segments VII-VIII with fibrous membrane (The patient was a 15-year-old boy and presented with intermittent upper abdominal pain of a few-month duration. He described long-term rural life history and contacted with animals such as dog, cattle, and sheep. Upper abdominal CT indicated that the right lobe of liver had a large low-density lesion, suggesting liver hydatid cyst . Casoni membrane . A 12-Frmembrane . Portal Nowadays, hydatid disease is still a severe national problem in highly endemic countries and urgently needs epidemiologic prevention for its eradication . HydrateThe symptoms of hydatid disease are varied depending on which organs are affected. The most commonly affected organ is the liver in adults and lung in children. Surgery remains the primary method of treatment for hydatid disease . SurgicaThe stripping process along the virtual space is smooth and can minimize the damage of the liver parenchyma to protect the intrahepatic pipeline system to avoid bleeding and bile leakage.


Primary sarcomas of the major blood vessels can be classified based on location in relationship to the wall or by histologic type. Angiosarcomas are malignant neoplasms that arise from the endothelial lining of the blood vessels; those arising in the intimal compartment of pulmonary artery are rare. We report a case of pulmonary artery angiosarcoma in a 36-year old female with pulmonary masses. The patient had no other primary malignant neoplasm, thus excluding a metastatic lesion. Gross examination revealed a thickened right pulmonary artery and a necrotic and hemorrhagic tumor, filling and occluding the vascular lumen. The mass extended distally, within the pulmonary vasculature of the right lung. Microscopically, an intravascular undifferentiated tumor was identified. The tumor cells showed expression for vascular markers VEGFR, VEGFR3, PDGFRa, FGF, Ulex europaeus, FVIII, FLI-1, CD31 and CD34; p53 was overexpressed and Ki67 proliferative rate was increased. Intravascular angiosarcomas are aggressive neoplasms, often associated with poor outcome.http://www.diagnosticpathology.diagnomx.eu/vs/2315906377648045.The virtual slide(s) for this article can be found here: Primary sarcomas of the major blood vessels can be classified based on location in relationship to the wall  or by histologic type. Angiosarcomas are malignant tumors that arise from the endothelial lining of the blood vessels. PulmonaA 36-year-old female presented to the clinic with a 3-month history of non-productive cough and weight loss. Her past medical history was unremarkable. Chest X-rays and a computed tomography (CT) scan showed two right perihilar lung masses, each measuring 3.5 and 2.5 cm in greater diameter, adjacent to the main right pulmonary artery Figure. No extrThe specimen consisted of a total right lung, weighing 994 grams and measuring 35 × 11 × 7 cm. On the anterior aspect of the right upper lobe, two masses that abut pleural surfaces were identified. Cut sections showed a right pulmonary artery thickening and a necrotic and hemorrhagic tumor, filling and near occluding the vascular lumen Figure. The masMicroscopic examination showed an intravascular undifferentiated tumor composed of loosely cohesive large, pleomorphic spindle and epithelioid cells with prominent nucleoli, admixed with multinucleated giant cells Figure. NumerouA broad panel of immunohistochemical markers was used as shown in TableBased on clinical, radiological and histopathological findings, the tumor was diagnosed as angiosarcoma arising on the pulmonary artery.The patient received four cycles of ifosfamide-based chemotherapy with tolerable toxicity. Eighteen months after diagnosis an extensive radiological examination showed no other primary neoplasm or metastatic lesion. The patient was disease free 18 months and then the tumor recurred . She developed metastatic disease to liver and contralateral lung and died 29 months after the recurrence. No autopsy was performed.et al.[Primary sarcomas arising from major blood vessels  are exceedingly rare-8, and set al. found thClinically, primary sarcomas of the major blood vessels, are usually associated to embolic phenomena,12,13; tGrossly, a careful examination of the specimen, the pulmonary vasculature and its branches is essential to achieve the correct diagnosis. PAS may spread and grow as intraluminal masses along the endothelium and an organizing thromboemboli needs to be ruled out. In addiPulmonary artery sarcomas of the lung are malignant tumors of indeterminate cause, usually presenting heterogenous histology that most likely reflect a pluripotential or mesenchymal cell origin. Some exet al.[et al.[Although in this case it was not possible to identify specific exposure, angiosarcomas have been reported associated to previous irradiation fields or arteret al. found thl.[et al. reportedOverall, PAS are considered aggressive neoplasms, often associated to poor outcome irrespective of treatment,10,32,33In summary, we report an unusual case of pulmonary artery sarcoma with angiosarcoma phenotype that mimics pleomorphic malignant fibrous histiocytoma. A high level of suspicion and identification of the intimal location of the tumor, in addition to the use of a broad panel of immunohistochemical markers were helpful for the identification of the vascular origin. A multidisciplinary clinical and radiological approach and an extensive work-up were key determinant for the appropriate conclusion of the case.Written informed consent was obtained from the patient’s family members for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this journal.The authors declare that they have no competing interests.OB, EA, OL, NR, SS and AL have been directly involved in diagnosis and interpretation of patient’s diagnosis. OB, SS and AL were responsible for the conception and design of the Case Report. All authors read and approved the final manuscript.


Kawasaki disease (KD) is a systemic vasculitis of unknown etiology and a leading cause of acquired heart disease. It is assumed that there is an activation of the immune system by an infectious trigger in a genetically susceptible host. Neuroblastoma is the most common extracranial solid tumor in young children. It mainly originates from primordial neural crest cells that generate the adrenal medulla and sympathetic ganglia. A diagnosis of concurrent KD and neuroblastoma in a living child has been made in only one previous report. We report the second case and review the literature. Kawasaki disease (KD) is an acute vasculitis of childhood that predominantly affects the coronary arteries. The etiology of KD remains unknown; however, an infectious agent is strongly suspected based on clinical and epidemiologic features . It typiNeuroblastoma is the most common extracranial solid tumor in children, accounting for 8% to 10% of all childhood cancers. The prevalence is about 1 case per 7,000 live births, and there are about 800 new cases of neuroblastoma per year in the United States , 5. It iAn 18-month-old girl was admitted to our infectious diseases department with a fever for 6 days and puffy red eyes. On physical examination, she was acutely ill, febrile, and irritable. Bulbar conjunctivitis, facial erythema at midline, red fissured lips, and a strawberry tongue were other significant findings . There win situ hybridization revealed 8 copy numbers of this oncogene. A bone scan as well as a bone marrow aspiration and biopsy were unremarkable. Three days after laparotomy, she developed periungual desquamation over the distal parts of her extremities. Chemotherapy with the N6 protocol  was initiated. The patient had an unremarkable course and repeat imaging three months later showing no evidence of residual tumor. The patient is free of tumor after 18 months at the time of the report of this case.She received 2 gr/kg intravenous immunoglobulin (IVIG) for two days as well as aspirin 80 mg/kg/day. Due to the persistence of fever, a computed tomography scan of the brain, chest, abdomen, and pelvis was performed, which was remarkable for a 3 cm × 3 cm abdominal mass originating from the right adrenal gland and with foci of calcification . A 24-hoYanagisawa et al. reported a 6-month-old male infant who died of KD and had a small encapsulated mass in the left paravertebral region found on necropsy. The histopathological diagnosis was neuroblastoma . In anotThere are a few reports of cases with malignancy diagnosed following a diagnosis of KD. The malignancies reported are acute lymphoblastic leukemia in 3 cases, Hodgkin's disease in one case, osteosarcoma in one case, Schwannoma in one case, giant cell tumor of the tendon sheath in one case, and malignant reticuloma in one case , 13. Alt


Gastrointestinal bleeding due to duodenal metastasis from renal cell carcinoma is extremely rare. Several previous reports have shown that embolic therapy or pancreatoduodenectomy  could be effective in controlling this type of clinical complication. Management is entirely dependent on the general condition and concurrent metastases at other sites. Optimizing the therapeutic strategies thus deserves further discussion and exploration.In this report, we describe a patient with severe co-morbidities who underwent successful palliative wedge resection of duodenum and direct duodenal wall defect repair without reconstruction of duodeno-jejunostomy for acute upper digestive tract hemorrhage caused by duodenal metastasis from renal clear cell carcinoma.The patient recovered uneventfully and did not experience rebleeding and frequent vomiting after surgery. Since then (1.5 years) he has had no evidence of rebleeding.Gastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities, and for palliative treatment. Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies, and is the third most frequent urologic malignancy after prostate and bladder cancer. AdditioA 56-year-old man was referred to us with a diagnosis of presumed duodenal carcinoma.The patient had undergone right nephrectomy in 2005 for renal clear cell carcinoma . The postoperative course was uneventful and no adjuvant therapy was given. During the 5-year follow-up, fecal occult blood test had been carried out as a routine test. No signs of tumor recurrence were detected during the follow-up with annual abdominal ultrasonography, and the physical examination was unremarkable.The patient was admitted by the department of gastroenterology. The main complaints were generalized fatigue, continuous melena, and frequent vomiting for 20 days. These symptoms were not relieved by using medications and supportive care . For further treatment, after 20 days admission, the patient was transferred to the department of hepatobiliary surgery. Peripheral blood cell counts demonstrated severe anemia and a hemoglobin level of (54 g/L). Blood analyses revealed hypoproteinemia (44 g/L) with hypoalbuminemia (25 g/L). Other laboratory examinations such as blood chemistry and serum tumor markers were normal. Gastroscopy showed a mass in the descending part of the duodenum with mucosal ulcerations and focal hemorrhage. The whole lumen of the duodenum was occupied by the mass, and the duodenal papilla could not be visualized Figure . A duodeAn exploratory laparotomy was carried out through a median laparotomy incision. A standard Kocher maneuver opening the gastrocolic ligament was performed to assess the duodenum and the extent of lesion. The lateral wall of the descending part of duodenum was longitudinally opened to visualize the ampulla of Vater and protect it during resection of the lesion. A lesion was identified that invaded the descending part of duodenum wall but not the ampulla of Vater. Part of the lesion was tightly adhered to the surrounding tissue, including part of the inferior vena cava and retroperitoneal space Figure . After cPathologic findings revealed a 4.3-cm mass in the duodenal that appeared to be a clear cell carcinoma of renal origin Figure . ImmunohRCC metastasis to the duodenum is a rare event, accounting for 7.1% of all small bowel metastases,7. DuodeUp to now there have been several similar cases reporting acute upper gastrointestinal hemorrhage due to duodenal metastasis from RCC. Currently management is entirely dependent on the general condition and concurrent metastases at other sites. Althoug1) A Kocher maneuver is performed to assess the anatomic relationship between the lesion and the bile duct and head of the pancreas. The ampulla of Vater is carefully identified and preserved during the resection process.2) The lesion is carefully dissected away from the inferior vena cava and retroperitoneal structures. Vascular anastomotic devices and an adequate supply of blood should be present.3) Clear surgical margins of 1 or 2 cm are obtained.4) A longitudinal incision and transverse suturing of the duodenum is performed to prevent stricture of the duodenum.5) A patent distal jejunum is present.In conclusion, gastrointestinal bleeding due to duodenal metastasis of RCC may benefit from emergent resection even in the presence of severe co-morbidities , and for palliative 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.CT: Computed tomography; EGFR: Epidermal growth factor receptor; GI: Gastrointestinal; RCC: Renal cell carcinoma; STC2: Stanniocalcin 2.The authors declare they have no competing interests. The authors have no conflict of interest to disclose which may have biased their work. The authors declare that they did not receive any funding for this work.HZZ operated on the patient, collected the majority of relevant clinical data, and drafted the manuscript. KQH researched the literature for this case and contributed significantly with figures and relevant intellectual comments on the manuscript. JL operated on the patient, collected the majority of relevant clinical data, and helped significantly with the writing of the manuscript. PL had the idea to write this case report, participated significantly in its design and coordination, and helped to improve the intellectual content of the manuscript. GHZ provided relevant surgical experience and advice and helped to improve the intellectual content of the manuscript. YZ operated on the patient, collected the part of relevant clinical data. HYL carried out the histological examination of the resected specimen, including immunohistochemistry, and helped with the writing of the manuscript. All authors read and approved the final manuscript.All authors of this article are clinically highly experienced surgeons who are regularly involved with interdisciplinary treatment decisions for patients with massive gastrointestinal bleeding due to cancer metastasis or post-hepatitis liver cirrhosis, encompassing up-to-date interventional, chemotherapeutic, and surgical approaches, in one of the largest department of hepatobiliary surgery in southwest of China.


Intercostal herniation is very rarely and sporadically reported in the literature. Intercostal hernia can occur following blunt trauma and may be associated with rib fractures. We present a case of a patient who presented with rib fractures, diaphragmatic rupture, and intrathoracic herniation of abdominal contents with subsequent herniation of both lung and abdominal contents through an intercostal defect. The patient was successfully treated with primary surgical repair of the diaphragm and intercostal hernia. The presentation, pathophysiology, and management of this rare clinical entity are discussed. A 59-year female presented via helipad as a trauma alert following head on motor vehicle collision with a tractor trailer. The patient was a restrained driver and denied loss of consciousness or head trauma. On arrival, she was awake, alert, and complaining only of right ankle pain. Her past medical history included hypertension, schizophrenia, anxiety, uterine cancer, and obesity. She had a prior surgical history of bilateral total hip arthroplasty. On physical examination the patient had multiple contusions and abrasions including an abdominal seat belt sign with several areas of ecchymosis and skin abrasions across the lower abdomen as well as a seatbelt contusion across the anterior chest wall.Unenhanced CT of the head demonstrated no acute intracranial abnormality. CT of the cervical spine demonstrated several vertebral and transverse processes fractures. A contrast enhanced CT of the chest, abdomen, and pelvis Figures  identifiThe patient was immediately taken to the operating room for exploratory laparotomy of the abdomen and primary repair of the diaphragm and intercostal hernia. Midline abdominal incision from xiphoid to pubis was performed. The abdomen was entered in its midline along the linea alba without difficulty. In the left upper quadrant, the transverse colon and splenic flexure were visualized within the chest. These were brought down into the abdominal cavity with ease. The diaphragmatic defect was noted to be approximately 15 cm in length in the posterolateral aspect. There were also rib fractures that were palpable and the lung tissue could be seen within the chest cavity. The diaphragmatic edges were reapproximated and repaired with continuous suture from the deep portion to the lateral edge encompassing all layers of the diaphragm. A second suture was started at the level of the abdominal wall hernia and brought together the abdominal wall tissue and all layers including where the diaphragm margins approximated the abdominal wall as there was somewhat hockey-shaped defect. A left thoracostomy tube was also placed. Within the peritoneal cavity, several adhesions were identified involving the omentum. Additionally, in the left lower quadrant due to her prior surgery, the bowel was densely adherent to abdominal wall and lysis was performed. In the distal jejunum, proximal ileum area, there was a linear mesenteric tear which was not actively bleeding and did not appear to have any vascular compromise to the small bowel in this region. There was no evidence of serosal tears or other bowel injury. Two small 1 cm liver lacerations were identified at the liver edge at approximately segment 5 and segment 3 of the liver and were cauterized. The abdomen was closed without difficulty. Intrathoracic pressures were noted to be stable. On routine postoperative follow-up CT 1 week following surgery Figures , there wExtrathoracic lung herniation involves protrusion of pulmonary tissue beyond the thoracic cavity through an abnormal opening in the chest wall . HerniatThe pathophysiology of traumatic transdiaphragmatic intercostal herniation specifically involves the forceful tearing of the intercostal muscles as well as the costal attachments of the diaphragm . This isDiaphragmatic rupture leads to a weakening in the resistance of the thoracic wall. Furthermore, the integrity of the thoracoabdominal wall is disrupted by the tearing of the intercostal muscles between fractured ribs . AnatomiTransdiaphragmatic intercostal hernias are suggested by the patient's history and physical examination. Clinically, transdiaphragmatic intercostals hernias are visible during suspended respiration on inspiration. Small hernias can be diagnosed only on inspiration. Chest radiographs may show herniation of the digestive tract through the chest wall. CT scans are necessary for confirming the diagnosis and for choosing the best curative strategy while determining the extent of associated injuries in the chest, abdomen, and pelvis. , 6. The Definitive management of transdiaphragmatic intercostal hernias is achieved through surgical repair. Occasionally spontaneous regression has been observed in small asymptomatic hernias, but large hernias or hernias which have a risk of incarceration must be treated by surgical repair , 12 The In our case, CT had previously showed the presence of mesenteric contusion and retromesenteric hematoma suggesting mesenteric vascular and/or bowel injury. Ultimately treatment requires suturing of the diaphragmatic and the intercostal defects. There is no consensus recommendation regarding the use of prostheses for hernia repair, however the insertion of a nonabsorbable mesh if there is no contamination has been successfully reported in a few instances . Rib fraIn conclusion, transdiaphragmatic intercostal herniation is a rare clinical entity which can be promptly diagnosed by computed tomography. Diaphragmatic injury should be suspected in all cases of intercostal herniation. Surgical repair of the diaphragm and intercostal defects can result in favorable outcomes.