Meigs syndrome is a rare condition, occurring in less than 1% of ovarian tumors and has the characteristic features of a benign ovarian tumor, ascites and a pleural effusion. We present a case of Meigs syndrome in a young patient presenting initially with an axillary vein thrombosis and local lymphadenopathy.A 28-year-old Caucasian woman presented with a short history of right arm swelling and shortness of breath as a result of an axillary vein thrombosis and pulmonary embolus.The initial assessment also demonstrated right axillary and subclavian lymphadenopathy, a pleural effusion, ascites and a large ovarian mass. Serum levels of the tumor markers human chorionic gonadotropin and alpha-fetoprotein were normal and the CA-125 level was only moderately elevated.The combination of thrombosis, lymphadenopathy and an ovarian mass raised the possibility of a disseminated malignancy potentially an epithelial ovarian cancer, a germ cell tumor or an ovarian sex cord-stromal tumor.Surgery, performed after a short period of anticoagulation, demonstrated a 13.5cm ovarian cellular fibroma of low malignant potential. Postoperatively the patient made an excellent recovery and the ascites, pleural effusion and lymphadenopathy all resolved promptly.In Meigs syndrome the classical findings of ascites, pleural effusion in combination with an ovarian mass can mimic disseminated malignancy but resolve spontaneously after surgery. In this current case, the patient also had lymphadenopathy and venous thrombosis, two other findings that are frequently associated with malignancy and was acutely unwell at presentation.It is unclear if the thrombosis and lymphadenopathy were simply coincidental or shared the same etiology as the ascites and pleural effusion. This case indicates that Meigs syndrome may on occasion present with additional findings that can further mimic disseminated malignancy and may lead to diagnostic uncertainty. Meigs syndrome has a classical triad of features: a benign ovarian tumor combined with ascites and a pleural effusion . The conThe clinical presentation is most frequently related to the ascites and generally right-side pleural effusion, while there may also be history of non-specific symptoms such as abdominal discomfort, fatigue, and weight loss and a tumor arising from the pelvis may be palpable.The investigations in Meigs syndrome usually show normal or only mildly raised serum CA-125 levels and normal human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) levels ,4. The aThe management of Meigs syndrome is surgical and the prognosis is excellent with normally prompt resolution of the pleural effusion and ascites postoperatively . AlthougA 28-year-old Caucasian woman presented to our Emergency Unit with a short history of progressive shortness of breath and a swollen right arm. She had previously been in good health with no medical history of note but was just recovering from a severe upper respiratory tract infection, which had caused her to be unwell in bed for several days. Aside from the oral contraceptive pill she took no regular medication and had no family medical history of note.Initial investigations with a Doppler ultrasound of her right arm and axilla demonstrated a deep vein thrombosis in the right subclavian vein with extension into the proximal internal jugular vein. A computed tomography scan confirmed the presence of the right axillary vein thrombus and the pulmonary embolus and a large right pleural effusion as shown in Figure The tumor markers performed at presentation demonstrated normal values for both hCG and AFP whereas the CA-125 level was moderately elevated at 368U/mL . The initial management centered on the treatment of the pulmonary embolus with anticoagulation and the insertion of a prophylactic inferior vena cava filter. The differential diagnoses at this stage included: epithelial ovarian cancer, an ovarian germ cell tumor, an ovarian sex cord-stromal tumor or an atypical Meigs syndrome.After a week of anticoagulation treatment, a laparotomy was performed which demonstrated a large left ovarian mass with ascites but no other abnormal findings. The ovarian mass was removed along with a biopsy of the omentum and a fine needle aspirate of the supraclavicular lymph nodes was performed. Postoperatively the patient made an excellent recovery and was well enough to be discharged home 6 days later.On pathological examination the ovarian mass measured 14×8.5×6.5cm and weighed 470g. The outer surface was predominantly smooth with a focus of roughened area, suggesting a site of adhesion to adjacent structures. The cut surface was solid, tan in color and focally hemorrhagic. Histological examination, as shown in Figure On immunostaining the tumor cells expressed inhibin, calretenin , progesterone receptor (weak expression in some cells) but were negative for estrogen receptor, CD34, HMB-45, S-100 protein, h-caldesmon, MNF116, epithelial membrane antigen, CAM 5.2 and cytokeratin 5/6. The morphology and immunoprofile were those of cellular fibroma. The omental tissue showed only mesothelial hyperplasia, and no tumor deposits and the ascitic fluid showed no malignant cells. The biopsy from the enlarged supraclavicular lymph nodes showed prominent interstitial reticulum cells, but no evidence of malignancy.The pathological findings, coupled with the rapid spontaneous resolution of the ascites, pleural effusion and lymphadenopathy postoperatively, confirmed the diagnosis of Meigs syndrome, combined with reactive lymphadenopathy.The patient was referred to the hematology team for investigation of any clotting tendency. Fortunately, the results of all investigations including Factor V, lupus and anti-cardiolipin screens were negative and routine anticoagulation was continued for 1 year and then discontinued. After 5 years of follow up the patient remains in good health and has recently had a successful pregnancy with a healthy baby girl delivered without complications.Meigs syndrome was originally described in 1937 and comprises a characteristic triad of features: a benign ovarian tumor, usually a fibroma, combined with ascites and a pleural effusion .Ovarian fibromas are usually characterized by an indolent clinical presentation and are frequently diagnosed as an incidental finding on imaging with a typical solid hypoechoic but non-vascular appearance on ultrasound and with low T1 and T2 signal with magnetic resonance imaging . The tumAlthough these findings are characteristic of ovarian fibromas, other more complex types of ovarian pathologies including ovarian germ cell tumors, sex cord-stromal tumors and fibrosarcoma of the ovary can also present with similar clinical findings and the diagnosis of Meigs syndrome can only be made after excluding the more serious potential pathologies. Pathologically ovarian fibromas are densely cellular tumors generally light yellow in color with spindle-shaped cells, high levels of intercellular collagen and frequent hemorrhages. The key diagnostic differential is to distinguish the low malignancy potential fibroma from the aggressive malignancy of ovarian fibrosarcoma. Historically this differentiation has been established using a proliferation index with less than three mitoses per 10 HPF linked to benign disease and those with four to 25 mitoses per 10 HPF associated with malignant fibrosarcoma .The pathogenesis of the production of ascitic and pleural fluid in Meigs syndrome is uncertain. It has been postulated that the fluid results from an imbalance between vascular supply and lymphatic drainage in these large tumors, An alternate hypothesis is that the process is inflammatory in nature, with an earlier report demonstrating elevations of several inflammatory molecules and cytokines including VEGF, FGF, interleukin (IL)-1b, IL-6 and IL-8, however, the detailed underlying mechanism is still unclear . InteresMeigs syndrome is characterized by a rapid resolution of the ascites and pleural effusion postoperatively and these occurred rapidly in the patient in this study. In keeping with the benign natural history of the syndrome, there have been no further problems and the patient has recently completed a successful pregnancy.The diagnosis of Meigs syndrome carries a good prognosis with no significant long-term health issues. In this case we have highlighted that patients with Meigs may present in combination with other clinical features that may further support the usual mimicry of the syndrome of disseminated malignancy. In this case, despite the complex presentation, surgery combined with standard medical management led to a complete resolution of the presenting symptoms.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.RI, JC ME-B and PS were all major contributors in writing the manuscript. All authors read and approved the final manuscript.


Malignant lymphoma of the oral cavity is rare and of the tongue even rarer. Location of oral lymphomas is more frequent in masticatory mucosa than in movable mucosa; the lingual and buccal mucosa is rarely involved; whereas the gingival vestibule and Waldeyer's ring seem to be the most frequent site of occurrence. We describe a 78 year old male who presented with a mass lesion primarily involving the base of tongue and was diagnosed as diffuse large B cell lymphoma. The patient was treated with CHOP chemotherapy and radiotherapy. The lesion was completely disappeared). He has currently remained disease free for 16 months. Although oral lymphoma of tongue is very uncommon, it should always be considered in differential diagnosis of various benign and malignant lesions in this region. A proper clinical evaluation, histopathologic as well as immunohistochemical evaluation of biopsy specimen may aid in the diagnosis and thus, help in proper management. Lymphomas form a group of uncommon solid malignant tumors with a wide spectrum of clinical and pathological features. Primary Non-Hodgkin's Lymphoma (NHL) represents the second leading malignancy of oral cavity, after squamous cell carcinoma . LocatioMost of the few reported cases of primary extranodal non-Hodgkin's lymphoma of the tongue had associated cervical lymph node involvement and manifested as an ulcerated exophytic lesion .we reporA 78 year old male patient presented with a three month history of dysphagia, shortness of breath and right-sided pain radiating to the ear. No weight loss, night sweats or fever were reported. There was no history of hoarseness. His medical history was unremarkable. No medications were taken on a regular basis, there were no known allergies and the patient was a smoker for 25 years.Oral examination by observation showed an obvious asymmetry of the tongue base. Digital palpation revealed a hard and large sub-mucosal mass involving the pharyngeal tongue especially in the left side. There was no ulceration or superficial growth on the surface of the tongue. The mobility of the oral tongue was unaffected. The left pharyngeal wall and tonsil were normal and no cervical lymph nodes were clinically apparent. His Systemic examination including respiratory, cardiac, abdominal and central nervous system were normal. Routine investigations: hemogram, urine analysis, chest X-ray and OPG (ortho-pantomogram), Chest radiograph, head, neck were normal. Serology for human immunodeficiency virus was negative.A Magnetic Resonance Imaging(MRI) revealed a raised mass (3.4cm x 1.6cm x 3.6cm) in the base of the tongue which filled and reduced the light of the oropharynx and the left vallecula . No enlaThe patient was treated with chemotherapy which consisted of four courses of CHOP . After four cycles of chemotherapy, the lesion was completely disappeared. The treatment was followed by radiotherapy (40Gy). He has currently remained disease free for 16 months.Written informed consent was obtained for publication of this case report and accompanying images.Malignant lymphoma of the oral cavity is rare , 20 to 3Primary malignant lymphoma a of the tongue is rare; we could find only eight cases of primary tongue lymphoma reported in English , 5. It gFrom the small number of well documented case reports of primary extranodal non-Hodgkin's lymphoma of the tongue, little is known about the etiological factors for primary lymphoma of the oral region. Few cases have been reported in which the presenting symptom was a submucosal mass with no exophytic lesion or ulceration , 7. Of tAlthough oral lymphoma of tongue is very uncommon, it should always be considered in differential diagnosis of various benign and malignant lesions in this region. A proper clinical evaluation, histopathologic as well as immunohistochemical evaluation of biopsy specimen may aid in the diagnosis and thus, help in proper management.


Introduction. Giant cell tumor of bones is an unusual neoplasm that accounts for 4% of all primary tumors of bone, and it represents about 10% of malignant primary bone tumors with its different grades from borderline to high grade malignancy. Case Report. A 35-year-old patient presented with complains of pain and swelling in left ankle since 1 year following a twisting injury to his left ankle. On examination, swelling was present over the distal and anterior part of leg and movements of ankle joint were normal. All routine blood investigations were normal. X-ray and CT ankle showed morphology of subarticular well-defined expansile lytic lesion in lower end of left tibia suggestive of giant cell tumor. Histopathology of the tissue shows multinucleated giant cells with uniform vesicular nucleus and mononuclear cells which are spindle shaped with uniform vesicular nucleus suggestive of GCT. The patient was treated by excision, curettage, and bone cement to fill the defect. Conclusion. The patient at 12-month followup is doing well and walking without any pain comfortably and with full range of motion at ankle joint with articular congruity maintained and no signs of recurrences. Giant cell tumor of bones is an unusual neoplasm that accounts for 4% of all primary tumors of bone, and it represent about 10%) of malignant primary bone tumors with its different grades from borderline to high grade malignancy. Usually, the age of patients ranges from 20 to 55 years, and the peak age incidence is in the third decade of life, with slight female predominance (1.2 : 1) 0% of mal.A 35 yr old male patient presented with complaints of pain and swelling on the distal aspect of the left leg. The patient suffered a twisting injury to the leg one year ago and had mild pain and swelling for which he took treatment from an osteopath. The pain reduced but the swelling persisted. One month ago, the swelling increased in size and was associated with severe pain which was exaggerated on walking. There was no history of fever, night cries, loss of weight, and loss of appetite present. History of massage therapy was present which was done 4-5 times.On examination, swelling was present over the distal aspect of the leg about 6 × 4 cm with well-defined margins, smooth surface, and bony deep. The skin over the swelling was normal. Tenderness was present over distal tibia. Ankle movements were normal.X-ray showed well-defined expansile lytic lesion at distal end of left tibia suggestive of giant cell tumor of distal end tibia. CT  ankle shThe condition and routine investigations done in preparation for operative procedure were explained to the patient. Patient was treated with intralesional excision and curettage and the cavity was filled with bone cement. Specimen was sent for histopathological  examinatGiant tumors are locally aggressive and some may be malignant. The benign form of GCT has the intriguing feature of being able, in rare instances, to metastasize despite otherwise benign characteristics. The malignant variety of GCT has been defined as a sarcomatous growth that is either primarily juxtaposed to a typical benign focus or occurs after a prolonged interval at the site of a previously treated and documented focus , 5.Curettage and wide resection have been the accepted methods of treatment for GCT of bone . AdjuvanBini et al.  publisheWe treated the patient with curettage and use of bone cement to pack the cavity which showed good postoperative results without any recurrences and functional problems. We conclude that it is a good treatment option for GCT of lower tibia.


Primary malignant tumours of spermatic cord are rare. The liposarcoma of spermatic cord is a rare entity and only a few cases have been reported in the literature. We report a case of forty five-year-old male with huge left inguinoscrotal swelling. Fine needle aspiration cytology (FNAC) of swelling revealed the diagnosis of a liposarcoma. The patient was subjected to radical orchidectomy and wide excision. Histopathological examination (HPE) of the resected specimen reported a well-differentiated liposarcoma of the spermatic cord and confirmed the diagnosis. Liposarcoma of the spermatic cord is a rare condition, representing approximately 7% of paratesticular sarcomas . Only a A 45-year-old man presented with chief complaint of a progressive, painless swelling in the left inguinoscrotal region from last seven months. Local examination revealed a huge left inguinoscrotal swelling, 11 × 6 cm, with penis pushed to opposite side and almost buried in the swelling .The swelling had no cough impulse. Palpation revealed a firm, smooth-surfaced tender swelling and at the same time testis could be felt separately. The swelling was irreducible and without any fluctuation. The transillumination test was also negative. Both hernial orifices were competent. There was no associated inguinal lymphadenopathy. Abdominal examination did not reveal any palpable lump. Ultrasonography (USG) reported this mass to be hyperechogenic and inhomogeneous and at the same time separate from the testis and epididymis. FNAC of the swelling was advised, which established the diagnosis of a liposarcoma. Subsequent CECT pelvis and abdomen also revealed a huge paratesticular tumor with an impression of a sarcoma .However, it excluded the presence of any lymph node involvement or distant metastasis. Surgical exploration was carried out with the help of a urologist. On exploration, a mass of lipomatous texture (12 × 5 cm) was found to be arising from inguinal segment of spermatic cord. Radical orchidectomy and wide excision was carried out. Histopathological examination of the resected specimen confirmed diagnosis by revealing a well differentiated liposarcoma (myxoid variant) of the spermatic cord .The mass did not show any signs of infiltration into the testis or epididymis. All resection margins were found to be free of tumor. Since a complete surgical resection of the tumor with wide margins of 2 cm was achieved so no adjuvant radiotherapy was advised. After 18 months of followup so far the patient does not show evidence of tumour-progression or recurrence and is doing well.The first case of a spermatic cord sarcoma was reported in 1845 by Lesauvage . 80% of Liposarcoma is a disease of the older age group. USG provides little information on paratesticular sarcomas, as some are visualized as homogenous and isoechogenic, others as inhomogeneous and echo-density is quite variable. The use of CT scans is not widely reported, but seems to be promising, as liposarcomas are of low density and can be well demarcated, but no pathognomonic features for the differentiation of benign versus malignant masses are defined . Use of Liposarcomas are locally aggressive tumors and recurrence is quite common after incomplete excision. The inguinal radical orchidectomy with wide resection margin is the standard approach for sarcomas of the spermatic cord . Some auRoutine adjuvant chemotherapy is not justified in liposaroma or any other seminal cord sarcoma due to their resistance against it. Specific outcome data for the disease are not available in the literature. As late recurrence can occur, follow-up examinations should exceed 10 years.The primary treatment for the radical cure of the disease continues to be surgery. However, if the margin status is in doubt, adjuvant radiation therapy should be advised. Distant disease has not been reported, but local relapse is common and may occur several years after primary therapy.


The case of a 72-year-old male patient with HCC is presented in whom percutaneous RFA was used as the sole first-line anticancer treatment, since he denied having partial hepatectomy. The patient underwent RFA two more times, at 1.5 years for treating a local tumor progression at the initial ablation site and at 11 years after the first session for treating a new remote intrahepatic recurrence. He revealed a long-term survival of more than 12 years so far and still remains in excellent clinical status. Although surgical resection is the gold standard treatment of HCC, only a limited number of HCC patients are surgical candidates because of their lack of hepatic reserve, resulting from coexisting advanced cirrhosis, widespread intrahepatic involvement, and concomitant diseases . Further RFA is a widely accepted alternative to surgical resection and plays a key role in the therapeutic management of early stage HCC . HoweverA 72-year-old cirrhotic male patient, related to hepatitis C virus infection, presented about 12 years ago with elevation of a-fetoprotein (AFP) levels up to 110 ng/mL during routine laboratory tests. Computed tomography (CT) scan performed at that time demonstrated a hypodense lesion, 4.5 cm in maximum diameter, located in the IVth segment of the liver, with signs of early arterial enhancement consistent with HCC characteristics . A biops Taking into consideration the tumor's size, location, and morphology, RFA seemed to be the most appropriate treatment. The whole procedure, which was performed percutaneously at the CT-scan suite, was explained to him, and an informed concept was obtained. The RFA was performed under local anesthesia. Forty-five minutes before the procedure, he received an analgesic and antidepressant medication, consisting of 0,05 gr pethidine hydrochloride intramuscularly and 3 mg bromazepam [Lexotanil Roche] per os for better patient's collaboration. Initially, a preprocedure CT scan was obtained. A cool-tip electrode was used [RADIONICS ] and a pulsed RF energy was applied for 15 min . After t The patient did not experience any pain, and the postprocedural imaging findings revealed no enhancement. AFP levels presented significant reduction and finally normalization two weeks later.  For a 18-month follow-up period the patient presented excellent clinical status with normal levels of AFP and stable appearance of the lesion on CT and magnetic resonance imaging (MRI) scans, when a new rise of the AFP levels to 80 ng/mL prompted us to repeat a new CT and MRI scan Figures ; the CT  For a 9-year follow-up period the patient presented excellent clinical status with normalization of AFP levels. Moreover, the tumor's maximum diameter decreased from 4.5 cm to 0.5 cm with well-defined margins mimicking a cystic formation on CT scans. Nine and half years after the second RFA, a new remote intrahepatic recurrence, located in the IInd segment of the liver, was suspected because of another increase of AFP values to 74 ng/mL during follow-up. RFA was once more the therapeutic option. A multitined expandable electrode was used [RITA StarBustTM XL electrosurgical device  2-3 cm/15 cm length], and a pulsed RF energy was applied for 15 min. Hypoattenuating, nonenhancing areas were observed during both the arterial and portal venous phases, so the technique was considered to be completed. Overall, 12 years after the initial RF procedure, the patient was still alive with good quality of life and no imaging findings or elevation of AFP levels that may indicate a new recurrence. In the latest CT scan, performed at the same period , both lesions were hardly visualized and could have been misdiagnosed as cystic formations in the liver Figures . Accurate tumor staging at diagnosis is crucial for the therapeutic management of patients with HCC. According to Barcelona-Clinic Liver Cancer classification, patients at an early stage are those who present asymptomatic single HCC <5 cm or up to 3 nodules <3 cm. They will benefit from curative/effective therapies: resection, liver transplantation, and percutaneous ablation. In the case of single HCC <5 cm with signs of liver deficiency or in the case of 3 nodules <3 cm, RFA is the optimal treatment when other diseases coexist .Additionally, the Child-Pugh score is used to assess the prognosis of cirrhosis, as well as the required strength of treatment and the necessity of liver transplantation. The score employs five clinical measures of liver disease. Each measure is scored 1–3, with 3 indicating most severe derangement . Chronic The therapeutic results of RFA of hepatic tumors are influenced by a variety of factors such as the skill of the operator, the choice of technique, the generator power of the RFA device, and the size, location, and morphology of the tumor , 6.RFA uses high temperatures aiming at the destruction of the cancer cells. Alternating current through the tissue creates friction on a molecular level. Increased intracellular temperature generates localized interstitial heating. Temperatures between 60–100°C cause rapid denaturation and coagulation of the cellular proteins. Moreover, RFA seems to stimulate tumor-specific T lymphocytes and produce expression of heat sock proteins activating the process of apoptosis , 8. Furt Despite of the effectiveness of the technique, few reports that include long-term survival rates have been published –12. In aP > .05). Four-year cancer-free survival rates in groups 1, 2, and 3 were 39%, 10%, and 0%, respectively. Rossi et al.  reported In our case although the overall survival could not have been predicted 12 years ago, our decision is now proving to have the most satisfactory result. At present, the ablated tumors are cystic and have a small size, evidence of a good response to RFA. During the 12 years period, the clinical status of the patient remained and remains still excellent.  Summarizing, taking into consideration our patient's survival and the fact that he remains still alive with good quality of life for a period of more than 12-years after the initial RF procedure, we may suggest that percutaneous RFA should be considered as an alternative means of treatment in the long-term management of hepatocellular carcinoma.


Castleman disease (CD) is an uncommon benign lymphoproliferative disorder, which usually presents as solitary or multiple masses in the mediastinum. Peripancreatic CD was rarely reported. Herein, we report two cases of unicentric peripancreatic CD from our center. A 43-year-old man and a 58-year-old woman were detected to have a pancreatic mass in the routine medical examinations. Both of them were asymptomatic. The computed tomography and ultrasonographic examination revealed a mild enhancing solitary mass at the pancreatic head/neck. No definite preoperative diagnosis was established and Whipple operations were originally planned. The intraoperative frozen section diagnosis of both patients revealed lymphoproliferation. Then the local excisions of mass were performed. Histological examination revealed features of CD of hyaline-vascular type. No recurrence was found during the follow-up period. CD should be included in the differential diagnosis of pancreatic tumors. Local excision is a suitable surgical choice. Castleman disease (CD) is an uncommon benign lymphoproliferative disorder of unknown etiology. It was first described by Castleman in 1956 . PlasmabCase 1: a 43-year-old man visited to us with an abdominal mass detected by ultrasonographic examination in a routine medical examination. He had a history of IgA nephropathy for 1 year. The preoperative serum creatinine was slightly elevated. The patient was asymptomatic with a normal appetite, no vomiting, no abdominal pain, no jaundice, and no weight loss. The tumor markers CEA, AFP, and CA125 were normal, the CA 19–9 was 54.8 U/mL. Chest X-ray was normal. As the serum creatinine was slightly elevated, the unenhanced computed tomography (CT) and contrast-enhanced ultrasonography were performed, the result showed a 3 × 2.1 cm, well-demarcated, mass at the pancreatic head  stains showed typical paracortical expansion with mixed inflammatory cells, and a prominent proliferation of blood vessels. High-power photomicrograph of one area showed a germinal center with the classic ‘onionskin’ appearance Figure . The tumet al. [The etiology and pathophysiologic basis of CD remains unclear until now. The chronic inflammation, immunodeficiency state, and autoimmune disorders  are considered to be the possible causal factors of CD. The dysregulation of inflammatory mediators, particularly interleukin-6 (IL-6) secretion has become the leading theory explaining constitutional symptoms and laboratory abnormalities ,5. Of thClinically, CD is usually divided into unicentric and multicentric types. The UCD is most common with Hyaline vascular type. The mass is usually asymptomatic and localized, and is discovered incidentally, although some patients present with fever, fatigue, and localized pressure symptoms from the mass. The histological findings are of a multiple germinal center surrounded by circumferentially arranged layers in an onionskin pattern, of small lymphocytes, with a prominent vascular stroma and occasional plasma cells, which are characteristic of hyaline-vascular disease.The preoperative diagnosis of the CD is very difficult. CD most commonly presents as a solitary mass. The classic CT appearance of hyaline vascular CD is that of a solitary enlarged lymph node or localized nodal mass that demonstrate homogeneous intense enhancement after contrast material administration. Diagnostic image sometimes mimics malignancy and CD cannot be identified because of the lack of disease specific signs. Some case reports had introduced an endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to establish the diagnosis of CD preoperatively ,8, howevSurgery, radiotherapy, steroids, immunotherapy (interferon-α or anti-IL-6 antibodies), and combination chemotherapy have all been used to manage the disease . CompletIn conclusion, CD should be included in the differential diagnosis of pancreatic tumors. Preoperative and intraoperative differential diagnosis of CD is important. The less morbidity local excision is a suitable surgical choice.Written informed consent was obtained from the patients for publication of this 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.Guo H had the idea of case report and wrote the main manuscript. Wang WL, Shen Y, and Zhang M performed the operations. Wu YS, Yan S, Xu X, and Wu J collected the patients’ data and follow-up radiological images. Li H participated in the manuscript preparation. Zheng SS revised the manuscript for important intellectual content, and gave the final approval for the version to be submitted for publication. All authors read and approve the final manuscript.


The aim of this presentation is to make readers aware; to look for pathology in pelvis in case of unexplained hip pain.83 yr old lady presented with pain in left thigh and lower leg. There was history of lethargy, feeling tired and cold chills. Inflammatory markers were high with ESR 127 and CRP 203. Patient had history of malignant melanoma (2008) and AF on Warfarin. Examination of the hip showed reduced internal rotation. X- ray pelvis, femur and chest were normal. USG abdomen showed heterogeneous vascular mass. MRI images showed enhancing soft tissue mass within left iliacus muscle this extends up to level of iliac crest down to level of inguinal ligament . Patient underwent CT guided biopsy confirmed grade 3 pleomorphic sarcoma of undifferentiated liposarcoma. She was referred to Sarcoma clinic at Leeds. She had palliative radiotherapy as the sarcoma was unresectable.CT image as shown in Figure Sarcomas are a rare and heterogeneous group of malignant tumours of mesenchymal origin. Incidence is less than 1% of all soft tissue tumours. Approximately 80% of sarcomas originate from soft tissue and the rest from bone. WHO classification of liposarcoma is well differentiated, myxoid, round cell & pleomorphic types. Pleomorphic sarcomas are more common in late adult life and carries increased risk of metastasis .Retroperitoneal sarcomas are uncommon malignancies with indolent presentations . You nee


Mature cystic teratomas (MCTs) of the ovary represent 44% of ovarian neoplasmas. The surgical approach is important in young women especially for the cosmetic results. Nowadays most of the ovarian surgeries can be performed laparoscopically. An alternative between laparoscopy and laparotomy is the minilaparotomy (ML) which can be an interesting option, thanks to the small incision. We report a 39-year-old woman who was referred to our hospital with acute abdominal pain. In her past history the patient had an uncomplicated delivery. During pregnancy a 6 cm bilateral MCT was diagnosed and expectant management was followed. A left-sided ovarial torsion was postulated, and laparoscopic detorsion was performed. To avoid a rupture of the left MCT, the operation was interrupted. To remove the cyst, a ML was done two weeks later. A left-sided salpingo-oophorectomy was performed due to a large cyst including the entire ovary. On the other side, the right dermoid cyst was entirely removed. The advantage of a ML is not only shorter operating time with less learning curve compared to laparoscopy but also the possibility to extract the adnexal mass from the abdominal cavity with lower risk of rupture and in addition the possibility to preserve more ovarian tissue. Mature cystic teratomas (MCTs) of the ovary, also known as dermoid cysts, represent 44% of ovarian neoplasmas. They are benign tumors containing mature tissue from all of the three germ-cell layers. MCT represents up to 52% of all ovarian tumors diagnosed in women younger than 40 years. Malignant transformation is rare and occurs in 1–3% of cases [The surgical approach is particularly important in young women who wish the best cosmetic results after the operation. Nowadays most surgeries for ovarian benign disease can be performed laparoscopically . AnotherWe present a case in which a woman affected from a bilateral dermoid cyst was operated with a minimal invasive procedure allowing, in this way, the preservation of their fertility.A 39-year-old woman was referred to our hospital with an acute abdominal pain. Five months before the time of admission, an uncomplicated spontaneous vaginal delivery occurred.During this pregnancy, a 6 cm bilateral adnexal mass was incidentally discovered by a routine gynecological check up. The ultrasound examination and its followup described these findings as a bilateral multicystic teratoma. Because of pregnancy, an expectant management was followed.At the time of admission, a physical and an sonographic examination was performed and a left-side ovarial torsion was suspected. A consecutive laparoscopic exploration confirmed our suspicion. A detorsion of the left adnexa was performed with a successful salvage of the ovary. The uterus was unremarkable. Both ovaries showed multiple smooth cysts of approximately 6 cm, which were identified as dermoid cysts. No ascites or tumour implants were found in the peritoneal cavity. To avoid a rupture of the left dermoid cysts, especially after an ovarial torsion, the operation was interrupted and an ML was planed.The ML was performed two weeks later. The suprapubic incision measuring 7 cm was close to the pubic hair line . The abdThe left dermoid cysts could be easily extracted from the abdominal cavity . A left-The patient had an uncomplicated postoperative recovery. Two month, after the operations an ultrasound was performed showing an intact ovary. After surgery no blood test for sex hormones was performed. The patient was in good general health with regular menses and without evidence of postmenopausal symptoms.The preservation of ovarian tissue in patients with an ovarian benign disease is considered as particularly important, especially for those in which fertility is an issue. The appropriate surgical treatment is still a matter of controversy. The laparoscopic approach to teratomas is nowadays considered as a safe and efficient procedure. In comparison to laparotomy, it does not increase complications and does not cause an increase in recovery time, hospital stay, and cost. Also the risk of adhesion formation is not as high as that in laparotomy . BetweenIf surgery is indicated for benign ovarian disease in particularly in premenopausal women, like in our case, a cystectomy or enucleation of a solid tumor from the ovary is generally considered the best alternative to preserve the ovarian tissue. If the ovary cannot be salvaged or insufficient viable tissue remains, then an oophorectomy has to be performed.Most teratomas are cystic and composed of mature adult-type tissues. The MCT accounts for more than 95 percent of all ovarian teratomas and is almost always benign. In 10 to 15 percent of cases, dermoid cysts can be bilateral and multicystic and therefore can cause complications during surgery .During an operation a rupture of a dermoid cyst with spillage of the material into the abdominal cavity is the most common complication that can occur during both, laparoscopy (15–100%) and laparotomy (4–13%). Shock and haemorrhages are the immediate consequence of a rupture caused by chemical peritonitis 0.2%), and this induces the formation of adhesions [%, and thThis is the reason why we recommend, in cases like the presented one, a minilaparotomy, which represents an approach between laparoscopy and laparotomy. The advantage of this technique, also considered in literature as a minimal invasive procedure, is not only a shorter operating time with a less learning curve than with laparoscopy but also the possibility to remove a complex adnexal mass preserving more ovarian tissue with a reduced risk of rupture and subsequent lower risk for complications , 7.In our case also a left oophorectomy was performed. In literature limited data is available about fertility following removal of one ovary. In those cases a pregnancy rate around 42 to 88 percent has been reported . This laIn conclusion if a teratoma occurs, laparoscopy is considered the gold standard for its treatment. In special cases if the dermoid cyst is bilateral, multicystic, very large with a high risk of rupture and childbearing is not completed, a minilaparotomy can be a good option also because each tumor can be easily extracted from the abdominal cavity reducing complications and in this way giving the chance to preserve more ovarian tissue.


Background. Teratoma with malignant transformation (TMT) is rare and most commonly encountered in adult patient with germ cell tumor (GCT). Method. We report a rare case of testicular teratoma with metastatic TMT/embryonal rhabdomyosarcoma (ERMS). A 44-year-old man underwent right orchiectomy which revealed a malignant teratoma, he subsequently had right pneumonectomy with two pulmonary masses containing a high-grade embryonal rhabdomyosarcoma. The patient developed liver metastasis three months after initial diagnosis. He was treated with a chemotherapy regimen with vincristine, dactinomycin, and cyclophosphamide (VAC) alternating with vincristine and irinotecan (VI) with complete resolution of his liver lesion. The tumors were examined with a battery of cytogenetic, immunohistochemical, and molecular assays. Results. The malignant cells were immunohistochemically positive for desmin, myogenin, and MyoD1. Molecular cytogenetics of embryonal rhabdomyosarcoma tissue revealed the presence of i(12p). The tumor expressed high level of TOPO2A, TOPO1, MRP1, MGMT, BCRP, ERCC1, RRM1, and TS. Conclusion. The activity of topoisomerase inhibitors and the potential usefulness of topoisomerase expression as biomarkers should be further tested in aprospective study. Teratoma with malignant transformation (TMT) is germ cell tumor (GCT) which underwent malignant transformation of a somatic teratomatous component to histology that is identical to a somatic malignancy  –8. TMTs α-fetoprotein, β-human chorionic gonadotropin, carcinoembryonic antigen (CEA), and lactate dehydrogenase assays were normal. A right orchiectomy revealed a malignant teratoma. The patient was subsequently transferred to our hospital for chest pain and hemoptysis. A bronchoscopy was performed which did not show any active bleeding, a suspicious endobronchial lesion was biopsied that showed no evidence of malignancy. PET scan showed increase uptake in both pulmonary lesions  studies were performed on paraffin sections from lung mass utilizing Homebrew 12p13.2 DNA probe with CEP 12 at the University of Nebraska Medical Center genetics laboratory. Molecular cytogenetic analysis revealed a normal male 46, XY karyotype with presence of i(12p).In order to identify potential target and biomarkers and therapies associated with clinical benefit, further immunohistochemistry and molecular studies were performed. As demonstrated by Somatic-type malignancies develop in 3% to 6% of GCT with teratomatous differentiation , 4. It wA notable feature of current case is the fact that no sarcomatous component was identified in the testicular mass and no germ cell element was identified in the resected pulmonary tumor. Although extensive histopathologic evaluation was undertaken, sampling error cannot be completely excluded. The presences of two different types of sarcomas  in the same metastasis favor a GCT origin. The GCT origin of rhabdomyosarcoma in this case is also strongly supported by the presence of i12p). Chromosomal abnormalities in these TMTs include i(12p), reflecting germ cell tumor clonality, as well as chromosomal abnormalities associated with the transformed histology. Only a few cytogenetic studies have been performed on transformed tumors . Motzer 2p. ChromThe treatment of TMTs remains a challenge. TMTs have traditionally been thought to be unresponsive to chemotherapy, including cisplatin-containing chemotherapy regimens . PatientOur finding of overexpression of several drug-resistant genes is in line with the clinical observations of lack of response to chemotherapy in these tumors. High expression of MRP1 has been associated with lack of response to etoposide and vincristine . High exThe outcome for patients with metastatic RMS has remained approximately 30% survival for several decades. It has long been recognized that interpatient variability in response to chemotherapy is associated with different outcomes. The complete clinical response with irinotecan-based regimen in this case is interesting. The overexpression of Topo IIa, Topo I in tumor suggested they are attractive targets for novel therapy. Topo I and IIa are enzymes that alter the supercoiling of double-stranded DNA. They act by transiently cutting one or both strands of the DNA. Topo I cuts one strand whereas topoisomerase II cuts both strands of the DNA to relax the coil and extend the DNA molecule . High exThe advent of the human genome sequencing project and the development of high-throughput technologies, including microarrays, have allowed oncologists to explore the possibility of using gene expression profiles to predict chemotherapy drug sensitivity or resistance before treatment, and thereby select the best possible therapies while decreasing the risk of toxicities for the patients. In order to achieve this goal, an international virtual sample bank of this rare tumor is necessary. The Sarcoma Foundation of American Patient Registry and ongoing international efforts to evaluate high-dose chemotherapy in the salvage setting (TIGER protocol) may provide a good opportunity to collect such rare cases. In conclusion, we report a rare case of malignant testicular teratoma with metastatic TMT/ERMS. Our findings of overexpression of several drug-resistant genes is consistent with the previous clinical observations of poor chemotherapy response in these tumors. The usefulness of biomarkers for chemotherapy selection should be further tested in a future study.


One of the rarest situations regarding an adrenal incidentaloma is an adrenal cyst. We present the case of a 61Z–year old male patient diagnosed with peritonitis. During surgery, a right adrenal tumor of 2 cm is discovered. The patient was referred to endocrinology. 6 months later the diameter of the tumor is 7 times bigger than the initial stage. It has no secretory phenotype, except for the small increase of serum aldosterone and the 24–h 17–ketosteroids. Open right adrenalectomy is performed and a cyst of 15 cm is removed. The evolution after surgery is good. The pathological exam reveals an adrenal cyst with calcifications and osteoid metaplasia. The immunohistochemistry showed a positive reaction for CD34 and ACT in the vessels and VIM in the stroma. The adrenal cysts are not frequent and represent a challenge regarding the preoperative diagnostic and surgical procedure of resection. The pathological exam highlights the major aspects. A gigantic adrenal tumor is a rare finding. In the lack of surgery, the differential diagnosis is difficult. Thus, the surgery becomes an important tool to evaluate the case. The adrenal cysts are exceptional. Because of the hemorrhage, the diameters of the cyst may enlarge rapidly but the clinical picture varies from asymptomatic  to acute complications such as abdominal pain, hypovolemic shock.The 61–year old male patient had an appendicle crisis complicated with peritonitis. Surgical approach is performed. During surgery, a right adrenal tumor of almost 2 cm is discovered. After surgery, the patient is referred to an endocrinologist. Six months later the CT scan found a right adrenal tumor of maximum 10 cm and several abdominal lymph nodes. Two more months later, he came to our attention. The clinical exam showed a slightly overweight patient. The biochemical profile pointed mild anemia . The patient had normal renal and hepatic functions.  The hormonal panel was normal. The plasma basal cortisol was of 15.53 mili g/dL , with suppression at 0.94 mili g/dL after 2 mg of dexametasone (2 days); plasma basal ACTH – 47.02 pg/mL . Mildly changed parameters were: serum aldosterone – 278.97 pg/mL  and 24–hours urinary 17 ketosteroids – 20.2 mg . The angioMRI revealed a tumor of 15 by 14.7 cm with a large central area filled with liquid signal, an intact capsule in contact with the right kidney, hepatic right lobe, inferior cave vein, preserving a demarcation limit. After the administration of the contrast substance, a loading into the periphery of the tumor took place.  Inter–aorto–cave lymph nodes of 1.8 cm are situated under the left renal hill.  ClassicaNo adrenal insufficiency was registered. Basal plasma cortisol was of 17 mili g/dL and mild hepatic cytolysis was remitted within 7 days, probably due the hepatic intra–surgery manipulation. The full recovery of the patient was present. The patient will be kept under observation in the next period. The pathological exam pointed an adrenal cyst having hemorrhagic content, a fibro–conjunctive capsule with areas of calcifications inside the capsule and osteoid metaplasia under the capsule. Normal adrenal tissue was found peri and intra–capsule.  The immunohistochemistry revealed stromal positive reaction for VIM, ACT and CD34 positive into the vessels, CROMO positive into the medullar and negative INHIBIN.  Adrenal cysts are rare. The reported incidence in clinical series is of 5.4%.  In the aAdrenal cysts are usually asymptomatic; mostly an occasional discovery during ultrasound or CT. In our case, it was a surgical procedure for a different cause. Acute abdominal pain may be presented in some cases.  In this From the histological point of view, the adrenal cysts are vascular or endothelial, hemorrhagic or pseudoscyst and epithelial–lined or ‘true’ adrenal cysts. There are a few cases of bilateral cysts reported.  7% of cyA patient with a giant adrenal mass is a challenge regarding the differential diagnosis from other types of adrenal masses. There are many parasitosis with cysts aspects.  The diagA giant adrenal cyst mimicking a carcinoma by the preoperative phenotype is a very rare finding. The surgical approach is challenging because of the large tumor dimensions and increased blood amount. Nevertheless, the pathological exam brings the most spectacular aspects regarding the differential diagnosis and the prognosis.


Nevus lipomatosus superficialis (NLS) is an uncommon hamartomatous lesion of the skin characterized by the presence of clusters of mature fat cells among the collagen bundles of the dermis. Usually, the number of adnexal structures is reduced in NLS as compared to the normal adjacent skin, but their morphology is not altered. Nevertheless, in some instances, associated pilar abnormalities have been reported. We here report 2 cases of NLS with disorganized pilosebaceous units. The follicular structures were dilated and showed infundibular type keratinization and there were numerous mature sebaceous lobules radiating from them resembling the histology of a folliculosebaceous cystic hamartoma (FSCH) or a sebaceous trichofolliculoma. Only 2 cases of NLS with FSCH have been previously reported. Our cases represent examples of a very rare hamartomatous cutaneous lesion composed of mesenchymal and epithelial components. Nevus lipomatosus superficialis (NLS) is an uncommon cutaneous hamartoma consisting of flesh-colored or yellowish soft nodules or papules with smooth or wrinkled surface, which are histologically composed of groups of mature fat cells located among the bundles of dermal collagen. Two clinical forms are recognized: the classical and the solitary one. In the first, there are multiple papules and nodules grouped in a zonal pattern forming a plaque or a cerebriform mass. They present at birth or in the first two decades of life and are usually located on the buttocks, lower back, or upper thighs. On the contrary, the solitary type can develop in adults and shows a wider distribution in the skin . NLS hasUsually, the number of adnexal structures is reduced in NLS as compared to the normal adjacent skin but their morphology is not altered . HoweverWe herein describe 2 cases of NLS with abnormal folliculosebaceous structures, a very rare hamartomatous lesion of the skin with mesenchymal and epithelial components.A 33-year-old male presented with a 90 × 40 mm, asymptomatic, slowly growing cutaneous plaque on his right lumbar region, which arose in childhood. It was composed of multiple, confluent, skin-colored nodules . Some ofA 51-year-old male visited our Dermatology Department for a 6 mm nodular dermal lesion on his right forearm. It had been present for several years. The clinical diagnosis was leiomyoma. The lesion was entirely excised. On cutting, it was observed that it occupied the whole dermis and showed a yellowish white color, a bland consistency, and a poorly demarcated margin. Histologically, it consisted of numerous, confluent groups of mature fat cells located among the dermal collagen bundles . Small pWe herein report 2 cases of cutaneous hamartoma consisting of clusters of mature fat cells located among the collagen bundles of the dermis and disorganized infundibular structures with numerous radiating well-developed sebaceous glands. We consider both cases as examples of NLS with a folliculosebaceous component. A follicular component in an NLS is a very unusual event, which can clinically be suggested by the presence of umbilicated papules in the lesion . Our case 1 resembled a giant FSCH. FSCH is a rare developmental cutaneous abnormality formed by dilated and distorted folliculosebaceous units embedded in a stroma containing spindle and stellate fibroblasts, and variable amounts of mature fat cells, blood vessels, nerves, and mucin. FSCH typically presents as a solitary small papulonodular lesion in the central face or scalp of adults . Other lOur case 2 must be differentiated from a skin tag with fat cells and from a sebaceous TF. The presence of a distorted folliculosebaceous structure allows the differential diagnosis with the former. Sebaceous TF is a rare cutaneous hamartoma that presents as a centrally depressed small lesion on the nose and, rarely, on other areas of the head, neck, and genitals. Histologically, it consists of a cystic central cavity connected to the epidermis and lined by squamous epithelium with infundibular keratinization. Sebaceous lobules and hair follicles in various stages of their growth cycle arise from the wall of the cyst . Some auTwo cases of NLS with FSCH have previously been published. The first one was reported by Brasanac and Boricic in 2005 and described as a 23 cm plaque on the sacral region of a 47-year-old female that had been present since birth. This lesion also contained dermoid cysts .Since mesenchymal dermal components other than fat cells, such as collagen bundles, elastic fibers, fibroblasts, and blood vessels used to be altered in NLS, some authors consider this lesion as a type of connective tissue nevus , 14. CasIn conclusion, we here report 2 cases of NLS with disorganized folliculosebaceous structures, a very rare hamartomatous cutaneous lesion composed of mesenchymal and epithelial components.


Cavernous transformation of the portal vein (CTPV) is a rare vascular deformity. It is thought to be secondary to extra-hepatic portal vein obstruction, with formation of serpiginous collateral vessels around the extra-hepatic bile duct, and even the gallbladder. Surgery is difficult because the vessels have irregular courses, are somewhat fragile and bleed easily. Single-incision laparoscopic cholecystectomy, an emerging procedure for symptomatic cholecystolithiasis, has limitations especially in anatomically complex cases.We describe a 44-year-old woman with symptomatic cholecystolithiasis. Computed tomography revealed a series of tortuous collateral veins at the liver hilum, with the extra-hepatic portal vein occluded at the level of the spleno-portal junction. However, the distended vessels were not particularly close to the cystic duct. We performed single-incision laparoscopic surgery (SILS) for cholecystectomy via a trans-umbilical incision. By pulling the cystic duct out along with neighboring cavernous vessels, we were able to secure detachment of the cystic duct from Calot’s triangle and ligation of the cystic artery. Total operating time was 132 minutes and blood loss was 370 grams. The patient was discharged on postoperative day 2 with no perfusion abnormalities in the liver.We must pay meticulous attention to the area of Calot’s triangle when performing SILS cholecystectomy with CTPV. SILS cholecystectomy might be an option in highly experienced facilities. In this era of minimally invasive procedures, single-incision laparoscopic surgery (SILS) has become a popular option for cholecystectomy ,2. SILS A 44-year-old Peruvian woman, who had immigrated to Japan 20 years earlier, presented with postprandial upper abdominal pain of four months duration. She was found to have a gallbladder stone, which might have been the cause of her epigastralgia. Her past medical history was unremarkable except for a left renal stone. She had been pregnant three times and given birth to three children. On physical examination, there were no remarkable findings. As to laboratory tests, levels of aspartate amino transferase (AST), alanine amino transferase (ALT), alkaline phosphatase (ALP), glutamyl transferase and total bilirubin were within normal ranges. Ultrasonography showed a few strongly echoic stones but there was no gallbladder wall thickening. Neither intra- nor extra-hepatic bile ducts were dilated. Routine preoperative computed tomography (CT) revealed a series of tortuous collateral veins at the liver hilum, irregularly surrounding the gallbladder from the neck to the fundus Figure a, 1b. ThWe considered SILS to be feasible because the cavernous vessels were not close to Calot’s triangle, and most ran from the middle to the left side of the hepatoduodenal ligament and liver hilum. Two distended collateral veins flowed extra-hepatically to the edge of the posterior segment of the liver. We were determined that these vessels could be sacrificed during the surgical procedure.The operation was performed under general anesthesia, starting with a trans-umbilical incision. The peritoneal cavity was entered employing the open method, and a LAP PROTECTOR  was then inserted with EZ ACCESS (HAKKO). There were three holes, for two 5 mm ports and one 12 mm port. A flexible laparoscope  and two operating forceps were used. The pneumoperitoneum was set at 8 mmHg. Suture suspension of the gallbladder was not adopted. The courses of the cavernous vessels surrounded the neck of the gallbladder , ALT (109 U/l) and ALP (188 U/l) on postoperative day 1, which decreased to 53, 78 and 181, respectively, the next day. Postoperative CT revealed that two extra-hepatic meandering vessels had been sacrificed but there were no hepatic perfusion abnormalities. She was uneventfully discharged on postoperative day 2. The liver enzymes dropped within normal ranges and she was asymptomatic on her last outpatient day of postoperative day 8.With the advent of less invasive operative procedures in every field of surgery, laparoscopic cholecystectomy has replaced open cholecystectomy for cholecystolithiasis. In recent years, SILS cholecystectomy has been widely accepted in numerous facilities . Its potCTPV was first reported by Gibson et al.  in 1955,The long operating time and major blood loss in this case might be points worthy of criticism. We think that the main cause of bleeding is that we tried to detach the cystic duct from neighboring cavernous vessels. These vessels were too fragile to be completely preserved in keeping the cystic duct. The small collateral vessels can be safely sacrificed to minimize bleeding. We believe that laparoscopic cholecystectomy for young women is feasible and that sudden bleeding in this case might have been overcome even if we had performed conventional multiport laparoscopy. A lesson learned from this case is that surgeons performing biliary operations in cases with CTPV might encounter unexpected bleeding. We must be prepared to control intraoperative bleeding regardless of operative procedures.In conclusion, when we perform SILS cholecystectomy in a case with CTPV, we must pay meticulous attention in the area of Calot’s triangle. SILS cholecystectomy might be an option in highly experienced facilities, but we must always keep in mind that patient safety has the highest priority.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.ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; AST: Aspartate amino-transferase; CT: Computed tomography; CTPV: Cavernous transformation of the portal vein; SILS: Single-incision laparoscopic surgery.The authors declare that they have no competing interests.All of the authors were involved in the literature search, writing and final review of this manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/13/10/prepub


Benign cystic mesothelioma or peritoneal inclusion cysts are rare benign abdominal tumors usually occurring in females of reproductive age. These cysts present as abdominopelvic pain or masses but are often found on imaging or incidentally at surgery. They are commonly associated with pelvic inflammatory disease, endometriosis, or ovarian cysts. We report what is, to the best of our knowledge, the first case of a benign cystic mesothelioma complicating a presentation of acute appendicitis.A 19-year-old Irish Caucasian woman presented with abdominal pain. Imaging suggested appendicitis with abscess formation. She was treated with antibiotics and scheduled for interval appendicectomy. At laparoscopy, an unusual cystic mass was found arising from the appendix. Histology revealed benign cystic mesothelioma.We report what is, to the best of our knowledge, the first case of a benign cystic mesothelioma arising from the appendix and complicating a presentation of acute appendicitis. This is a benign pathology, but recurrences are not uncommon. Benign cystic mesothelioma should be included in the differential when investigating pelvic masses or abscesses associated with either appendicitis or pelvic inflammatory disease in women. Benign cystic mesothelioma (BCM) or peritoneal inclusion cysts are rare abdominal tumors usually occurring in women of reproductive age. These cysts present as abdominal or pelvic pain or masses but are often found on imaging or incidentally at surgery. There have been many cases described associated with pelvic inflammatory disease, endometriosis, or ovarian cysts. We describe the first case of a benign cystic mesothelioma arising from the appendix and complicating a presentation of acute appendicitis.A 19-year-old Irish Caucasian woman presented to the hospital with a three-day history of abdominal pain and fever. The pain was gradual in onset and associated with nausea and one episode of vomiting. She had no urinary symptoms, and her last menstrual period had finished the previous day. She had no surgical history, and her medical history was significant only for viral meningitis two years previously. She denied any history of sexually transmitted disease or recent urinary tract infection. She was not taking regular medications and had no allergies. On examination, her vital signs were normal except for mild pyrexia of 37.4 °C. Examination of the abdomen revealed a tender mass in the right iliac fossa.Laboratory investigations included a white cell count of 10,500 cells/mm, hemoglobin of 13.3 g/dl, and platelets of 212,000/mm. Urea and electrolytes were within normal ranges. Urine analysis was negative for leucocytes and urinary βHCG was negative.A computed tomography (CT) scan of the abdomen and pelvis was requested and showed a 10.4 × 4.5 × 3.8 cm loculated cystic mass in the right pelvis that appeared to contain the tip of the appendix , they are cystic mesothelial proliferations. They are thought to be due to an inflammatory reaction. They usually occur in the peritoneal cavity in the abdomen or pelvis, and the most common predisposing factors in the clinical history are previous surgery, pelvic inflammatory disease, or endometriosis. These conditions are believed to interfere with peritoneal reabsorption. This would tend to support a hypothesis of BCM being reactive and inflammatory rather than neoplastic (2). These conditions tend to occur in women of reproductive age, but cases have been reported in men (3). The most common sites are the serosal surfaces of the ovary and uterus, but cases outside the abdomen have been described, including the pleural cavity (4). Typical microscopic findings are a single layer of flattened mesothelial cells sometimes described as a hobnail configuration. Squamous metaplasia and papillae may also be seen (3).The clinical presentation is usually abdominal or pelvic pain, a mass found clinically or radiologically, or an incidental surgical finding (5). BCM is considered to be a benign inflammatory process; however, malignant transformation has been reported (6). Diagnostic modalities include ultrasound and CT, but preoperative diagnosis is often not conclusive and there are no protocols for diagnostic imaging. The main differentials are ovarian cysts, ovarian tumors , or cystic lymphangioma. When presenting acutely with signs of infection as in the case described here, pelvic inflammatory disease complicated by abscess would be the most common differential as associations with appendicitis are very rare.Management currently involves surgical resection, but recurrences are well documented. There are no protocols for surgical management, and the literature is based on case reports and small case series. Laparoscopic resections have been described. While laparoscopy is an elegant tool for investigation of masses or pain in women, we believed open surgery to be safer when a malignant process was suspected owing to the possibility of cyst rupture and seeding. Follow-up after surgical resection includes clinical review and ultrasound or CT, but again there are no guidelines.BCM involving the appendix is very rare. Only four other cases have been reported. Two were in middle-aged women presenting with abdominal pain and suspected appendicitis where cysts were found adjacent to but not involving the appendix . In a third case, a BCM was found incidentally beside an otherwise unremarkable appendix at laparotomy for sigmoid diverticular disease (9). The other case involved a 28-year-old man who presented with appendicitis in which a 25-cm separate cystic mass was found (10). Our patient's case is unique in that the BCM was in direct continuity with the tip of the appendix and presented with both clinical signs and histological evidence of acute appendicitis.BCM is a rare benign tumor, but surgeons should include it in the differential when investigating abdominal masses or pain in women of reproductive age. This is the first reported case of a BCM arising from the appendix which complicated a presentation of acute appendicitis. Surgery is the authors' recommended treatment, but patients should be advised of the possibility of recurrence.The authors declare that they have no competing interests.DB O'C drafted and conceived the manuscript, DB assisted in the drafting and editing of the final manuscript, and MA performed critical revisions of the manuscript.DB O'C and MA performed the operation. All authors read and approved the final manuscript.The authors have written informed consent from the patient for the publication in a medical journal of the manuscript and images. A copy of this consent can be made available to the editorial team.


Herniation of the liver through an anterior abdominal wall hernia defect is rare. To the best of our knowledge, only three cases have been described in the literature.A 70-year-old Mexican woman presented with a one-week history of right upper quadrant abdominal pain, nausea, vomiting, and jaundice to our Department of General Surgery. Her medical history included an open cholecystectomy from 20 years earlier and excessive weight. She presented with jaundice, abdominal distension with a midline surgical scar, right upper quadrant tenderness, and a large midline abdominal wall defect with dullness upon percussion and protrusion of a large, tender, and firm mass. The results of laboratory tests were suggestive of cholestasis. Ultrasound revealed choledocholithiasis. A computed tomography scan showed a protrusion of the left hepatic lobe through the anterior abdominal wall defect and a well-defined, soft tissue density lesion in the right adrenal topography. An endoscopic common bile duct stone extraction was unsuccessful. During surgery, the right adrenal tumor was resected first. The hernia was approached through a median supraumbilical incision; the totality of the left lobe was protruding through the abdominal wall defect, and once the lobe was reduced to its normal position, a common bile duct surgical exploration with multiple stone extraction was performed. Finally, the abdominal wall was reconstructed. Histopathology revealed an adrenal myelolipoma. Six months after the operation, our patient remains in good health.The case of liver herniation through an incisional anterior abdominal wall hernia in this report represents, to the best of our knowledge, the fourth such case reported in the literature. The rarity of this medical entity makes it almost impossible to specifically describe predisposing risk factors for liver herniation. Obesity, the right adrenal myelolipoma mass effect, and the previous abdominal surgery are likely to have contributed to incisional hernia formation. Herniation of the liver is uncommon. This entity has been described in patients with omphalocele, congenital diaphragmatic hernia, and blunt trauma diaphragmatic rupture -3. To thA 70-year-old Mexican woman presented with a one-week history of right upper quadrant abdominal pain, nausea, vomiting, and jaundice to our Department of General Surgery. Her medical history included an open cholecystectomy, which was performed 20 years earlier in another hospital to treat acute cholecystitis, and excessive weight during the past 45 years.A physical examination revealed jaundice, abdominal distension with a midline surgical scar, right upper quadrant tenderness, and a large abdominal wall defect suggestive of a post-incisional hernia with protrusion of a large, tender, and firm mass. Percussion elicited dullness over the entire hernia content. No rebound tenderness, shifting dullness, or fluid wave was observed.Laboratory tests revealed a total bilirubin value of 3.2 mg/dL , direct bilirubin of 2.2 mg/dL , alkaline phosphatase of 415 U/L , gamma-glutamyl transferase of 241 U/L , alanine aminotransferase of 139 U/L , and aspartate aminotransferase of 142 U/L .During transabdominal ultrasound (US), intrahepatic and extrahepatic bile duct dilatation and stones in the common bile duct were observed Figure . A compuOur patient was scheduled for surgery. The right adrenal tumor was approached and resected through a right subcostal incision. The hernia was approached through a median supraumbilical incision. A left lobe protrusion through the abdominal wall defect was found, and a reduction of the lobe to its normal position was performed Figure . The comMacroscopically, a 12cm, yellowish, soft tumor was found Figure . HistopaHerniation of the liver is an uncommon situation. An entity known as exclusive hepatocele, in which the liver is part of the omphalocele content, has been described in the neonatal period . CompromPseudomonas sepsis [Sheer and Runyon  reporteds sepsis .Abci and colleagues  reportedShanbhogue and Fasih  reported2) after an emergency laparoscopic surgery for acute calculous cholecystitis was converted to open surgery.Rodríguez-Hermosa and colleagues  reportedHerniation of the liver through other types of incisional hernias has been described. Salemis and colleagues  reportedAdrenal myelolipomas are uncommon, benign, unilateral, and non-functioning tumors composed of mature adipose tissue admixed with hematopoietic cells . As refeDiagnosis of adrenal myelolipomas is made by US, CT, and MR in more than 90% of cases. CT is the most sensitive diagnostic imaging modality . In US, Histologic diagnosis of myelolipoma is based on the presence of mature adipocytes and hematopoietic elements. Treatment modalities include watchful waiting and resection. Small asymptomatic tumors can be monitored expectantly since they pose little risk of spontaneous rupture or bleeding. Often, although these tumors are benign, their size and propensity to grow warrant surgical removal. Symptomatic tumors and those rare hormonally active tumors should be excised. Smaller tumors are amenable to laparoscopic resection .The clinical presentation of liver herniation through an anterior abdominal wall hernia tends to be non-acute with no peritonitis and probably is associated with the large hernia defect and the absence of strangulation. The decision to perform an abdominal wall reconstruction should be made on an individual basis. In the case reported here, the one-week clinical presentation of abdominal pain and jaundice, the previous cholecystectomy, and the liver biochemical markers made a common bile duct obstruction highly probable, and this was confirmed by US. The difficulty of performing a successful stone extraction by ERCP because of the patient's obesity and duodenal compression by a displaced liver and the right adrenal tumor made the surgical decision mandatory. In our case, obesity and the mass effect caused by the adrenal myelolipoma are likely to have contributed to an increased intra-abdominal pressure, which was exerted over a previously operated abdominal wall, with subsequent incisional hernia formation. Although a common background of major surgery is present in the three cases of liver herniation through an anterior incisional defect as well as in our case, the rarity of this medical entity makes it almost impossible to specifically describe predisposing risk factors for liver herniation.The case of liver herniation through an incisional anterior abdominal wall hernia in this report represents, to the best of our knowledge, the fourth such case reported in the literature. Obesity, the right adrenal myelolipoma mass effect, and the previous surgical event are likely to have contributed to the incisional hernia formation. The description of the diagnostic approach and the consideration of comorbidities in this and previous case reports are important for such rare cases.CT: computed tomography; ERCP: endoscopic retrograde cholangiopancreatography; MR: magnetic resonance; US: ultrasound.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.CMNG and JAJ were involved in the medical care of the patient and helped to write the manuscript. JVG, HB, AMR, and RIOO were involved in the medical care of the patient and contributed to the literature review. IE performed the histological examination of the myelolipoma and contributed to the literature review. All authors read and approved the final manuscript.


A keratocystic odontogenic tumor is a benign intra-bone mass originating from dental lamina or its residue. It represents 2–11% of jaw cysts, and has a slow but aggressive growth. The evaluation of molecular characteristics, immunohistochemistry, and genetic expression currently have no established classification regarding the evolution and pathophysiologic pattern of these lesions. This is a clinical retrospective study with a full analysis of patient history regarding physical evaluation, radiologic images, pathology results, and surgical resection. We performed a major literature review concerning current concepts relating to its biological characterization. Three cases of keratocystic odontogenic tumor were identified. Two of the cases were large, with aggressive behavior and significant bone destruction and recurrence, which had been overlooked for more than a decade. The third case had an early diagnosis, and the treatment led to full recovery and complete healing. The keratocystic odontogenic tumor is a benign lesion with slow growth, which lends itself to a more conservative treatment, even in cases of large lesions. A better understanding of these tumors, both at the biological and molecular level, could lead to guidelines for treatment and prognosis of such patients. Odontogenic tumors are considered rare neoplasms, with a challenging diagnosis and treatment. The numerous publications concerning these tumors tend to be case reports with unusual histopathologic or clinical behavior. Furthermore, publications prior to 2006 were based on the 1971 World Health Organization (WHO) histological classification. In 2005, the new histological classification of odontogenic tumors by the WHO reclassified the odontogenic keratocyst as benign intra-osseous neoplasia, calling it a keratocystic odontogenic tumor (KOT) . OriginaRecent molecular and genetic investigations targeted towards odontogenic tumors, especially the KOT, suggest its biological origins, thus broadening the understanding of its pathophysiology . AlthougWe describe three KOT cases, including two large cases with aggressive behavior, and review the current knowledge regarding their biological characterization.This is a retrospective clinical study, which evaluated three patients at the Maxillo-Facial Surgery Service from the Department of Otorhinolaryngology Head and Neck at the University of Campinas Teaching Hospital  during 2011. The work consisted of a complete review of medical records from patients who underwent surgical treatment for mandibular lesions with a final diagnosis of KOT, in addition to a literature review regarding its biological characterization.All patients underwent preoperative 3D reconstruction computed tomography (CT) scans followed by surgeries, performed by the same team, with histopathological diagnostic confirmation. They were followed postoperatively with clinical and radiographic control. Two cases presented large and aggressive behavior lesions, with distinct evolutions. A medical literature review was performed using PubMed/ MedLine, without research limits, with the MesH terms: keratocystic tumor; mandible; odontogenic tumor, immunohistochemistry. This study followed the institution Ethics Committee guidelines.Case 1A female patient, 53 years of age, with a 1-year history of bulging in the left ramus of the mandible, noticed after dental treatment, without any pain, bleeding, limited mandibular movement or weight loss complaints. The patient had no other history of disease. During a physical examination an enlargement was noticed in the left ramus of the mandible region, approximately 8 cm wide, painless, without involving the mouth floor, the gingivolabial sulcus, teeth, or cervical lymph nodes. A CT scan showed an insufflated lytic formation in the mandibular left ramus and angle, approximately 7 cm wide with the presence of thinness and rupture of the medial cortical with hypodense content and related dental elements preserved. The patient underwent surgical resection with complete removal of the intraoral cyst with thickened capsule filled with cornea formations. Histological analysis confirmed the KOT diagnosis. The left inferior alveolar nerve was identified and preserved. No grafts were used and complete regeneration of the surgical cavity was observed 4 years after the procedure.Case 2 A female patient, 28 years of age, with complaints of bulging, pain, and hyperemia in the right mandibular angle region for 18 years and pus drainage recurrence in the oral cavity, always with spontaneous resolution. The lesion evolved with increasingly frequent relapses, bulging progression, worsening pain, difficulty in opening the mouth, and episodes of hypoesthesia in the right inferior alveolar nerve territory. No fever, weight loss or other complaints were reported. During a physical examination we observed bulging of approximately 10 cm in the body region and angle of the right mandible which was firm, painless, and without signs of inflammation. The buccal opening decreased by an average of 2.5 cm. Neck palpation was without alterations.A CT scan showed expansive formation of approximately 5 cm in the ramus and the right angle region of the mandible with well-defined bone limits which was insufflated with hypo-attenuation and medial cortical rupture in the 3D reconstructions. The cuts without reconstruction presented no trabeculations or calcifications. There were no remaining teeth in the lesion. The lesion excision was performed intraorally, and was histologically diagnosed as a KOT; thus, confirming widespread erosion of the mandibular cortical bone corresponding to the lateral and medial cyst wall. Complete removal of the tumor was impossible to ensure in these sites and the bipolar cauterization of soft tissues was liberally used. The inferior alveolar nerve was not identified, and no cavity filling was used.A year after the initial surgery, a control CT scan showed persistence of the cystic area in the right ramus of the mandible approximately 7.5 cm in diameter, despite the evident thickening of the cortical basilar. Suspicion of a tumor recurrence was confirmed by subsequent histological analysis. Recently, the patient underwent resection of the residual lesion with removal of laminated white scaly tissue from the affected area, in addition to peripheral osteotomy reaching the bone with healthy appearance. There was no requirement for the use of reconstruction plates or any other kind of cavity fillers. The patient underwent a 6-month observational period without signs of recurrence .Case 3A male patient, 60 years of age, with a 20-year history of progressive bulging at the right angle of the mandible and chewing pain for approximately 1 year. He reported no bleeding, weight loss, or cervical masses. During a physical examination, we noticed a disfiguring angular bulging in the right mandibular, approximately 10×7 cm in size. This was indurated, painless, and jeopardizing the region of the mouth's floor and swelling the sulcus and the gum border. No neck lymphadenopathy was detected. A CT scan showed a cystic formation in the region of the angle and the right ramus of the mandible, approximately 8.0 cm wide, with irregular and inflated bone contours, in the presence of thin bone trabeculae, with evidence of cortical disruption, hypo-attenuating content without dental residues, and destroying the entire coronoid process.The patient underwent tumor surgical resection via the intraoral route. We performed KOT confirmation in the frozen biopsy and in the final microscopy examination from paraffin. During surgery we observed substantial bone erosion, thin trabeculations, and numerous characteristic corneas structures. All the remaining bone from the ramus, angle, and coronoid process was removed by progressive osteotomy. The mandible was rebuilt with a 2.4 titanium plate, without bone grafts. We chose to sacrifice the inferior alveolar nerve involved by the tumor along its path. After 30 days, there was partial exposure of the plate portion within the oral cavity without evidence of infection or related complaints from the patient, who recovered the mandible contour, maintaining proper chewing. After a 9-month follow-up, no signs of recurrence were detected .As a lesion displaying more aggressive behavior when compared to other odontogenic cysts, the KOT presents, among other histopathological features, a layer of parakeratinized epithelium of lining which distinguishes it from other cysts with epithelial odontogenic cysts, called orthokera- tinized odontogenic cysts. With only partially elucidated histopathogenesis, these cysts are considered as separate entities. In order to better understand them, Aragaki evaluated the immunohistochemical profile from the keratin expression in each one . In a series of 32 surgically treated KOTs, Kuroyanagi observed significant expression of Ki-67 and p53 in the group with recurrences, suggesting that the evaluation of these marker proteins helps inform the decision regarding adjuvant procedures and that it has a prognostic value .Anticipating the proposition of future therapies, Zhang postulated that the development of synthetic active receptor antagonists or transcription factors from the Sonic hedgehog (SHH) signaling pathway may result in an effective treatment for this tumor. He suggested that inhibition of the Smoothened (SMO) by intracystic injection of a protein antagonist would be the treatment with the greatest potential .For small KOTs, the most conservative procedure available  would be mandatory. Endoscopic removal allows the careful exploration of difficult-to-reach areas through direct visualization, allowing not only the monitoring of the wall separation between the tumor and the inferior alveolar nerve, but also promoting the complete removal of the lesion . For larIn resections resulting in large residual fragility of the mandible, we recommend, as a preventive measure for possible secondary fracture of the bone, reinforcement with 2.4 titanium plates overlapping the lesion area, similar to the one from the reported case. With the expectation of substantial bone removal and interruption of the continuity, we suggest placing a plate before the tumor resection is finalized, since there is no requirement for en bloc removal. Therefore, a better quality mandibular reconstruction is accomplished by maintaining the correct positioning of the distal fragments associated with the condyle, particularly in the complete edentulous. The mandibular evaluation with computerized densitometry after the KOTs enucleation, showed progressive regeneration of the defect area without any grafting material, with a more significant increase in bone density 6 months after the surgery . ConsistOwing to the frequent recurrence, a variety of adjuvant treatments have been proposed, including the removal of the peripheral bone (osteotomy), en bloc resection of the cyst with the surrounding bone, cryotherapy (freezing) with liquid azote, and use of Carnoy's fixative solution into the cavity after the enucleation. For Madras, a resection or enucleation supplemented with Carnoy's solution, with or without osteotomy, would result in a lower recurrence than with the enucleation or the marsupialization alone. However, the recurrence after marsupialization followed by enucleation did not differ from more aggressive therapies . In anotBoyne proposed an interesting thesis involving seven patients with multiple recurrences over a period up to 21 years. In this work, he highlights the histological analysis performed in resected hemimandibles from patients operated on several times, in which, besides the recurrence on the edges of old lesions, the presence of other lesions was also verified in different locations. From these observations, the author establishes the multifocal nature of the KOTs, and emphasizes that recurrences were not necessarily related to the surgeon's skills, but to the very nature of the lesion . We beliAlthough extremely rare, it is important to remember that there are reports of squamous cell carcinomas derived from odontogenic keratocystic tumors .The benign nature of these tumors and their slow evolution justify conservative treatment, even in the case of large lesions. The knowledge relating to the biological profile of the KOTs is of great importance in order to better understand the evolution of these lesions; thus establishing more precise treatment and prognosis.


Fibro-osseous pseudotumor of the digit is rare benign lesion of subcutaneous tissue which is thought to be reactive process as a result of repeated trauma. We report a case of an ulcerated lesion of skin of middle finger, clinically thought to be leishmaniasis which after punch biopsy followed by excision turned out to be fibrosseous pseudotumor. Diagnosis of fibro-osseous pseudotumor requires immense precision as it can clinically mimic unungal exostosis and can sometimes be misinterpreted clinically and radiologically as myositis ossificans. We suggested an algorithimic approach for histopathologic assessment of fibro-osseous soft tissue lesions with evaluation of both stromal and osseous components. Bland fibroblastic stroma, mature osseous component with prominent osteoblastic rimming and absence of zonation pattern will support the diagnosis of fibro-osseous pseudotumor especially if located at a superficial and distal location. Ossifying lesions of soft tissue are fairly uncommon. However they may be a cause of concern to the clinicians as aggressive bone forming tumors like extraskeletal osteosarcoma is one of the differential diagnosis. Fibro-oIn our opinion, early diagnosis and treatment (resection) of fibro-osseous pseudotumor is important due to three reasons. Firstly, as this is a rare entity, potential for misdiagnosis and overtreatment is high. As in our case it was misdiagnosed as an infectious process, while in other cases it was thought of a vascular lesion. Secondly although no case till date of malignant transformation of fibro-osseous pseudotumor is described, but a definite link between long standing chronic inflammatory or irritative lesions and neoplasia exists, therefore early excision is necessary. Lastly as this lesion is located superficially in dermis, therefore chances of ulceration and secondary infections are high necessitating early treatment.Leishmaniasis is endemic in some rural parts of Pakistan. It usually presents as a papule which later converts to nodule and can ulcerate. On the other hand fibro-osseous pseudotumor presents as a hard subcutaneous nodule, which can also ulcerate mimicking leishmaniasis especially in endemic areas. A simple cytologic test looking for LD bodies can help in differentiation. In difficult cases a punch biopsy can lead to a definite diagnosis.Our case is that of a 32 year old male, who had a small dermal nodule on the dorsal aspect of middle finger for three years. There was no associated pain, joint swelling, redness or restriction of joint mobility. The patient did not recall any specific history of trauma. Later on the lesion becomes ulcerated due to which he seek medical attention. The patient was laborer by occupation and belonged to the rural part of the country. The initial clinical suspicion was leishmaniasis, due to which a punch biopsy was done. The biopsy revealed a dermal fibro-osseous lesion and therefore excision was advised. The lesion measured 1.7 × 1.5 × 1.2 cm and no connection with underlying bone was demonstrated. Post-operatively, the wound healed quickly. The patient was followed for one year, however no recurrence was noted.Grossly the specimen consisted of a skin covered fragment with a firm nodular lesion in dermis measuring 1.5 cm in maximum dimention. Microscopic sections examined revealed biphasic fibro-osseous lesion present in the dermis, composed of stromal and osseous components. Overlying skin appeared midly hyperplastic and borders of the lesion were well circumscribed. Stromal component of the tumor is composed of bland spindle shaped cells with interspersed blood vessels. Stromal cells appear fibroblastic with elongated nuclei, eiosinophillic cytoplasm and indistinct cell borders. They show minimal nuclear atypia and pleomorphism. Osseous component was formed by mature bony trabeculae with prominent osteoblastic rimming. Zonation pattern was not evident in the lesion. No mitotic activity was noted. The lesion appeared completely excised , ASMA, S100 and CD 34. Stromal cells were negative with cytokeratin, however focal positivity was noted with ASMA, CD 34 and S100 stains Figure .Fibro-osseous pseudotumor of the digit is a rare benign ossifying lesion which had been called in the past by various names like florid reactive periostitis, parosteal fasciitis and fasciitis ossificans-7. To ouPathogenesis of fibro-osseous pseudotumor is thought to be related to repeated trauma to the area, however a specific history of antecedent trauma was revealed in a small number of cases. In our Main pathologic differentials to this entity are myositis ossificans, subungal exostosis and extraskeletal osteosarcoma. Fibro-osseous pseudotumor is closely related to myositis ossifians and some authors regard it as a cutaneous counterpart of myositis ossificans. HoweverWe found focal positivity of ASMA, S100 and CD 34 immunostains in our case. Other authors found positivity with ASMA, however staining with S100 and CD34 was not demonstrated.Prognosis of fibro-osseous pseudotumor is good with complete excision being curative without evidence of local recurrence,9, as waFibro-osseous pseudotumor is a rare benign reactive condition diagnosis of which requires immense precision as it can clinically mimic unungal exostosis and can sometimes be misinterpreted clinically and radiologically as myositis ossificans. We suggested an algorithimic approach for the histopathologic interpretation of soft tissue fibro-osseous lesions.Patient has given their informed consent for the case report to be published.The authors declare that they have no competing interests.AAH: main author of manuscript, have made substantial contributions to conception, design and acquisition of data. NF: have given final approval of the version to be published. MME: involved in drafting the manuscript and revising it critically for important intellectual content. AJ: have given final approval of the version to be published. MK: involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.


Gastric adenocarcinoma with a large bowel obstruction as the first presentation of the condition is rare. The present study describes the case of a 59-year-old female who was diagnosed with a large bowel obstruction that was caused by gastric adenocarcinoma. The patient suffered from abdominal pain and had not defecated for 15 days. The patient had no significant medical history. The right epigastric region was slightly tender and active bowel sounds were identified. A computed tomography (CT) scan revealed a dilated fluid-filled colon with a thickened wall and adjacent fat infiltration. An upper gastrointestinal endoscopy revealed that the margin and gastric mucosa in the antrum were raised and thickened without evidence of ulcerative lesions. The patient underwent surgery and was administered adjuvant chemotherapy. The patient was followed-up for 18 months without recurrence of the tumor. This study demonstrates that the presentation of gastric cancer may vary. Gastric cancer is the second leading cause of cancer-related mortality worldwide ,2. The vA 59-year-old female without no significant medical history visited Linan People’s Hospital  complaining of central abdominal pain and not being able to defecate for 15 days. Although the patient had been admitted to Hangzhou Provincial Hospital due to recurrent abdominal pain six months previously, the colon was not considered abnormal following a colonoscopy and ultrasound. A gastroscopy only revealed chronic superficial gastritis (data not shown). Upon admittance to the Department of Surgery, the right epigastric region was slightly tender and active bowel sounds were identified, followed by intermittent bilious vomiting and weight loss, despite a distended abdomen without rebound pain or hepatomegaly. Computed tomography (CT) of the abdomen revealed a dilated fluid-filled colon and a protruding tumor abutting the transverse colon. No other abnormalities/metastases to the liver or the involvement of adjacent organs/tissues were observed . An uppeThe patient underwent a radical distal gastrectomy with systematic lymph node dissection and a right colectomy . The hisAlthough highly advanced stage gastric cancer often causes gastric outlet obstruction and results in gastrointestinal symptoms, including abdominal pain, nausea and vomiting, an acute large bowel obstruction as the first presentation of gastric cancer is a rare event. The main route of cancer infiltrating the abdominal organs is known as the diffusion of the adjacent tissues and the invasion of the superficial serosal layer . In the The poor prognosis of gastric cancer is mainly due to a late diagnosis . Therefo