The management of recurrent cervical cancer depends mainly on previous treatment as well as on the site and extent of recurrence. Pelvic exenteration usually represents the only therapeutic approach with curative intent for women with central pelvic relapse who have previously received irradiation. In the present report, we share our experience regarding survival outcome in a patient with recurrent endocervical carcinoma who underwent total pelvic exenteration. Up to 25% of women with FIGO stage IB-IIA cervical cancer may recur after initial therapy. Frequently, these recurrences may be treated with radiotherapy; however, radical surgery may offer an alternative for curative treatment. Long-term survival is directly correlated with complete tumor resection, so establishing resectability is a key aspect of preoperative planning.Cervical malignancy is the second most common malignancy in women worldwide. This surgery involves en bloc resection of the pelvic organs, including the internal reproductive organs, bladder, and rectosigmoid. Traditionally, PE has been used for centrally recurrent cervical carcinoma.Pelvic exenteration (PE) is an ultraradical surgery that was first described by Brunschwig in 1948The purpose of the present case is to share our experience of total pelvic exenteration (TPE) in a patient with recurrent endocervical carcinoma regarding survival outcome.A 51-year-old woman underwent type 1 hysterectomy at outer center, has been reported with histopathology of leiomyoma uteri and endocervical adenocarcinoma. She has been observed without treatment for 15 months until presenting with abnormal vaginal bleeding at outer center. Vaginal cuff biopsy has revealed adenocarcinoma. Due to recurrence of cervical carcinoma, she has undergone pelvic radiotherapy and vaginal brachytherapy with 7 courses of weekly cisplatin (concurrent chemoradiotherapy). After 6 months of following chemoradiotherapy, on account of recurrent complaint of vaginal bleeding and cuff biopsy with histopathology of adenocarcinoma, patient has been referred to our clinic for advanced evaluation and management.Pelvic examination revealed fullness (size 35x20 mm) on vaginal cuff and infiltration of left parametrium. Irregularity and more wall thickening at the right superolateral side of the vaginal cuff, nearly 23x22 mm, were detected on magnetic resonance imaging (MRI). MRI of the upper abdomen and computerized tomography (CT) of thorax confirmed no residual mass.Based on the findings and clinical status of the patient, we decided to perform surgery of exenteration as a therapeutic option. We performed TPE + paraaortic lymphadenectomy + indiana pouch + ileocolic anastomosis + colostomy + omental J-plasty . Histopa2) was infused in 3 hours. Then, cisplatin (75 mg/m2) was infused in 2 hours. Six courses of this combination were given every 3 weeks. The complete clinical response was obtained after treatment.Adjuvant chemotherapy with paclitaxel and cisplatin was given due to ovarian metastasis. After premedication, initially paclitaxel , chest X-ray (every year or if necessary), complete blood count, serum biochemistry and CA-125 level (because of ovarian metastasis). There was no recurrence of the disease in follow-up. The patient is alive with no evidence of recurrence for more than 80 months after TPE.,7. In the present case, the patient has recently completed a treatment of chemoradiation after central pelvic recurrence, around vaginal cuff, has been determined 15 months after type 1 hysterectomy.The management of recurrent cervical cancer depends mainly on previous treatment and on the site and extent of recurrenceThe original classification of PE into three groups, i.e., anterior , posterior  and total (anterior + posterior), addresses only the nature of the pelvic viscera removed. The patient underwent total pelvic exenteration in our case.. Similarly, one study defined the candidates for exenteration is those with central local recurrences that have not extended to the pelvic sidewalls. In addition, in the same study, it was noticed that all patients who have undergone previous radiation therapy should be considered for surgical resection for centrally located recurrences. According to Shingleton et al., the best candidates for cure by PE were the patients with recurrent small (<3 cm), mobile central tumors and with a disease free interval of one year or longer. In the present case, our indicated parameters for TPE were no documented distant metastasis, central pelvic recurrence with no extension to the pelvic sidewall, tumor size smaller than 3 cm and the history of previous radiation therapy.In the literature, there are specific criteria for surgical resection. Patients with resectable central recurrences that involve the bladder and/or rectum, without evidence of intraperitoneal or extra-pelvic spread, and who have a dissectible tumor-free space along the pelvic side wall are potentially suitable for exenteration. The clinical improvements obtained in the last decades may be mainly due to better surgical techniques and more intensive postoperative care. We have no detected any complication or morbidity after operation. One study noticed that the more strict criteria for the patient selection , the greater the chance for a favorable clinical outcome. A better definition of patient selection criteria made easier by the availability of new diagnostic techniques such as positron emission tomography scanning (PET scan), CT, MRI,11. The patient was pre-operatively evaluated by MRI of the upper and lower abdomen, and CT of thorax for metastasis and recurrence.PE is a major surgery with significant morbidity. In a recent series, the 5-year overall survival after PE ranged from 22% to 48%, respectively,8,12,13. In presented case, patient is alive and free of disease for more than 80 months after TPE. Free surgical margins,8,12, negative lymph nodes,14, small tumor size and long disease-free interval,8,12 were associated with a more favorable prognosis. In our case, histopathological findings after PE surgery have been reported as negative lymph nodes, level of lower vagina margins remained free, metastasis to the left ovary and right tuba uterina. Independent from stage of the disease ovarian metastasis is a poor prognostic factor in cervical carcinoma. It leads to a regression of overall survival with decrease in quality of life. Despite the presence of ovarian metastasis, the patient lives for more than six years with no evidence of disease recurrence.PE remains the only therapeutic option that offers the possibility of long-term survival for most patients. In that study, 5-year survival was 16.8% for disease failure in first 2 years, 28% for 2-5 years and 83.2% for after 5 years. In the present case, recurrence after primary surgery was identified 15 months later. According to the study of Mourton et al., 68% of patients subsequently developed recurrence after TPE. The median time from TPE to recurrence was 7 months (range 2-73 months), 92% occurring within 2 years. In the presented case, no evidence with recurrence was noticed for 80 months after exenteration. One study showed that affecting factors for overall survival were resection margin status, pelvic wall and rectal involvement. In our case, there were no pelvic wall and rectal involvement.Marnitz et al. reported that survival correlated significantly with the time interval between primary treatment and recurrence. Indiana pouch (Indiana continent urinary reservoir), firstly described by Rowland et al. in 1987, was performed to our case. Colostomy was performed for fecal diversion. Omental J-plasty was performed for pelvic floor coverage.At present, pelvic reconstructive procedures are strongly recommended after exenteration. An ileocolonic segment is currently employed for continent urinary diversionIn conclusion, the present case showed that total pelvic exenteration has a potential to provide long-term survival despite the second recurrence which is seen in 2 years after primary surgery and presence of ovarian metastasis.


Hematometra is a pathologic collection of blood in the uterus. It is a rare condition that is most commonly associated with congenital anomalies or prior surgical procedures causing an obstruction of the genitourinary outflow tract. We present an unusual case of hematometra in a healthy and active adolescent female with no prior risk factors. This is a rare and important case report due to the complexity of diagnosis when a young female presents with an acute abdomen. In addition, for a patient who presents with no prior risk factors for hematometra, such as in our patient, the diagnosis and workup may become overly complicated, adding strain to patient care and health care cost. To the best of our knowledge and based on an extensive literature search, there has not been a reported case of hematometra in an adolescent female without any aforementioned risk factors.Our patient is a healthy 18 year-old white woman with no significant prior medical or surgical history. Her only medication was depot medroxyprogesterone acetate use for contraception. She presented to a local emergency department with acute abdominal pain, accompanied by emesis and nausea. Workup with ultrasonography showed uterine distention most likely caused by hematometra, although no obvious cause was noted. She was treated with dilation and curettage; she was also advised to discontinue depot medroxyprogesterone acetate use. She was symptom free without recurrence of hematometra at 6-month follow-up.Due to the high prevalence of abdominal pain, this case report has a wide breadth of implications for health care providers ranging from general family practitioners to emergency room physicians and obstetricians/gynecologists. This case report provides potential future advancement in management and differential diagnosis in adolescent females presenting with acute abdominal pain. In addition, the use of depot medroxyprogesterone acetate contributing to or causing hematometra cannot be ruled out in our patient and warrants further investigation. Acute abdominal pain is one of the most common causes of emergency department (ED) visits in the USA . The difWe present a case that is unusual due to the patient being an adolescent female with no congenital defects or prior history of the aforementioned risk factors associated with hematometra.An 18-year-old, gravida 0, white woman presented to an ED with acute lower abdominal pain. The pain began gradually during her strenuous sporting practice hours earlier, limiting her ability to participate. She localized the pain to her lower abdomen, describing it both as similar to menstrual cramps and reminiscent of her appendicitis 3 years ago. Hours later, she experienced nausea and emesis. She found pain relief when crouching, exacerbation during emesis and micturition, and no relief with nonsteroidal anti-inflammatory drugs.She was previously healthy and physically active, with no surgical history besides an uncomplicated appendectomy. Menarche was at 12-years old and her menstrual cycles were regular, not painful, and occurred every 60 days. She was previously sexually active, with no history of sexually transmitted infections. Her last menstrual period was 7 months prior to her current symptoms. She had a 3-year history of depot medroxyprogesterone acetate (DMPA) use for contraception. Her family and social history were otherwise non-contributory.3/μL (reference range 3.8 to 11.0) with no left shift on automated differential. Her pregnancy test was negative. The ED provider listed menstrual cramps as the main differential diagnosis at the time and she was sent for pelvic ultrasonography.On examination, both her lower abdominal quadrants were severely tender to light and deep palpation, without rigidity, rebound tenderness, or palpable masses. A pelvic examination was not performed. She was afebrile; her vital signs were age appropriate and stable. A complete blood count showed an elevated white blood cell count at 16.4×10Transabdominal and transvaginal pelvic ultrasound Fig.  was perfShe was scheduled for hysteroscopy followed by fractional dilatation and curettage under general anesthesia. During the procedure, her cervix was sequentially dilated up to 8 mm using a Hegar dilator. Her cervix did not appear to be constricted. A large amount of old bloody material was expelled from her cervix upon dilation and after entrance into her uterine cavity with a hysteroscope. The old bloody material was washed out with sterile saline. Her uterine lining could then be visualized and was noted to be pale and thin, consistent with her history of DMPA use. Both ostia were present and there were no masses or other abnormalities upon visualization. Dilation and curettage by endocervical and endometrial curettings was performed and tissue was sent for pathology. She tolerated the procedures well.The pathology of her endocervix showed normal benign tissue. The endometrium showed benign inactive to weakly proliferative endometrium and the lower uterine segment had scattered plasma cells consistent with chronic endometritis along with patchy mild nonspecific acute inflammation.Her symptoms were resolved by the procedure and her 6-month follow-up showed no recurrence of hematometra or other complications. Her DMPA was discontinued at the same time and she switched to oral contraception.Hematometra presenting as abdominal pain can be a challenging diagnosis. In one case, multiple diagnostic workups including invasive procedures such as exploratory laparoscopy were conducted prior to the appropriate diagnosis . In anotThis difficult diagnosis could be further compounded in patients lacking congenital abnormalities and those who have not undergone a prior gynecologic procedure, such as in our patient. In other reports of hematometra, there were additional risk factors to help increase the index of suspicion. One case reported a post-cesarean section hematometra due to uterine adhesion surrounding the internal cervical os , and anoTo help raise the index of suspicion and aid in the diagnosis of hematometra in an acute abdomen, we recommend the use of abdominal and pelvic ultrasonography. Bedside ultrasound in EDs is becoming ubiquitous in the USA and when combined with sound clinical judgment it can be a useful tool in the evaluation of abdominal pain . FurtherThere have been a few reports associating the use of DMPA as contraception with cervical stenosis leading to the formation of hematometra . In one The cause of our patient’s hematometra is unclear given her apparent lack of cervical stenosis, anatomic anomalies, or obstructions. In addition, our patient lacked the known risk factors for chronic endometritis including previous sexually transmitted infections, intrauterine growths, or radiation therapy . This suAlthough rare, hematometra should be on the differential diagnosis of acute abdominal pain in adolescent females when other common causes have been ruled out. An index of suspicion should be raised when there are positive ultrasound findings and risk factors such as congenital anomalies or prior gynecologic procedures. However, this case highlights that patients may lack risk factors that contribute to hematometra, making the diagnosis potentially challenging. In such instances, complicated diagnostic workups might not always be warranted and a patient’s symptoms could improve immediately following dilation and curettage and the evacuation of old menstrual blood. While not recognized in our patient, it is worthwhile to note the use of DMPA and its possible relation to cervical stenosis as a cause of hematometra.


Vesicocutaneous fistulas are very rare pathologies in the urinary tract. We present the second case of a vesicocutaneus fistula after cesarean section, and discuss strategies for prevention, diagnosis, and treatment of this exceptional complication. A woman with a vesicocutaneous fistula after cesarean delivery was admitted and diagnostic tests including fluoroscopy, magnetic resonance imaging (MRI), and reconstructed MRI revealed the fistula tract and an urachal anomaly. The patient was treated through excision of the fistula tract. Laparotomy should be performed carefully, and the surgeon should be aware of the urachus. Inadvertent trauma to the urachus during laparotomy might cause serious unexpected complications. Possible etiologic factors for vesicocutaneous fistulae, prevention, and treatment methods are discussed. We present the second reported case of vesicocutaneus fistula occurring after cesarean section, and discuss strategies for prevention, diagnosis, and treatment of this exceptional complication.. Lower urinary tract injuries are not infrequent and may occur during this procedure. If not intraoperatively detected and repaired, diagnosis will be delayed and a genitourinary fistula may be encountered later. There are case reports of vesico-vaginal, uretero-vaginal, vesico-uterine fistulas after cesarean section. There are also reported cases of uretero-vesico-cervical and vesico-peritoneal fistulas,3,4. Vesicocutaneous fistulas are very rare pathologies in the urinary tract. Trauma, neoplasia, inflammation, and iatrogenic injury are the most frequent causes. Anomalies of the urachus may predispose patients to injury and subsequent fistula formation during surgery due to the distorted anatomy. We present the second case of vesicocutaneus fistula, which occurred after cesarean section, and discuss strategies for prevention, diagnosis, and treatment of this exceptional complication.The cesarean delivery rate has risen from 4.5 percent to 31.8 percent of all deliveriesA gravida 2, para 2 woman aged 44 years with a history of two cesarean sections was referred because of recurrent urinary tract infection and urinary leakage through the abdomen. In her past medical history, she had Sjogren’s syndrome and optic neuritis. In her past surgical history, she had a bladder injury in a caesarean section, which was repaired with a primary suture. One month later, she presented with a 10 cm subcutaneous hematoma at its largest dimension. The hematoma was drained surgically, and during the exploration, no source of bleeding was found. Four months later , she was admitted to the hospital and referred for urinary leakage through the abdomen, about 5 cm below the level of umbilicus. The leakage was periodic and she had an episode of subcutaneous abscess, which was managed conservatively using antibiotics and non-steroidal anti-inflammatory drugs. A fistula tract was observed in a retrograde fluoroscopic examination; however, the distal end of the fistulous tract was not clear . An ultrThe patient underwent a laparotomy with the plan for excision of the fistula tract and repairing the bladder defect. A suprapubic incision parallel to the Langer’s lines of the skin was made with a 1.5-2 cm margin with the fistulous tract. The fistula tract was about 12 cm in length and 4 cm wide, and was totally excised with the involved skin , 4. The ,5. Due to the rarity of vesicocutaneus fistulas, their risk factors are not clearly identified. Pelvic radiation, radical hysterectomies, pelvic fractures, hip arthroplasties, bladder calculus, and inguinoscrotal hernia operations are reported risk factors. Actinomyces infections and factitious disorders have also been reported to cause vesicocutaneous fistula,8. Unrecognized urachal anomalies may be a predisposing risk factor during surgical procedures. Cesarean delivery might be a risk factor due to the nature of the procedure, compared with vaginal delivery. There was an urachal anomaly, a possible urachal diverticula that was asymptomatic until the surgical intervention in our case. Urachal anomalies are very rare. Their true incidence is unknown, but is estimated to be between 0.015 to 0.13 in 1000 births according to a large case series,7. They may be asymptomatic, especially when presenting as a urachal cyst or diverticulum. These anomalies may predispose a patient to injury during abdominal surgery, especially in cesarean section. Inadvertent injury to the urachus with a diverticulum may be complicated by vesicocutaneous fistula.Vesicocutaneus fistulas are rare. Their exact incidence is not known due to their rarity. Trauma, neoplasia, inflammation, and iatrogenic injury are the most frequent causes of these urinary fistulas. Magnetic resonance imaging and computed tomography (CT) are currently the imaging modalities of choice for the initial evaluation of patients with suspected pelvic fistulae. MR seems to be one of the most sensitive methods to define the exact location and complexity of a fistula tract, with more than 90% sensitivity and correlates well with surgical findings. Multi-detector CT is the choice for patients who are unable to tolerate fluoroscopy or MR imaging. As in our case, the best imaging modality was contrast-enhanced magnetic resonance (MR) imaging, which clearly identified the exact location of the lesion and its relation with the surrounding tissues.Radiographic imaging is the traditional method to identify a fistula. Fluoroscopy may identify the lesion, but it may not clarify it. Sonography was one of the imaging modalities used in the past, but due to its poor sensitivity, especially in identifying complexity, size, and multiplicity, it is rarely used now for identification of fistulae. It was treated with conservative management and an indwelling bladder catheter was left for 3 weeks and parenteral antibiotics were given. The authors reported that the fistula tract closed spontaneously. A conservative approach may be tried in small fresh fistulas. We chose a curative surgical approach for a major fistula. The treatment approach depends on type of the fistula, symptoms, the time passed from injury, and the patient. For vesico-vaginal fistula, fistulectomy is the preferred management method. Delayed repair is the classic approach, but some articles advocated immediate repair because of better results,13,14. Conservative management is also described, but an option not chosen frequently. When the case is a uretero-vaginal fistula, conservative management can be considered initially, especially if the patient is appropriate for ureteral stenting, otherwise surgery is the definitive treatment method. Vesicocutaneous fistulas are very rare, and to the best of our knowledge, there has been no report of a vesicocutaneus fistula occurring secondary to cesarean section and as a consequence, the optimal management strategy is unknown.There is one case report of vesicocutaneus fistula secondary to cesarean hysterectomy from Pakistan by Toufique and Merani. Laparotomy should be performed carefully, and the surgeon should be aware of patent urachus. Inadvertent trauma to the urachus during laparotomy might be a cause for serious unexpected complications.Although conservative management can be reasonable in asymptomatic patients with urachal remnants, fistulectomy with primary closure of the bladder is a logical approach, especially for symptomatic patients with recurrent infections as in our case


Most cases of disseminated carcinomatosis of the bone marrow (DCBM) arise from gastric cancer. DCBM from pancreatic cancer is very rare. We herein present a case of DCBM from pancreatic cancer.A 57-year-old man was referred to our hospital for severe lumbago. Laboratory data indicated that he suffered from disseminated intravascular coagulation (DIC). Non-contrast abdominal computed tomography (CT) revealed multiple bone masses but no other abnormal findings. Left iliac bone marrow biopsy revealed poorly differentiated adenocarcinoma cells. Positron emission tomography (PET)-CT showed diffuse abnormal uptake in the bones and tail of the pancreas. Contrast whole-body CT showed a tumor measuring approximately 28 mm in diameter with poor enhancement in the tail of the pancreas. The patient’s final diagnosis was pancreatic cancer located in the tail of the pancreas with diffuse bone metastases and DIC. His DCBM was thus believed to originate from the pancreatic cancer. He succumbed to the disease approximately 2 months after admission to our hospital.We herein describe a case of pancreatic cancer located in the tail of the pancreas with diffuse bone metastases and DIC, which, in our case, was DCBM. Therefore, in cases of DCBM with an unknown primary tumor, pancreatic cancer should be considered during differential diagnosis. Disseminated carcinomatosis of the bone marrow (DCBM) caused by solid tumors is often accompanied by disseminated intravascular coagulation (DIC) . The pro3, platelet count of 73,000/mm3, international normalized ratio for prothrombin time of 1.15, fibrinogen level of 102 mg/dL, fibrin degradation products of 65.7 μg/mL, d-dimer level of 18.1 μg/mL, antithrombin-III activity of 61 %, C reactive protein level of 3.63 mg/dL, creatinine level of 1.32 mg/dL, calcium level of 11.3 mg/dL, aspartate aminotransferase level of 164 U/L, alanine aminotransferase level of 119 U/L, alkaline phosphatase level of 547 U/L, and lactate dehydrogenase level of 552 U/L. Other test results are shown in Table A 57-year-old man was referred to our hospital for severe lumbago. His symptoms appeared approximately 3 months prior to referral. After experiencing such symptoms for about a month, the patient consulted an orthopedist. A lumbar spinal radiography showed no significant findings. Despite treatment for pain relief, his lumbago persisted. At presentation, the patient reported no particular past medical history or known allergies. His medication included oxycodone hydrochloride hydrate, loxoprofen sodium hydrate, rebamipide, prochlorperazine maleate, and magnesium oxide. He did not smoke or consume alcohol, and worked as a designer. His mother had diabetes mellitus, hypertension, and hepatocellular carcinoma, and his sister had colon cancer. On physical examination, the patient weight 82 kg and was 174 cm tall. His blood pressure was 189/128 mmHg; his pulse was 92 beats per minute; body temperature was 36.9 °C; respiratory rate was 18 breaths per minute, and the oxygen saturation level was 98 % while breathing ambient air. No swelling of the lymph nodes was palpable. His physical examination was otherwise normal. Laboratory data showed a white blood cell count of 11,100/mmAbdominal ultrasonography showed mild splenomegaly. Non-contrast chest computed tomography (CT), gastrointestinal endoscopy, and colonoscopy detected no abnormal findings. Non-contrast abdominal CT revealed multiple bone masses Fig. ; howeverWe administered nafamostat mesilate to treat DIC and opioid analgesics to relieve the patient’s lumbago and sharp osteocopic pain. However, we were unable to administer systemic chemotherapy owing to his poor condition. The patient’s general status rapidly deteriorate, and he was transferred to a palliative care unit (PCU). Laboratory data at discharge are shown in Table A pathological condition derived from carcinoma and diffuse bone metastases with DIC was first reported by Jarcho in 1936 . HayashiA previous report indicates that the tumor detection rate with non-contrast CT was 23 % when tumor size was less than 20 mm, 59 % for tumors measuring less than 40 mm, and 100 % in cases of tumors measuring more than 40 mm . In the While the serum CA19-9 levels were normal in cases of gastric cancer with DCBM , the serExacerbation of DCBM occurs rapidly, and the mean survival time is 4.6 months after the onset of DCBM . A propeWe herein describe a case of pancreatic cancer located in the tail of the pancreas with diffuse bone metastases and DIC, which, in our case, was DCBM. This is the first case report to demonstrate DCBM arising from the small pancreatic cancer, to the best of our knowledge. Therefore, in cases of DCBM with an unknown primary tumor, pancreatic cancer should be considered during differential diagnosis to properly identify the primary site for the timely administration of chemotherapy and DIC treatment.


Traumatic neuromas are rare benign tumors, which are common in trauma or post-operation and accompanied with obvious symptoms of pain. This study will show the superficial peroneal nerve neuroma occurring after resection of hemangioma.A 44-year-old male had an operation of the right leg cavernous hemangioma resection in 1995. Half a year after the operation, pain around the wound appeared and gradually aggravated. The patient had the lesion exploration resection in 2013, and the pathological result showed traumatic neuroma. Within half a year of the second operation, severe pain showed up again, so neuroma resection proceeded in May 2015. The postoperative pathological and immunohistochemical results showed traumatic neuroma. According to the postoperative follow-up, there were no symptoms of pain appearing again.The pain is obvious, and B ultrasonography is the most efficient way to find neuromas. Both conservative and operative therapy have their advantages and disadvantages.There remain many unanswered questions in relation to the treatment of traumatic neuromas, and further research is required, although we have already had adequate understanding of traumatic neuromas. Traumatic neuromas are rarely seen in clinical practice but are common in trauma or post-operation. The main clinical manifestations are pain and paresthesia. Most scholars consider the occurrence of traumatic neuroma to be related to excess hyperplasia and irregular hyperplasia after nerve injury, so they are often regarded as benign tumors . Most reA male, 44 years old, had an operation of hemangioma resection, because of the right leg cavernous hemangioma in 1995. Six months later, the patient reported increased pain in the original surgical site, radiating to both the upper and lower sides, and further aggravated with the rising of temperature. In 2013, the hemangioma recurrence was taken into account, so lesion exploration resection was performed. The pathological result showed traumatic neuroma  Fig. . CompletGross appearance: two separately fusiform masses about 12.0 × 5.0 mm and 10.0 × 2.0 mm are connected to the upper and lower nerves, with smooth surface, clear boundary, and tough texture, and adhere to peripheral scar tissue Fig. . PatholoTraumatic neuroma is very rare and seldom reported in English literature. Relatively, many traumatic neuromas occurring in the limbs, face, and neck can be found in the current literatures, and studies have also reported that traumatic neuroma could occur in the mammary gland, penis, and other body parts –4. As diThe generating mechanism of superficial peroneal neuroma reported in this study may be the reactive hyperplasia of the nerve. The injury is exactly at the branch of superficial peroneal nerve, reactive hyperplasia occurs in proximal end and further extends toward the trunk, thus generating eccentric neuroma occurring in superficial peroneal nerve trunk. In addition, we consider that the compression induced by scarring of surrounding soft tissues is also an important cause of traumatic neuroma.The main manifestation of traumatic neuroma is pain, especially intense neuralgia , 11. TheMRI is only used in differential diagnosis with other soft tissue diseases , and itsThe position and size of lesion and the relation between lesion and surrounding tissues and nerves can be detected directly via ultrasonography examination. Ultrasonography is one of most valuable methods in the diagnosis of traumatic neuroma. On one hand, ultrasonography examination is inexpensive, noninvasive, and non-harmful. And on the other hand, local nerve blocking can be conducted under the guidance of ultrasonography for the enhancement of the diagnosis, and pathological examination of living tissue can be implemented for the definite diagnoses , 28–30. The treatment of traumatic neuroma is still considered controversial. Conservative and operative therapy both have its advantage and disadvantage, which are listed in following content.(1) Pharmacotherapy: Opioid analgesics, antidepressant drugs, antispasmodic drugs, α receptor blockers, and lidocaine are all used in the treatment of traumatic neuroma, but only have short-term therapeutic effect, and show significant side effects and declined therapeutic effect in long-term use –33. Gaba(1) Neuroma resection: Simple neuroma resection tends to have short-term therapeutic effect, together with relapse of neuroma . (2) NeuAdequate understanding of the traumatic neuroma appears essential. However, there remain many problems which require future research, such as (1) Should further remedial measures such as B ultrasound-guided percutaneous ethanol injection be taken after traumatic neuroma is confirmed by postoperative pathological report?; (2) Is it (traumatic neuroma) recurrent? Will it occur in sensory branch or motor branch?; (3) Does it develop to proximal trunk which is not adjacent with injured sites?; and (4) Is it useful to inject lidocaine when the nerve stump is closed? Further follow-up for condition of the patient and research is required.


We present a case of a previously healthy 50-year-old gentleman who had recurrent vomiting and abdominal pain of two-month duration. The patient was subsequently diagnosed with abdominal cocoon on computed tomography. Idiopathic sclerosing encapsulating peritonitis, also known as abdominal cocoon, is a rare cause of small bowel obstruction. Visualization of variable encasement of the small bowel loops by a characteristic membranous sac, either preoperatively with cross-sectional imaging or intraoperatively, is the key to diagnosis. This is a highly treatable condition; surgical excision of the sac with adhesiolysis facilitates a full recovery in affected patients. Sclerosing encapsulating peritonitis (SEP) is an uncommon cause of subacute small bowel obstruction. SEP is classically described as a partial or total encasement of the small intestines by a fibrotic sac-like membrane , 2. TherWe describe a case of idiopathic SEP in an adult gentleman that presented with symptoms of intermittent intestinal obstruction. In this report, we seek to highlight the pertinent radiological, surgical, and histopathological characteristics that facilitate the diagnosis and review the current literature on this rare condition. A potential mimic for this condition, midgut volvulus, will be briefly discussed.9/L (reference range 3.6–9.3 × 109/L) and C-reactive protein level of 18.5 (reference range 0.0–0.5). Tumour markers were not raised.A 50-year-old Chinese man presented with recurrent episodes of vomiting, diarrhoea, and abdominal distension over two months. He had no significant medical, surgical, or family history of note. The patient was afebrile and haemodynamically stable. Physical examination revealed a vague central abdominal mass that was soft and nontender on palpation. There was no evidence of peritonitis and bowel sounds were normal. Initial laboratory investigations showed mildly elevated white cell count of 12.6 × 10Abdominal radiographs performed showed no dilated bowel loops. A contrast-enhanced computed tomography (CT) scan was subsequently performed, which demonstrated generalized mild dilatation of the small bowel loops. There was total encasement of the small bowel loops by a thin membrane of imperceptible wall within a fluid-filled sac . There wThe patient underwent explorative laparotomy, which found multiple dilated small bowel loops enclosed within a fluid-filled membranous sac. Interloop adhesions were seen extending from the duodenojejunal junction to the ileocecal junction. Cystostomy of the sac and adhesiolysis were subsequently performed, with decompression of the dilated bowel loops. Straw-colour fluid was noted on cystotomy.Histology of the sac showed membranous soft tissue featuring a fibrocollagenous wall with no apparent epithelial or mesothelial lining. Patchy acute and chronic inflammation was noted . There wThe patient experienced prolonged postoperative ileus. He was managed conservatively and progressive recovery was observed. The patient had an uneventful discharge on postoperative day 26. One-year follow-up of the patient revealed no evidence of recurrence.Idiopathic or primary SEP, also known as abdominal cocoon, is first described by Foo et al. in 1978. It was initially reported to typically affect adolescent girls from the tropical or subtropical climate and postulated retrograde menstruation as a cause for the condition .Secondary SEP is a more common form and is most frequently associated with continuous ambulatory peritoneal dialysis (CAPD) . About 1Other less frequent associations include ventriculoperitoneal or peritoneal-venous shunting, prolonged consumption of beta-blocker (particularly practolol), and, rarely, postliver transplantation, tuberculosis, sarcoidosis, gastrointestinal malignancy, ovarian thecoma, endometriosis, presence of fibrogenic foreign body, and postpenetrating abdominal injury , 6.SEP is an unusual cause of subacute small bowel obstruction. Although the pathogenesis is largely obscured, SEP is a benign and highly treatable condition. Diagnosis may be initially suspected in a patient with recurrent episodes of vomiting, diarrhoea, abdominal pain, or distension which may resolve spontaneously. A nontender abdominal mass may be palpated during physical examination.Abdominal radiographs are generally nonspecific and may demonstrate dilated small bowel loops with air-fluid levels. Normal radiographs may also be encountered, such as in our case.CT scan, being one of the common requested investigations in patients with suspected intestinal obstruction, will facilitate clinching the diagnosis upon visualization of characteristic encasement of variable length of the small bowel loops in the central abdomen within a membrane-like sac, causing small bowel obstruction –10. OtheOn barium meal and follow-through, the appearance of a conglomerate of multiple small bowel loops giving rise to a “cauliflower” configuration is described . TransitThe definite diagnosis is made during exploratory laparotomy or laparoscopy , 12. A sHistology of the excised membrane characteristically shows fibrin deposits, thought to be as a result of increase exudation of plasma contents from the small vessels of the peritoneum . AssociaWe also present a rare case of midgut volvulus in a 31-year-old man for comparison . Midgut Abdominal cocoon, though rare, is a benign and highly treatable condition. It should be considered in the differential diagnoses in patients presenting with symptoms of intermittent bowel obstruction. In the past, diagnosis was generally made intraoperatively upon visualization of an encapsulating membranous sac which is adherent to underlying bowel loops. With improving resolution of CT imaging, preoperative imaging can now help clinch the diagnosis. A high index of suspicion is critical to make the correct diagnosis.


Endovascular interventions are increasingly used in the treatment of a splenic artery aneurysm (SAA), which is a rare and life-threatening clinical disorder. However, in cases of SAA rupture, minimally invasive interventions are unsuitable, and open surgery remains the gold standard method. In open surgery, care should be taken to preserve the spleen and its immune function in cases where an arterial segment of sufficient length allows for reconstruction. An SAA was detected in a 51-year-old woman who presented to our polyclinic with left upper quadrant pain. An endovascular intervention was unsuccessful, and open surgery was performed. Approximately 5 cm of aneurysm in the middle segment of the splenic artery was treated by arterial anastomosis, and the spleen was preserved. The patient experienced no postoperative complications and remained asymptomatic at the seventh month of follow-up. The aim of this case report is to emphasize the importance of splenic sparing surgery in cases of SAAs. A splenic artery aneurysm (SAA) is a rare condition, in which the diameter of the splenic artery dilates to over 1 cm. SAA rupture is associated with relatively high mortality . There iIn this study, arterial reconstruction was performed in a symptomatic SAA patient to preserve the spleen.2, and laboratory measurements were within the normal range. Endoscopy and a colonoscopy conducted to determine the cause of pain revealed no pathological findings. An ultrasonic evaluation revealed no evidence of an aneurysm. However, magnetic resonance imaging (MRI) was conducted due to the presence of a hyperechoic lesion (53 × 39 mm in size) in the right lobe of the subcapsular area of the liver. The MRI study revealed a 35 mm diameter hemangioma in the liver segment 8 and a 40 mm aneurysm with a thrombus in the splenic artery of the pancreas tail region (A 52-year-old female presented to our polyclinic with increasing pain in the left upper quadrant in the previous month. She had been treated for hypertension and had a hysterectomy 7 years ago due to a myoma. The patient had quit smoking 3 years earlier and was taking alprazolam 0.5 mg/day for an anxiety disorder. A physical examination revealed minimal sensitivity of the left upper quadrant upon deep palpation and an incision scar from the gynaecologic surgery. Nothing else of note was detected. The patient's body mass index was 32.5 kg/ml region . Tortuosl region .H. influenza and pneumococcal vaccinations were performed. The gastrocolic ligament was opened by median laparotomy, and the aneurysm was revealed. In the middle segment of the splenic artery, approximately 5 cm of aneurysm, which was adherent to the upper pancreas and retroperitoneal area, was opened by controlling the proximal and distal flow of the splenic artery. Collateral flow was not monitored. The proximal and distal ends of the splenic artery were anastomosed to provide flow continuity (Following a consultation with the interventional cardiovascular department, an endovascular intervention was planned for the treatment of the aneurysm. Endovascular interventions made from the femoral region were inconclusive because of extreme angulation of the truncus celiacus, aneurysmal dilatation of the trunk, and tortuosity of the splenic artery. The patient was informed about the surgical procedure, and written consent was obtained. ntinuity . The posntinuity .Visceral artery aneurysms are rare, and most are SAAs. They are most commonly seen in patients in their 50s and 60s and show a female predominance , 5. The Although open surgery is accepted as the gold standard for SAAs, debate continues among clinicians about the ideal treatment. Perioperative morbidity and mortality rates are higher . RecentlRupture of an SAA is a rare and life-threatening disorder. In symptomatic young women planning future pregnancies, treatment should take place without delay in cases of 2 cm deep aneurysms. Minimally invasive procedures should be the first choice in the treatment of SAAs. In appropriate cases, preservation of the spleen and splenic artery reconstruction are possible in open surgery.


Rhabdomyosarcoma (RMS) represents a malignant tumor of skeletal muscle cells arising from rhabdomyoblasts. RMS represents the most common soft tissue sarcoma in children. In adults it is uncommon and accounts for less than 1% of all malignant solid tumors. While treatment protocols are well known for children, there is no standardized regimen in adults. This is one reason, why the outcome in adults is worse than in children. We present the case of a 59-year-old female patient with pleomorphic rhabdomyosarcoma (PRMS) infiltrating the thoracic spine. Multimodality treatment was performed including en-bloc resection, adjuvant multidrug chemotherapy and radiation beam therapy. The patient was tumor free and had no relapse within 6 month follow-up.  Sarcoma is a rare cancer with a reported incidence of 1% of all malignancies and 20% of all mesenchymal malignancies. 80% arise from soft tissues and 20% from bone , e.g.: L A 59-year-old woman presented with persistent pain in the thoracic spine after low energy trauma 6 weeks ago. X-ray imaging showed vertebra compression fracture of Th9 with kyphosis of 20°. The patient had a history of three strokes, 15 and 13 years ago, with residual paralysis on the right side. She did not report of new neurological disability after trauma: no new motor dysfunction, no long tract signs, neither bladder nor bowel dysfunction. There was no history of malignancy in her family. MRI studies revealed a solid mass of 16x14x12 cm in the inferior posterior mediastinum on the left side with infiltration of Th9 and Th10 vertebral body and spinal canal infiltration with myelon compression Figure 1 . StagingRMS accounts for less than 1% of all malignant solid tumors in adults , 13], , , 22], , , 24]. R. R24]. RPleomorphic rhabdomyosarcoma is a rare disease. There are only a few cases with spinal involvement in adults. Like in our case, the histopathological classification is often difficult, therefore referencing by specialized pathologists and molecular pathological methods are indispensable. An individual case discussion in a specialized multidisciplinary tumor board as well as a multimodality treatment concept is crucial to improve survival rates. Frequent follow-up examinations are necessary due to high rates of treatment failure.The authors declare that they have no competing interests.


Uterine leiomyomas are very common tumors found in women. Rupture of veins on the surface of uterine leiomyoma is an unusual source of hemoperitoneum. It is an extremely uncommon gynaecological cause of hemoperitoneum. It is a life threatening emergency. We report a case of massive intraperitoneal hemorrhage due to rupture of vessels on the surface of subserous leiomyoma. A differential diagnosis of rupture of leiomyoma’ssurface vessel should be considered, while dealing with a case of hemoperitoneum with pelvic mass. Uterine leiomyoma is the most common benign tumor in women, with an estimated prevalence of between 20 and 77%. Leiomyomas are usually asymptomatic (50-80%).As a cause of hemoperitoneum, spontaneous rupture of a vein overlying a myoma is extremely rare. Fewer than 100 cases have been reported [A 37-years-old woman, G0P0, was admitted to the emergency room complainingof lower abdominal-pelvic pain and generally feeling unwell. No trauma or other gastrointestinal or genitourinary system problems were noted. She had started menses the day of admission. The symptomatology was of rough installation for 10 hours. Clinical examination had foundstable hemodynamicstate, an enormous median abdominal mass arriving up to the navel  and umbilical and right iliac fossa sensitivity.A pelvic ultrasound was performed. She showed polymyomatous uterus with a 11x10 centimeters serosal-type fundal uterine myoma  and 3 ceFibroid of the uterus is the commonest benign tumor seen in women of reproductive age. Spontaneous hemoperitoneum due to rupture of a vein overlying a myoma, however, is a rare entity with less than 100 cases reported in the literature .The causTreatment aims to stop the haemorrhage and ideallypreserve the uterus in women in childbearing age. When it is possible to make the diagnosis preoperatively,emergency uterine artery embolisationis suggested so that surgery can be scheduledlater.In our case,the patient underwent diagnostic by laparotomy seen the size of the fundal fibroid and the precariousness of her state. She got a myomectomy. She doesn’t receive any units of fresh blood transfusion and had smooth postoperative period. Management of similar cases includes stabilizing the vitalsigns and urgent diagnostic laparoscopy. The laparoscopicapproach is highly recommended in cases of acute abdomen with an uncertain diagnosis.Uterine leiomyoma is a frequently seen benign tumor in women of reproductive age group. Bleeding from the rupture of a vein overlying a myomais a rare cause of hemoperitoneumthat we have to keep on mind for patient who consultsfor pelvic pain and known having a fibroid. It may be life-threatening, and needs prompt surgical intervention to stabilize the patient and to establish the diagnosis.The authors declare no competing interests.


Sigmoid mesocolon hernia is an uncommon type of internal hernia with only a few cases reported to date. This disease entity can progress rapidly to cause vascular disturbance, necrosis, and perforation of the bowel wall; therefore, early diagnosis and surgical treatment are essential. We describe the case of an intra-mesosigmoid hernia in a 60-year-old man without history of previous abdominal surgery who presented with sudden acute abdominal pain and vomiting. Based on computed tomography, which showed ascites and small bowel obstruction, we diagnosed him as having strangulation of the small intestine caused by a sigmoid mesocolic hernia and performed emergency surgery. Laparotomy revealed small intestinal strangulation, extensive engorgement, and discoloration of bowel loops. Approximately 100 cm of the small intestine extending from the ligament of Treitz had undergone strangulation and herniated into the defect of sigmoid mesocolon, leading to a diagnosis of an intra-mesosigmoid hernia. Because the incarcerated portion of the small intestine was viable, we did not perform intestinal resection and reconstruction but closed the defect in the sigmoid mesocolon. His postoperative course was uneventful. Internal hernia is a protrusion of the small intestine or other abdominal organs through peritoneal or mesenteric orifices within the peritoneal cavity, occasionally leading to strangulation or incarceration. Additionally, an internal hernia is a rare cause of small bowel obstruction in patients without a history of abdominal surgery or trauma with a reported incidence of up to 5.8% of small bowel obstruction –3. Howev3/μl) although his C-reactive protein (CRP) level was within reference range  count . The defect was incomplete and the right leaf of sigmoid mesocolon was remained, therefore, we diagnosed as an IMSH Figs.  and 3. BInternal hernia is caused by defects within the peritoneal cavity, which might be congenital, postoperative, and/or idiopathic. The incidence of internal hernias based on autopsy diagnosis is 0.2–2.0%, and most of them are asymptomatic . SMH  intCT plays an important role in the evaluation of intestinal obstruction and acute abdomen . It is aPatients with small bowel obstruction refractory to conservative therapy require emergency surgical treatment if an internal herniation is suspected, and laparoscopy is useful if there is no evidence of strangulation or necrosis. Recently, some reports have recommended laparoscopic abdominal surgery for both diagnosis and surgical treatment , 14, 15.We describe a case of an IMSH, which is a rare type of SMH. Although rare and often underdiagnosed, internal hernias are an important cause of intestinal obstruction given the high mortality associated with this disease entity. Primary internal hernias should be considered among the differential diagnosis in adults with no previous history of surgery or trauma who present with acute intestinal obstruction. If clinicians identify an internal hernia, it may be better to take SMH into consideration as a likely diagnosis, which ought to be immediately confirmed followed by emergency surgical treatment.


Osteochondromas, occurring usually in the metaphyses of long bones, are among the most frequent benign musculoskeletal neoplasms and both their sporadic and hereditary variants have been studied extensively. Extraskeletal osteochondromas, however, are much less common. They have been shown to arise near joints or synovial spaces of feet, hands, or bursae. Herein, we present a very rare case of an extraskeletal osteochondroma within the iliopsoas muscle. Osteochondromas of long bones are among the most frequent benign musculoskeletal neoplasms and both their sporadic and hereditary variants have been studied extensively. Their extraskeletal counterpart, however, is much less common and usually arises at sites which are in proximity to synovial tissue. The most frequent locations are within or near the knee, smaller joints of the hands, feet, tendon sheaths, bursae, and sometimes in intramuscular planes –3. To thA 42-year-old woman with type 2 diabetes and ischemic coronary disease was referred to our institution with pain in the right inguinal region with a duration of two months, swelling of the lower leg, inability to fully extend the hip joint for one month, and a palpable mass that had been noticed two weeks prior to the referral. She had had selective coronary arteriography six months earlier with ultrasound-guided access through the right femoral artery. Sonography at that time failed to detect any abnormality. No peri- or postinterventional complications had been recorded.Clinical examination revealed a tender, dense, hardly movable mass in the left inguinal region measuring about 10 cm by 10 cm. Pain was exacerbated by hip extension and relieved by flexion. Ipsilateral calf circumference was 1 cm greater than the contralateral calf. Plain radiography showed a well-circumscribed ovoid radiopaque mass with a structure resembling that of cancellous bone with a thin cortical shell  and 1b. Soft tissue osteochondromas (STO) are defined as a variant of soft tissue chondromas representing benign soft tissue tumors occurring in extra-osseous and extra-synovial locations, predominantly composed of adult type hyaline cartilage, devoid of other differentiated elements, except osseous, fibrous, and/or myxoid stroma .Their etiology is unknown, trauma being inconsistently reported. Their histogenesis is still in debate. Pluripotent cells of synovial or fibroblastic origin, as well as synovial metaplasia, have been suspected to give rise to this neoplasm. In some cases, chromosomal aberrations common to other benign connective tissue tumors have been reported while in others no chromosomal abnormalities have been detected , 7.The STO usually appear after the fourth decade of life in the hands or feet 82–84%) and less frequently near the knee or hip, in the thigh, buttock, skin, or other parts of the body , 7, 8. T2–84% andAfter an extensive review of the PubMed database, we identified one similar case published in the literature. El Samman et al. (2010) presents a case of a 44-year-old patient with complaints of increasing pain in the right groin due to extraskeletal osteochondroma treated successfully by excision [The diagnosis is usually based on radiography and MRT. The tumor presents as a well-defined soft tissue radiodensity possibly with a cancellous bone structure. The MRT reveals the thickness of its cartilaginous component, hence the risk of transformation into a chondrosarcoma, its relation to critical anatomic structures and confirms its benign nature.Histologically, the tumor consists of an outer layer of mature hyaline cartilage, areas of endochondral ossification, and different amounts of mature bone; few authors mention fatty marrow in the intertrabecular spaces . AlthougApart from other benign soft tissue radiodense tumors that need the same type of marginal excision, the main differential diagnoses include chondrosarcoma, synovial sarcoma and extraskeletal osteosarcoma that require much more aggressive surgical and non-surgical treatment, but also non-tumorous conditions like myositis ossificans and tumoral calcinosis where surgery might produce more harm than good.SS and GG certify that they have no financial conflict of interest.


Phyllodes tumors (PTs) are uncommon biphasic fibroepithelial neoplasms of the breast occurring in elderly females with a peak incidence between 45 and 49 years. Depending on various histological criteria, they are subdivided into benign, borderline, and malignant forms. Metaplastic changes occur, but are quite infrequent and cystic squamous metaplasia is very rare among the observed metaplastic changes in PT.The current paper presents the case of a 41-year-old female with a progressively enlarging swelling in the left breast. Subsequent histopathological examination revealed benign PT with cystic squamous metaplasia. The previously done fine needle aspiration smears were also reviewed, which showed important diagnostic clues to this rare entity, but were ignored due to the rarity of the lesion.The case was presented because of its unique cytological and histopathological morphology and also to determine the role of aspiration cytology to diagnose such a rare occurrence. These art tumors . The pea These art tumors . Metaplat tumors , of whict tumors ,7.A 41-year-old female referred to the surgical outpatient department with chief complaints of swelling in the left breast of five years’ duration, which rapidly increasing in size for the last four months with no history of trauma or any constitutional symptoms.Her general and systemic examination was within normal limit. Local examination showed a well-defined irregular mass of 9 cm in diameter approximately, not fixed to the skin or chest wall, firm in consistency, but soft at places and tender on palpation. Ultrasonograhic evaluation revealed an 8.9 x 6.6 x 3.9 cm heterogeneous soft tissue mass in retroareolar and periareolar regions of the left breast.The mass was excised and sent to the Department of Pathology, North Bengal Medical College, The West Bengal University of Health sciences, India for histopathological examination.Gross examinationGross examination showed a mass with attached overlying skin measuring 10 x 7 x 6 cm. Serial cut sections revealed multiple cystic spaces with mucoid material and few cysts containing whitish material and well defined whitish homogenous areas with one area showing leaf-like mass projecting inside a cystic cavity .Microscopic examinationMultiple sections were taken from representative areas, processed, and examined. The periphery of the tumor was well-circumscribed. The sections showed features of benign PT characterized by stromal hypercellularity and stromal overgrowth. There was no cellular atypia and mitotic activity was low. The sections also revealed multiple cystic and glandular spaces enclosed within cellular stroma. The spaces were lined by multilayered benign squamous cells and the cystic spaces were filled with keratin material  and 3. PPTs, uncommon biphasic fibroepithelial neoplasms , usuallyHence, the current case was presented due to its unique cytological and histopathological morphology and also to determine the role of aspiration cytology to diagnose such a rare occurrence.


Leiomyosarcomas are sarcomas that originate within smooth muscle cells and generally occur in older patients. These tumours account for 10% of all soft-tissue sarcomas. Metastases occur most commonly to the lungs, kidneys, and liver. Cutaneous metastases may also occur but are usually a very rare and late event. We present a case of a 46-year-old woman who developed subcutaneous metastasis to the axilla, arm and breast after surgical resection of the primary tumour.The patient maintained controlled disease with surgical resections and clinical follow-up, initiating chemotherapy one year after the diagnosis of metastatic disease. Soft-tissue sarcomas are a heterogeneous group of malignancies with different morphological patterns of mesenchymal lineage, representing about 1% of malignancies in adults . PrimaryA 46-year-old female patient sought medical attention, complaining of lumbar pain and discreet abdominal discomfort. She underwent magnetic resonance imaging (MRI), which identified a solid mass of approximately 5 cm, located in the right paramedian region of the pelvic cavity . She wasIn December, she noticed a round mobile palpable mass in the left axilla, measuring 2–3 cm. Ultrasound features were consistent with sebaceous cyst . In JanuLeiomyosarcoma is a rare malignant tumour that arises from smooth muscle cells. Although leiomyosarcoma is well known for its metastatic potential, cutaneous metastasis is a remarkably uncommon event . The majRetroperitoneal and intra-abdominal leiomyosarcoma, the most common subgroup, is associated with an aggressive clinical course. In contrast, leiomyosarcoma of the somatic soft tissues represent the second subgroup and has a better prognosis. Primary cutaneous leiomyosarcoma comprises the third subgroup and arises from the piloerector muscle of the dermis. These lesions present as pyogenic granuloma, basal cell carcinoma, squamous cell carcinoma, fibroids and node injury. Multiple lesions of cutaneous leiomyosarcoma should raise the possibility of abdominal or retroperitoneal metastatic disease .Leiomyosarcomas grow slowly and may remain asymptomatic for a long period of time, delaying diagnosis and resulting in a worse prognosis . DiagnosA study involving 139 patients found that complete surgical resection without microscopic residual tumour and contamination is likely to offer the best chance of long-term survival. Aggressive surgery for recurrent sarcoma is recommended .There have been few treatment options for advanced leiomyosarcomas. Chemotherapy is administered with palliative intent. It is usually associated with low response rates and may cause significant distress. However, it is still the cornerstone of treatment for metastatic soft-tissue sarcomas, reducing symptoms, decreasing tumour bulk and even prolonging survival. For patients with unresectable extrauterine leiomyosarcomas, metastatic disease is often treated with doxorubicin or doxorubicin-based combinations. Gemcitabine and docetaxel are often considered first-line or second-line treatment for leiomyosarcomas and are particularly effective in managing uterine leiomyosarcoma .Surgical resection of metastatic disease can provide long-term relapse-free survival and probable cure in selected patients, the majority of whom have isolated pulmonary metastatic disease . The patClinicians should be aware of this unusual presentation. This case also draws attention to the importance of regular follow-up, including history taking and the performance of a meticulous physical examination in patients with leiomyosarcoma, to rule out subcutaneous metastasis. Furthermore, although palliative chemotherapy is standard practice for metastatic disease, this case highlights that metastasectomy can provide long-term relapse-free survival, postpone chemotherapy and may improve the quality of life in these patients. Hence, oligometastatic patients should be preferentially managed with surgical resection in leiomyosarcoma exhibiting indolent behaviour.The authors have no conflicts of interest to declare.


Bladder perforation, especially when atraumatic, is a rare cause of ascites and is often difficult to differentiate from other causes of abdominal pain and ascites in the acute setting. A 43-year-old Caucasian woman with a history of multiple sclerosis presented with acute abdominal pain. A computed tomography (CT) scan of her abdomen and pelvis without contrast revealed ascites, acute kidney injury (AKI) was noted on laboratory workup, and very little urine was drained by Foley catheter. Over the next several days, the patient's clinical condition deteriorated with no definitive diagnosis. A repeat CT of her abdomen and pelvis without contrast showed worsening ascites. She underwent paracentesis, which revealed a markedly elevated ascitic fluid creatinine consistent with bladder rupture. She then underwent an urgent cystogram to confirm the diagnosis, and the urologic consultant recommended conservative management with a Foley catheter to allow for bladder healing. Conservative treatment failed however, and she underwent a surgical repair with drain placement which was followed by an improvement in her clinical condition.This case illustrates a unique presentation of a young woman with multiple sclerosis whose bladder perforation presented as abdominal pain and ascites. The multidisciplinary approach required here highlights the difficulty in reaching this diagnosis which is often undermined in patients who lack a history of traumatic injury. Such delays led to a complicated hospital course for our patient. Maintaining a broad differential for abdominal pain and ascites is essential. Bladder rupture is usually considered in cases of abdominal trauma. Atraumatic bladder rupture is a very rare occurrence but is associated with a high morbidity and mortality, and the clinical course if often complicated by a delayed diagnosis . For patOur patient is a 43-year-old Caucasian woman who presented to the emergency department with severe, sharp lower abdominal pain that began immediately after voiding. She experienced associated symptoms of nausea, vomiting, and increased urinary frequency and urgency. She had no history of trauma to the abdomen, but she did have a history significant for untreated multiple sclerosis and a previous ovarian cyst rupture status-post right oophorectomy. In the emergency department, her physical exam revealed a soft, non-distended abdomen, with tenderness on palpation throughout the lower quadrants, but without guarding, rigidity, or rebound tenderness.On initial presentation, she underwent a computed tomography (CT) scan of her abdomen and pelvis without contrast . The scan revealed ascites. According to the patient, she had been diagnosed with pelvic ascites of unclear etiology at an outside facility one year prior to presentation while experiencing similar symptoms. Pelvic ultrasound was only significant for a small left para-ovarian cyst (2.0 x 1.2 x 1.5 cm in dimension), and a partially visualized bladder appeared normal. Following gynecological consultation, there was a concern for a ruptured hemorrhagic cyst and conservative management was recommended until the episode resolved. Concurrent workups for pyelonephritis was negative. The patient developed an acute kidney injury (AKI) and urinary retention with a bladder scan revealing 584 mL of retained urine. However, straight catheterization drained only 250 mL.Over the next few days, she began to complain of epigastric pain with worsening nausea and hematemesis, and had difficulty breathing. Her chest x-ray showed bilateral pleural effusions and atelectasis. The gastroenterologic consultant planned to perform an esophagogastroduodenoscopy, but the procedure was canceled due to a rapid deterioration of her condition, with worsening abdominal distension, sluggish bowel sounds, worsening AKI and a new anion gap metabolic acidosis. A second CT of her abdomen and pelvis without contrast showed a marked increase in abdominal ascites as well as a new abnormality of the bladder wall that likely represented a bladder diverticulum, but a bladder wall rupture or diverticular rupture could not be excluded Figure . A fluidDue to her declining urine output, low urine volumes were seen in her bladder scan with high ascitic fluid creatinine; a cystogram was immediately performed due to concerns of bladder rupture. The cystogram confirmed this diagnosis Figure . Her serThe urologic consultant recommended nonsurgical, conservative management with postobstructive diuresis by a Foley catheter for 14 days to allow adequate healing of the bladder wall. However, the conservative management approach failed, and the patient experienced increased abdominal pain and ileus and, subsequently, underwent cystoscopy, cystorrhaphy, and diverticulectomy with drain placement.The patient’s pain markedly improved postoperatively. The drain was removed, and she was discharged with a 2-week follow-up in the Urology clinic.While traumatic rupture of the bladder is a more common occurrence, ascites secondary to a spontaneous bladder rupture is rare and documented sparsely in case reports. Due to the delay in diagnosis, patients have poorer outcomes and a high mortality rate. Cases have previously been reported secondary to a state of chronic inflammation, bladder outlet obstruction, bladder malignancy , as wellMultiple sclerosis, through its disseminated, patchy demyelination in the brain and spinal cord is known to cause bladder dysfunction, including urinary retention, which is likely from decreased sensation of filling. A PubMed search found two other cases of bladder rupture in multiple sclerosis patients in a paper written in 1977 . Both caWith urinary ascites low on the list of most physicians’ differential diagnoses, it is not surprising that patients often go undiagnosed and face a more complicated hospitalization as a result. Failure to diagnose spontaneous bladder perforation within the first 24 hours contributed to a mortality rate of 25% . The tesThe AKI or rise in serum creatinine in such cases of urinary ascites from bladder rupture is due to the process of “reverse auto dialysis” by the peritoneal membrane, which allows the diffusion of urea and creatinine from the ascitic fluid into the blood, causing the elevation of serum urea and creatinine .Management can be conservative or invasive—both of which were demonstrated during the care of our patient. Our patient was fortunate her symptoms resolved despite the delay in reaching the diagnosis due to the complexity of her presentation. However, urinary ascites should be considered as a differential for someone presenting with abdominal ascites, especially when a more common cause is not obvious on presentation.Atraumatic or spontaneous perforation of the urinary bladder should be considered in the differential diagnoses in patients presenting with new onset ascites and AKI without any evidence of chronic liver or heart disease or other common causes of ascites. Early diagnosis can greatly improve the patient’s hospital course and overall outcome.


Gastric duplication cysts are rare cystic neoplasms that are often difficult to distinguish from other entities. We describe a healthy 44-year-old woman who presented with acute right lower quadrant abdominal and flank pain as well as chronic nausea and constipation. Her physical examination was unremarkable but contrasted computed tomography revealed a 6cm cystic lesion between the stomach and body of the pancreas. Endoscopic ultrasonography and fluid analysis were consistent with a mucinous cyst with a markedly elevated fluid carcinoembryonic antigen level. The patient subsequently underwent a laparoscopic distal pancreatectomy, which was converted to an open procedure when the lesion was noted to be adherent to the coeliac axis. Intraoperative endoscopy revealed no abnormality. Final pathology revealed a gastric duplication cyst. The patient recovered well and was asymptomatic on follow-up. In this report, we discuss the incidence, natural history and management of this rare entity. Gastric duplication cysts (GDCs) are rare and benign but difficult to distinguish from cystic neoplasms of the pancreas or pseudocysts on imaging. Endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) and fluid analysis is the most common modality used in attempting to distinguish between these entities. Nevertheless, in some cases, a definitive diagnosis may not be possible preoperatively. Resection is usually performed in symptomatic patients while the choice to resect or observe in asymptomatic patients is less clear. In this report, we describe a patient who presented with a large cystic lesion that appeared to be a mucinous pancreatic neoplasm by preoperative imaging and fluid analysis. On surgical exploration, the diagnosis of a GDC was made and resection was performed. A review of the literature on the diagnosis and management of GDCs is also discussed.A 44-year-old woman presented with a 3-day history of right flank and lower quadrant abdominal pain associated with nausea and constipation. Her past medical, family and medication history were otherwise non-contributory and her physical examination was unremarkable. She underwent contrast enhanced computed tomography, demonstrating a 6cm cystic lesion between the stomach and body/tail of the pancreas . She subA laparoscopic distal pancreatectomy was planned. At the time of the laparoscopic exploration, entrance to the lesser sac was first obtained and, on mobilising the posterior wall of the stomach, the lesion was noted to be tightly adherent to both the stomach and pancreas. The pancreas was mobilised free of the cyst and it was evident that the lesion originated from the stomach. Intraoperative endoscopy was performed and no mucosal abnormalities of the stomach were noted.enbloc resection of the cyst along with a portion of the posterior wall of the stomach with a surgical stapler was performed. Repeat oesophagogastroduodenoscopy revealed the presence of an intact staple line on the posterior stomach wall and no evidence of bleeding or leak. The gross margins were uninvolved.On further mobilisation, the cyst was adherent to the coeliac axis and the procedure was converted to an open resection. The stomach was fully mobilised and the gastric duplication cyst was noted to be arising from the posterior wall. It was dissected off the coeliac vessels and an Final pathology revealed a 9.5cm × 4.5cm × 2.0cm cyst with a smooth internal cyst wall consistent with a GDC –5. The p2 They are most commonly present on the distal greater curve of the stomach and, in general, do not directly communicate with the lumen of the alimentary tract. Theories for the development of duplication cysts include that they represent transient enteric diverticula that fail to degenerate, that the failure of the separation of notochordal plates results in traction diverticula that develop into duplications and that embryonic enteric longitudinal folds fuse with a bridge of tissue in between, resulting in one tract developing into the true alimentary tract and the second into the duplication.GDCs occur in approximately 0.001% of the general population, and represent 2–8% of all alimentary tract duplication cysts behind those of the ileum, oesophagus and colon.5 Associated congenital anomalies can include oesophageal and duodenal diverticula, other duplication cysts in the alimentary tract, annular and ectopic pancreas, and spinal anomalies such as hemivertebrae and spina bifida. Complications of duplication include torsion of pedunculated cysts, malignant changes into carcinoma, infection, peptic ulcer, obstruction, haemorrhage, pancreatitis and fistula formation.In the paediatric population, patients often present with an abdominal mass, gastrointestinal obstruction or anaemiaThe differential diagnoses of a suspected GDC often include cystic pancreatic neoplasms and pseudocysts. With the development of more modern imaging techniques including EUS with fluid analysis, the diagnosis is now more often made before surgery. Although GDCs typically have elevated fluid CA19-9 levels without elevated CEA, our patient had a markedly elevated fluid CEA level but a normal fluid CA19-9 level as well as the presence of extracellular mucin. This is more consistent with a mucinous cystic neoplasm of the pancreas. Elevated fluid CEA levels in pancreatic cysts are not always indicative of mucinous cysts. However, large cysts with CEA levels over 6,000ng/ml combined with the presence of mucin are worrisome for mucinous cysts with high malignant potential and are almost always resected uniformly.Once diagnosed, the treatment of most foregut duplication cysts is surgical excision due to the majority being symptomatic and/or complicated at the time of presentation as well as reports of the development of malignancies within them.This report demonstrates the difficulty in distinguishing between a GDC and a cystic mucinous pancreatic neoplasm, even with modern imaging and diagnostic modalities such as EUS. In the case of our patient, her GDC was symptomatic and, consequently, even if the correct diagnosis had been made, resection would have been recommended. In asymptomatic patients, however, indications for resection as well as the operative approach may be different. Surgeons should therefore be aware of its possibility.


Osteochondromas are common benign tumors of cartilage and bone. They are usually found as contiguous bone with a cartilage cap at the end of the growth plate of long bones. Similar to structure are extraskeletal osteochondromas. However, unlike typical osteochondromas, extraskeletal osteochondromas are noncontinuous with bone. To our knowledge, all reported extraskeletal osteochondromas have been contained within fascial compartments. Here we present the case of a 5-year-old female who had a slow growing mass of the anterior distal right thigh. Imaging studies revealed an ossified mass extending from dermal layer of the subcutaneous tissue with no connection to the underlying deep fascia. An excisional biopsy was performed and proved to be a subdermal extraskeletal osteochondroma.  An osteochondroma by definition is a benign tumor that includes components of both cartilage and bone –4. A conA 5-year-old female was seen at clinic, with a chief complaint of a mass in the anterior distal right thigh. The mass was noted to be slow growing but unknown when it first appeared. There were no complaints of pain, no history of trauma in the region, and no other lesions identified. On physical examination, the mass was firm and well adhered to the dermis but freely mobile over the underlying fascia. There were no skin changes or discoloration and the knee exam was otherwise normal.Plain radiographs showed an oval, calcified mass within the soft tissue of the suprapatellar region Figures . MagnetiFor the excision biopsy, an elliptical incision was made surrounding the nonadhesive area of the skin in Langer's lines . The masOsteochondromas are the most common benign tumors occurring in the metaphysis of long bones , 2, 5. MRarely are these lesions extraskeletal or independent of the bone, but they have been reported in the hand, feet , 10–12, When presented with a well-circumscribed calcified lesion various possible differential diagnoses should be considered. These include myositis ossificans, lipomatous lesion, tumoral calcinosis, synovial sarcoma, and extraskeletal osteosarcoma, the most common being myositis ossificans. This diagnosis was considered initially with radiographic and magnetic resonance imaging. However, this lesion was confirmed by histopathology with the presence of trabecular bone surrounded by a cartilaginous cap and fibrous capsule . This is


Introduction. Inflammatory pseudotumor is an uncommon entity, and its cardiac origin is exceedingly rare. Case History. A previously healthy 27-year-old man was found to have a systolic murmur during preemployment screening evaluation. A transthoracic echocardiogram revealed a 4 × 2.5 cm mass originating from the right ventricle (RV) outflow tract extending into the aortic root. A computed tomography guided biopsy confirmed an IgG4-related inflammatory pseudotumor. Patient was started on oral prednisone with subsequent reduction in mass size. Conclusion. Cardiac inflammatory pseudotumors are markedly rare tumors that should be considered in the differential of intracardiac tumors which otherwise includes cardiac fibromas, myxomas, and sarcomas.  Inflammatory pseudotumor of cardiac origin is an exceedingly rare tumor but one that deserves to be included in the differential diagnosis for intracardiac tumors. There is a general lack of consensus on pathogenesis, prognosis, and treatment of these tumors given the paucity of literature on the topic. We describe a case of a previously healthy 27-year-old man who presented with a murmur detected on a preemployment physical screening found to have mass originating from the interventricular septum and extending into the aortic root. The location of the mass, specifically its proximity to the aorta, and its branches made the case a diagnostic and therapeutic challenge further complicated by lack of information available on inflammatory pseudotumors of cardiac origin. We report this case to add to the literature on this topic and contribute to the process of developing a consensus for prognosis and treatment.A 27-year-old male was found to have a systolic murmur during a preemployment screening evaluation. At baseline, patient was a healthy, active male who participated in team sports during high school without any cardiac symptoms. Examination revealed a heart rate of 60 beats per minute and a blood pressure of 131/77 mmHg, with prominent right ventricular heave, and a 5/6 harsh systolic murmur best heard on the left parasternal region, which increased in intensity with Valsalva maneuver without any respirophasic variation. There was no appreciable lymphadenopathy and no testicular masses palpated on exam. An Electrocardiogram (EKG) was revealing for normal sinus rhythm. A transthoracic echocardiogram revealed a 4 × 2.5 cm mass with wide base firmly attached to the right ventricle outflow tract . The RV Inflammatory pseudotumor (IPT) is a rare benign condition that can mimic a malignant lesion. Most commonly reported in the lungs and orbit, IPT is an immunologic lesion usually in response to infection, necrosis, or neoplasm . CardiacGiven variability in the clinical manifestation and course of cardiac IPT no consensus on treatment has been formed. Surgical resection when technically feasible appears to be the treatment of choice. Reports of good outcome with both complete excision and subtotal excision suggest that rate of growth is unpredictable. Involvement of the vascular structures including the aorta in our patient made resection a near impossibility. A similar case report of inoperable cardiac inflammatory pseudotumor had spontaneous decrease in size by 40% over an 11-month period . Two othIn conclusion, cardiac inflammatory pseudotumors are markedly rare tumors that should be considered in the differential of intracardiac tumors which otherwise includes cardiac fibromas, myxomas, and sarcomas. We hope to add to the sparse literature and contribute to coming up with a consensus on treatment on this rare phenomenon by reporting our case.


A dog presented with a retrobulbar mass, diagnosed histopathologically as malignant spindle cell neoplasia. Emergence of analogous findings in the contralateral orbit prompted extended immunohistochemistry of the original mass and reassignment to idiopathic sclerosing orbital inflammation. Early incisional biopsy with extended immunohistochemical analysis should be considered for canine orbital tumors. A 7‐year‐old, entire male crossbreed dog presented with an 11‐month history of diffuse, left episcleritis. This was initially mild and had been managed by the primary veterinarian with 1% prednisolone acetate ophthalmic suspension. Despite a good therapeutic response, the inflammation repeatedly recurred after each course of treatment. Over the course of 7 months, the condition progressed to unilateral exophthalmos alongside clinical signs consistent with pain including blepharospasm and self‐trauma. The dog was referred to a veterinary ophthalmologist at which point intraocular pressures , Schirmer Tear Tests, and visual assessments were within normal limits. Oral prednisolone  treatment induced transient clinical improvement, but lateral deviation of the left globe ensued over the subsequent 4 months. Periorbital ultrasonography revealed a soft tissue lesion in the left medial retrobulbar space and on suspicion of an abscess or neoplasm, the dog was referred to the University of Edinburgh Hospital for Small Animals.On presentation, left exophthalmos, lateral strabismus, brown‐tinged epiphora, and diffuse scleral congestion were evident. The globe was soft on palpation but resistant to retropulsion. An acute pain response was not elicited during globe manipulation or upon mouth opening, inconsistent with the typical presentation of a retrobulbar abscess in the dog. Direct and consensual pupillary light reflexes and menace responses were normal OU. Other clinical examination findings were unremarkable. Differential diagnoses included neoplasia, cyst, infection (cellulitis or abscess), noninfectious inflammatory disease, or foreign body draining tract. The insidious onset of signs with absence of fever and painless palpation decreased the likelihood of an infectious etiology. Although globe retraction  could not be assessed because of the retrobulbar mass, there was also no behavioral expression of photophobia. Some level of discomfort was however presumed on the basis of inflammatory signs.Written informed consent was obtained from the owner for all procedures performed. A complete blood count with biochemistry and coagulation profile revealed only an increase in alkaline phosphatase at 237 U/L  and a mild increase in creatine kinase at 259 U/L (50–200 U/L). Cultures of ultrasound‐guided aspirates of the mass  produced no growth; May–Grünwald–Giemsa (MGG) cytology of the same aspirates yielded only keratin bars and keratinaceous debris and was considered nondiagnostic. Magnetic resonance imaging (MRI) of the head was performed under general anesthesia at 1.5T, acquiring multi‐sequence images in transverse  and dorsal (T1w postgadolinium and short tau inversion recovery) planes. Findings  architecture lacking storiform structure  Fig. . The spiDue to incomplete excision of the suspected retrobulbar sarcoma, definitive‐intent radiation therapy was recommended to decrease the likelihood of tumor recurrence. Radiation therapy consisted of 19 fractions of 2.8 Gy prescribed to the planning target volume (PTV) to a total dose of 53.2 Gy, normalized to 100% in isocenter. The clinical target volume (CTV) included all residual tumor tissue, postsurgical swelling, and 3–5 mm radially to account for microscopic disease. The PTV was created following an expansion of the CTV by 3 mm in all dimensions. Tissue equivalent material (5 mm) was utilized to ensure adequate dose to the superficial subcutaneous tissues. The minimum dose and heterogeneity within the PTV and CTV were 49.3 Gy and 14% and 50.1 Gy and 12%, respectively; the maximum dose was contained within the PTV. The dog tolerated radiation therapy well, although he developed acute grade 2 skin toxicity with erythema and dry desquamation and grade 3 oral mucositis Twenty weeks postsurgery, the dog was clinically well and restaging with computed tomography (CT) provided no evidence of local tumor recurrence Fig. . The regWe have reported the progressive clinical course and key diagnostic features of a novel, noninfectious inflammatory orbital disease in a dog. Such disorders occur infrequently in animals and include immune‐mediated conditions and idiopathic orbital inflammation  Other differentials for progressive inflammatory lesions leading to exophthalmos in the dog include nodular granulomatous episcleritis (NGE), nodular fasciitis, and fibrous histiocytoma The left retrobulbar mass described herein penetrated the bony walls of the orbit, and compressed the left olfactory bulb. Likewise, bony destruction occasionally results from severe chronic IOI in humans, which classically involve orbital fibrosis, optic nerve compression, and impaired ocular rotation Histologically, the canine mass was dominated by patchy aggregates of lymphocytes and fibrous proliferation – akin to late‐stage human IOI lesions in which increased connective tissue is consistently present Idiopathic sclerosing orbital inflammation accounts for 6–8% of human inflammatory orbital lesions and is otherwise described as “sclerosing orbital pseudotumor” A small proportion of IgG4‐positive plasma cells were identified within the ISOI which, to the best of our knowledge, is the first reported observation of this cell subclass within a pathological lesion affecting the canine orbit. Recently characterized, human IgG4‐related disease comprises a group of fibro‐inflammatory conditions of unknown origin featuring tumor‐like expansions in one or multiple organs, with sclerosing fibrosis and a dense lymphoplasmacytic infiltrate rich in IgG4‐positive plasma cells In conclusion, this report represents the first description of ISOI in an animal, with pathological features distinct from FROMS, IMT, NGE, and nodular fasciitis. Whilst IOI is rare beyond human medicine, our findings highlight the need to consider this diagnosis in dogs presenting with recalcitrant ophthalmic signs associated with a retrobulbar mass. Given their proximity to the brain, and propensity for local invasion and contralateral emergence, early referral for these lesions is warranted, even though a standard‐of‐care therapy is not clear None declared.


Congenital infantile fibrosarcoma (CIF) is a rare malignant mesenchymal tumor and only 14 cases have been reported with gastrointestinal manifestation. We report about a female newborn delivered per emergency cesarean section at 34 weeks of gestation. Postnatally, she rapidly developed an acute abdomen and sonographic evidence of intestinal perforation requiring laparotomy on the first day of life. A perforated 2 × 3 cm sized spherical tumorous structure of the jejunum was identified. Due to unknown histopathology at this point and unclear resectional margins, she received a temporary ileostomy, which was closed two months later. Histopathology revealed a congenital intestinal fibrosarcoma without the characteristic ETV6-NTRK3 fusion transcript. In conclusion, this rare tumor must be considered as differential diagnosis of intestinal perforations in newborns. Congenital infantile fibrosarcoma (CIF) represents a malignant mesenchymal tumor accounting for 10–20% of soft-tissue tumors diagnosed in the early years of life .Approximately 40% of CIFs are diagnosed in infants younger than 3 months or even prenatally. Nearly 80% of the cases are diagnosed within the first year of life . A predoThe extremities, head, neck, and trunk represent the most frequent sites of occurrence. The ovaries, mesentery, and the retroperitoneum, however, are seldom involved . Only a Herein, we report a rare case of congenital infantile fibrosarcoma of the intestine without the classical ETV6-NTRK3 fusion.The female patient was born per emergency cesarean section at 34 weeks of gestation because a volvulus was suspected on prenatal ultrasound. The birth weight was 2,270 g. Postnatally, the APGAR score was 8/8/9. The clinical condition, however, rapidly declined and the newborn developed tachypnea and tachycardia. An abdominal ultrasound revealed free fluid as a sign of meconium perforation . Both a The newborn was immediately taken to the operating room and underwent laparotomy. Intraoperatively, a perforated 2 × 3 cm sized spherical tumorous structure of the jejunum could be detected . No pathHistopathological examination confirmed complete removal of the tumor. HE stains revealed a circumferential cellular mesenchymal spindle cell proliferation involving mainly the submucosa and muscularis propria . The tumThe further postoperative course was uneventful. The baby developed well and constantly gained weight. Therefore, the jejunostomy was closed at an age of two months. An MRI scan in the third month of life was unsuspicious and the patient was free of symptoms.The present case report describes a female newborn suffering from intestinal perforation due to a congenital infantile fibrosarcoma located in the jejunum. Complete removal was performed on the first day of life.n = 6 ileum, n = 2 jejunum, and n = 1 duodenum) and in 5 patients the colon was affected [The exact etiology of CIF still remains unclear. However, a cytogenetic abnormality consisting of translocation t12;15)p13:q25) bearing the fusion of Tel gene EVT6 with TrkC gene has been shown for CIF , 5. For (p13:q25):q25 bearaffected . The preApproximately 40% of CIFs are diagnosed in infants younger than 3 months of age . MoreoveIn most cases of intestinal CIFs explorative laparotomy with subsequent resection of the tumor and end-to-end anastomosis was performed , 6. Due In contrast to adult fibrosarcomas, the infantile form is considered as a low-grade malignant tumor with an excellent prognosis , 2. For In conclusion, the present report adds a patient with a jejunal CIF without ETV6-NTRK3 fusion transcript to the literature. In cases of intestinal perforation in a newborn, intestinal CIF can be included as a rare but possible differential diagnosis.


Primary lymphangiomas or lymphangiomatous polyps of the palatine tonsil are rare benign lesions that are described infrequently in the literature. The majority of the published cases concern adults. We report a case of a lymphangiomatous lesion of the right palatine tonsil of a 9-year-old boy. Our clinical suspicion was confirmed by the histological examination after tonsillectomy and the diagnosis of primary lymphangioma of the tonsil was made. In this case we discuss the clinical and histopathological features of this lesion and present a short review of the current literature. Lymphangiomas or lymphagiomatous polyps of the palatine tonsil are rare benign tumors. They present as unilateral or bilateral tonsillar outgrowths and cause a large spectrum of symptoms related to local irritation and airway obstruction . Their pA 9-year-old boy presented to our hospital complaining of a foreign body feeling in the throat of a few months' duration, causing him a nonproductive cough, mild dysphagia, and sleep disturbance. His medical and surgical history were unremarkable. The examination of the oral cavity revealed a large, oval, pale mass protruding from the lower pole of the right tonsil, which was partially obstructing the airway . It was The histopathological examination showed macroscopically a tonsil of 3.2 × 2 × 0.8 cm in size with an exophytic polypoid nodule measuring 1.8 × 1.2 × 1.2 cm . Under tMore than 90% of all lymphagiomatous lesions occur in the head and neck area, including the cheek, tongue, and floor of mouth . HoweverHistologically, lymphangiomas are formed by abundant dilated lymphatic and blood channels mixed with a fibrous stroma of lymphoid and adipose elements . There aThe clinical behavior of the tumor is largely unknown, because most of these lesions are diagnosed histologically after surgical excision of the tonsils. Common presenting symptoms include dysphagia, dyspnea, foreign body sensations, sore throat, and chronic tonsillitis. When the mass is very large, it can affect surrounding vital structures to produce rhinolalia clausa, respiratory difficulty, stridor, excessive saliva, or nausea . In all The history and the clinical examination are important for the diagnosis, but a histological examination is required to establish the diagnosis. The differential diagnosis includes lymphangiectasia, hemangioma, arteriovenous malformation, fibroepithelial polyps, and papilloma. In our young patient's case, the preoperative suspicion was strong because of the typical appearance and the large size of the lesion. However, as a lymphangioma clinically may resemble a true neoplasm of the palatine tonsil, the lesion needed to be removed in order to complete an accurate histological diagnosis and to rule out malignancy.Tonsillectomy is the curative procedure of choice for the management of these tonsillar polypoid lesions. An excision of the polypoid mass may be the only necessary procedure, while sclerosing therapy with OK-432 or radiotherapy is not suggested. Furthermore, a carbon dioxide laser has been frequently used to treat a group of pediatric patients with benign lesions of the upper aerodigestive tract exclusive of the larynx, but there have been no benefits compared to the cold steel tonsillectomy . As our In summary, this case demonstrates a case of tonsillar lymphangiomatous polyp occurring in a 9-year-old boy. It is believed that the incidence of the tonsillar lymphangiomatous polyps is greater than what is reported in the literature, especially in the pediatric population. The aim of this case report is to consider this type of benign tumor in the differential diagnosis of tonsillar masses in childhood.