Brown tumors of hyperparathyroidism are locally destructive bone lesions. They are the late clinical consequence of the disease. They can occur in primary, secondary, and rarely tertiary forms. They affect usually long bones and less frequently those of the maxilla.  Our 45-year-old female patient presented with a mandibular tumor next to the first right lower molar. At first, we have chosen tooth extraction and tumor excision. When the histological report showed the giant cell tumor we suspected a metabolic bone disorder. Biochemical tests screened hyperparathyroidism and severe vitamin D deficiency, and parathyroid scintiscan revealed parathyroid adenoma.  The association of hyperparathyroidism and vitamin D deficiency leads to diagnostic uncertainty. First, secondary hyperparathyroidism can be due vitamin D deficiency. Second, data available show that vitamin D deficiency is more prevalent in patients with primary hyperparathyroidism than in general population. Hyperparathyroidism management is based on correct and precise diagnosis. Furthermore, the resolution of brown tumors depends on the cure of hyperparathyroidism. In fact, bone lesions should regress after biological tests' normalization.  Clinicians should be aware of such rare and complicated presentation. They must consider the diagnosis of the brown tumor to avoid extensive surgical excision and teeth extractions. Hyperparathyroidism (HPT) is a prevailing endocrine disease. Determined by the cause of PTH production, HPT can be characterized into primary, secondary, and tertiary form(s). Primary hyperparathyroidism (PHPT) is a disorder of calcium, phosphate, and thus bone metabolism. The main cause of PHPT is adenoma in about 80% of cases followed by glandular hyperplasia 15%) and more rarely due to the presence of parathyroid carcinoma. In primary HPT, hypercalcemia and hypophosphatemia are omnipresent in laboratory tests [5% and moTertiary hyperparathyroidism is a state of excessive secretion of PTH after a long period of SHPT. It leads to autonomous parathyroid glands that induce hypercalcemia .HPT leads to bone involvement that includes generalized osteoporosis, multiple focal skull areas of demineralization, and brown tumors.Brown tumors affect usually clavicles, ribs, and pelvis. Head and neck involvement is rare, and the mandible is affected more often than the maxilla.The aim of this paper was to describe a case of the brown tumor in the mandible which was the first sign of hyperparathyroidism.A female patient aged 45 years with no known comorbidities came to our department at the university hospital Sahloul Sousse with the chief complaint of a right-sided swelling in the mandible. This swelling has caused slight asymmetry of the face since 6 months, which gradually enlarged up to the present size .The patient gave a history of generalized weakness, lethargy, and weight loss noticed since past few months. Her family history and past medical history were nonsignificant.Intraoral examination revealed a 4.0 × 4.0 cm bulbous mass hard to palpation arising from the mandible and extending from the distal aspect of the lower right first premolar (44) to the second right molar (47) . She hadRadiographic examination with orthopantamogram showed unilocular radiolucency close to the mandibular first right molar's roots, without involving the mandibular canal. Roots erosion of the relative tooth was noted .A computed tomography (CT) scan showed multiloculated ground-glass ossification of the lesion .After the first molar extraction (46) and the surgical excision of the lesion, the histological report was akin to the giant cell tumor .So, serum parathormone level was advised to rule out metabolic bone disease. Laboratory investigations were done: serum PTH level was slightly high, and serum calcium and phosphorus levels were normal .The lesion was identified as a brown tumor of hyperparathyroidism, and the patient was referred to the endocrinology department.Kidney function blood tests were done. Serum creatinine and blood urea nitrogen were normal. Chronic renal failure could not be considered the cause of hyperparathyroidism. However, we noted severe vitamin D deficiency . The iniIt was decided that vitamin D supplementation was the best therapeutic option. The patient was started on vitamin D 100,000 IU per fortnight for 6 weeks which is the equivalent of half an ampoule of 200,000 IU/1 ml. Thereafter, the patient was kept on 200,000 IU every 6 months. Her PTH levels decreased after 6 months on vitamin D therapy, and her calcium and phosphorus levels remained in the standards.The patient underwent ultrasound scan of the neck, which showed a left lower lobe parathyroid solid nodule. The lesion had irregular hypoechoic component and was suggestive of parathyroid adenoma. Parathyroid technetium scintiscan  was requisite and revealed left lower parathyroid adenoma . SkeletoAccordingly, we retained the diagnosis of primary hyperparathyroidism masked by vitamin D deficiency and caused by parathyroid adenoma.There was a normalization of calcium, PTH, and vitamin D serum levels. The bone mineral density test was not lower than normal which excludes osteopenia and osteoporosis. So, surgical treatment of the adenoma was not indicated. The patient was compliant and presented a favorable evolution .Before the 1970s, the presentation of HPT was characterized by recurrent nephrolithiasis, brown tumors, neuromuscular dysfunction, symptomatic hypercalcemia, peptic ulcer disease, psychosis, and pancreatitis . After tThe brown tumor also known as osteitis fibrosa cystica or Von Recklinghausen's disease of bone is a reactive nonneoplastic giant cell lesion associated with hyperparathyroidism. Products from microbleeding like hemosiderin assign the brown color to the lesion , 5. The The preferential location of brown tumors is ribs, clavicle, and pelvic girdle. When they arise in the maxillofacial region, the mandible is so far the most frequent localization . HoweverThe physical examination usually reveals painful and hard bone swelling which may produce disfiguring deformities. However, our patient denied any ache. Asymptomatic brown tumors are also described by several authors. Therefore, their discovery is fortuitous following a radiological examination.On radiographic and computed tomography exams, well-defined radiolucent or hypodense image are described, usually not demonstrating cortical disruptions and periosteal reactions or inflammatory signs . This tyClinical and radiological presentation of the brown tumor can mimic other diseases, the most likely diagnoses include odontogenic and nonodontogenic cysts and tumors , infectious diseases , and metastasis from a known or an unknown primary site  , 10.The usefulness of the tumor biopsy is controversial. When biological disorder guides to brown tumor diagnosis, it is useless. Histologically, the presence of diffuse giant cells is characteristic, but there is no pathognomonic sign .Brown tumors occur in 4.5% of patients with PHPT and between 1.5% and 1.7% in cases of SHPT  with an To correct hyperparathyroidism, it is worthwhile to know its form. Secondary HPT results when hypersecretion of PTH is a response to decreased calcium. It is generally associated with serum hypocalcemia and hyperphosphatemia. This condition is found in patients with chronic kidney disease or vitamin D deficiency .The main cause of primary HPT is parathyroid adenoma. Glandular hyperplasia and parathyroid carcinomas are more rare etiologies. Primary HPT is characterized by elevated or inappropriately normal PTH levels and the persistent elevation of total serum calcium levels . NormocaThe American Association of Endocrine Surgeons recommends the biochemical evaluation of serum total calcium, PTH, creatinine, and vitamin D levels if primary HPT is suspected  .Low levels of vitamin D are found more often in primary HPT than in the general population. This observation is dyed in the wool  and is bIn our case report, biological findings could go along not only with the secondary HPT but also with the normocalcemic variant of primary HPT. To fix on the diagnosis, neck scintiscan revealed parathyroid adenoma. So, diagnosis of primary HPT was retained.The supplementation for vitamin D deficiency is required, and maintaining vitamin D to levels beyond 30 ng/ml is recommended. The endocrine society supported vitamin D2 or D3 supplementation of 50,000 IU once a week for 8 weeks or its daily equivalent followed by 1,500 to 2,000 IU daily use maintenance. In our case, the protocol has been modified since only pharmaceutical form of 200,000 IU/1 ml is available .Parathyroidectomy should be considered for most patients with primary HPT and is more worthwhile than observation or pharmacologic therapy. It is the definitive treatment option for all patients with symptomatic primary HPT or associated with osteoporosis. Surgical treatment is also indicated when the serum calcium level is higher than 1 mg/dL (0.25 mmol/l) above normal, even if there are no symptoms. Patients, younger than 50 years, and those unable or unwilling to comply with observation protocols, are rather candidates for surgery , 13, 16.The incidence of primary hyperparathyroidism is increasing. Surprisingly, it tripled between 1995 and 2010, and clinicians from all specialties will likely encounter patients with this disorder. There is some evidence to suggest that vitamin D deficiency may increase the likelihood of a more symptomatic presentation of PHPT. The exact influence of vitamin D status upon the modern presentation of PHPT is yet to be fully defined.The treatment of brown tumors is the cure of the underlying hyperparathyroidism. When hypersecretion of PTH is corrected, spontaneous regression of the lesion is expected. A typical radiological presentation of the giant cell tumor should be completed by measurement of calcium, phosphorus, and PTH serum levels. Then, a proper diagnosis avoids inadequate surgical excision and teeth extractions.


The clinical presentation of non-Hodgkin lymphoma (NHL) varies tremendously depending upon the type of lymphoma and the areas of involvement. NHL can rarely present as an abdominal mass compressing the inferior vena cava. The clinical presentation due to obstruction of inferior vena cava has often been called the inferior vena cava syndrome (IVCS). It can present acutely or chronically.A 35-year-old male presented with 3 months history of fever, anorexia, weight loss and abdominal discomfort. His abdominal examination showed dilated superficial veins with blood flowing rostrally. CECT abdomen revealed multiple enlarged some necrotic, retroperitoneal lymph nodes. The inferior vena cava was noted to be compressed by the lymph nodes. The lymph node biopsy revealed non- Hodgkin lymphoma, precursor B cell.An abdominal mass compressing the inferior vena cava is a rare but possible cause for appearance of dilated superficial abdominal veins and should be looked for. NHL varies tremendously depending upon the type of lymphoma and the areas of involvement. Inferior vena cava (IVC) obstruction can result from thrombosis secondary to hypercoagulable disorders, extrinsic compression by tumors, infective phlebitis, inflammation, trauma, surgery, or in many number of cases, idiopathic -4. When A 35-year-old male presented with 3 months history of fever, anorexia, weight loss and abdominal discomfort in the month of August 2012 to the Department of Medicine at SKIMS, Soura. He was emaciated. His abdominal examination showed dilated superficial veins with blood flowing rostrally . HepatosThe inferior vena cava was noted to be compressed by the lymph nodes causing multiple collateral blood vessels to open up in compensation and thus manifesting on the skin of the abdomen as well. An image guided biopsy of one of the lymph nodes was done and the patient was given enoxaparin to prevent deep venous thrombosis of lower limbs and abdominal veins. The lymph node biopsy revealed non- Hodgkin lymphoma, precursor B cell . PatientNon-Hodgkin lymphoma (NHL) is a collective term for a heterogeneous group of lymphoproliferative malignancies with differing patterns of behavior and responses to treatment.  The clinInferior vena cava (IVC) obstruction can result from thrombosis secondary to hypercoagulable disorders, extrinsic compression by tumors, infective phlebitis, inflammation, trauma, surgery, or in many number of cases, idiopathic. , 6 The cPrecursor B-cell acute lymphoblastic leukemia/ lymphoma is a neoplasm of lymphoblasts committed to the B-cell lineage, typically composed of small to medium-sized blast cells with scant cytoplasm, moderately condensed to dispersed chromatin and indistinct nucleoli, involving bone marrow and blood (acute lymphoblastic leukemia), and occasionally presenting with primary involvement of nodal or extranodal sites (lymphoblastic lymphoma). When presenting as an abdominal mass compressing the inferior vena cava, the focus is to acutely prevent deep venous thrombosis or pulmonary embolism. Following this chemotherapy to control lymphoma is important. Both these goals of interest are usually started simultaneously in the form of heparin and chemotherapy. Aggressive supportive therapy is required to prevent the complications of chemotherapy. In our case, although we were able to prevent deep venous thrombosis, the patient succumbed to sepsis due to chemotherapy-related complications.


Esophageal schwannomas are rare primary submucosal esophageal tumors. We herein report a case of an esophageal schwannoma that was difficult to diagnose.A 39-year-old woman presented with chief complaints of difficulty swallowing and epigastric pain. Enhanced computed tomography of her chest revealed a tumor mass at the upper thoracic esophagus with internal heterogeneity. 18-Fluorodeoxyglucose positron emission tomography/computed tomography showed a hypermetabolic appearance matching the tumor mass; the accumulation had a maximum standardized uptake value of 5.5. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy under general anesthesia, but the small specimens obtained prevented a definitive diagnosis. Thoracoscopic esophagectomy was performed due to the large size of the tumor, suspicion of its malignant potential, and the patient’s symptoms. Histopathological examination revealed spindle-shaped cells in a fasciculated and disarrayed architecture in the proper muscle layer. Immunohistochemical studies showed S100 protein positivity and the absence of CD34 and c-kit. We diagnosed the tumor as a benign schwannoma.We herein report a relatively rare case of schwannoma of the esophagus that was diagnosed with difficulty. The incidence of benign primary tumors of the esophagus is low. The most common histological type is leiomyoma; the incidence of schwannoma among benign tumors is low –5. Esoph18-Fluorodeoxyglucose positron emission tomography (FDG-PET) has been used to detect metabolism of glucose by tumors. High FDG uptake is generally found in malignant tumors; it is also found in inflammation. Although they are benign tumors, schwannomas reportedly show a hypermetabolic appearance on FDG-PET –8. We prIn general, surgical resection of esophageal submucosal tumors is dependent upon the tumor size, malignant potential, and patient’s symptomatic state. Although the final diagnosis must be obtained surgically, as in the present case, minimally invasive thoracoscopic surgery is considered to be an appropriate technique for esophageal submucosal tumors.A 39-year-old woman presented for evaluation of difficulty swallowing and epigastric pain. Her medical and familial histories were unremarkable. Upper gastrointestinal endoscopy showed a smooth elevated lesion located 19 to 24 cm from the incisor teeth  scan revealed a tumor mass (39 × 28 × 56 mm) at the upper thoracic esophagus with internal heterogeneity. No metastasis to the lymph nodes or other organs was seen on the CT scan Fig. . FDG-PETMagnetic resonance imaging of the chest revealed that the boundary of the tumor was clear and smooth. The mass exhibited isointensity or low intensity compared with the muscles on T1-weighted images and high intensity on T2-weighted images. There was no invasion into the surrounding tissue.We performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) with the patient under general anesthesia. Because the specimen was small, we were unable to establish a definitive diagnosis. We suspected an esophageal schwannoma, leiomyoma, or gastrointestinal stromal tumor (GIST).The patient underwent surgery because of her difficulty swallowing and our suspicion of malignant potential. We performed thoracoscopic surgery with the patient under general anesthesia and single-lung ventilation.First, we attempted enucleation of the tumor. However, the mass was larger than 5 cm, and enucleation was difficult without creating an extensive defect of the esophageal wall. Therefore, subtotal esophagectomy was performed with thoracoscopic assistance.The resected specimen measured 55 × 45 × 24 mm. The cut surface was solid milky white Fig. . HistopaBenign primary tumors of the esophagus account for less than 1 % of all esophageal tumors . Benign A few cases of primary esophageal schwannomas have been reported , 4. GastThe definitive diagnosis of an esophageal submucosal tumor should be made before tumor excision to avoid unnecessary surgery. However, the preoperative pathological diagnosis of a submucosal tumor is unclear in some cases. As in the present case, an adequate specimen is difficult to obtain during biopsy of a submucosal tumor, even if a boring biopsy is performed. This is because the surface of the submucosal tumor is often covered with normal epithelium. EUS-FNAB is now commonly performed to diagnose submucosal tumors. This technique obtains more adequate specimens than does biopsy with upper gastrointestinal endoscopy. Rong et al.  reportedBecause the preoperative pathological diagnosis was not clear in our case, we performed subtotal thoracoscopic esophagectomy to both treat the patient’s symptoms and possibly diagnose a malignancy. Even if the tumor mass had been a malignancy such as a GIST, the operation would have been curative because we performed subtotal esophagectomy.Although the final diagnosis in this case was a benign schwannoma, FDG-PET showed a hypermetabolic appearance, suggesting malignant potential. Schwannomas are benign tumors, but a hypermetabolic appearance on FDG-PET has been reported. Schwannomas originate from nerve cells that express glucose transporter type 3 , and FDGThere is no consensus regarding the surgical treatment of esophageal submucosal tumors. Although the stomach and esophagus differ, the clinical practice guidelines for GIST in Japan declare that surgery is indicated for gastric submucosal tumors larger than 5.0 cm . In our We usually first try endoscopic treatment for small tumors originating in the submucosal layer. We then attempt enucleation by a thoracoscopic approach because it is less invasive. If the defect of the esophageal wall is expected to be large upon intraoperative examination or the mass has malignant potential, we perform an extended operation based on the individual patient. In this case, we considered open subtotal esophagectomy when the tumor was diagnosed as malignancy or it was difficult to resect it safely and radically.Thoracoscopic surgery is becoming common . In our In conclusion, we have reported a relatively rare case of an esophageal schwannoma. The diagnosis was difficult because we could not obtain an adequately sized specimen by boring biopsy and EUS-FNAB. The thoracoscopic approach is a good treatment option for large submucosal tumors of the esophagus.


Some infantile hemangiomas called in literature “minimal or arrested growth hemangiomas” or “abortive hemangiomas” are present at birth and have a proliferative component equaling less than 25% of its total surface area. Often, they are mistaken for vascular malformation. We present five patients (three girls and two boys) with abortive hemangiomas diagnosed between January 2010 and December 2015 localized in acral part of the extremities. They were congenital lesions resembling precursor of hemangiomas but did not show proliferation phase. Immunohistochemical Glut-1 was performed in all of them as a way to confirm the abortive hemangioma diagnosis. The most common appearance was a reticulated erythematous patch with multiple fine telangiectasias on the surface. We remark that one of them presented a segmental patch with two different morphologies and evolutions. The proximal part showed pebbled patches of bright-red hemangioma and presented proliferation and the distal part with a reticulated network-like telangiectasia morphology remained unchanged. We detected lower half of the body preference and dorsal region involvement preference without ventral involvement. The ulceration occurred in three patients with two different degrees of severity. Infantile hemangiomas (IH) are the most common tumour of infancy and childhood, usually absent at birth or present as a premonitory mark . The hallmarks of IH are their 3 clearly defined stages: they appear in the first weeks of life and undergo a rapid growth phase, followed by a period of slow involution with possible residual lesions , 2. ThisSome IH have a proliferative component equaling less than 25% of its total surface area. They resemble premonitory marks and they have been called in medical literature “minimal or arrested growth hemangioma”(IH-MAG) or “abortive hemangiomas.” Diagnosis of IH-MAGs can be difficult because they can present as a macular infantile hemangioma with a network-like and blotchy appearance and they are often mistaken for vascular malformation . We descWe report five patients seen between January 2010 and December 2015 with IH that did not show postnatal proliferation. All patients did not have family history of similar lesions and the rest of their physical examination was normal. We performed a punch biopsy and immunohistochemistry in all cases. GLUT-1 positive immunostaining was seen and it confirmed that it was IH-MAG.An 11-month-old Caucasian boy presented at birth an erythematous patch with a network-like and blotchy appearance in the dorsal surface of his right foot that extended onto the digits but not to the distal tip . He was A 4-month-old Caucasian baby girl presented at birth an erythematous scaly plaque with geometric border covering all lateral aspect of her right ankle as a sock-like distribution was seen. She was born full-term weighing 3.270 g, the result of the mother's first pregnancy and an eutocic delivery, with no personal or family history of interest. This plaque had bright-red papules, telangiectatic in appearance with a surrounding area darker in colour . The resA 2-month-old Caucasian girl presented at birth an erythematous scaly patch in the dorsal and lateral surface of the left foot extending onto the digits . She wasAn 8-month-old Caucasian boy was referred to our centre for a segmental patch with two different morphologies. The proximal part presented pebbled patches of bright-red hemangioma and the distal part extending onto the digits presented a reticulated network-like telangiectasia morphology . He was A 3-month-old Caucasian girl presented at birth an erythematous patch with prominent surface telangiectases on her dorsal arm . She wasThe characteristic clinical features at birth of IH and of congenital haemangioma are well established. HI are usually absent at birth or present in one-third as a premonitory mark in the form of telangiectatic papules, pale pinkish maculae, or mottled vascular stain. Its hallmark is its rapid postnatal growth beginning 2 weeks after birth and followed by slow involution .In our five cases, the lesions were present at birth and showed neither the typical morphology present in a RICH nor NICH. Then as the clinical presentation was not typical for either a congenital haemangioma or an IH, vascular malformation was considered in the differential diagnosis. A biopsy for histology study and Glut-1 antibody staining was performed in all cases. Glut-1-positive immunostaining was seen, confirming that it was true IH and not congenital hemangioma (RICH or NICH) or vascular malformation . In partWe present these five cases of IH-MAGs with three different morphologies localized on acral part of the extremities. The most common appearance was as reticulated erythematous patches with multiple fine telangiectasias on the surface as in cases 2, 3, and 5. The first patient had an erythematous patch with a network-like and blotchy appearance in the dorsal surface of his right foot that extended onto the digits. The fourth case presented a segmental patch with two different morphologies. The proximal part exhibiting pebbled patches of bright-red hemangioma and the distal part extending onto the digits had a reticulated network-like telangiectasia morphology. This last morphology had not been described before and in our experience we have not seen the other two morphologies described in IH-MAGs: grouped telangiectasias overlying normal-appearing skin or bluish plaques with normal or a pale peripheral halo .We reviewed the literature and we detected that IH-MAG frequently involved the lower half of the body . It is characterized by severe complications including intractable ulceration, tissue, and bone destruction. Additionally it can be associated with structural anomalies , 11. UlcThe presence of ulceration in an IH-MAG suggests that proliferation alone may not be the sole reason and that other mechanisms such as hypoxia or local environment may have a role.The natural history of IH-MAG is regression as other forms of infantile hemangioma. We detected that the involution phase is slower than usual and begins by about 1 year of age. Some of them do not require any treatment other than observation. The need for treatment in acral IH-MAG comes from ulceration showing a good response to propranolol as normal IH. They can leave residual lesions composed of a slightly puffy skin and telangiectasias.We present a subtype of infantile haemangioma with similar clinical course: present at birth, located on the dorsum of feet, and showing minimal and arrested growth and developing characteristic ulceration. We highlight the importance of performing immunohistochemical Glut-1 examination in order to confirm diagnosis when clinical features are atypical. IH-MAGs were more likely than IH to appear in girls, on the lower half of the body and on dorsal surface. Acral abortive hemangiomas were more likely to have a predominantly reticular morphology. Ulceration is a frequent complication of acral abortive hemangiomas.


Disseminated oligodendroglial-like leptomeningeal tumor is a recently acknowledged entity whose radiological characteristics have rarely been discussed before. Typical of the childhood period, it should be differentiated clinically and radiographically from granulomatous or infectious conditions such as tuberculous meningitis, which is more common in this age group. The key to the diagnosis, even at an early stage, might be the presence of tiny T2 hyperintense lesions on the surface of the brain or spine. When suspected, a meningeal biopsy should be performed to confirm the diagnostic. Disseminated oligodendroglial-like leptomeningeal tumors (DOLT), also called diffuse leptomeningeal oligodendrogliomatosis, are rare neoplasms with extensive dissemination in leptomeninges of brain and spine, with or without very small intraparenchymal lesions, most commonly depicted in the spinal cord . This raA four-year-old boy presented in October 2012 with a history of asthenia, vomiting, gait disturbance, and drowsiness lasting over two weeks. Neurologic examination revealed stiff neck, hyperreflexia in lower limbs, and moderate dysmetria. Blood samples showed no inflammatory syndrome. Brain and spine MRI demonstrated communicating hydrocephalus and diffuse leptomeningeal thickening and enhancement along the brain and spine, including few cranial nerves and nerve roots of the cauda equina Figure . LeptomeRepeated CSF analysis revealed slightly elevated proteins (82 mg/dl); bacteriology analysis was negative, and no neoplastic cells were found. PCR was positive for Mycobacterium tuberculosis. Intradermal test was negative.The placement of a venticuloperitoneal shunt and anti-tuberculosis treatment  associated with glucocorticoids resulted in a transient clinical improvement that lasted for two months. The lung lesion disappeared a month after the beginning of treatment. As from December 2012, the patient regularly suffered from early morning emesis, and in June 2013, he was admitted for neurological deterioration, including dysmetria, ataxia, and cranial nerve paresis associated with severe weight loss.He continued to clinically deteriorate despite a change in the anti-tuberculosis treatment and presented in May 2014 with repeated generalized seizures. MRI performed at that moment disclosed a raise in both the number and size of the small T2 hyperintense pseudocystic deposits, some of which were enhanced, along the parenchymal surface of the cerebellum, brainstem, anterior and medial temporal lobes, basal frontal lobes, thalami, and spinal cord Figure . The masSurgery with decompressive craniectomy of the posterior fossa, along with biopsy of meninges, was performed. Histopathological examination showed a leptomeningeal infiltration by oligodendrocyte-like cells with rounded nuclei and perinuclear halo, showing positive immunostaining for OLIG2 and GFAP Figure . Growth Chemotherapy (carboplatine and vincristine) was initiated, thereby helping to improve the patient’s clinical conditions. Follow-up MRI performed after 14 months of chemotherapy revealed no regression of the pseudocystic lesions along the surface of the brain and spine. Recent medical reports from October 2016 describe diffuse sensory-motor sequelae due to the diffuse leptomeningeal lesions as well as cerebellar disorders. Neurocognitive sequelae implied enrollment in a centre for children with special needs. Fits were also frequent due to an epileptogenic focus in the frontal lobe.A disorder similar to that of our patient was first reported in 1942, and it was designated as “oligodendrogliomatosis of the cerebrospinal pathway” . DiffuseA recent paper defined diffuse leptomeningeal oligodendroglioma-like neoplasm as a desmoplasia inciting tumor, principally or exclusively involving leptomeninges and made up of low-grade-oligodendroglioma-like cells that are extensively disseminated in the subarachnoid space . It typiThe neuroimaging profile is characteristic in advanced disease where innumerable, small pseudocystic implants are observed along the surface of the brain, mainly in the posterior fossa and spine, as reported in our case . The chaIn our case, the clinico-radiological settings associated to an apical pulmonary condensation and a PCR positive for mycobacterium tuberculosis initially led to anti-tuberculous treatment, even though other infectious tests were negative. The clinical improvement yet observed was probably related to the implantation of a ventricular shunt.To be able to suggest the diagnostic of DOLT early enough, the presence of pseudocystic T2 or FLAIR hyperintense lesions along the subpial surface of the spinal cord or the brain should be investigated. In our patient, those superficial pseudocystic lesions were seen in the initial MRI examination at the level of the cerebellum and brainstem.From an anatomopathologic point of view, these T2 or FLAIR hyperintense pseudocystic lesions along the central nervous system surface actually correspond to tumor cell infiltration with focal rarefaction of surrounding neural tissue, the tumor implants being embedded in a myxoid stroma 6. Micros5Widespread infiltration of basal cranial nerves by oligodendroglioma-like cells may be an additional feature that explains the enhancement along cranial nerves demonstrated in our patient . The preClinical course is generally marked by periods of stability or slow progression, although evolution towards anaplasia and aggressiveness has been described in few cases . Early tDiagnostic can only be confirmed through biopsy, since cerebrospinal fluid frequently merely shows increased protein levels while more rarely revealing lymphocytosis . CytologTo summarise, disseminated oligodendroglial–like leptomeningeal tumors are rare, low-grade, glial or glioneuronal tumors which predominate in the pediatric population. They are characterised by the presence of multiple, nodular cystic-like lesions scattered over the brain and spinal cord surface. Neuroradiologists and pediatric radiologists should be aware of the distinctive neuroimaging features of this entity and be able to recognise it even at an early stage. Indeed, this entity should not to be confused with an infectious or inflammatory condition, as early diagnosis is linked to better prognosis.


A 42-years-old male presented with left medial canthal swelling, accompanied with only mild epiphora. There was no history of dacryocystitis, mid-facial trauma, surgery, or bloody tears. On examination, there was an immobile, subcutaneous, non-inflammatory mass below the medial canthal tendon. Lacrimal irrigation showed blockade at the nasolacrimal duct. A computerized axial tomography (CAT) scan revealed a non-enhancing, low-density, cystic lesion at the inferomedial margin of the orbit. There were no signs of bony erosion, consistent with idiopathic acquired dacryocystocele. The patient underwent external dacryocystorhinostomy (DCR) with silicone tube intubation. The patient’s symptoms of epiphora resolved after surgery. Idiopathic acquired dacryocystocele with only epiphora, although rare, should be considered in differential diagnosis of medial canthal, non-inflammatory swellings. In areas with insufficient endoscopic facilities, external dacryocystorhinostomy gives similar promising results. An acquired dacryocystocele is a diffused enlargement of the lacrimal sac that forms as a result of a proximal or distal obstruction of the lacrimal drainage system. Swelling of the medial canthal region along with watery eyes are the most common symptoms. It is common in children but its incidence is very rare in the adults. Dacryocystocele is associated with irreversible fibrosis leading to the narrowing of the lacrimal system, ossification of the nasolacrimal duct, and low-grade inflammation . Adult dRadiographically, a dacryocystocele appears as a collection of fluid surrounded by a rim that separates it from the adjacent bony structures . DivertiA 42-year-old man presented with swelling at the medial canthus of the left eye associated with epiphora. The swelling appeared four years back and gradually increased in size. There was no history of dacryocystitis, mid-facial trauma, surgery, or bloody tears. On examination, there was an immobile, subcutaneous, noninflammatory mass below the left medial canthal tendon Figure . RegurgiA computerized axial tomography (CAT) scan revealed a 2.0 x 2.0 cm non-enhancing, low-density, cystic lesion at the inferomedial margin of the left orbit. There were no signs of bony erosion consistent with idiopathic acquired dacryocystocele  with silicone tube intubation. During the surgery, a clear, yellowish fluid was drained from the lacrimal sac. The lacrimal sac was biopsied and the fluid was sent for culture. The culture of the fluid was negative and histopathology of the sac showed a squamous epithelium with goblet cells. There were no neoplastic cells, confirming the diagnosis of idiopathic acquired dacryocystocele.The patient’s symptoms of epiphora resolved right after the surgery. The silicone tube is in place and it will be removed after six months.Acquired dacryocystocele, contrary to its congenital counterpart, occurs solely in adults and is a very rare condition . To labeDacryocystitis is a common complication that can occur with idiopathic acquired dacryocystitis. It was present in all patients in two case series conducted by Woo K, et al. and Xiao MY, et al. -6. EpiphConservative treatment with eye drops, lacrimal sac massage, and probing of nasolacrimal duct relieves the occlusion in congenital dacryocystocele, but in adults, surgical correction is the mainstay of treatment due to different pathogenesis . DacryocAlthough very rare, idiopathic acquired dacryocystocele should be kept as a differential diagnosis of non-inflammatory medial canthal swelling. Uncomplicated idiopathic acquired dacryocystocele presenting only with epipohora is an extremely rare condition that responds to dacryocystorhinostomy very effectively.


Aortoenteric fistulas (AEFs) are deadly, abnormal connections between the aorta and gastrointestinal (GI) tract. While secondary aortoenteric fistulas (SAEFs) are more common and arise after aortic reconstruction, primary aortoenteric fistulas (PAEFs) are generally caused by abdominal aortic aneurysms (AAAs). PAEFs may present with self-limited GI bleeds called “herald bleeds,” and the fistula often goes undiagnosed until patients undergo laparotomy for a massive GI bleed. We describe a case of a PAEF in a 79-year-old man with known AAA. Due to variable clinical presentations and the rarity of the condition, many patients with PAEF die before an accurate diagnosis is made. In interpreting computed tomography (CT) scans of AEFs, the role of the radiologist is critical in the management of PAEF patients. Aortoenteric fistulas (AEFs) are deadly, abnormal connections between the aorta and gastrointestinal (GI) tract, first described by Sir Astley Cooper in the early 19th century. While secondary aortoenteric fistulas (SAEFs) are more common and arise after aortic reconstruction, primary aortoenteric fistulas (PAEFs) are generally caused by abdominal aortic aneurysms (AAAs). Rare causes such as syphilis, tuberculosis, peptic ulcer disease, and malignancy have also been described . The incA 79-year-old man with a past medical history of non-operative AAA, hypertension, and atrial fibrillation was vacationing when he presented to a nearby hospital for both melena and large volume hematemesis. Computed tomography (CT) of the patient’s abdomen showed a saccular 11 cm AAA with fistulization into the third part of the duodenum Figures .A 3D reconstruction of the PAEF was also created Figure . The patThe patient was hypotensive with a blood pressure of 81/52 and heart rate of 107. Abdominal palpation demonstrated a pulsatile midline abdominal mass. On his right side, he had impalpable dorsalis pedis pulses, though they were audible via Doppler. Otherwise, his examination had no other positive findings.TM abdominal closure device  was placed. The patient was transferred to the intensive care unit (ICU) after hemostasis was obtained.The patient was consented for emergent surgery by vascular surgery. A midline laparotomy was performed with dissection down to the aorta. Reconstruction of the aorta using a Dacron graft was completed and augmented with mobilized omentum. Following this, the general surgeon excised the fistulous portion of the duodenum and ligated the remaining ends. An ABtheraThe patient tolerated the procedure, but he remained hemodynamically unstable secondary to five liters of intraoperative blood loss in addition to prior GI blood loss. He remained in the intensive care unit for eight days post-procedure at which time the health care proxy terminated supportive care.Diagnosis of a PAEF is often delayed due to its rarity. While 94% of patients present with a GI bleed, the classic triad of a palpable abdominal mass, abdominal pain, and a GI bleed presents only in 11% of individuals [Patients considered hemodynamically stable are usually evaluated with esophagogastroduodenoscopy (EGD). However, this technique only yields images suggestive of PAEF in a quarter of cases . CT remaCT, like other imaging modalities, has increased in overall use and detection rate as a diagnostic tool for PAEF. While EGD remains the necessary first-line investigation, CT is the best investigative tool if AEF is suspected. This is likely due to CT’s ability to detect indirect signs better than other modalities. Surgical technique has also been improving; at present, mortality associated with PAEF repair is 34% compared with 44% prior to 1994 . Therefo


Gastrointestinal stromal tumors (GISTs) originate from interstitial Cajal cells on intestinal pacemaker cells that arise from the muscularis propria of the gastrointestinal tract wall. GISTs are characterized by the expression of c-KIT protein  and are the most common mesenchymal tumors of the digestive tract. That protein, which is detected via immunohistochemical analysis, is the primary diagnostic criterion for a GIST. The rupture of a gastrointestinal stromal tumor of the peritoneal cavity is critical complication, although it is infrequently described in the literature. We describe the computed tomographic findings of a ruptured gastrointestinal stromal tumor of the jejunal wall with an accompanying abscess. We also review the clinical features, radiologic and pathologic findings, and treatment of similar previously reported cases. Gastrointestinal stromal tumors (GISTs), which are the most common ‘mesenchymal’ tumor of the gastrointestinal tract, are nonepithelial neoplasms that arise from the muscularis propria of the gastrointestinal tract wall. GISTs originate from interstitial Cajal cells on intestinal pacemaker cells , 2. GISTTumors can develop anywhere in the gastrointestinal tract. GISTs occur most frequently in the stomach (60%) and then most often in the small bowel (30%); other sites include the colon and rectum (5%) and the esophagus (< 5%) -4. GISTsAlthough there are a few reports of ruptured GISTs, this is to our knowledge the first case in the English literature of a GIST with an accompanying abscess.A 52-year-old woman with abdominal pain and tenderness, fever, and swelling of the lower abdomen of a few days’ duration was admitted to our institution. Physical examination revealed a palpable abdominal mass.A preoperative computed tomographic scan showed a huge primary calcified soft tissue tumor (18 x 13 x 7 cm) in the upper abdomen. A cystic component of the tumor and hemoperitoneum were also identified . One cysThe findings at surgery confirmed that the primary GIST site was identified from the preoperative computed tomographic scan. The primary tumor had ruptured on 2 sides, and what appeared to be a cystic pelvic lesion on computed tomographic examination was a large pelvic abscess. Culture of the abscess yielded Enterococcus species.The results of pathologic examination suggested that the primary lesion had originated in the serosa of the small bowel and had not invaded adjacent visceral organs. The mitotic index of the lesion was 3 mitoses per 50 high-power fields (HPFs). The tumor formed by spindle cells with round hyperchromatic nuclei and prominent nucleoli forming bundles immunohistochemically; the cells were diffusely positive for CD-117 (c kit) and focal and weak positivite for S-100; SMA, CD-34 and desmin were negative . ChemothIn the gastrointestinal tract, CD 117-positive cells  are autonomic nerve-related gastrointestinal pacemaker cells that regulate intestinal motility . BecauseA few previous studies have investigated ruptured GISTs by means of several radiologic modalities such as ultrasonography and computed tomography. A literature search yielded only 9 reports of ruptured primary GISTs to date. Cegarra-Navarro et al reported 5 patients with a ruptured primary GIST and 1 patient with a ruptured metastatic GIST [To our knowledge, this case is the second published report of a spontaneously ruptured GIST in the small bowel. Eight cases of a GIST with hemoperitoneum and 1 case of a GIST with concomitant hemoperitoneum and peritonitis have been reported , 7-9. OuThe computed tomographic findings of ruptured GISTs (noncontrast and postcontrast images) showed huge masses of low density with exophytic growth in the peritoneal cavity and ascites. These ruptured tumors are echogenic on ultrasonography and dense on computed tomographic scans (findings that suggest hemoperitoneum). The size of 3 of the 9 previously reported GISTs was less than 10 cm , and theSeven of the previously reported GISTs exhibited low mitotic activity (less than 5 mitoses per 50 HPF) . Two of All primary GISTs that were previously reported except 2 demonstrated low or borderline mitotic activity -8, but aMost of the patients with a ruptured GIST presented for urgent care and all patients underwent emergency laparotomy -9. SegmeTo our knowledge, a ruptured GIST with an accompanying abscess has not been previously reported. We describe the postcontrast computed tomographic findings, surgical correction, and histopathologic findings of a ruptured primary GIST and review the clinical and radiologic follow-up. In our patient, the operation was successful, and she did well after surgery.


Leiomyosarcomas of the inferior Vena Cava (IVC) are rare soft tissue sarcomas accounting for only 0.5% of all soft tissue sarcomas in adults with fewer than 300 cases reported. Extraluminal tumor growth along the adventitia of the IVC seems to be the common presentation. Intraluminal tumor growth is rare. The origin of the tumor is divided into three levels in relation to the hepatic and renal veins. The presentations and surgical modalities vary accordingly. Retroperitoneal tumors are often not diagnosed until the disease is at an advanced stage with large tumor growth and involvement of surrounding structures. This is partly because of the nonspecific clinical presentation as well as absence of early symptoms. Most patients present with abdominal or flank pain. Symptoms vary according to the dimensions of the tumor, growth pattern and localization of the tumor. Radical en bloc resection of the affected venous segment remains the only therapeutic option associated with prolonged survival. The goals of surgical management of these tumors include the achievement of local tumor control, maintenance of caval flow, and the prevention of recurrence. The involvement of renal or hepatic veins determines the strategy for vascular reconstruction. Reconstruction of the IVC is not always required, because gradual occlusion of the IVC allows the development of venous collaterals. However, when pararenal leiomyosarcoma of the IVC is present, reconstruction of the IVC and the renal vein is necessary to prevent transient or permanent renal dysfunction. Recent study has shown that radical surgery combined with adjuvant multimodal therapy has improved the cumulative survival rate. We report a case of IVC leiomyosarcoma in a young healthy woman along with details of its diagnostic workup and discussion of the surgical options and reconstruction of caval continuity. Primary vascular leiomyosarcoma is a rare tumor of mesenchymal origin and arises from the smooth muscle cells of the tunica media predominantly within the inferior vena cava , 2. ExtrThe origin of the tumor is described in relation to the hepatic and renal veins. The IVC is divided into three levels , 4-6: a)Retroperitoneal tumors are often not diagnosed until the disease is at an advanced stage with large tumor growth and involvement of surrounding structures. This is partly because of the nonspecific clinical presentation as well as absence of early symptoms. Most patients present with abdominal or flank pain , 4.Radical en bloc resection of the affected venous segment remains the only therapeutic option associated with prolonged survival , 4, 5. IThe goals of surgical management of these tumors include the achievement of local tumor control, maintenance of caval flow, and the prevention of recurrence. The involvement of renal or hepatic veins determines the strategy for vascular reconstruction.Reconstruction of the IVC is not always required, because gradual occlusion of the IVC allows the development of venous collaterals. However, when pararenal leiomyosarcoma of the IVC is present, reconstruction of the IVC and the renal vein is necessary to prevent transient or permanent renal dysfunction , 5, 7.We report a case of leiomyosarcoma of the IVC with discussion of the surgical procedure and reconstruction of caval continuity.A 47-year-old previously healthy female presented with abdominal pain and generalized discomfort over a span of 4 to 6 months. The patient had no exacerbating or alleviating factors. The respiratory, cardiovascular, and CNS system review was essentially normal.The abdomen was grossly soft, with no rigidity or guarding. Upon auscultation, bowel sounds were audible in all four quadrants. On deep palpation, there was a mass in the right upper and right mid quadrant with overlying mild tenderness.Her past medical history included nephrolithiasis and gastroesophageal reflux disease. Previous surgical history was significant for bilateral tubal ligation. Her family history was notable for bladder cancer in her mother. The patient denied taking medications or having any allergies. She was married, lived with her 3 children, and denied smoking, alcohol, and illicit drug use.Due to persistent discomfort, she was evaluated by gastroenterology by an upper endoscopy, ultrasound of the abdomen, and colonoscopy which were all unremarkable. The preliminary labs included a CBC and a Basic Metabolic Panel which were essentially within normal limits.Radiology work up included a CT scan of the abdomen and pelvis which revealed a 4.6 × 3.6 × 3.9 cm right paracaval mass extending to the right renal vein and artery alongside effacement of the inferior vena cava . In addiA CT guided biopsy was performed of the retroperitoneal/pericaval abdominal mass, and multiple core samples were obtained. Initial light microscopy evaluation of the sample demonstrated evidence of atypical spindle cells however, the precise type of cancer could not be determined on this exam. The core samples were sent to pathology for additional evaluation.A PET imaging scan was performed from the skull base to the mid-thigh with concurrently acquired low-dose CT for attenuation correction and anatomical localization. The scan showed a heterogeneous area of increased radiotracer activity in the upper right retroperitoneum in the region of the IVC. A large focus of increased radiotracer activity was noted along the right side of the uterus, more intense than usual for a benign fibroid. There was otherwise normal, physiological distribution of radiotracer activity throughout the visualized portion of the body. No other focal areas of abnormally increased activity were identified.After obtaining sufficient evidence that there were no pulmonary or hepatic metastases, the patient was cleared as a candidate for surgery. The small intestine and large colon were mobilized and lifted out of the way. The large mass was identified in the retroperitoneal space. The liver was mobilized, and dense attachments to the gallbladder were taken down.The inferior vena cava was completely mobilized and encircled near the iliac bifurcation giving us distal control of the inferior vena cava . The aorThe tumor, as well as the right kidney was resected off the IVC en bloc using a bevelling technique to preserve the orifice of the left renal vein within the confluence of the suprarenal cava and then transecting the infrarenal vena cava just above the bifurcation. With the tumor removed, a 20 mm Gore-Tex graft was then doubled approximately and an end-to-end anastomosis was completed using running 4-0 Prolene . This anThe closest margin was confirmed to be less than 1 mm and consisted of multiple mitotic figures per high-power field. The patient was subsequently classified as T1b N0 M0 AJCC stage IIA.A radically resected retroperitoneal/Inferior vena caval specimen was submitted to pathology for evaluation. The soft tissue was fresh, 251 grams in weight, and 11.5 × 6.5 × 4.0 cm in dimensions. On sectioning the IVC, the cut surface showed a 4.5 × 4.2 × 4.0 cm firm pink-tan to white lobulated mass . The masA uterus was also submitted to pathology which was 229 grams and 6.5 × 6.0 × 5.5 cm in dimensions. On sectioning, four firm irregular intramural masses were noted ranging from 1.2 cm up to 3.2 cm in greatest dimension. The cut surface of each was homogenous pink-tan to white whorled and bulging, grossly consistent with leiomyomata. No areas of calcification, hemorrhage, necrosis, or cystic degeneration were noted.Microscopic evaluation of the tumor revealed malignant spindle cells with marked nuclear atypia. The malignant spindle cells had elongated eosinophilic cytoplasm and elongated nuclei with rounded ends. The mitotic rate was 7/10 high power fields, with focal microscopic necrosis. The cells were arranged in fascicles .The patient had an unremarkable postoperative course and was discharged the following week. A limited non diagnostic post surgical CT scan was performed for placement of radiation therapy. No radiological evidence of lung metastases or lymphadenopathy was noted.Radiation therapy began with 10 mV photons being prescribed, 5400 cGy was delivered in 30 equal fractions and inverse treatment planning techniques were utilized to maximize dose to the target and minimize dose to the normal surrounding tissues, particularly the left kidney. Daily image-guided radiation therapy was utilized to facilitate precision of beam delivery.The patient tolerated adjuvant radiation therapy well. She is presently without clinical evidence of disease and is scheduled for repeat CT of the chest, abdomen and pelvis for restaging purposes and treatment course.Leiomyosarcomas are the second most common primary retroperitoneal tumor in adults , 8, 70-9Pathological features of the IVC leiomyosarcoma help in understanding clinical and radiological features better. In majority of retroperitoneal leiomyosarcomas growth is extrinsic to blood vessels. Tumors expand along tissue planes of least resistance often displacing adjacent organs. Direct invasion of the viscera is rare at least initially. The tumor is circumscribed by a pseudocapsule formed when the expanding tumor compresses adjacent organs. Intraluminal leiomyosarcomas are smaller than those that are extravascular. Often they present as nodular or polypoid masses attached to the vessel wall firmly. The cut section has a whitish gray whorled appearance. The intraluminal growth expands the IVC diameter, at times extending into the right heart and even into the pulmonary artery. Leiomyosarcomas with extraluminal and intraluminal growth pattern show great variation in the size of individual components. The finding of intra and extraluminal growth pattern is unique to leiomyosarcoma compared to other primary retroperitoneal tumors .Leiomyosarcoma on a microscopic level present a typical pattern of interlacing bundles of spindle shaped cells with blunt ended nuclei. Metastases to the liver, lungs and lymph nodes usually occur late. Recurrences are common, often exhibiting more aggressive histologic features than the original neoplasm .Leiomyosarcoma of the IVC are often limited in clinical expression. The main presenting symptoms are abdominal pain, a palpable mass and lower extremity edema. Symptoms vary according to dimension of the tumor, growth pattern and localization of the tumor , 10.Suprahepatic leiomyosarcoma generally present with intraluminal venous extension and may result in Budd Chiari syndrome with hepatomegaly, jaundice and massive ascites . The rigNoninvasive imaging modalities such as CT scan, USG and MRI are often used to diagnose these tumors. They provide valuable information regarding their origin, evaluating the presence of local invasion and excluding distant metastases. The sensitivity and specificity of CT in assessment of the tumors are 78% and 96% respectively and even higher with MRI (95-100%) . AscendiMultivisceral resection including the IVC is a technically demanding procedure but can be useful to allow extension of a potentially curable resection. Clinical conditions requiring resection of the inferior vena cava (IVC) are rare. Traumatic or iatrogenic injury, chronic post-thrombotic or membranous occlusion, and malignancy are the main indications. The notable malignant conditions include renal cell carcinoma, Wilms tumor, leiomyosarcoma, adrenal tumor, hepatic carcinoma, and retroperitoneal metastatic lymph nodes from testicular carcinoma .Operative management for tumors involving segment II and especially segment III are challenging. If the superior border of the tumor does not extend beyond the inferior hepatic edge, an abdominal approach is usually used, either by conventional laparotomy or preferably by right subcostal incision .If the subcostal approach is used, exposure of the infrahepatic and retrohepatic IVC can be optimized by extending the incision into a lombotomy with the patient in a slightly lateral decubitus position . A thoraKieffer et al mentions of the advantage of combining laparotomy with sternotomy over thoracophrenotomy . With miSome authors recommend wide tumor resection at a safe distance from the tumor , 8. PartSimple ligation is possible after complete or subtotal resection of the infra-renal IVC (segment I) and/or retrohepatic portion of the IVC (segment II) in association with resection of the right kidney. There is a difference in collateral circulation between the left and the right. Collaterals on the left  are generally sufficient for satisfactory venous return without occurrence of renal insufficiency. On the contrary, on the right there are no effective collaterals .In cases of incomplete obstruction of the IVC, ligation may be required especially if the procedure involves the gastrointestinal tract, whereby the risk of prosthetic infection is high. Pressure monitoring is performed in such cases to rule out excessive venous hypertension during clamping. As a general rule, a proximal pressure reading of 30 mm Hg or more indicates caval reconstruction to avoid postoperative edema of the lower extremity.Ringed reinforced ePTFE graft is prosthesis of choice for IVC replacement. It provides the best results, given the length of the missing segment and the need for strength to resist compression in the abdomen. Collapse of the graft may be an important factor in thrombosis. Many authors prefer a 20-mm-diameter graft for best congruency with the native vessel , 8, 10. Some authors strongly recommended the creation of an arteriovenous fistula to ensure patency. The fistula eliminates the need for long-term anticoagulation therapy.For infrahepatic IVC reconstruction simple clamping is often adequate. Complications such as arterial hypotension or proximal venous hypertension are rare and can be dealt with by associated clamping of the infrarenal aorta or supraceliac aorta. Vascular exclusion, indicated for tumors extending to the retrohepatic portion of the IVC allows to perform the upper anastomosis of the prosthesis near the infrahepatic veins so that hepatic circulation can be reestablished quickly thus reducing hepatic ischemia time , 11. VasFor surgical treatment of tumors involving the suprarenal segment of the IVC venovenous shunting with selective hypothermic hepatic perfusion may be helpful , 12, 13.Reports of long-term patency have been well documented in literature without anticoagulation although in our case we decided to administer anticoagulation therapy , 15. InfIn rare cases involving tumors with intracardiac extension, cardiopulmonary bypass may be required. Venous cannulations should be placed through the tip of the right atrium for the territory drained by the SVC and in the femoral vein or infrarenal IVC for the territory drained by the IVC. Some authors prefer to perform hypothermic circulatory arrest at 18 °C rather than normothermic cardiopulmonary bypass because the former provides a blood-free operating field.Right nephrectomy is often required for tumors involving segment II of the IVC, even if the kidney is not directly involved. If the tumor only brushes the ostium of the right kidney vein, autotransplantation of the right kidney can be performed into the right iliac fossa. This procedure requires prosthetic reconstruction of the IVC.Aggressive management of advanced abdominal tumors can produce long-term survival. The 5-year actuarial survival rate after curative resection exceeds 50% for renal cell carcinoma with caval extension and 28% for primary leiomyosarcoma , 15-17. The use of adjuvant treatment has evolved over the last decade. Contrary to prior belief, at the present time, radical resection followed by adjuvant chemotherapy is considered the optimal therapeutic strategy for tumors without metastasis at the time of initial diagnosis. Hines et al suggests that new radiation therapy techniques, especially applicable to tumors involving the infrahepatic part of the IVC, may prolong survival after surgical resection .Neoadjuvant therapy may be given to downsize the tumor and increase resectability rates. Nonetheless, when complete resection is not possible, debulking combined with radiation therapy still provides good palliation , 18.In another series, 14 patients with leiomyosarcoma of the IVC were treated with wide resection between 1978 and 1997; in this series, radiation therapy diminished local recurrence and improved median survival (6 months in 2 patients without irradiation compared to 51 months in 12 irradiated patients) . PatientChemotherapy, using adriamycin- ifosfamide or chemotherapy combined withradiation therapy offer potential adjuvant treatment options , 18. TheEven with radical surgery, 5- and 10-year survival of 49.4% and 29.5% respectively has been reported . With re


To describe a patient with lumbar angiolipoma mimicking schwannoma in the posterolateral side of the spinal canal with expansion of the left lumbar foramen and to discuss the clinical, radiologic, and surgical features of these lesions with literature.Without language restriction in this paper, the electronic databases; The Cochrane Collaboration the Cochrane, The Cochrane Library , ProQuest, US National Library of Medicine, National Institutes of Health (NLM) and PubMed dating from 1966 September to January Week 2 2017, were searched for comparative experimental studies using the terms: “OR”, “AND”. On-line literature searches were conducted using the key words “lumbar angiolipoma”, “schwannoma “, “spinal angiolipoma”, “spinal cord”, and “spinal canal”. We compared this research with our patient.Bilateral L2 total laminectomy, excision of the tumors and bilateral L2-L3 transpedicular stabilization were performed, and complaints improved prominently. Pathological examination was reported as angiolipoma.The research shows that a probable diagnosis in such tumor cases could be made by sufficient pre-op scanning before surgical operations and although angiolipoma has been rarely seen in lumbar posterolateral space, it can be seen in lumbar region and mimic schwannoma as producing symptoms and signs of spinal cord and nerve root compression. They generally occur under the skin. 2/3 of the cases are forearm based. Besides, they locate in the body and arm . AngioliSpinal angiolipoma is a rare specific clinicopathologic entity, which is to be distinguished from skin angiolipoma . Spinal Spinal angiolipomas do not often show infiltration, yet in some cases, infiltration to soft surrounding tissues and bone may occur , 11. SinAngiolipoma with lumbar posterolateral location is an extremely rare tumor , 11. In Schwannoma, which is known as norilemma, is based on benign peripheral nerve sheath stemming from a schwann cell. This is the most common solitary tumor of the peripheral nerves , 18. MalThe present study aimed to analyze the patient that mimics lumbar schwannoma, which is extradural posterolateral located in the lumbar area before the operation. In addition, it was intended to indicate spinal angiolipoma case, which arose suspicion regarding its malignity, along with a literature review as they infiltrated to adjacent bone and soft tissues which were seen during the operation.22. The history of smoking and alcohol did not present in the patient. The patient was referred to our clinics with back pain and having difficulty in walking due to weakness in her left leg which had aggravated last 3 months. After careful anamnesis, it was found that the patient had a history of the left hemiparesis that had started one year ago, due to the right-sided thalamic cerebrovascular occlusion. However, during the neurological examination, it was discovered that lower extremity weakness was relatively more significant than that was seen in the upper extremity.The patient was a 65-year-old-woman with body mass index 23 kg/mWhile nearly normal muscle strength was found due to cerebrovascular occlusion in the left upper extremity, 3/5 muscular force was detected in the left lower extremity of proximal extensor muscle groups. The patient had difficulty of knee extension which suggested primarily a pathology of L3 nerve root. Following examination of positive leg test, it was discovered that there was a motor deficit in lower extremity.In laboratory tests, no result was observed to consider hematologic malignity. However, it was not excluded the fact that the pathologic diagnosis was crucial for lymphoma. The biological and hormone values were found to be in the limits.A Magnetic Resonance Image (MRI) scan of the patient was immediately taken and a tumor was seen in L2-L3 disc level. It was in the left posterolateral extradural area and its long axis was parallel to the spinal cord.1A-1C). Moreover, there were heterogeneous hyperintensity in T1 and T2 weighted images detected on MRI, which expanded along left L2-L3 neural foramen causing extension in neural foramen whereas there were hypo intense focuses on T2-weighted images . Following contrast agent administration, in T1-weighted fat suppressed images, it was found that there was a lesion in which there was an intensive contrast enhancement.The tumor diameter was 3.2 cm in craniocaudal plane and it shrank on both sides. Anteroposterior diameter was 0.8 cm on the largest zone and the dural sac was found to be compressed slightly and postero-laterally by this mass . The patient was diagnosed with the tumor, which was thought to be schwannoma or lymphoma before the operation. Tumor excision was then performed and stabilization was ensured by using bilateral L2 total laminectomy, left L2/L3 facetectomy technique and bilateral L2-L3 transpedicular screw rod system [The lumbar computed tomography (CT) of the patient was also performed, it was found that lesion was seen isodense with spinal cord and caused extension in the left L2-L3 neural foramen and stenosis of the spinal canal  and examined under the light microscope.2A and 2B).Cautery artefact was seen in tissue fragments during histological examination. Besides, mature adipose tissue and tumor composed of abnormal vascular proliferation were mostly seen in the capillary structure. Fibrin thrombus was also the case in lumens of some capillary vessels. There wasn’t atypia and mitosis but abundant adipose tissue was seen in component of resected tumor tissue -34 and S100 were detected as well as positive stain. Stain with LCA and pancytokeratin were not detected. The Ki-67 proliferation index was found low.The patient was evaluated in line with angiolipoma. There weren’t infiltration of extradural soft tissues and bone.3The first spinal angiolipoma case was reported in 1890 by Berenbruch , 28. Howet al. divided spinal angiolipoma into two groups: noninfiltrative and infiltrative [Lin ltrative , 7. The ltrative , 4.The histogenesis of angiolipomas are not known. These tumors are most likely to be caused by abnormal primitive pluripotential mesenchymal cells which are differentiating in lipomatosis, angiomatous and mix tissues . Tumor iIn histological incisions, mature adipocytes and vessel proliferation comprised of vessels at the size of branching capillary are seen . In someIn tumor, the rate of fat tissue to the vascular compartment ranges between 1/3 and 2/3 , 8, 21. Immunohistochemical examination from the literature was performed in some cases and Ki-67 index is also lower in angiolipoma , 22. SpiAlmost all spinal angiolipomas are localized in extradural site. Most of these extradural angiolipomas are in posterior part in thoracic site . ThoracoIn literature, it is reported that typical angiolipoma is radiolucent in both plain radiography and CT. In addition, CT is adjuvant imaging method since vascular enclosing radiolucent may contain calcific sites , 26. Als1A and 1D). Also, CT show isodense mass with calcific foci expanding left neural foramen. L2 vertebrae foraminal enlargement could be understood on plain film. Multi-modality imaging should be performed on spinal epidural angiolipoma as well as on the breast [MRI and CT devices were used in order to diagnose the patient in the present study. Similar images that had been defined were seen in MRI images that were carried out by contrasted pharmacologic agents (Figs. e breast .Patient of this case had no family history, skin neurofibroma, 'cafe-au-lait spots' skin lesions, Lisch Nodule or optic glioma, but neurofibroma had not excluded with a low differential diagnosis. Because neurofibroma and as well as schwannoma may have similar radiological appearance on CT and MRI.Angiolipomas cannot be easily excised like lipoma because they are slim with irregular capsule. Wide local excision of angiolipoma minimizes the risk of relapse. Wide resection may require excision of a significant part of healthy tissue containing critical neurovascular structures. Excision of an important nerve or vessel is to be operated by considering high incidence of local recurrence of the tumor that was insufficiently excised with the purpose of gain wider bounds. For this reason, the surgery should be individualized .Application of tumor excision by laminoplasty and/or laminectomy in the area of tumor is a standard treatment modality in extradural located angiolipoma operations , 29.However, in literature, in the surgery of tumors with extraforaminal component, it is emphasized that facetectomy might be applied in treatment of tumors for the extraforaminal component. Afterwards, stabilization is recommended using transpedicular screw in order to prevent lumbar instability after tumor excision , 30. UnlAlso, the pre-operative malign tumor was suspected because of invasive radiological appearance, marginal resection of the tumor was planned and carried out in this patient. So that posterior transpedicular stabilization should had done.et al. studied characterization of histological types in order to contribute to treatment modalities in spinal cord tumors before operations [In literature, there are some studies indicating that malign transformation of angiolipomas may rarely seen . Althougerations . SimilarAs a result, it was found that a probable diagnosis in such tumor cases could be made by sufficient pre-op scannings before surgical operations and total excision and full treatment could be sustained by means of correct surgical techniques. Although angiolipoma has been rarely seen in lumbar posterolateral space, it can be seen in lumbar region and mimic schwannoma as producing symptoms and signs of spinal cord and nerve root compression.


Cerebellar liponeurocytoma is a rare central nervous system tumor, we investigate its biological behaviors and clinical prognosis to improve the understanding of this tumor. We retrospectively analyzed the clinical, radiological and histopathological findings as well as follow-up data of two patients with intraventricular liponeurocytomas in Beijing Tiantan Hospital between July 2000 and July 2016. The main clinical manifestations of the two patients were headache. The supratentorial intraventricular liponeurocytoma appeared as isodense to slight hyperdense on CT scan and heterogeneous intensity on T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI). The plaque-like hypodense on CT images and hyperintensity on T1WI resembling fat could be seen inside the tumor. The liponeurocytoma located in the fourth ventricle showed isointensity on T1 and T2WI as well as slight enhancement on contrast. Two patients accepted gross total resection of tumors. Two intraventricular tumors demonstrated similarly histopathological features, such as isomorphic small tumor cells with clear cytoplasm, sheets of monomorphic round cells and focal lipomatous differentiation. In addition, expression of synaptophysin, neuron specific enolase, microtubule-associated protein 2 and S-100 were found. No radiological or clinical evidence of recurrence of the tumors was observed in their follow-up surveys. In conclusion, intraventricular liponeurocytoma has a favorable clinical course, radiological features may be useful in the diagnosis of this rare tumor before surgery. Cerebellar liponeurocytoma is a very rare neoplasm of adults with distinctive morphologic feature of central nervous system (CNS). Some previous cases were reported as unusual tumor in adults under many different names such as lipomatous medulloblastoma, lipidized medulloblastoma and neurolipocytoma. The most accurate description was attributed by Bechtel et al in 1978, they first recognized the salient features of cerebellar liponeurocytoma such as advanced neuronal and focal lipomatous differentiation [The tumor was first introduced to the World Health Organization (WHO) classification in 2000 as a distinct entity under the heading of glioneuronal tumor among the CNS tumors , 4.This neoplasm develops predominantly in cerebellar hemisphere and vermis, occasionally in supratentorial lateral ventricle and the fourth ventricle. So far, approximately 47 cases of cerebellar, 11 cases of supratentorial intraventricular and 2 cases of fourth ventricular liponeurocytomas are on record in the English literature -11. CompComputed tomography (CT) and magnetic resonance imaging (MRI) can clearly show the features of the tumor such as location, size, component and aggression, and these features are very helpful to determine preoperative diagnosis and postoperative recurrence of patients with the tumor.In this study, we present the clinical, radiological and histopathological features as well as follow-up data of two cases of intraventricular liponeurocytomas, and also review the related literature. We discuss the characteristics of cerebellar liponeurocytoma that may prove useful in identifying this rare tumor.A 29-year-old man complained of episodic headache for 3 months, progressive aggravation and occasional vomiting. There was no seizure or disorder of consciousness, the patient had normal sensory motor examination. CT scan revealed an isodense to slight hyperdense round mass in the supratentorial right lateral ventricle. The diameter of the mass was approximately 4.5 cm. The lesion was heterogeneous, and an irregular hypodense similar to fat was observed within the lesion Figure . MRI shoThe lesion was operated through a right fronto-parietal craniotomy. Under operative microscopy, the mass was mostly located in the front of right lateral ventricle, the base of the mass was situated in the anterior of septum pellucidum, tightly adhering to the thalamus and thalamostriate vein. The mass was yellow-gray, soft suckable, moderately vascular and microcystic. Gross total resection of the tumor was achieved.The second patient was a 48-year-old woman presented with headache for 1 year, progressive aggravation and numbness of right upper limb. Physical examination showed the decline of superficial sensation of right limbs. MRI revealed an irregular mass with isointensity on T1 and T2WI, several microcysts and slight enhancement on contrast. The mass was located in the fourth ventricle, and involved the right cerebellar hemisphere and lateral foramen of the fourth ventricle Figure . The masThe neurosurgical excision of the tumor was performed by foramen magnum region craniotomy. The mass was located at the right side of the top of the fourth ventricle, grown down along the cerebellar medullary fissure to the middle of the second cervical vertebral plate, and compressed the medulla oblongata and upper cervical cord. The mass was well-defined, generally yellowish and moderately vascular. Gross total resection of this tumor was achieved.Histopathological examination showed yellowish coloration, granular calcification and lipomatous tissue in patient 1, and grayish appearance with lipoid tissue in patient 2, on the sections of gross specimen. For two cases, histopathology showed a background of isomorphic small neoplastic cells resembling neurocyte with focal lipomatous differentiation, round to oval hyperchromatic nuclei and clear cytoplasm. Besides the background, the tumors showed respectively the neoplastic cells arrayed intensively with a lot of aggregative cells between the nests of tumor cells in patient 1 Figure , and theBoth patients were admitted to our institute and received whole tumor resection, there were no adjuvant therapy. In subsequent years, two patients complained of no apparent symptoms. No radiological or clinical evidence of recurrence or residual of the tumor was observed during a nearly 2-year for patient 1 and 5-year for patient 2 follow-up.Cerebellar liponeurocytoma is a rare central nervous system neoplasm that was initially described as a mixed mesenchymal and neuroectodermal tumor of the cerebellum . The tumCerebellar liponeurocytoma usually appears to be solid mass relative to brain parenchyma on CT and MRI images, the presence of fat inside the tumor revealed on CT and T1WI are the characteristic findings, and the features are very helpful in distinguishing this rare neoplasm from other tumors such as medulloblastoma, ependymoma and central neurocytoma . The hypWith regard to histopathological features, liponeurocytomas in our cases had biphasic appearance including neurocytic neoplastic cells and focal lipomatous differentiation. The neurocytic tumor cells were arranged in sheet and possessed round to oval nuclei enclosed within clear cytoplasm. The focal lipomatous differentiation presented in clusters or scattered among small tumor cells. These histopathological features were also observed in other cases of intraventricular liponeurocytomas , 14. TheSimilar to liponeurocytoma occurred in cerebral ventricle, there are few reports on central neurocytoma with lipidized cells , 17, 18.Cerebellar liponeurocytoma generally has a favorable clinical course for its benign biological behaviors. However, the increased risk of recurrence should be taken into account when mentioned the atypical liponeurocytoma. It has been reported that the recurrence rate of cerebellar liponeurocytoma was about 31% . From thIn summary, intraventricular liponeurocytoma has distinctive morphologic and immunophenotypic features. The characteristic findings corresponding to fat content inside tumor on CT and MRI may be useful in differentiating this rare tumor from other neoplasms before surgery. Larger studies based on long-term follow-up are necessary to elucidate the clinical features and prognosis of cerebellar liponeurocytoma.This study was pre-approved by Beijing Tiantan Hospital Institutional Review Boards. We reviewed our records at the Department of Radiology and Neuropathology, Beijing Tiantan Hospital, a tertiary medical institution specialized for neurological diseases, over a period of 16 years from July 2000 to July 2016. Two cases of adult intraventricular liponeurocytomas defined by routine histopathological and immunohistochemical examinations after neurosurgical operation were found. One occurred in supratentorial lateral ventricle and the other located in the fourth ventricle. We reviewed the clinical, radiological and histopathological features, and contacted with the patients and their family members to get their serial follow-up data.elbow vein cannula, and contrast-enhanced T1WI was obtained.CT scan was performed with a Somatom Sensation 16 CT scanner . Scanning was conducted with 120 kVp, 310 mAs, field of view = 228, matrix = 512 × 512, and 5 mm slice thickness. MRI data were acquired on a 1.5 T MRI system . MR images were collected with the following parameters: axial T1WI FLAIR  and T2WI , field of view = 240 mm × 240 mm, matrix = 512 × 512, slice thickness = 5 mm, and four averages. A bolus of 4 mL/s of gadolinium-diethylene-triamine pentaacetic acid  was injected through an The excised tumor tissues were routinely processed. The sections were stained with hematoxylin and eosin (H&E) for routine histopathological evaluation. Immunohistochemical examinations were also conducted on representative sections using indirect immunoperoxidase technique with antibodies to NSE , GFAP , Synaptophysin , NeuN , S-100 , NF , MAP-2  and MIB-1 .


Eccrine nevus is a rare skin lesion with protean manifestations like hyperhidrosis, discolored nodules, papules, and so forth, which has been reported in various anatomic parts of the body including the forearm, leg, thigh, back, and coccyx. Our patient was a 26-year-old male, who presented with increasing colorless and odorless episodic umbilical discharge. First impression for the patient was an umbilical sinus and the patient underwent surgery. Histopathological study revealed the lesion to be an eccrine nevus of the umbilicus. This is the first case of eccrine nevus presenting with umbilical discharge. We recommend that eccrine nevus should be considered as a differential diagnosis for umbilical discharge. Eccrine nevus is a rare skin lesion with protean manifestations . It may We present a 26-year-old male with the chief complaint of umbilical discharge. The problem had started approximately 7 years ago with a gradual increase in the volume and frequency of colorless, odorless, watery-serous discharge. The discharge was recently happening several times a day, with each course lasting 10 to 15 minutes. The patient noted no exacerbating factor for the discharge and no umbilical discoloration or pain. He used to dry this discharge and manipulate the umbilicus with a towel several times a day. The past medical history was insignificant. On physical exam, he had normal vital signs with no fever. In abdominal exam, no erythema, tenderness, or odor was appreciated. Umbilicus was normal looking . HoweverUmbilical discharge can be the result of acquired pathologies, such as pilonidal sinus of umbilicus (suggested as the most common cause in one study), acute omphalitis , or congEccrine nevus is a rare lesion, with 20 cases reported till 2004, reviewed by Vázquez et al. [Another review by Dr. Tempark and Shwayder  includedOther interesting cases include a 3-month-old male with a congenital midline scalp lesion , an 11-yEtiology of eccrine nevus is unknown. The proposed pathogenic factors include congenital defects in embryogenesis, trauma, and stress, but none of them has been proven .Treatment of eccrine nevus can be very challenging. Different methods have been used including surgery , antidepTo the best of our knowledge, this is the second case of umbilical eccrine nevus and the first case of this kind with the chief compliant of umbilical discharge.Thus, we recommend that eccrine nevus should be considered as a differential diagnosis of patients presenting with odorless, colorless, watery, nonbloody umbilical discharge, after excluding fistula, sinus, and infectious process. We strongly recommend a biopsy in all cases similar to our case.


Intestinal loop stoma is a common surgical procedure performed for various benign and malignant abdominal problems, but it rarely undergoes spontaneous closure, without surgical intervention. Two male patients presented to our emergency surgical department with acute abdominal pain. One of them was diagnosed as having rectosigmoid perforation and underwent diversion sigmoid loop colostomy after primary closure of the perforation. The other was a known case of carcinoma of the rectum who had already undergone low anterior resection with covering loop ileostomy; the patient underwent second loop ileostomy, this time for complicated intestinal obstruction. To our surprise, both the loop colostomy and ileostomy closed spontaneously at 8 weeks and 6 weeks, respectively, without any consequences. Spontaneous stoma closure is a rare and interesting event. The exact etiology for spontaneous closure remains unknown, but it may be hypothesized to result from slow retraction of the stoma, added to the concept of a tendency towards spontaneous closure of enterocutaneous fistula. An intestinal stoma is an artificial opening made in the small bowel or colon to divert flatus, faeces or urine outside the abdomen, where they are collected in external appliances . Stomas A 64-year-old gentleman presented to surgical emergency with pain in the lower abdomen, constipation and fever of 2 days duration. Clinical examination showed tachycardia of 106 beats/min and blood pressure of 110/70 mmHg. Abdominal examination revealed mild abdominal distension with lower abdominal tenderness. Digital rectal examination was unremarkable.Contrast-enhanced computed tomography (CT) of the abdomen with rectal contrast revealed mural thickening involving the rectosigmoid region with contrast extravasation, and pneumoperitoneum suggestive of rectosigmoid perforation. The patient underwent emergency exploratory laparotomy. Intraoperative findings revealed 500 mL of purulent fluid in the pelvis and a 1 × 1 cm perforation at the rectosigmoid junction on its anterior wall, with oedematous and thickened bowel wall. The perforation was closed with absorbable interrupted sutures. A proximal sigmoid loop colostomy was carried out. The perforation margin biopsy revealed non-specific inflammation. At a 2-month follow-up visit, the stoma was functioning, along with rectal passage of stool. The patient also had a retracted but well-functioning stoma, without any complaints. Three week later, the patient visited the outpatient department, exhibiting complete closure of the stoma, while passing stools rectally without any difficulty. Also the complete epithelialization of the stoma site was noted . Now, atA 45-year-old gentleman presented with bleeding from the rectum and tenesmus that had lasted for 6 months. General and systemic examination was unremarkable. On digital rectal examination, an ulcerated mass was palpable, 6 cm from the anal verge. Biopsy showed moderately differentiated adenocarcinoma. Contrast-enhanced CT of the abdomen showed rectal malignancy with no distant metastases. The patient underwent laparoscopic low anterior resection with covering loop ileostomy. The post-operative period was uneventful and the patient was discharged on post-operative day 6.Histopathological examination of a specimen showed adenocarcinoma of the rectum. The pathological stage of the tumour was T3N0M0 (Stage IIA). The patient received 5 Fluorouracil based adjuvant chemoradiotherpy with radiation dose of 45 Gy/25# over 4 week. One month after completion of chemoradiotherapy, the patient presented to the emergency surgical department with features of acute small bowel obstruction. He underwent exploratory laparotomy, which revealed an ileal loop, proximal to the covering loop ileostomy was densely adherent to pelvis which was the transition zone for the obstruction. The densely adherent bowel was difficult to release and, hence, another loop ileostomy was made on the left iliac fossa, 10 cm proximal to the site of obstruction.Three weeks later, the right-sided covering loop ileostomy started functioning, with effluent also collecting partly in the left side stoma. The left stoma was gradually retracting and so was the effluent, with a corresponding increase of effluent in the right stoma. There was no intraperitoneal spillage of content. At 6 weeks following surgery there was complete retraction of the left stoma, with a completely functioning right-sided covering ileostomy. At 3-month follow-up, there was complete epithelialization of the left stoma site . Now, atIntestinal stoma (ileostomy or colostomy) is a common surgical procedure performed for various benign and malignant problems. These stomas are generally created when the distal anastomosis or bowel closure is precarious or the patient is presenting with perforation peritonitis, where closure of perforation is risky. When the purpose of creating a stoma is achieved, it is closed but, in the interim period, some patients may develop stoma-related complications such as dehydration, necrosis and retraction .Reports of spontaneous stoma closure are rarely found in the literature. We consider that these effects are probably due to the complications occurring with the stoma and we offer this insight into the mechanism of stoma closure by correlating the retraction of stoma and the process of healing of enterocutaneous fistula.The overall incidence of retraction of a stoma—either an ileostomy or colostomy—ranges from 1.4–9.0%. It can develop either in the early post-operative period, or as a late complication . These rIn both of our cases, spontaneous stoma closure can be explained by the mechanism of stoma retraction. In the spontaneous colostomy closure patient, it was the late retraction which added tension on the stoma, leading to gradual retraction with apposition and later fusion of the anterior stoma opening without any consequence. Similarly, in the second patient with spontaneous ileostomy closure, there was mucocutaneous separation—probably due to peristomal leakage and infection. This led to gradual retraction of the stoma and spontaneous complete closure of the ileostomy .Another possible mechanism to explain this phenomenon may be seen as spontaneous closure of an enterocutaneous fistula; stomas are iatrogenic enterocutaneous fistulae. With conservative management, 19–92% of post-operative fistulae heal spontaneously, as long as there is no distal obstruction, the bowel is not diseased and the patient is in an anabolic state . Even thTo summarize, spontaneous closure of a stoma is a rare event. The exact mechanism leading to closure is poorly understood; further studies, perhaps animal-based, may be required to obtain insight into the probable mechanism.Conflict of interest statement: none declared.


Pseudocarcinomatous hyperplasia of the fallopian tube is a rare, benign disease characterized by florid epithelial hyperplasia.The authors present the history and details of a 22-year-old woman with bilateral pelvic masses and a highly elevated serum CA-125 level . Ultrasonography and magnetic resonance imaging (MRI) of the pelvis showed bilateral adnexal complex cystic masses with a fusiform or sausage-like shape. Contrast-enhanced fat-suppressed T1-weighted images showed enhancement of papillary projections of the right adnexal mass and enhancement of an irregular thick wall on the left adnexal mass, suggestive of tubal cancer. Based on MRI and laboratory findings, laparotomy was performed under a putative preoperative diagnosis of tubal cancer. The final pathologic diagnosis was pseudocarcinomatous hyperplasia of tubal epithelium associated with acute and chronic salpingitis in both tubes.The authors report a rare case of pseudocarcinomatous hyperplasia of the fallopian tubes mimicking tubal cancer. Various benign conditions of the female genital tract may be confused with malignant neoplasms. Pseudocarcinomatous hyperplasia of fallopian tubes is a rare, reactive response to an underlying inflammatory or neoplastic process, and can mimic adenocarcinoma clinically and pathologically. Epithelial hyperplasia of a tube has been reported in association with estrogen administration, estrogenic ovarian lesions, tuberculous salpingitis, and nontuberculous salpingitis . Mild toSince this condition has not been discussed extensively in the literature, its differentiation from tubal cancer can be problematic , and morHerein, we present a case of pseudocarcinomatous hyperplasia of fallopian tubes with chronic salpingitis and endometriosis in tubes mimicking tubal cancer.A 22-year-old nulliparous woman presented with persistent lower abdominal pain and vaginal spotting of 4 weeks’ duration. She was referred to our hospital due to bilateral adnexal masses and a highly elevated CA-125 level . Pelvic ultrasonography showed well defined bilateral adnexal cysts with irregular thickened walls  either grossly or microscopically, whereas carcinomas do not.No previous report has described the imaging appearance of pseudocarcinomatous hyperplasia of the fallopian tube. In our patient, it was visualized by pelvic ultrasonography and MRI as bilateral tubular cystic adnexal masses with papillary projections of the right mass and an irregular thick wall on the left mass. Furthermore, both of these features were intensely enhanced on contrast-enhanced MR images. The detection of a dilated fallopian tube by imaging aids determination that a cystic mass has a tubal origin, and is visualized as a thin-walled C- or S-shaped tubular cystic structure. The fluid is anechoic or shows low-level echoes by ultrasonography, and hyperintensity on T2-weighted images and hypointensity or hyperintensity (if hemorrhagic fluid is present) on T1-weighted images , 6. In oRadiologically, pseudocarcinomatous hyperplasia of fallopian tube may mimic tubal cancer, chronic salpingitis, or tubal tuberculosis. Tubal cancer also manifests as a solid, cystic adnexal mass, and the presence of enhancing intraluminal masses within a dilated tube is suggestive of its presence. On the other hand, thick-walled tubular adnexal cystic structures with intense enhancement and surrounding inflammation are indicative of salpingitis. However, thickened tube folding due to inflammation can be mistaken for enhancing mural nodules, and sometimes make it difficult to differentiate chronic salpingitis and tubal carcinoma , 6.Pseudocarcinomatous hyperplasia of the fallopian tube is a rare disease and its radiologic features overlap with other fallopian tube diseases, such as, tubal cancer and salpingitis, and thus, intraoperative frozen section is needed to confirm the diagnosis.Serum CA125 levels may provide information preoperatively that aid the differentiation of benign and malignant adnexal masses , and levIn conclusion, pseudocarcinomatous hyperplasia of the fallopian tube is a benign, reactive response to an underlying inflammatory process. Accurate discrimination is dependent on the identification of morphologic features, because there are no characteristic immunohistochemical findings that aid the differentiation of pseudocarcinomatous hyperplasia and tubal carcinoma. Thus, a meticulous morphological assessment is required to avoid an erroneous diagnosis of tubal cancer and subsequent overtreatment of this benign disease.


Schwannomas of the paranasal sinus are uncommon. Less than 4% of schwannomas involve the nasal cavity and paranasal sinuses, even less in the pediatric age group. A case of schwannoma arising in maxillary sinus in a 2.5-year-old Chinese boy is reported. The basis for discussion of this case is the exceptional rarity of sinonasal schwannoma in pediatric patients. Schwannomas are neoplasms that originate from Schwann cells of the neural sheath, most of which are benign and well encapsulated occurring in middle-aged adults, between the ages of 40 and 60, with an equal gender distribution . SchwannA 2.5-year-old boy presented with a half-year history of nasal obstruction, rhinorrhea. There was no history of pain, fever, or trauma. Nasal stuffiness was aggravated gradually, in particular the right nasal passage, with nocturnal snoring and mouth breathing and without suffocation, headache, coma, and convulsions. Eyes secretions increased during the last 3 months, with frequent tears. The boy had a normal appetite, stool, and urine and did not have significant weight loss since the onset. A smooth surface bright red mass could be seen in the forepart of right nasal cavity with considerable purulent secretions in bilateral nasal cavity and without exophthalmos and lymphadenectasis. Bilateral external auditory canals were unobstructed, without fluid inside, and both had tympanic membrane integrity, though depression was observed in the right side. The rest of the patient's physical examinations were normal, without pigmentary changes of the skin or any other signs or symptoms of neurofibromatosis (NF); there was no family history as well.Unenhanced CT images revealed a round (diameter = 42 mm) expansive soft-tissue mass with stellate-shaped calcification which originated from the right maxillary sinus, invaded into ethmoid sinus, sphenoid sinus region, and forepart of the right nasopharynx and oropharynx, and prolapsed into ipsilateral nasal cavity, pressuring and remodeling the adjacent bony wall of maxilla, nasal septum, and sphenoid bone with most bony margins preserved and without teeth being involved . The posSchwannomas may develop virtually in all parts of the body, while the head and neck region is the most common site of origin accounting for 25% to 45% of benign schwannomas  and an eSchwannomas develop from any peripheral, cranial, or any autonomic nerve that has a Schwann sheath. It has been postulated that sinonasal schwannomas arise from Schwann cells of the ophthalmic and maxillary branches of the trigeminal nerve or from autonomic nerves to the septal vessels and mucosa , 7.Schwannomas are usually benign neoplasms that could take place in individuals with neurofibromatosis type 2 (NF2), a kind of autosomal-dominant inherited tumor predisposition syndrome induced by NF2 gene mutations located in chromosome 22, hallmark tumor of which is the vestibular schwannoma occurring bilaterally . It has Sinonasal schwannoma, in which the nasal cavity and ethmoid sinus were more frequently involved than other paranasal sinuses , are comCT imaging usually shows round expansile soft-tissue masses with the adjacent bony walls smoothly eroded and scalloped and with cystic or hemorrhagic degeneration often, especially in large tumors, without calcification generally . These lPostoperative histological diagnosis confirmed that the mass was a schwannoma. In the specimen two microscopic patterns, named Antoni A and Antoni B, were seen. The characteristic of Antoni A is extended spindle-shaped cells with elongated nuclei, arranged in bundles, drifts, and whorls, and Verocay bodies, while hypocellular Antoni B areas present very loose tissue composed by polymorphism of cells and abundant myxoid. In addition, scattered psammomatous calcifications were observed in specimens .The immunohistochemical study showed strong and diffuse immune response for S100 protein in tumor cells and negative response for CD34 or smooth muscle actin (SMA).Our case is distinctive because of a number of reasons. The age of our patient is unusual as most of these cases occur between the third and fifth decades of life according to reports –13, and