Objective. Ewing's sarcoma of the kidney is rare and is usually found in young adults. We present here a single case study of Ewing's sarcoma found in an elderly man. Material and methods. A 73-year-old man underwent routine surgery for hydrocoele of the testis. He developed urinary obstruction symptoms, and radiological examinations revealed a tumour in the right kidney. Results. Microscopical, immunohistochemical, and molecular pathological analysis of the tumour was consistent with Ewing's sarcoma. FISH showed rearrangement of chromosomes 22q12 (EWSR1). The patient subsequently underwent nephrectomy followed by 6 adjuvant chemotherapy cycles. Follow-up after 7 months shows no recurrence. Conclusion. This case report presents not only the rare finding of Ewing's sarcoma in the kidney, but also the occurrence of this tumour entity in an elderly patient. Treatment options for the different types of renal tumours are vastly different and the need for a correct diagnosis is, therefore, vital. Ewing's sarcomas are high-grade malignant tumours typically found in children and adolescents and are uncommon after the age of thirty. These tumours belong to the family of small-round cell tumours and are of neuroectodermal origin. They are mostly localized in bone or soft tissue of the extremities, the pelvis and central axis, and are rarely found in visceral organs.Ewing's sarcomas of the kidneys are rare although the incidence is increasing . In thisA 73-year-old man underwent surgery for hydrocoele of the testis. He had no other significant medical history. Due to postoperative symptoms of urinary obstruction, a CT scan was performed revealing a contrast filling tumour in the right renal pelvis and perirenal fatty tissue . There wHowever, an individual assessment should always be done striving to give the same treatment regardless of the patient's age. Our patient received a total of six chemotherapy cycles. He experienced fatigue from the 6-month-long treatment regimen and did not wish to continue. His 7-month-response evaluations with CT scan and chest X-ray showed no sign of recurrence.Gross examination showed a large tumour in the right kidney extending into the renal pelvis and through the renal capsule into perirenal fat, but not through the Gerota's fascie. The tumour consisted of solidly packed, strikingly uniform small round cells with scanty, pale cytoplasm and round to oval nuclei with sharp borders and one to two small nucleoli .Immunohistochemical analysis showed positive staining for vimentin, CD99 and CD 117 . The tumFISH showed rearrangement of chromosomes 22q12 (EWSR1). Real-time RT-PCR showed EWSR-1-FLI1 or EWSR1-ERG genfusion consistent with Ewing's sarcoma, supporting the FISH findings.Ewing's sarcoma of the kidney is rare. The majority are seen in young adults with a mean age of presentation between 28 and 34 years (range 4–69 years), and a slight male predominance [Ewing's sarcoma  belongs to a family of small round-cell tumours known as “The Ewing family of tumours.” They are derived from neuroectodermal cells and are localized both in soft tissue, visceral organs, and bone, the latter more commonly. PNET's can occur in numerous visceral organs including urogenital, intra-abdominal and intrathoracic organs, with kidney being the most common , 5. Renal cell carcinoma is the most common renal tumour and accounts for approximately 85% of all renal tumours and 2% of all new cancer cases in Norway according to data from the Norwegian Cancer Registry; hence, renal cell carcinoma has to be ruled out when finding a renal tumour in an elderly patient (>50 years of age). If the tumour shows a small round-cell pattern as in our case, the differential diagnosis ranges from malignant lymphomas, small cell carcinoma, small cell osteosarcoma, rhabdomyosarcoma, synovial sarcoma, and desmoplastic small round-cell tumours. When diagnosing Ewing's sarcoma, the combination of morphological findings, immunohistochemical analyses, and genetic changes together forms the base of the diagnosis. Our patient had a tumour that consisted of small round cells which stained positive for CD99. FISH showed the classic rearrangement that is seen in Ewing's sarcoma, and PCR confirmed this finding.Ewing's sarcoma/PNET has diagnostic genetical findings. The most common translocation is t  with EWSR1-FLI1 genfusion (>90%) , 6, 7. EThere are different views of the value of adjuvant chemotherapy in this group of patients. Several studies show the benefit of adjuvant chemotherapy –10 whils Ewing's sarcoma/PNET of the kidney is an aggressive tumour, and 5-year disease-free survival is reported around 45–55% –15. MukkEwing's sarcoma of the kidney is in itself a rare diagnosis. This tumour is generally seen in young adults in bone and soft tissue of the extremities and pelvis. This case shows that Ewing's sarcomas in the kidney may occur in all ages. The treatment options for the different types of renal tumours are vastly different and the need for a correct diagnosis is, therefore, vital. The best practice treatment today is based on both surgical dissection and chemotherapy.The authors declared that there is no conflict of interests.


Minimal deviation adenocarcinoma (MDA) of the uterine cervix, otherwise known as adenoma malignum, is a rare variant of cervical adenocarcinoma, which represents a diagnostic challenge in the field of gynecologic oncology, due to its benign-resembling histological characteristics. To achieve a better understanding of this disease, we present two cases of MDA: one case presented with profuse watery discharge and cervical enlargement, accompanied by retention cysts and hardening; the other presented with a history of myoma cervicis uteri. Both patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy and our follow-up indicated that the patients were still free of any disease. Subsequently, a literature review was performed and the results demonstrated that early diagnosis, clinical stage and surgical protocols are the main factors affecting the prognosis of MDA. Close follow-up of the cases may provide more information regarding this disease and the efficacy of the available therapeutic methods. Minimal deviation adenocarcinoma of the uterine cervix (MDA), otherwise known as adenoma malignum, is a rare variant of cervical adenocarcinoma, which represents a diagnostic challenge in the field of gynecologic oncology. It is a rare neoplasm with an incidence of 1–3% and was first designated as ‘malignant adenoma of the cervix’ by Gusserow  proposedIn this study, we present two cases of MDA, in order to demonstrate the characteristics, diagnostic and therapeutic strategies that distinguish it from ordinary endometrioid adenocarcinoma.A 45-year-old, multiparous woman  presented with a 5-year history of large amounts of vaginal discharge. The ThinPrep cytology test revealed moderate inflammation. Several transvaginal ultrasonography scans revealed an edematous cervix and multiple cysts with a honeycomb appearance . The innGrossly, the cervix was thickened and hard with multiple retention cysts, with no other abnormal macroscopic findings . The micA 41-year-old, multiparous woman (G6P1) underwent myomectomy for a cervical hysteromyoma in 2011 and pathological examination of the hysteromyoma revealed an MDA. The patient was medically fit and in good overall condition. Her medical history revealed myomectomy and oophoritic cystectomy (10 years ago). The gynecologic examination showed cervical moderate inflammation, with no other abnormal findings. The patient subsequently underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy.The gross uterine appearance was normal, apart from an enlarged corpus. The microscopic examination revealed cervical chronic inflammation with retention cysts and squamous metaplasia, adenomyosis and chronic salpingitis. The pelvic lymph nodes exhibited reactive hyperplasia, with no other abnormalities. The tumor was stage Ib and there were no high risk factors for the patient; therefore, adjunctive therapy was not administered. At the last follow-up the patient exhibited no evidence of tumor recurrence.To gain more insight into MDA, we performed a review of the literature, during which 60 cases were identified . In almoet al and cervical conization contribute to the definitive diagnosis of MDA . DiagnosIn conclusion, early diagnosis followed by appropriate ancillary evaluation and treatment have been a challenge for gynecologists. Close follow-up of established cases is essential in gaining more information regarding the disease and the efficacy of the available therapeutic methods.


Chondrosarcoma of the mandible is rare, especially in children. The available literature consists mostly of a few case reports which are partly integrated in small studies. Growing this small pool of literature is helpful in solidifying knowledge about this disease and facilitating appropriate treatment for children. Therefore, we present such a case in a 12-year-old boy, exhibit comprehensive and relevant information concerning this entity, and discuss our findings in the context of other publications.  A 12-year-old boy was referred to our ambulant institution for an MRI examination of the right temporomandibular joint (TMJ). He reported to have received a hit on the right side of the face 6 months earlier and from that moment experienced intermittent cheek swelling and pain in combination with an incomplete ability to open the mouth. However, no diagnostic imaging was conducted since then. At the day of presentation, a distinct swelling around the parotid gland was observed. In his medical history, allergic asthma and neurodermitis were documented.The MRI scan revealed several findings. Extending from the middle third of the mandibular ramus to the mandibular head, the bony structures were enlarged with multifocal loss of bony cortex. Alterations in bone marrow signal intensity were encountered, T1-weighted signals were hypointense, and T2-weighted signals were isointense. The TMJ was not involved. A 33 × 28 × 25 mm measuring soft tissue mass was visible partly overlying most of the medial aspect of the mandible and infiltrating the temporal and masseter muscles Figures . No suspIn the following stationary setting, the patient was discussed within a multidisciplinary pediatric oncology tumor board. He received a PET-CT examination for staging reasons. The right mandible and its surrounding muscles showed a solitary FDG avid mass with no other evidence of disease. CT with oral and intravenous contrast confirmed subtotal destruction of the right mandibular head and both osteolytic and osteoblastic lesions in the mandibular ramus, matching the MRI results. The tumor was staged T2 N0 M0.To classify the tumor surgical bone biopsy was performed to retrieve multiple osseous tissue samples. The pathology result and reference pathology were consistent with chondrosarcoma.Wide resection was executed en bloc together with the biopsy scar and track followed by adequate reconstruction. Chondrosarcoma is the second most frequently seen malignant bone tumor after osteosarcoma, accounting for about 20%. In adulthood, it is one of the most frequently occurring bone sarcomas. The tumors develop as primary entities or secondary to malignant transformation of benign enchondroma and osteochondroma. Syndromes of familial multiple enchondroma like Maffucci and Ollier as well as hereditary multiple exostoses (HME) are related to an increased risk of secondary chondrosarcoma, in the latter case affecting younger patients. The patient age ranges from 1 to 75, averaging between 30 and 60 years.Generally, the tumor can arise in every region of the body where cartilage is present but it usually emerges from the axial skeleton, pelvic girdle, femur, humerus, vertebra, shoulder, sternum, or ribs . About 90% of chondrosarcomas are classified central and are located intramedullary, 5% are extraskeletal myxoid, 2% each are mesenchymal and periosteal , and 1% are clear cell.There is no distinct gender predominance in conventional chondrosarcoma.The mesenchymal type, which contains an extensive soft tissue component, appears in younger patients (second to fourth life decade) and is accompanied by a poorer prognosis . The periosteal subtype is less aggressive and has a better prognosis . Based on the mitotic index, cellularity and tumor size, low (80–90%) and higher grade malignancies were differentiated by Evans et al. in 1977, and this grading system is still most commonly used . Low grade (G1) malignancy has an ample chondroid matrix with initial signs of hypercellularity, chondrocytes with an increased size, and sometimes slightly hyperchromatic, near normal nuclei forms. Slight-to-moderate atypia is seen but mitoses are quite rare.Higher grade (G2/G3) malignancies have a less chondroid and more myxoid matrix, a higher degree of hypercellularity, a progressive increase in nuclear polymorphisms and enlargements, an increasing mitotic activity.An additional immunohistochemical analysis of the biopsy can be helpful by checking the cellular proliferation markers Ki-67 and Cyclin B1, which are often increased.Chondrosarcoma occurrence in the head and neck region is reported to be seen in only 5–12% of cases, involving mostly the maxilla, nasal septum and cavity, ethmoid bone, and sphenoid bone. Out of this minority of cases, the mandible accounts only for 10%, involving mostly the molar regions and mandibular symphysis. Chondrosarcoma in the ramus, head, or even TMJ is of absolute rareness [However, especially the TMJ is a challenging location due to functional and aesthetic aspects like ingestion, speech, and facial expressions. Comparing the involvement of the maxilla and mandible, patients with the latter have been reported to be 4 years younger in average, explained by the fact that the mandible is more forming of the facial appearance and the maxilla offers more inner space to hide the tumor, causing a difference in the rapidity of diagnosis. The same explanation applies to the fact that chondrosarcoma of the mandibular symphysis seems to have the best prognosis .Mostly pain and progressive, often painless, swelling are reported at doctor consultation. Those symptoms in the region of the TMJ, especially in combination with biting or chewing difficulties, are often misinterpreted as TMJ disorders. This can cause a significant delay in finding the correct diagnosis. If the tumor arises in the molar regions, loosening of the associated teeth and widening of the periodontal ligament spaces are important warning signals, especially for the dentist .In our case, the patient reported a trauma as the starting point for the symptoms. This phenomenon has been documented in previous studies in a minority of patients and should therefore be an investigation parameter in possibly upcoming studies .Diagnostic imaging is an important part of the diagnostic workup, especially to evaluate the size of the tumor, which has been reported to average at 4 cm, ranging from 1 to 12 cm, matching our maximum diameter of 3.3 cm .The tumor site is another fundamental parameter because a solitary involvement of the medial cortical aspect of the mandible can cause a diagnostic delay due to missing symptoms while involvement of the lateral site leads to swelling, pain, and dysfunction. We could confirm this in our case in which the medial site was affected more so that the patient waited 6 months before seeing a doctor. Several radiological modalities are beneficial. Conventional radiography is often the first modality performed in the course of events and findings consist mostly of variable radiolucencies.For further evaluation, MRI should be performed to have an overview of bone and soft tissue involvement and CT to assess the degree of bone destruction and the presence of calcifications. Those signs raise suspicion of a malignancy but are not pathognomonic for chondrosarcoma. Osteosarcoma can appear similar although calcifications are much more infrequent. Ultimately, biopsy has to be performed to establish the definite diagnosis.In conventional chondrosarcoma, distant metastases are rare but sometimes seen in advanced or recurrent diseases. When they occur, they are usually detected in the lungs and bones, infrequently in lymph nodes, so that a neck dissection is not obligatory.For the TMJ region, there are no reports about distant metastases in G1-chondrosarcoma, while they were seen in 10% of cases in G2-chondrosarcoma and 71% of cases in G3-chondrosarcoma .Concerning therapy, due to a slow growth rate chondrosarcoma is little sensitive to radiochemotherapy, which is reserved for cases of unresectable tumor and incomplete resection margins and as an adjuvant therapy for patients with high grade tumors .Radical surgery is the treatment of choice and surgical bone and soft tissue resection margins of 2-3 cm need to be tumor-free and are otherwise related to a poor prognosis.After successful surgical therapy with inconspicuous resection margins, the 5-year survival rate is still only 50%, by reason of a tendency to recur locally uncontrollable. Prognosis is generally poorer in the head and neck region than in more frequently involved body parts.Regarding pediatric patients with chondrosarcoma of the head and neck, we found one comparable case report of an 11-year-old girl with a chondrosarcoma of the TMJ. The main difference was that in our case the tumor did not actually reach the TMJ, affecting only the mandible [In addition, we found a publication investigating primary chondrosarcoma of the head and neck in the pediatric age group, consisting of 14 patients of 18 years or of younger age with a mean age of 11.8 years. No genetic dispositions were detected. The tumors were mostly low grade and had a peak incidence in the maxillary sinus and mandible. The long-term prognosis was stated to be excellent .Apart from this, pediatric cases were integrated in general chondrosarcoma studies, for instance, in reports from 1992 of 28 cases with 21.4% children or from 1995 of 634 patients with 2.2% children.In both reports, the tumor in children was not more aggressive than in adults and there was no significant difference in the survival rate , 13.


Rosai-Dorfman disease (RDD) is a rare, benign pseudolymphomatous condition, predominantly involving lymph nodes. Rosai-Dorfman disease (RDD) (sinus histiocytes with massive lymphadenopathy) rarely affects the intracranial region without involvement of other sites. It is a rare and idiopathic histoproliferation disorder characterized by painless lymphadenopathy. We report a case of 43-year-old male who presented with unconsciousness; MRI was done and right temporofrontal mass was found. Excision was done, and on histopathology it confirmed RDD. Rosai-Dorfman disease is a benign lymphohistiocytosis that often involves lymph nodes and presents as massive lymphadenopathy with sinus histocytiosis characterized by painless cervical lymphadenopathy, fever, leukocytosis, elevated ESR and polyclonal hypergammaglobulinemia. The disease was first described by Destombes in 1965 and later, in 1969, Rosai-Dorfman disease was first reported by Juan Rosai and Roland Dorfman as sinus histiocytosis with massive lymphadenopathy in young black males. RDD predominantly affected the children and young adult with mean age of 20.6 years but can be seen in the range of 1 to 74 years old. There is a slight male to female predominance  .α was found negative.43-year-old male was referred to our hospital in December 2012, with history of new onset of sudden fainting attack at home for 8 min 4 days ago. He was unconscious for 8 min but with no seizure, no mouth frothing, no uprolling of eyes, no headache, no nausea, vomiting. At local hospital he has done MRI and found right temporofrontal lobe mass with edema. Four days later he came to our hospital in outpatient department of neurosurgery for further checkup. On the time of arrival in our hospital he was fully conscious and well oriented; GCS 15/15. He has never experienced this symptom before. There was no significant past history, no family history; hearts and lungs are clear. Vitals are within normal limit. Patient had normal movement, symmetrical pupil size, normal head wrinkle, normal facial expression and lymph node not palpable. On abdomen, spider nevi sign was seen. Muscle power was 5/5. Pathological sign was negative. He is smoker and consumes alcohol occasionally. MRI (Siemens 3.0 T) with contrast was repeated and showed right temoporofrontal lobe mass, subdural mass, corona radiate edema, and B/L sinusitis. Differential diagnosis was made on meningioma and glioma. EEG was unremarkable. CT scan was performed and showed left lower lung nodule and chronic inflammation. Partial removal of right temporofrontal mass was done and 5.5 × 4 × 2.5 tissue size was found, which was grey yellow in color. Sample was sent for histopathology, and Rosai-Dorfman disease was confirmed. The rest blood test included ESR, WBC, CRP, TC, DC, and HB which were normal. Urine test and tumor markers were normal such as AFP, Ca199, and Ca152 except CEA which was found as high as 8.35 . Histopathology reported that S-100 protein was found positive and CDRosai-Dorfman disease rarely occurs in CNS. Most of time it occurs in cervical lymph node. Postulated causes include infectious causes, immunodeficiency, autoimmune disease, and a neoplastic process; however, none has been substantiated . Regardiα-1-antichymotrypsin, CD68, EMA, and MAC387 antibodies [α, and LCA with negative CD1α, CK, EMA and GFAP shows in Histopathologically, the Rosai-Dorfman disease infiltrate shows “sinusal” lymph node architecture with clustering of lymphocytes simulating the appearance of germinal centers. The characteristic histopathologic feature is emperipolesis tibodies –7. The cMultiple strategies of therapy have been used with varying success, including radiation therapy, chemotherapy, steroids, and surgery . SurgicaRosai-Dorfman disease is benign. Although Rosai-Dorfman disease is a rare process, we present a case of extranodal RDD involving Rt. Temporo-parietal intracranial region. It should be included in the differential diagnoses for a dural mass mimicking meningioma or cerebral mass mimicking glioma. It can be misinterpreted as plasma cell granuloma, plasma cell rich meningioma, and Langerhans cell histiocytosis in histopathological examinations due to an intense infiltration of inflammatory cells. Thus, a definite diagnosis relies on the histological pattern and immunohistochemical characterization of the lesions. Therefore, immunohistochemical staining for EMA, S100, and CD1a should be performed. Surgical excision of the lesion is the treatment of choice. In cases with subtotal tumor resection or recurrence of the lesion, adjuvant therapy with local low dose radiotherapy and steroids can be considered. Prognosis is benign especially in the absence of nodal disease.


Dermatofibrosarcoma protuberans (DFSP) of the vulva is a rare low-grade soft tissue sarcoma. Magnetic resonance imaging (MRI) findings of vulvar DFSP were essentially unreported in the literature.We report a DFSP of vulva with its clinical, histological and MRI features. As far we know this is the first case of histologically confirmed vulvar DFSP presenting with MR images. The diagnosis of DFSP is usually made by histopathologic and clinical findings.MRI is useful both for the diagnosis of DFSP and following up the patients since it has high soft tissue resolution and no risk of radiation exposure. With MRI the relation to the adjacent anatomical structures, extension and depth of the tumour and possible lymph node involvement can also be demonstrated. Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade soft tissue sarcoma that occurs in dermis and usually invades the subcutaneous tissue and muscles.A 60-year-old woman complaining of slowly growing foci of nodular mass extending beyond left vulva towards the left groin was admitted to our hospital. Physical examination revealed an approximately 6 cm erythematous plaque. MRI including T1 and T2 weighted (W), short tau inversion recovery (STIR) and contrast enhanced fat-suppressed T1W sequences were performed. On T1W sequence, the lesion was hypo intense; on T2W and STIR sequences it was hyper intense and after the administration of contrast-material it was enhanced heterogeneously . There wThe patient was operated. Wide resection was performed and rectus abdominis muscle-skin flap was adapted to the defect area. Histologic examination revealed a tumour specimen in a storiform and honeycomb pattern which was stained positive for CD 34 and vimentin indicating DFSP . The patDFSP is a rare low grade soft tissue malignancy and is characterized by local invasion and recurrence.2American Musculoskeletal Tumour Society set a staging system considering the tumour grade and compartment.8DFSP may be asymptomatic with its characteristic clinical appearance as an irregular flesh-coloured, reddish-brown to bluish nodule or violaceous plaque. It usually occurs as a solitary lesion but multiple foci could be seen.DFSP could dedifferentiate to the high grade sarcomas with an increased risk of local recurrence and metastasis. Advanced age, high mitotic index and increased cellularity are associated with poor outcome as well.Ultrasonography (US) or computed tomography (CT) could demonstrate DFSP as a heterogeneous subcutaneous solid mass with spiculated or lobulated margins.10DFSP is frequently iso intense or hypo intense to muscle on T1W images, and iso intense or hyper intense on T2W sequences. The margin of the lesion is best seen on short tau inversion recovery (STIR) sequences. On contrast-material enhanced images, it enhances heterogeneously due to the foci of haemorrhage, myxoid change, and tumour necrosis.All of the preoperative MR sequences of the presented patient demonstrated that the contour of the lesion was irregular and there were some multiple millimetres’ foci with variable signal characteristics. We believed that these foci represented the haemorrhage, myxoid change, and/or tumour necrosis as reported in the literature. Besides, the existence of lipomatous area at the centre of the lesion could be important in the diagnosis of DFSP as in our case. All of these mentioned MRI findings which were not clearly indicated in literature could be useful in differentiating DFSP from the other soft tissue sarcomas, but however it can overlap.9DFSP can also be distinguished from other soft tissue since it is generally a large-sized tumour, it has suspicious deeper component, and it has history of recurrent lesion and recurrent excision with positive surgical margins.10DFSP of our patient had the characteristic clinical appearance and it was diagnosed by histological examinations after the patient was operated. Thus, we performed only MRI after the physical examination since US or CT was unnecessary for our patient.A wide surgical resection with a margin of 2–3 cm of normal tissue is recommended as the optimal treatment for both primary and recurrent DFSP. Mohs micrographic surgery has presented as an alternative approach as well. Wide surgical resection with skin-muscle flapping was preferred for our patient.DFSP of vulva is a rare low grade soft tissue sarcoma. The diagnosis is usually made by histological examinations after suspecting clinical findings. Radiologic examinations are necessary in some conditions including large tumour size, suspicious deeper component, recurrent tumours, critical locations and recurrent excision of DFSPs with positive surgical margins. MR is the most appropriate radiologic methods since it has good soft tissue contrast resolution can demonstrate the relation to the adjacent anatomical structures, extension and depth of the tumour and show the possible lymph node involvement. Also it is useful as a follow up method.


Clostridium perfringens in an adult patient with noncirrhotic ascites and a Krukenberg tumor.Secondary bacterial peritonitis, in comparison to spontaneous, presents with a surgically treatable intraabdominal source for infection such as a gastrointestinal perforation or abscess and is nearly always polymicrobial. We present a rare case of secondary bacterial peritonitis from  Clostridium perfringens in an adult patient with noncirrhotic ascites and a Krukenberg tumor.Secondary bacterial peritonitis presents with a surgically treatable intraabdominal source for infection, such as a gastrointestinal perforation or abscess, and is nearly always polymicrobial . With a 2 41, albumin 1.8, prealbumin 8.5, transferrin 85, International normalized ration (INR) 1.7, partial thromboplastin time (PTT) 56.2, and normal liver function test other than an elevated alkaline phosphatase level of 284. A 51-year-old white female with a known history of metastatic gastric cancer receiving chemotherapy  presented with a 12–24 hour history of nausea, bilious emesis, trivial hematemesis, mild abdominal pain, and distention. On presentation, she was lethargic, hypoxic, hypotensive, and minimally responsive though alert and oriented. Her last dose of chemotherapy was three days prior. Laboratory evaluation revealed a WBC of 1.5 with 80% bands, creatinine 2.13, ABG 7.31/34/53/16/−9/85%, lactic acid 9.9, CvOOther than metastatic gastric cancer, her medical history was only significant for biliary and right ureteral obstruction (secondary to metastasis), which necessitated prior placement (over a year preceding her presentation) of biliary and ureteral stents for decompression. She had no surgical history, was on Lexapro, Nystatin, and her chemotherapy regimen, and was without allergies. She did not smoke or drink and had no family history.2 of 94% on a 100% nonrebreather. She appeared cachetic and in distress. Her abdomen was distended, firm, minimally tender without overt signs of peritonitis, and an upright CXR revealed free air under both hemidiaphragms. After aggressive fluid resuscitation, which led to improvement in her vital signs, an abdominal and pelvic computed tomography scan was obtained, exposing significant intra-abdominal ascites and a large nonhomogenous cystic mass-like structure in the pelvis surrounded by numerous air bubbles, along with scattered free air throughout the peritoneal cavity  is an extremely rare, though known, event with only a mere handful of cases reported in the literature [Escherichia coli and Klebsiella-pneumoniae). Isolation of aerobic organisms is seen in roughly 25% of cases, with streptococci and enterococci being the most frequently isolated species [Isolation of terature –7. Most  species . Seconda species . In the face of a nonsurgically identifiable cause of bacterial peritonitis (spontaneous), intestinal bacterial overgrowth, intestinal permeability, bacterial translocation, and alterations in the immune, reticuloendothelial, and ascitic fluid defense systems are all hypothesized to play a part . IntestiClostridium perfringens. Though the right ovary appeared to be the source for the C. perfringens, this cannot be concluded with absolute certainty. We hypothesize that with her severe protein calorie malnutrition, ascites, and altered humoral and cellular mediated immunity as a result of her chemotherapy, vaginal clostridial translocation likely occurred, migrating to her ovarian tumor, which spread to her ascitic fluid and bloodstream. With her lack of cirrhosis and portal hypertension, intestinal bacterial overgrowth, increased permeability, and subsequent intestinal translocation are less likely causes of her mono-organismal infection. Though biliary tract origin and stenting are known phenomena for causing C. perfringens bacterial peritonitis, our patient was stented well over a year prior to her presentation and her stent had not been manipulated, making this a less likely source in our particular patient though possible. In conclusion, when evaluating a patient with abdominal free air, surgical consultation should be entertained, as surgical intervention may be necessary. Our particular patient presented with a nonperitoneal examination. Given her computed tomography findings of free air and a pelvic mass, the decision to proceed with exploratory laparotomy to search for a gastrointestinal perforation was made. The intraperitoneal air was a perplexing phenomenon until the final tissue and fluid cultures revealed


Ovarian mature cystic teratomas are common, benign, pelvic tumors that are easily detected by pelvic ultrasonography. However, patients with recurrent teratomas are rarely noted, and cases of bilateral teratomas are even less common.A young woman with a recurrent, right ovarian teratoma had previously undergone surgical removal 2 times. After the second surgery, she underwent regular out-patient follow-up, and no residual tumor was observed. However, 3 years after the second surgery, she developed recurrent, bilateral ovarian teratomas, in conjunction with elevated carbohydrate antigen-125 levels.Routine checking of the contralateral ovary during the surgical procedure along with frequent postoperative pelvic sonography for both ovaries in the patient at high recurrence rich is necessary. Additionally, the features of that kind tumor may mislead the surgeon into performing more extensive surgery that might compromise the fertility of young patients. Mature cystic teratomas, also called dermoid cysts, are a type of germ cell tumor comprising well-differentiated tissues and three germ cell layers: ectoderm, mesoderm, and endoderm. These tA 20-year-old nulliparous woman presented to our gynecologic department because of intermittent abdominal pain and a 3-month history of dysmenorrhea. She had a history of 2 right ovarian teratomas that were managed surgically. At the age of 16 years, she experienced lower abdominal pain for 2 weeks. A subsequent pelvic sonography showed a complex, right ovarian cyst, of approximately 5.36 × 4.3 cm in size; her carbohydrate antigen (CA) 125 level was 23.4 U/mL . We performed a laparoscopically assisted ovarian cystectomy, and the subsequent pathologic analysis revealed a mature cystic teratoma. During the laparoscopy, the left ovary was visually examined, and morbid findings were not noted. One month after the surgery, her symptoms had improved and no residual tumor was observed on pelvic sonography. The patient was subsequently lost to follow-up. After 1 year, she presented to our out-patient department with a 2-month history of prolonged menstrual periods; a right ovarian complex mass, approximately 3.7 × 4.3 cm, with a solid component, was noted during a pelvic ultrasound examination  scan, which revealed an 8.9 × 5.7-cm, complex, cystic tumor of the left adnexa, with compression and displacement of the urinary bladder. Moreover, a 5.1 × 3.9-cm, complex, cystic, partially solid tumor was noted on the right adnexa , postoperative pelvic sonographic examinations of both ovaries are also necessary in patients at high risk of recurrence. As suggested by this case, clinicians might be easily misled by the apparent features of these ovarian tumors that may suggest malignancy, resulting in an extensive surgery that might compromise the fertility of young patients.Written consent was obtained from the patient for publication of this study.The authors declare that they have no competing interests.C-KL: Investigation of the patient, Literature research, Drafting of the manuscript, and corresponding author; C-FC: Literature research, and Drafting of the manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/57/prepub


A case study of 39-year old man with persistent wheezing, episodes of haemoptysis and dry cough unsuccessfully treated with inhaled beta2-agonists and steroids for about 10 months. Chest radiograph revealed a disproportion in dimensions between both lungs, with the left one being smaller than the right one. Spirometry demonstrated a restrictive pattern. During bronchoscopy, a polypoid endobronchial tumor, localized in the left main bronchus, completely occluding its lumen, was found. The tumor was diagnosed as carcinoid. In this case, due to the lack of characteristic symptoms, diagnosis of carcinoid was delayed. Patients unsuccessfully treated for bronchial asthma or chronic obstructive pulmonary disease should undergo bronchoscopic examination. Apart from these medications, he took no other drugs. On auscultation, there were wheezes in upper fields of both lungs. The chest radiograph , the patient reported no other complaints or diseases in his medical history. His family history was not clinically significant. He had a 10 pack-years smoking history, until the age of 31 when he stopped smoking. He drank alcohol occasionally. His symptoms were unsuccessfully treated with inhaled β1) of 59% predicted and forced vital capacity (FVC) of 66% predicted. The FEV1/FVC ratio was 70% predicted.Spirometry performed during hospitalization in our clinic showed a restrictive pattern figure  with forBronchoscopy was performed, revealing a polypoid endobronchial tumor, localized in the left main bronchus , completely occluding its lumen. The tumor was biopsied and the specimen was sent to histological examination which gave the diagnosis of bronchial carcinoid.Thoracic computed tomography showed a polypoid mass in the left main bronchus with a diameter of about 20 mm. The tumor showed very high enhancement after contrast medium administration: from 9 HU (Hounsfield units) figure  to 119 HHilar and mediastinal nodes were not enlarged. In virtual bronchoscopy, as well as in transparent reconstruction of the airways, a total occlusion of the left main bronchus by the tumor could be observed Figure  and 5.The patient was transferred to thoracic surgery ward for surgical treatment. He underwent left pulmonectomy and histopathological analysis of post-operative material confirmed the diagnosis of bronchial carcinoid. There were no complications during post-operative period and the patient was discharged from hospital 10 days after the operation. Then, the patient went abroad and was lost for follow-up until May 2008. On control visit in May, he was in very good condition, presenting no signs of pulmonary disease. On physical examination, except from diminished breath sounds and dullness to percussion over left lung  no abnormalities were found. In control computed tomography there were no signs of recurrence of the disease.Pulmonary carcinoids comprise 1-2% of all lung tumors. They may develop in many locations in the body but most often, they are found in small intestine (26%), respiratory system (25%) and appendix (19%) [Carcinoid tumors are classified as typical or atypical according to histopathological criteria. This division has a strict extrapolation to survival rates: in case of typical pulmonary carcinoids 5-year survival rate is over 90%, in atypical ones- it is within the range of 40-60% .The following symptoms are observed most often in patients with carcinoid localized in respiratory system: haemoptysis, cough, recurrent pulmonary infections, fever, chest discomfort, unilateral wheezing and shortness of breath .Due to the lack of characteristic symptoms, diagnosis of pulmonary carcinoid is delayed and patients are often misdiagnosed with asthma or chronic obstructive pulmonary disease. According to three studies, there is an average delay of, respectively, 19, 13 and 10 months from the first symptoms to the final diagnosis of carcinoid -6. AlthoAs the majority of pulmonary carcinoids 70%) are located in the main or lobar bronchi 0% are lo. BronchoThis case is a good example of misdiagnosis of the disease. Extended clinical diagnosis, including computed tomography and bronchoscopy, should be considered in all cases of bronchial asthma or chronic obstructive pulmonary disease which do not respond to standard treatment."Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."The authors declare that they have no competing interests.JE performed acquisition of data, review of literature and wrote the paper. ECC performed computed tomography imagings and prepared virtual bronchoscopy reconstructions. EK performed histopathological examination of the tumour. MK was responsible for patient care, follow-up and data collection. IWS was responsible for patient care and drafting of paper. JM performed acquisition of data, revised the manuscript and provided general support as the head of department. All authors read and approved the final manuscript.


Congenital granular cell epulis (CGCE) is a very rare benign soft tissue lesion of the neonate, it most frequently located on the anterior maxillary alveolar ridge. It has a female predilection. It is a tumor with no tendency to recur after excision. The exact histogenesis of this tumor remains unresolved and it may be hamartomata. Congenital granular cell tumour (CGCT) was first described by Neumann in 1871 . The etiA 2 day old girl, born at 41 weeks gestation weighting 3,500kg, was referred with a growth in the anterior maxillary alveolus which was noticed at birth. Clinical examination revealed a full term female neonate with a huge, exophytic growth protruding from the oral cavity, measured approximately 4x2 cm in size. The tumor was attached by a large pedicle to the anterior maxillary ridge; the mass was firm in consistency and not tender to digital palpation. The initial management included intravenous fluids and gastric feeding as oral feeding was impossible for this child .The tumor was excised under local anesthesia without a prior biopsy. No other lesions or systemic involvement was found. These were no complication after surgery. Histopathology confirmed the diagnosis of a completely excised congenital gingival granular cell tumour . ImmunohCGCT occurs in the mucosa of the maxillary alveolus as smooth surface pink mass, usually not associated with any other abnormality of the teeth or other congenital abnormalities . It haveCGCT is a very rare mouth tumor, the lesion can be removed under local anesthesia if intubation is not possible, and the diagnosis can be confirmed after histopathology study, without possibility of recurrence.


Lithopedion is an exceedingly rare entity in the modern era of medicine. Since the earliest case discovered in 1582 in France Bondeson , less thA 20 years old lady married for 2 years came with complaints of inability to conceive. Her menstrual cycles were regular except for a single missed cycle which occurred about 18 months back. She did not visit any doctor for confirmation of pregnancy. She resumed her menstruation thereafter and continued to have it till date. She however had occasional pain abdomen which was relieved by analgesics she purchased over the counter. Physical examination revealed a lump in the right lumber region hard in consistency with restricted mobility and tender on movement. Laboratory workup revealed no abnormal values. X-ray of abdomen and pelvis in erect posture revealed radio-opaque shadow resembling foetal skeleton in right lumber region (Figure With these findings, a provisional diagnosis of lithopedion was made and laparotomy was planned. A hard globular mass adherent to the omentum was found in the right flank. The mass was dissected off the omental tissue and a calcified foetal skeleton was recovered Figure . FallopiLithopedion is a greek word which means ‘stonechild’. This rare event occurs in 0.0054% of all gestations (Ede et al. Lithopedion describes an intraabdominal calcified dead fetus. A lithopedion can result from a primary abdominal pregnancy, or from a secondary abdominal implantation following tubal abortion or rupture of tubal or intrauterine pregnancy. It occurs when a sterile extrauterine fetus survives for more than 3 months in abdominal cavity and escapes medical discovery along with minimal and sluggish circulation inviting calcium deposition (Irick et al. Age of the patients in various case reports ranged from 23 to 100 years at the time of diagnosis (Lachman et al. A rare entity though, lithopedion is not exinct and its diagnosis should not be missed in young infertile patients where period of retention may be small with minimal symptoms and vague obstetrical history. Appropriate history and keen suspicion in such cases from areas with limited access to healthcare facilities not only helps in diagnosis but can avert the dreadful complications it can accrue in course of time.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


The worldwide experience of surgical resection for isolated metastasis following liver transplantation (LT) for hepatocellular carcinoma (HCC) is limited.The case of a 60-year-old patient performed successful surgical management for metachronous pulmonary and adrenal metastases from HCC after LT.Eighty months after LT, he was presently alive and disease-free with a normal AFP value.The case is an interesting report on a somehow indolent metastatic spread of HCC after LT. It should be considered that metachronous metastatic resectable disease, with no data of recurrence at the primary site in an operable patient, is an indication to perform a surgical resection. The worldwide experience of surgical resection for isolated metastasis following liver transplantation (LT) for hepatocellular carcinoma (HCC) is limited -3. Here A 60-year-old man, with a 20-year history of type B hepatitis and hepatic cirrhosis, presented with a solid large mass in the left lateral segment. The patient was poor-hepatic functional reserve because of atrophy of the right liver and compensative hyperplasia of the left liver according to imaging studies. The serum alpha-fetoprotein (AFP) value was 7,812.0 ng/ml, serum albumin level was 29.4 g/L, and other laboratory data were within normal limits. The Child-Pugh classification of the cirrhosis was Child early B cirrhosis. He underwent LT on 9 February 2004 and had received 3 cycles' postoperative adjuvant chemotherapy with capecitabine and oxaliplatin for 5 months. After LT, the AFP value decreased within a normal range and stayed normal for thirty months.Thirty-three months after LT, a 3.0 cm×3.5 cm lesion was detected in the right lung with elevated AFP value (167.1 ng/ml). Because positron emission tomography (PET) scan revealed no fluorodeoxyglucose (FDG)-avid focus in transplanted liver and other extrahepatic organs, partial resection of the lower lobe of the right lung was performed. After pulmonary resection, the AFP value decreased within a normal range.Thirty-nine months after LT, an abdominal computed tomography (CT) scan revealed a 4.0 cm×3.5 cm homogeneous mass in the left adrenal gland with elevated AFP value (55.8 ng/ml) Figure . FurtherThe histopathology of the resected liver revealed a large tumor in the left lobe (9 cm×8 cm×8 cm) with features of poorly differentiated hepatocellular carcinoma. The uninvolved liver showed cirrhosis Figure . The tumLT is claimed to cure HCC and the underlying cirrhosis simultaneously in selected patients. Nevertheless, a careful follow-up is needed in those cases due to the possibility of neoplastic recurrence, which could take place not only in the graft, but also in extrahepatic organs such as lung, adrenal glands, and bone . The cumThe worldwide experience of surgical resection for isolated metastasis following LT for HCC is limited to case reports -3. RubioIn conclusion, this is an interesting report on a somehow indolent metastatic spread of HCC. It should be considered that metachronous metastatic resectable disease, with no data of recurrence at the primary site in an operable patient, is an indication to perform a surgical resection.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.LT: Liver transplantation; HCC: hepatocellular carcinoma; AFP: serum alpha-fetoprotein.The authors declare that they have no competing interests.SWC, SW, WDL, and SY participated in the admission and the care of this patient. All the authors participated in the conception, the design, data collection and interpretation, manuscript preparation and literature search. All authors have read and approved the final manuscript.


Hepatic pseudolymphoma (HPL) and primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases and the differential diagnosis between these two entities is sometimes difficult. We herein report a 56-year-old Japanese woman who was pointed out to have a space occupying lesion in the left lateral segment of the liver. Hepatitis viral-associated antigen/antibody was negative and liver function tests including lactic dehydrogenase, peripheral blood count, tumor markers and soluble interleukin-2 receptor were all within normal limit. Imaging study using computed tomography and magnetic resonance imaging were not typical for hepatocellular carcinoma, cholangiocarcinoma, or other metastatic cancer. Fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning showed high standardized uptake value in the solitary lesion in the liver. Under a diagnosis of primary liver neoplasm, laparoscopic-assisted lateral segmentectomy was performed. Liver tumor of maximal 1.0 cm in diameter was consisted of aggregation of lymphocytes of predominantly B-cell, containing multiple lymphocyte follicles positive for CD10 and bcl-2, consistent with a diagnosis of HPL rather than MALT lymphoma, although a definitive differentiation was pending. The background liver showed non-alcoholic fatty liver disease/early non-alcoholic steatohepatitis. The patient is currently doing well with no sign of relapse 13 months after the surgery. Since the accurate diagnosis is difficult, laparoscopic approach would provide a reasonable procedure of diagnostic and therapeutic advantage with minimal invasiveness for patients. Considering that the real nature of this entity remains unclear, vigilant follow-up of patient is essential. A primary hepatic lymphoma (PHL) is defined as lymphoma localized and limited in the liver , not theOn the other hand, hepatic pseudolymphoma (HPL), also termed as reactive lymphoid hyperplasia, or nodular lymphoid lesion, is extremely rare disease and characterized by the proliferation of non-neoplastic, polyclonal lymphocytes forming follicles with an active germinal center , and mosThe etiology, pathogenesis and clinical implications of these two diseases remain unknown to a large extent. Reported underlying liver diseases include chronic viral hepatitis, autoimmune liver diseases, etc .Since clinical diagnosis is often difficult especially at its earlier stage, surgical resection appears a mainstay for diagnostic/therapeutic purpose.We herein present a laparoscopically operated case of hepatic pseudolymphoma which was difficult to differentially diagnose from primary hepatic MALT lymphoma, and discuss the clinicopathological features and clinical implications of these two disease entity.In April 2009, a 56-year-old Japanese woman was pointed out to have a space occupying lesion in the lateral segment of the liver on abdominal ultrasonography during health examination. Her social and family history was noncontributory and she had a previous medical history of appendectomy for acute appendicitis and laparoscopic cholecystectomy for cholecystolithiasis. She showed no abnormal physical findings, including lymphadenopathy and hepatosplenomegaly.Laboratory findings of blood examination were almost normal, including blood cell counts and differentiation, serochemical tests including liver enzymes and lactate dehydrogenase (LDH), hepatitis viral associated markers including hepatitis B virus surface antigen (HBsAg), hepatitis B virus core antibody (HBcAb) and hepatitis C virus (HCV) antibody. Also, tumor markers including carcinoembryonic antigen and carbohydrate antigen 19-9, alpha-fetoprotein (AFP), fucosylated AFP (L3-AFP), protein induced by vitamin-K absence or antagonist II , and soluble interleukin 2 (s-IL2) receptor were within normal limits.Abdominal ultrasonography showed 15-mm-diameter hypoechoic in segment 3 in the liver, and on enhancement study, it showed slight enhancement of ring-like in the peripheral but not in the entire tumor, the center of which being minimally enhanced, which indicated metastatic tumor rather than hepatocellular carcinoma (HCC).On abdominal computed tomography (CT) scan Figure , 15-mm-dOn magnetic resonance imaging , also known as reactive lymphoid hyperplasia, or nodular lymphoid lesion, is extremely rare disease entity and so far 35 cases have been reported worldwide ,6-9 sincPrimary hepatic marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue type (MALT lymphoma), also rare entity with only 48 cases being reported in the worldwide literature -22 sinceThe etiopathogenesis of HPL remains unclear, although 27% of the patients had chronic liver diseases including HBV- or HCV-related liver cirrhosis, and moreover, 23% had autoimmune disorders, such as PBC, in extrahepatic organs . In termAs a background liver condition associating with HPL, in accordance with the case reported by Zen et al , our casClinical resemblance includes the age of patients , and tumor characteristics including the size  and the number, where the majority of cases had solitary tumor at presentation in both entities . The single pronounced difference would be the female preponderance in HPL .The diagnosis of HPL, not to mention the preoperative one, appears challenging. In fact, the case report by Sato et al indicating the transformation of HPL into lymphoma  would imRegarding the diagnostic significance of FDG-PET, no report on HPL is currently available. In contrast, FDG-PET has been reported in the recent two reports as a useful and convenient modality for the diagnosis of hepatic MALT lymphoma ,22. ConsNatural history of HPL is yet delineated. Malignant transformation of pseudolymphoma into true lymphoma has been reported in the various organs, such as lung, stomach, and skin -34, but With respect to treatment strategy, reported cases demonstrated that even MALT lymphoma has a favorable prognosis compared with other subtypes of PHL; the former is usually limited to the liver and surgical resection cures the patient in most cases . Also, wRegarding prognosis after treatment, since no recurrence of MALT lymphoma has been reported to date to occur after adequate surgical resection or chemotherapy treatments , even ifPHL and lymphoid lesions in general should be considered in the differential diagnosis of space occupying lesions of the liver in the absence of elevated levels of ordinary tumor markers including AFP and CEA . In addiHPL and MALT lymphoma are very rare. We herein report a case with a space occupying lesion in the left lateral segment of the liver, which was completely resected by laparoscopic-assisted lateral segmentectomy. The tumor of maximal 1.0 cm in diameter was consisted of aggregation of lymphocytes of predominantly B-cell, containing multiple lymphocyte follicles positive for CD10 and bcl-2, consistent with a diagnosis of HPL, but still necessitating differential diagnosis from MALT lymphoma. Since the accurate diagnosis of this entity is difficult, laparoscopic approach would provide a reasonable procedure of diagnostic and therapeutic advantage with minimal invasiveness for patients. Considering that the real nature of this entity remains unclear to date, vigilant follow-up of patient is essential.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.HPL: hepatic pseudolymphoma; MALT: mucosa-associated lymphoid tissue; PHL: primary hepatic lymphoma; LDH: lactate dehydrogenase; s-IL2: soluble interleukin 2; CEA: carcinoembryonic antigen; AFP: alpha-fetoprotein; HCV: hepatitis C virus; CT: computed tomography; MRI: magnetic resonance imaging; HCC: hepatocellular carcinoma; Gd-EOB-DTPA: gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid; FDG-PET: fluorodeoxyglucose-positron emission tomography; SUV: standardized uptake value; IGH: immunoglobulin heavy chain; NAFLD: non-alcoholic fatty liver disease; NASH: non-alcoholic steatohepatitis; PBC: primary biliary cirrhosis.The authors declare that they have no competing interests.MH conceived the study concept and design, was involved with patient care and drafted the manuscript and literature review. NY, FH, MA, KM, AT, KY HH, and TT were involved with formation of the study concept and design, patient care and drafting of the manuscript and literature review. NT carried out the operation on the patient and was the main contributor in the writing of the manuscript. All authors have read and approved the final version of the manuscript.


Psoas and thigh, although rare localizations, could represent the site of primary or secondary hydatidosis.Muscular hydatidosis should always be considered in patients with previous history of such a disease, especially in cases of previous surgical dissemination.A muscle- or nerve-sparing attempt should always be performed in cases of wide diffusion as well.A 46-year-old male shepherd presented with a mildly painful mass 4.5 cm in diameter localized at the right groin and thigh, diffuse edema involving the right leg lasting for 2 weeks, and fever. The patient had had eight previous operations for diffuse hydatidosis with reported intraperitoneal seeding, but further information was unavailable.Laboratory tests are shown in Piperacillin/tazobactam was administered from the date of admission to the day of surgery. Preoperative prophylaxis with benzimidazole derivatives was not performed due to the extent of the disease, the history of recurrences, and the need to perform the operation promptly to reduce the symptoms.At surgery, the retroperitoneum was accessed and tissues surrounding the cysts were covered with sponges soaked with hypertonic saline. The cystic content was evacuated and the interior of the cyst was repeatedly washed with protoscolicides. Due to the tight adhesions with the peritoneal sac, only the lateral-lower portion of the cystic wall could be resected. No daughter cyst was found. Subsequently, the right thigh was anteriorly incised and the cysts were evacuated. The washing treatment was repeated but extensive resection was avoided to prevent any risk of unnecessary damage.Histopathological examination did not detect viable protoscolices and routine cultures performed to individuate other pathogens were negative.A CT scan performed before discharge showed the integrity of the psoas muscle  and the In secondary hydatidosis, whose reported incidence is between 1.1% and 25% Hydatid cysts of the psoas and thigh are reported very rarely Different types of serological tests may help in diagnosis US represents the preferred diagnostic method Medical therapy with a benzimidazole derivative is preferable whenever there is multi-organ involvement or when patients are not fit for surgery Abnormalities in liver function, leucopenia and alopecia are side effects of the benzimidazoles The treatment of choice is complete surgical excision of the cyst and irrigation of the surrounding tissues with hypertonic saline. World Health Organization guidelines suggest several specific approaches for classic hydatidosis, but there is no mention regarding unusual localizations An alternative to surgery is the US-guided cyst puncture and injection of protoscolicides , indicated for inoperable patients Since our patient had eight prior operations with recurrence each time, perhaps none of these operations was adequately performed and the post-operative treatment was not properly instituted or monitored. The contemporary excision of all the macroscopic localization, the careful protection of the surgical field, and the postoperative administration of mebendazole distinguish our intervention from the eight that preceded it.This report emphasizes the importance of conservative treatment for a benign disease like diffuse recurrent hydatidosis. A muscle- or nerve-sparing attempt should always be performed and prolonged medical therapy is the mainstay of treatment. The risk/benefit ratio should always be analyzed in order to avoid extended surgical resections that may result in possible disability. Rare manifestations of neglected diseases are extremely important, especially for inexperienced physicians.


Background. Benign cystic mesothelioma (BCM) is a rare tumor that arises from the abdominal peritoneum with a predilection to the pelvic peritoneum. For this reason, it can often mimic gynecologic malignancies. Case. A 47-year-old perimenopausal female presented reporting several weeks of abdominal distention associated with abdominal tenderness and constipation. Computed tomography revealed a 24 cm multiloculated pelvic mass, and tumor markers were notable for an elevated CA-125. The patient was taken to the operating room for an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingoophorectomy, and removal of pelvic mass. Final pathologic evaluation revealed a benign cystic mesothelioma. Conclusion. Classically these tumors present as large multicystic masses with thin-walled septations and on preoperative evaluation BCM can mimic many different disease entities including ovarian malignancies and cystic lymphangioma. Often diagnosis can only be made at time of surgery. Differential diagnosis of a pelvic mass in a reproductive age female can be difficult and often requires surgical exploration and pathologic diagnosis. Benign cystic mesothelioma is a rare intra-abdominal tumor that can present as a large multicystic mass arising from the pelvis. To date, approximately 140 cases have been described in the literature, most occurring in reproductive aged women. The pathogenesis of this disease remains unclear, although many agree that it is likely the result of a chronic inflammatory process as in the case of endometriosis. BCM is generally considered a benign process; however given the high rate of recurrence and possible malignant transformation, close follow-up is important.Written informed consent for publication was first obtained from the patient as outlined by the Institutional Review Board. A 47-year-old perimenopausal female presented to her gynecologist's office complaining of worsening abdominal distention, abdominal tenderness, and constipation for over 3 weeks. Past medical and surgical history was significant for hypothyroidism, latent tuberculosis, and cesarean section with bilateral tubal ligation. She had no smoking history and family medical history was noncontributory. On physical exam, vital signs were within normal limits and the abdomen was distended and diffusely tender. Pelvic exam was significant for a 30 cm adnexal mass. The uterus was small and difficult to palpate secondary to the large adnexal mass. The remainder of the physical exam and review of systems were otherwise unremarkable.Transvaginal and transabdominal ultrasound with color Doppler was performed. Findings were notable for a large pelvic mass likely originating in the left ovary and extending to the level of the first intercostal space. The mass was described as a multiloculated complex with multiple thick septations measuring 24 × 18 cm . ModeratThe patient underwent an exploratory laparotomy, pelvic mass excision, partial omentectomy, adhesiolysis, total abdominal hysterectomy, and bilateral salpingoophorectomy. There was high suspicion for malignancy and a gynecologic oncologist was present at time of surgery. Surgical findings included a normal uterus, fallopian tubes, and ovaries. The large 26–28 cm multiloculated peritoneal cyst was noted to be originating from the left cornual region of the uterine fundus from a wide pedicle . There wHer postoperative course was unremarkable and the patient was discharged home on the third hospital day. She has had several follow-up visits and at 1 year after surgery she has no new complaints and no evidence of recurrence.Benign cystic mesothelioma (BCM) is a rare tumor that arises from the abdominal peritoneum. Classically these tumors present as large multicystic masses with thin-walled septations and predilection to the pelvic peritoneum . TypicalOn preoperative evaluation BCM can mimic many different disease entities including ovarian malignancies and cystic lymphangioma. Often diagnosis can only be made at time of surgery. On ultrasound BCM typically appears as a multicystic, vascular mass without calcifications. CT scan and magnetic resonance imaging (MRI) scan typically reveal multilocular cystic lesions, with thin-walled septations and fluid densities , 4. FineAlthough reports of BCM first appeared in the literature in 1979 the pathogenesis of this disease remains unclear . In femaBCM is generally described as a benign entity; however due to the high rate of recurrence 27–75%) some researchers have disputed this point. Recurrence tends to be local and can occur many years later. It has been proposed that BCM acts more as a borderline lesion with potential for transformation to a malignant tumor , 5. Rare% some re


Several are the causes of cervical masses and among them a spontaneous hemorrhage presents a rare and life-threatening condition. Sometimes hemorrhage develops from a previous silent neck lesion as in the case of an anaplastic thyroid carcinoma associated with bleeding. We present two cases: a 70-year-old woman suffering from enlarging cervical mass causing respiratory distress because of upper airway compression due to a spontaneous rupture of the superior thyroid artery and a 74-year-old woman who drew our attention because of a progressively worsening dyspnea due to a large medial cervical mass with rapid onset. We removed it surgically, finding out an anaplastic thyroid carcinoma that is associated with internal bleeding. We discuss our management of these rare and life-threatening conditions, recalling that the patency of upper airway should always be the prerogative in every emergency. Besides, we make a review of the recent literature. A spontaneous cervical hemorrhage presents a rare and life-threatening condition due to potential airway injury. The ethiologies of spontaneous cervical hemorrhage may be different; according to Gonzàlez-Cruz et al. , the mosIt is also possible that a sudden neck swelling occurs due to hemorrhage of a rare thyroid cancer, such as an anaplastic thyroid carcinoma (ATC). This is the rarest, but the deadliest histologic type among thyroid malignancies, with a dismal median survival of 3–9 months –9. It reWe present two rare cases of airway compromission: a spontaneous intrathyroid hemorrhage due to the rupture of the superior thyroid artery (STA) and a bleeding ATC.A 70-year-old woman presented to our outpatient department with a sudden swelling on the left side of her neck. At the beginning, the patient did not show any dyspnea or dysphonia, but only enhancing dysphagia. Indirect laryngoscopy revealed dislocation of the larynx to the right side. She denied symptoms of an upper respiratory tract infection or history of trauma. Her medical history displayed assumption of Warfarin, because of a periodical deep venous thrombosis. She suffered from hypertension, which was pharmacologically well treated.Ultrasound scan revealed a large neck hematoma with transversal diameters of 4.8 × 6.3 cm. Then, the increasing size of the swelling connected to early dyspnea aroused the suspicious of an acute cervical hemorrhage, hence the patient was subjected to an angiography.This test revealed bleeding from the final arterial branch of the STA with extravasation . An atteA 74-year-old woman with a small cell lung cancer that metastasized to the kidney, liver, and bones, was admitted to the internal medicine department of our hospital. The Patient presented enlarging medial cervical mass developed in four days, with progressive impairment of the upper airway. She has been suffering from Graves' disease for years.The neck computed tomography scans showed a large mass of 96 × 62 × 77 mm that originated in the left lobe of the thyroid gland with severe displacement of tracheal axis to the right side and compression of oropharynx, with impairment of upper airway lumen. Moreover, the hyoid bone and larynx turned out to be moved to more than 3 cm from the midline. Finally, a compression of the common carotid artery came out, with several nodes in all left cervical levels .Consequently, because of an increasing dyspnea associated with dysphagia and dysphonia, a surgical exploration of her neck was carried out in emergency regimen. After a difficult oropharyngeal intubation, a large bleeding thyroid mass of the left lobe was detected. The mass spread all through the surrounding structures. Afterwards, a left hemithyroidectomy was performed with binding and resection of the left internal jugular vein, as well as the sacrifice of the left vagus nerve, completely embedded by the tumor . A huge The cervical masses caused by a spontaneous intrathyroid haemorrhage or by a bleeding ATC are extremely rare, but also life-threatening conditions. Consequently it is important to know how to recognize them promptly, in order to prevent fatal acute airway distress , 11, 12.Because of the rarity of these entities, a wrong management may be common: the first and most important step is to secure airway, then after this, the diagnostic workup could be undertaken. Endotracheal intubation is generally used; however, sometimes nasotracheal intubation through the use of flexible fiber optic is fundamental. If it is not possible, then you could appeal to emergency tracheotomy.Referring to the first patient, the angiography was very important. In fact, it gave us the opportunity to make a diagnosis, and secondly because it is a useful instrument to close a bleeding vessel, often representing a good alternative to open surgery.About our second case, it is interesting to note that performing a tracheotomy could be very difficult, because of compression by the bleeding mass, that deviated tracheal axis so markedly . In our


A 61-year-old male presented with a rare case of glioblastoma mimicking a cerebral contusion subsequent to collapsing. The patient had been medicated for hypertension for seven years and diabetes for eight years prior to hospitalization. Brain computed tomography (CT) revealed a cerebral contusion and intracerebral hemorrhage (ICH) in the left temporal region. The patient was initially administered intravenous drugs to reduce the intracranial pressure following the diagnosis of a cerebral contusion. Serial CT revealed ICH resorption. However, the patient was again admitted due to a headache and vomiting two months later. Magnetic resonance imaging (MRI) demonstrated an enhanced ring-shaped mass around the cyst cavity within the left temporal region, with surrounding edema. The patient underwent cyst puncture drainage in the temporal region. No tumor cells were identified in the cyst fluid and the culture was also negative. The patient was admitted for a headache and vomiting for the third time one month after being discharged. A cyst, tumor and meningoencephalitis were suspected following an MRI scan. The patient was treated with a left temporal craniotomy for a mass resection and biopsy. The histological diagnosis of the biopsy specimen was that of a glioblastoma. Two months later, MRI revealed a recurrence of the glioblastoma. In the present case, a brain tumor should have initially been suspected as the cause of the ICH, despite the history of craniocerebral trauma and hypertension. Early awareness of this potential cause of ICH may facilitate a more prompt diagnosis and treatment. Highly-vascularized, malignant primary brain tumors (BTs), including glioblastoma, oligodendroglioma and metastatic BT, tend to bleed spontaneously and should always be included in the differential diagnosis of non-traumatic intracerebral hemorrhage (ICH) . HoweverA 61-year-old male, who had been medicated for hypertension for seven years and diabetes for eight years, was brought to the Emergency Department, Sir Run Run Shaw Hospital, Medical College, Zhejiang University  subsequent to collapsing at home. The patient had exhibited the symptoms of a headache and vomiting for the last two days. The Glasgow Coma Scale score was E4V4M6 and the patient demonstrated mixed aphasia. Computed tomography (CT) revealed a cerebral contusion in the left temporal region . The patICH accounts for nearly one-half of all cerebrovascular events . ClinicaThe approach to the present case had been biased towards the treatment of a cerebral contusion in the left temporal region due to the initial pretreatment CT and pre-existing hypertension. The diagnosis of a cerebral contusion and ICH was easily justifiable, which attributed to the delayed correct diagnosis and treatment of the patient. Initially, only CT was performed, as craniocerebral trauma was the only cause of the ICH and also as the conservative treatment was apparently effective. Cyst puncture drainage was performed in the temporal region and, notably, the histological examination revealed no tumor cells in the cyst fluid and the cyst fluid culture demonstrated negative results. These results confirmed the first diagnosis until the pathological investigation finally revealed the definitive diagnosis of a glioblastoma.The present case shows that pre-operative CT with or without MRI does not exclude brain tumors as the cause of ICH, despite the present patient having a history of craniocerebral trauma and hypertension. Up to 10% of patients with BTs may experience a diagnostic delay if CT is the only imaging modality that is used . Dual-enIn the present case, since the signs and symptoms developed shortly following a head trauma, it is possible that the trauma participated in the induction of the hemorrhage. The numerous tumor vessels and microcysts may have been distorted by the force of the impact, causing their thin walls to rupture. In such cases, BT should be suspected as a cause of ICH, despite a history of craniocerebral trauma and hypertension. An appropriate and prompt investigation should be performed and clinical follow up is also essential for detecting subtle neurological deterioration of the patient to avoid a delay in the diagnosis and treatment.


Primary pericardial malignant mesothelioma is an extremely rare neoplasm that arises from the pericardial mesothelial cell layers. Clinical symptoms and signs are frequently nonspecific, and the diagnosis is usually made after surgery or at autopsy. There is no standard treatment for pericardial mesothelioma; nonetheless, radical surgery is the mainstay of therapy for localized disease. The neoplasm is highly aggressive and carries a dismal prognosis with an overall survival of less than six months. This paper presents a case study of a 68-year-old patient with a primary pericardial malignant mesothelioma. Radiologic evaluation revealed a small nodule in the posterior pericardium with pericardial and bilateral pleural effusions. The diagnosis was established after surgery by histological and immunohistochemical studies. The patient remained alive and free of disease for about 24 months; however, due to rapid local recurrence, the patient died 27 months after the surgical treatment. Primary cardiac tumors of heart are uncommon, whereas primary pericardial mesothelioma (PPM) is exceptionally rare with an incidence of only 0.0022% in a series of nearly 500,000 random autopsies . PPM accA previously healthy 68-year-old man came to our hospital in May 2010 with a 1-month history of malaise, dyspnea on exertion, bilateral lower-extremity edema, and a 5-kilogram weight loss. His past medical history was unremarkable. The patient was a nonsmoker and denied history of prior asbestos exposure. The physical examination was notable for bilateral pitting edema of lower legs and muffled heart sounds on cardiac auscultation. The hematologic and biochemical studies were unremarkable. Electrocardiography was nonspecific except for low-voltage QRS complexes, and a chest radiograph revealed an enlarged cardiac silhouette. Transthoracic echocardiography revealed a circumferential pericardial effusion with a heterogeneous hyperechoic mass in the posterior pericardial wall without signs of cardiac tamponade. Computed tomography (CT) scan of the chest and abdomen was performed to determine the extent of the disease which demonstrated a nearly isoattenuating nodular mass, around 3.6 cm × 2.2 cm in diameter, arising from left posterior pericardial wall and a pericardial effusion encasing the heart with small bilateral pleural effusions. The lesion showed enhancement on contrast-enhanced CT image . Aside fPrimary pericardial malignancy was suspected based on the imaging results; consequently, the patient underwent surgery. Grossly, the tumor was 3.5 cm in diameter, well encapsulated with a significant serosanguinous pericardial effusion which was drained. The cut surface of the tumor was fleshy and grey-white to yellowish in color without any signs of invasion or infiltration to adjacent organs. Cytological and microbiological analyses of pericardial fluid were noncontributory. Pathological evaluation of the postpericardiotomy specimen confirmed the diagnosis of pericardial mesothelioma, epitheloid type. The epitheloid cells had eosinophilic cytoplasm and open nuclei with prominent nucleoli, exhibiting tubulopapillary patterns of growth with connective tissue cores accompanied by a lymphoplasmacytic infiltration. Mitoses were frequent . On immuMalignant mesothelioma is an uncommon neoplasm that derives from the mesothelial cells linings of pleural, peritoneal, or pericardial surfaces. About 65%–70% of malignant mesotheliomas arise from pleura and 30% from peritoneum, whereas mesothelioma originating from the pericardium or tunica vaginalis testis is rare and accounts for 1%-2% of all mesotheliomas . PericarTypically, the onset of PPM is insidious in nature with nonspecific symptoms such as cough, dyspnea, orthopnea, chest pain, and sometimes paradoxical pulse , that caThe diagnosis of pericardial mesothelioma is usually difficult and late, and to date, about 200 cases of PPM have been reported in the medical literature with only 25% of these being diagnosed antemortem , 9. PeriOwning to rarity, there is no standard treatment regimes for PPM. Surgical resection remains the main treatment modality in PPM, and may be curative for the localized disease , 6, 8, 9


Osteomyelitis is an inflammatory infectious condition of bones, occurringeither acutely or chronically. The clinical course of the disease leads to destructive or sclerosing patterns of the involved bone. This report presents a case of chronic focal sclerosing osteomyelitis in a 19-year-old male with a history of an uncontrolled convulsive condition. The lesion was first diagnosed as an osteoblastoma. Chronic trauma or traumatic occlusion has the potential to induce osteomyelitis and should be considered a possible diagnosis in differentiating periapical radiopacities, even in relation with vital teeth. Low-virulent bacteria plus a young immunocompetent patient with a high capacity for bone remodeling is more probable to show a sclerosing form of the condition.2Osteomyelitis is rare in young people except when there is a traumatic condition.3Osteomyelitis is an inflammatory infectious condition of bones. It occurs either acutely or chronically, depending on the virulence of contributing pathogens, the immune system efficacy and the remodeling capacity of the involved bones.A 19-year-old man with a chief complaint of severe continuous pain referred to the Department of Oral Medicine, Shahid Sadoughi University of Medical Sciences. The patient felt pain in the periapical areas of maxillary right second premolar and first molar teeth (teeth #3 and #4). Pain had initiated about 20 days previously and exacerbated during the week before. It had a severe, deep, dull nature and was poorly responsive to analgesics. The patient’s medical history was non-contributory except for an uncontrolled convulsive condition with the last attack occurring three months before.Extraoral examination revealed a mild asymmetry, corresponding to the painful area and a firm, non-tender, mobile submandibular lymph node, less than 1 cm in diameter. On intraoral examination, an approximately 1.5 × 2.5 cm buccal expansion of the maxillary alveolar ridge was obvious around the tooth #3. It was bony hard in palpation and covered with a smooth, intact mucosa. All thePanoramic and periapical radiographic views were ordered. On the A well-defined radiopaque expansile mass in a young male adult, which did not respond well to NSAID analgesics, guided us to perform an incisional biopsy with the initial differential diagnosis of osteoblastoma. Unfortunately, the histopathological report was inconclusive but in favor of an osteoblastoma. The patient was referred to a maxillofacial surgeon for an excisional biopsy. Contrar4Accordingly, a list of differential diagnosis for a single localized radiopaque lesion of jaw should have been arranged in this case. The so-called list included idiopathic osteoscelerosis, chronic localized sclerosing osteomyelitis, cemento-osseous dysplasia (FCOD), cementoblastoma, osteoid osteoma, osteoblastoma and osteogenic osteosarcoma.Approaching a pathologic condition in a systematic manner is the cornerstone of any diagnostic challenge.2 The least possible diagnosis was isosteogenic osteosarcoma. Although osteosarcoma occurs more frequently in males than in females, it is very rare and the remaining features of it, such as older age of incidence, involvement of the posterior mandible, poorly defined borders and invasiveness were not compatible with our patient.1Considering the clinical picture of the current patient, one may choose painful pathoses from the prepared list, including chronic localized sclerosing osteomyelitis, cementoblastoma, osteoid osteoma, osteoblastoma and osteogenic osteosarcoma.Cementoblastoma, a true neoplasm of cementoblasts, can present as a periapical radiopacity, which is fused to the roots of involved tooth at the very beginning. It usually forms at the periapical region of first mandibular molar and gradually expands the involved bone. A distinct radiolucent hallow almost always surrounds the central calcified mass of cementoblastoma. The opaque materials are cementoids and are not arranged in a radiating pattern.Osteoid osteoma and osteoblastoma may exhibit completely the same features except for their response to nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoblastoma has a peak incidence in the second decade of life and does not respond to NSAIDs. It originates mainly from the basal bone of posterior mandible and may affect teeth as they erupt but does not commonly initiate near the apical area of a posterior tooth.2 With a fully competent immune defense, intact osseous tissue is able to restrict the infectious pathogens or kill them.4 Remodeling capacity of the involved bone has an important role in reactive bone formation following the inflammatory processes.5These reactive calcifications may show snowflake, cotton-wool or even sun ray appearances. It is a critical rule that traumatic, infectious and benign reactive lesions are more common than malignant pathoses in the oral cavity. Osteomyelitis may share some radiographic features with primary or metastatic malignancies of the jaw.6In the presented case, we would put the localized sclerosing osteomyelitis in top ranking of our differential diagnosis if we remembered that chronic traumatic conditions may induce osteomyelitis by causing microinfarctions.9The patient suffered from an untreated convulsive disease. Panoramic view of his jaws signified a sclerotic thickening of cortical bone around the mandibular premolars and some hyperostotic reactions in the lower left quadrant. These findings indicate a chronic occurrence of heavy occlusal trauma in a young bone with a high remodeling capacity.Osteomyelitis is an infectious process with a spectrum of clinical demonstrations from a localized small sclerosing lesion to a generalized suppurative destructive one. It represents the interactions between host immunity and microbial virulence.Chronic trauma or traumatic occlusion has the potential to induce osteomyelitis and should be considered as a possible diagnosis in differentiating periapical radiopacities, even in relation to vital teeth.


Paragangliomas represent only 10% of chromaffin tissue tumors and those arising from the mesentery seem to be a rare occurrence. We report a case of a 55 year old man in whom an abdominal mass was discovered fortuitously by ultrasonography during a routine health exam. He presented occasional heart palpitations and diaphoresis as well as a well-demarcated mass upon abdominal physical examination. CT scan revealed a solid polylobulated mass in the right lower quadrant. Exploration laparotomy revealed a voluminous multi-nodular tumoral mass, which contained hemorrhagic spots. Histopathological studies confirmed the presence of a paraganglioma. The excision of the mass as well as the surrounding intestine and mesentery also revealed two lymphatic metastases, the first among 14 documented cases to be described concerning mesenteric paragangliomas. One year follow up and CT scan revealed neither recurrence nor the presence of distant metastases. With an annual incidence estimated at 1/100,000, paragangliomas represent ten percent of catecholamine secreting tumors. Paragangliomas arise from chromaffin tissue most commonly found in the Zuckerkandl body, the sympathetic plexus of the urinary bladder, the kidneys, and the heart or in the sympathetic ganglia of the head or neck . Given tA 55-year-old man followed and treated for acid reflux and dyslipidemia as well as resection of a cutaneous sebaceous cyst, was admitted in our institution for the investigation of an abdominal mass discovered fortuitously during a routine annual abdominal ultrasound. The ultrasound, which revealed an asymptomatic hypoechogenous polylobulated solid mass in the right supraumbilical territory, was followed up and confirmed with a CT scan Figure . The masThe resected specimen consisted of segment of small intestine measuring 30 cm in length, accompanied by a small portion of adipo-fibrous mesenteric tissue. With the mesenteric tissue was a voluminous multi-nodular tumoral mass, measuring 11.5 × 9.5 × 6.5 cm. Upon further dissection of the solid mass, hemorrhagic spots were uncovered, which were well demarcated in the periphery.Histologic examination revealed a solid cellular proliferation with an alveolar and focally diffuse architecture. Groups of cells were separated by fibrovascular septae, giving a characteristic "zellballen" nested appearance. The group of cells were composed of polyhedral cells with granular amphophilic cytoplasm. Nuclei were round to oval in appearance with moderate atypia and prominent nucleoli. The mitotic count and proliferative indices were low . Figure .Given the presence of a paraganglioma, a urinary search for catecholamines and its derivatives was conducted and was unremarkable post operatively.Throughout the procedure, and well before the identification of the mass, the patient remained asymptomatic aside from occasional palpitations and diaphoresis. The patient has been followed for almost a year and a follow up abdominal scan was conducted, all indicating the patient was free from any signs of recurrence including the palpitations and diaphoresis.Neural crest cells give rise to the parenchymal cells of the paraganglia and other elements of the autonomic nervous system. These neural crest cells have the ability to migrate to various regions along the paravertebral and para-aortic axis, while remaining in close relation to the sympathetic nervous system. They extend to various places, anywhere from the neck to the base of the pelvis . In rare18F] fluoro-DOPA help identify and characterize the extent of the mass as well as the staging [131I-MIBG is not a curative therapy, its involvement as an adjuvant to surgical resection as well as the possibility of a synergistic effect with chemotherapy seem promising and are venues to be explored in the near future [Diagnosing paragangliomas, and in particular those of the mesentery, can be achieved via biochemistry and/or imagery. Given the capacity of a paraganglioma to secrete catecholamines, plasma or urinary metanephrines have been described in the literature as a very sensitive technique. Unfortunately the secreting property is only found in 25% of mesenteric paragangliomas . Anatomi staging . These t staging . Finally staging . Treatmer future . Radioacr future . Focus hr future .With the exception of a single case documenting liver metastases, and to the best of our knowledge, this is the first case documenting regional lymph node metastases. As a result, this case can further be classified as one of malignant paraganglioma. This comes to no surprise given malignant chromaffin cell tumor have been documented to metastasize to local lymph nodes, bone liver and lung .Paragangliomas represent only 10% of chromaffin tissue tumors and the mesenteric form seems to be a rare occurrence, but should be among the preoperative differential diagnosis of abdominal masses of unknown etiology. The diagnosis is best achieved by imagery and laparoscopic exploration. Metastases although extremely rare, must be taken into account. Finally resection has proven to be the most effective method of treatment, while chemotherapy and radiotherapy have both been proven ineffective in previous cases.Written informed consent was obtained from the patient for publication of the Case report and any accompanying images. A copy of the written consent is available for review by the Editor in Chief of this journal.The authors declare that they have no competing interests.MC was involved in the review of literature, acquisition of data and drafting and completing the manuscript. LS conceived the study, participated in the coordination and acquisition of data and helped to draft the manuscript. VR carried out the immunohistological staining and interpretation of the resected specimens as well as contributed to the drafting of the manuscript. GL and PD participated in the critical review of the paper. All authors read and approved the final manuscript.


We report a 48-year-old woman with a pleural pseudoneoplasm requiring different diagnostic and therapeutic strategies. After initial presentation with increasing dyspnoea, temperature, dry cough, and interscapular pain diagnostic processing showed a large mediastinal mass with marked pleural effusion and high metabolic activity in the 18F-FDG-PET/CT. Extensive CT-guided biopsy of the tumor reaching from the visceral pleura into the right upper lobe revealed no malignancy, but a marked inflammatory tissue reaction containing foam cells. Initial empiric antibiotic therapy was temporarily successful. However, in the further course the mass relapsed and was resistant to antibiotics and a corticosteroid trial. With the working hypothesis of an inflammatory myofibroblastic tumor the patient underwent surgical tumor resection, finally confirming the suspected diagnosis. Due to residual disease intravenous immunoglobulins were administered leading to sustained response. This case with a pleural localisation of a large inflammatory pseudotumor with responsiveness to immunomodulation after incomplete resection extends the reported spectrum of thoracopulmonary manifestations of this rare entity. Inflammatory myofibroblastic tumor (IMT) is a rare non-neoplastic lesion with unknown pathogenesis, comprising less than one percent of all surgically resected lung tumors in adults . They caA 48-year-old woman presented to a peripheral hospital with a 14 days' history of progressive shortness of breath on exertion, dry cough, and interscapular pain. On physical examination the patient displayed reduced breath sounds and a dull percussion note at the right lung base, but was otherwise unremarkable. The initial radiologic work-up revealed a large mediastinal mass measuring 9 cm in size with concomitant marked pleural effusion . The maiTwo weeks after the start of moxifloxacin therapy the patient presented herself as afebrile with a marked decrease in CRP (from 27.96 mg/dL to 3.5 mg/dL). Two further weeks later, along with the clinical improvement, a reduction of the size of the mediastinal mass by one-half was noted  consistent with residual inflammatory disease . Thus, fEikenella corrodens infection, DNA expression of Epstein Barr virus or Human Herpes Virus 8, association with mycobacteria, actinomycetes, nocardiae, and pseudomonas have so far been reported [In inflammatory pseudotumors the myofibroblast was recognized as the principal cell type and provided the recent classification as inflammatory myofibroblastic tumor . Diversereported –13. The reported . EspeciaApproximately 70% of patients are asymptomatic , but lik