Calcification rarely occurs in vestibular schwannoma (VS), and only seven cases of calcified VS have been reported in the literature. Here, we report a 48-year-old man with VS, who had a history of progressive left-sided hearing loss for 3 years. Neurological examination revealed that he had left-sided hearing loss and left cerebellar ataxia. Magnetic resonance imaging and computerized tomography angiography showed a mass with calcification in the left cerebellopontine angle (CPA). The tumor was successfully removed via suboccipital craniotomy, and postoperative histopathology showed that the tumor was a schwannoma. We reviewed seven cases of calcified VS that were previously reported in the literature, and we analyzed and summarized the characteristics of these tumors, including the calcification, texture, and blood supply. We conclude that calcification in VS is associated with its texture and blood supply, and these characteristics affect the surgical removal of the tumor. Vestibular schwannoma (VS), often called acoustic neuroma, is a common cerebellopontine angle (CPA) tumor. Calcification rarely occurs in vestibular schwannoma, and only seven cases of calcified VS have been reported in the literature -6. CalciThe patient, a 48-year old man, was hospitalized for progressive left-sided hearing loss for 3 years. Upon examination, he had left-sided hearing loss. He also had an abnormal finger-nose pointing test, an abnormal rapid alternating movement, and a heel-knee-shin ataxia on the left side. He did not present with facial palsy and had normal muscle tone in the extremities. Magnetic resonance imaging (MRI) of the brain showed a round mass with a size of 5.42 × 4.27 × 5.35 cm in the left CPA region. The lesion was hypointense in the T1-weighted imaging (T1WI) and unevenly hyperintense in the T2-weighted imaging (T2WI). Heterogeneous enhancement in the tumor was observed in the contrast-enhanced MRI. The left cerebellum, the fourth ventricle, and the brain stem were compressed  scan and MRI, which showed that the tumor was completely removed Figure . The hisWe performed a Medline literature search to identify cases of calcified VS that had been reported between 1980 and 2011. We found seven cases of calcified VS in six papers. Table The seven cases included five men and two women with a mean disease duration of 9.6 years . All of these patients presented with the initial symptom of hearing loss, and two patients also presented with facial numbness. Neurological examinations were performed in six patients, and CPA symptoms with different severities were identified in these patients.All the patients underwent CT scanning, and calcification in the VS was clearly observed on the CT scans. A conglomerate of dense calcifications in the VS was reported in three cases, and local calcified deposits were reported in four cases. MRI was performed in five of seven cases. Hypointensity on T1WI and hyperintensity on T2WI were found in four cases, and heterogeneous signals on both T1WI and T2WI were observed in one case. Contrast-enhanced MRI was performed in four of five cases. Heterogeneous enhancement was identified in three cases, and homogeneous enhancement was found in one case. Digital subtraction angiography (DSA) was performed in two cases, in which no tumors were stained in the images.The tumor was removed via the translabyrinthine approach in two cases and via the suboccipital approach in five cases. Total excision of the tumor was performed in five cases, and subtotal excision was performed in two cases. The detailed surgical procedure was described for four cases, in which the tumor was hard in three cases and cystic and soft in one case. Tumors with a rich blood supply were reported in three cases.Among the seven cases, two patients had no postoperative facial palsy, two patients had mild postoperative facial palsy, and one patient had complete facial palsy. The severity of postoperative facial palsy was not reported in one case. Postoperative death occurred in one case due to myocardial infarction complications.It is very rare for VS to demonstrate calcification. When calcification occurs, the schwannoma usually hardens, making it difficult to dissect the tumor surgically ,12,13. IThe texture of the tumor is one of the factors that affect its surgical removal. The texture is dependent not only on calcification but also on cyst formation and hemorrhage inside the tumors ,16. We rThe tumor’s blood supply is also a critical factor affecting surgical dissection of the tumor. Three of the seven cases in the literature reported a rich blood supply in the tumors and identified enhancement in contrast-enhanced MRI or CT. However, no tumor staining was identified on angiography in two patients who underwent DSA. Consistent with these reports, no tumor staining was observed with CTA in our case, although a rich blood supply was identified during the operation. The finding that the tumor was not stained in the angiography is likely because the tumor was supplied by a thin artery that was difficult to stain using this procedure . Total eThe main surgeries for VS removal are translabyrinthine craniotomy and suboccipital craniotomy . The sevA calcified tumor in the CPA suggests a diagnosis of meningioma or cavernous angioma. Identification of the features of these tumors on MRI, CT, and angiography is critical for differential diagnosis among calcified VS, meningioma, and cavernous angioma. Meningiomas usually have a wide base attached to the dura mater and thus have characteristic dural tail signs on the MRI . HoweverIn summary, we report a case of calcified VS and a literature review of seven cases of calcified VS. We analyzed the tumor’s texture and blood supply, the radiological findings, and the surgical procedures. It is difficult to remove hard calcified VS with a rich blood supply. However, cystic formation in VS can soften the tumor, thus facilitating its dissection. We conclude that radiological findings are helpful to differentiate calcified VS from other tumors in the CPA.Written informed consent was obtained from the patient for publication of this case report and the accompanying images. Copies of the written consent are available for review upon request.The authors declare that they have no competing interests.Yang Zhang and Yunqian Li wrote the initial draft. Jinlu Yu was the surgeon. Limei Qu performed the pathological examination. Yang Zhang and Jinlu Yu contributed equally to this work. All authors read and approved the final manuscript.This study had no funding support.


Background. Numerous reports have demonstrated how postoperative intracranial granulomas can often mimic neoplasm clinically, radiologically, and even macroscopically. Herein we present an unusual case of postsurgical intracranial aseptic granuloma secondary to a chronic inflammatory reaction without any identifiable retained foreign body. Case Description. A 71-year-old patient started complaining of severe headache seven months after surgical excision of WHO Grade I right frontal falx meningioma. CT and MRI scans disclosed a contrast-enhanced lesion with diffuse mass effect in the previous surgical site. The lesion was resected; intraoperative finding and histological specimens led to the diagnosis of postoperative granuloma, likely expression of a glial reaction to the fluid absorbable hemostatics applied in the surgical site after meningioma excision. The possible granuloma-inducing materials and the timing of granuloma formation are discussed. Conclusion. A comprehensive analysis of clinical and neuroradiological data, as well as results of blood tests including positive and negative acute phase proteins, is mandatory to raise the suspicion of postoperative granuloma. The treatment options should be evaluated on a case-by-case basis, with a conservative attitude being the one of choice only for patients without progressive neurological deficit. Alternatively, aggressive surgical treatment and histopathological examination should be advocated. Intracranial granulomas are a rare pathologic finding; their formation is expression of chronic inflammation characterized by accumulation of modified macrophages and is initiated by a variety of infectious and noninfectious agents . InfectiIn this paper we present an unusual case of delayed intracranial granuloma, occurring seven months after total resection of a right frontal falx transitional meningioma (WHO Grade I). The mass mimicking a relapse of tumor growth was microscopically excised: interestingly, histological examination showed a chronic aseptic inflammatory process inconsistent with tumor recurrence, abscess, or plasma cell granuloma. After a revision of all the clinical and radiological data and supported by the fact that no evidence of foreign body was histologically found into the granuloma, but elements of advanced degradation of the fluid absorbable hemostatics applied in the surgical site after the meningioma excision, we have speculated that this space-occupying mass might likely result as a glial reaction to their intraoperative use.Identification of postoperative granulomas is important to prevent inappropriate treatment of presumed tumor recurrence. A discussion of the relevant literature is provided with special attention to possible granuloma-inducing materials, diagnostic flow chart, and therapeutic options.A 71-year-old woman was rehospitalized in our Neurosurgical Department with an irregular intracranial contrast enhanced lesion, seven months after a craniotomy for removal of a frontal falx meningioma .Anamnesis was positive for hypertension, diabetes, poliallergic asthma, Hashimoto's thyroiditis, and bladder carcinoma. At the time of the first admission the frontal lesion was responsible for specific symptoms such as mood disturbances, insomnia, and headache. Surgical excision was then proposed and, after desensibilization therapy (antihistaminics and corticosteroids administered for three days prior to the scheduled intervention), performed through a right frontal craniotomy with removal of the infiltrated falx by standard technique with ultrasonic surgical aspirator. Hemostasis was obtained by filling part of the surgical cavity with absorbable hemostatics such as bovine-derived gelatine and human-derived thrombin matrix  and oxidized regenerated cellulose ; finally, a dural graft implant  was used to replace the calvarian dura mater removed, in order to achieve a Simpson Grade I excision.Her postoperative course was uneventful; as well the early CT and MRI scans were unremarkable, confirming the complete excision of the tumor. Blood tests revealed an unspecific increase of the high-sensitivity C-reactive protein (hs-CRP) levels above the range of normality , but this data was not associated with fever, leucocytosis, alteration of seric procalcitonin, or other signs of flogosis. Given the histological diagnosis of WHO Grade I transitional (mixed) meningioma  and goodSeven months later she was referred back by her General Practitioner for persistent headache. The surgical wound was completely healed; there was no evidence, nor history of fever, but hs-CRP levels kept being slightly higher than normal range values 59,4 mg/L). A cephalorachidian liquor (CSF) analysis was then performed by a lumbar puncture, but resulted completely normal both chemically and microbiologically. The CT scan of the brain revealed along the right frontal falx an irregular 2.5 cm contrast-enhanced lesion, associated with surrounding edema responsible for diffuse mass effect ; on MRI 9,4 mg/L.Postoperative intracranial granulomas are luckily rare. A Medline search of the literature published until December 2011, using subject heading “intracranial postoperative granuloma,” produced only 42 results. Most of these articles describe aseptic foreign body granuloma formation caused by a variety of substances including gel foam , surgicaDespite the location and the surrounding oedema, suggestive for parenchymal invasion, a recurrence of the meningioma was thought to be unlikely because of three reasons: (1) the Simpson grade I excision obtained, (2) the histological low grade at first surgical removal, and (3) the short delay between the two hospitalizations. Furthermore, the hypothesis of infection was not supported by the anamnesis, since surgical wound was originally classified as Class I according to CDC Surgical Wound Classification, nor by any clinical signs or symptoms. Moreover, the negativity of procalcitonin firstly, and CSF examination secondary, seemed to controvert the elevation of hs-CRP. Although we had many concerns regarding the possible diagnosis, the degree of the surrounding edema contributed to prompt exploration via reopening of the previous frontal craniotomy: the lesion was inconsistent with a meningioma recurrence or with tumor-like growth, and no foreign body or exudates were found to support the suspicion of abscess. The histopathological examination was the only tool allowing for a definitive diagnosis of postoperative granuloma; at that time, despite the presence of some mononuclear cells within the specimen, the differential diagnosis of plasma cell granuloma was definitely excluded by the absence of polyclonal proliferation of mature plasma cells. After a reanalysis of the surgical technique used for the removal of the falx meningioma, we argued that the granuloma formation was most likely due to the amount of absorbable hemostatics used to fill the surgical cavity at the time of the first surgery.A variety of local hemostatics including absorbable gelatin sponge, collagen, and oxidized cellulose are commercially available; their application is recommended when cautery, ligature, or other conventional procedures are ineffective or impractical. Proper handling of absorbable hemostatic agents is essential to control bleeding, and even if the hemostat is expected to dissolve promptly, when it is retained in or near bony or neural spaces, the minimum amount should be left in place after hemostasis is achieved. Generally, topic hemostatics are reabsorbed within a couple of weeks, and during this period minimum inflammation without strong foreign body reactions or blockade of healing is possible; rarely, strong foreign body reactions, chronic inflammation, and infections can cause granuloma formation after their use . AlthougIt is generally accepted that by using local hemostats, it is possible to improve the condition of the patient, reduce complications, and lower direct and indirect costs, but it is necessary to stress the point that documentation is important with regard to the hemostat used, including the name of the agent, site, and amount: that information may be useful as a reference in the interpretation of postoperative diagnostic images changes . PostopeGiven the possibility of a multifactorial process , that may also be self-limited in certain individuals, the success rate of treatment is equally difficult to determine. Surgical exploration and lysis of adhesions, corticosteroids, antibiotics, and conservative observation have all been attempted. Some reports confirm that symptoms may improve after corticosteroid administration, but others suggest that this correlation might be questionable; nevertheless the failure of a high dosage 3-to-6-week course of steroids should lead to surgical reexploration.The review of the literature confirms that despite the widespread use of fluid hemostatics in thousands of operations performed by neurosurgeons each year, this is not a well-recognized outcome. Any proposal for a diagnostic flow chart is merely difficult, since history or signs of flogosis may be lacking; consequently a comprehensive analysis of clinical  and neuroradiological data, as well as results of blood tests including positive  and, when available, negative  acute phase proteins is mandatory to raise the suspicion. Thus, it seems reasonable that treatment options should be evaluated on a case-by-case basis, with a conservative attitude being the one of choice only for patients without progressive neurological deficit; in the other cases an aggressive surgical treatment and histopathological examination should be considered in order to guarantee an accurate diagnosis and definitive cure.


Verrucous carcinoma of the external genitalia and perianal region is a rare variant of well-differentiated squamous cell carcinoma. It has been reported to have limited metastatic potential.We report the case of a 54 year-old Moroccan man who presented with locally advanced giant condyloma acuminatum (Buschke–Löwenstein tumor) after prolonged intervals of neglect (approximately 10 years). The disease covered his suprapubic, external genitalia and perianal region. It was locally aggressive with extensive tissue destruction. After a biopsy of the lesion, the diagnosis of verrucous carcinoma was confirmed. He initially received chemoradiotherapy, followed by extensive local excision, but he developed septic shock and died a few days later.The purpose of this case report is to present a case of verrucous carcinoma arising in an extensive giant condyloma acuminatum (Buschke–Löwenstein tumor) and discuss the literature on its diagnosis and management. Verrucous carcinoma (VC) was first described as a distinct well-differentiated variety of squamous cell carcinoma (SCC) by Ackerman . VC tendTo the best of our knowledge, this is the first case report in which a history of BLT is complicated by malignant transformation covering a large part of the patient’s lower body. We present a recent systematic literature review regarding the clinical presentation and treatment of this rare tumor.A 54-year-old heterosexual married Moroccan man presented with a previous uncomplicated medical history. He did not report any risk factors for human immunodeficiency virus infection (HIV). He was seen in our emergency department with a foul smelling, exquisitely tender mass arising in his suprapubic, external genitalia and perianal region that extended laterally to both thighs Figure . This leAdditional radiological investigations consisted of a thoracic-abdominal-pelvic computed tomography scan Figures  and 6 wh2 on day one and 5-fluorouracil (5- FU) 600mg/m2 on day one to five given as a continuous infusion. After two cycles of chemotherapy the tumor size was reduced to 30% of initial size. The radiation was planned in two phases, two total doses of 45Gy in 25 fractions over 5 weeks, given at 1.8Gy per fraction. The combined therapy was well tolerated with just diarrhea as a side effect. Six months after completing the treatment, he underwent local excision with extensive abdominoperineal rectum excision and emasculation. In addition, a temporary diverting colostomy and a bilateral ureterostomy were constructed. Pedicled anterolateral thigh flaps and abdominal flap were used to cover the perineal defects. Unfortunately he developed septic shock and died some days later. The final pathology report after surgical resection of the tissue confirmed the diagnosis of VC.After treatment of a local infection, our patient received two cycles of intravenous chemotherapy given three weekly with cisplatin 80mg/mBLT is a rare sexually transmitted disease triggered by HPV, usually genotype 6 or 11 . Risk faThe absence of high-risk HPV subtypes in a case of BLT cannot exclude focally invasive SCC. Histopathological criteria for malignancy and clinical presentation continue to lead management decisions ,6. The aThe disease is located on the penis in 81 to 94% of cases, in the anorectal area in 10 to 17%, and in the urethra in 5%. In females, the location is chiefly the vulva (90%) and an anorectal location is less frequent . SuprapuClinically, the tumor presents as exophytic fungating masses, sometimes with a cauliflower-like morphology. The gross appearance is generally a bulky tumor suggesting an aggressive behavior, whereas histopathology reveals a relatively low-grade malignancy. Biologically, this tumor shows a high recurrence rate and it is characterized by a low incidence of metastasis ,18. MaliThe diagnosis of VC requires evaluation of the clinical and microscopic appearance and biologic behavior of the neoplasm . It is iVC presents as a distinct entity with an exo-endophytic growth pattern (in contrast to condyloma accuminata) of squamous cells showing mild atypia with pushing margins (in contrast to the invasive character of well-differentiated squamous carcinoma). This results in slow-growing lesions, locally invasive behavior, and very infrequent metastatic spread .Differentiation between BLT and VC is difficult. Some authors consider these lesions to be similar. However, others maintain that BLT represents an intermediate lesion between condyloma acuminatum and VC, referring to it as a condyloma-like precancerous lesion .Wide surgical excision, chemoradiation, topical and intralesional chemotherapy, carbon dioxide laser therapy, and photodynamic therapy have all been used in different combinations in the treatment of BLT, with varying success. Surgery is the treatment of choice and is effective in the early stages of the disease. Excision must be wide, and ranges from the Mohs technique when the size of the tumor is small, to abdominoperineal excision with pelvic lymph node dissection if lymph metastasis was suspected ,21.Radiotherapy alone is rarely used; it is usually used alone when excision cannot be performed or in recurrences. It may also be indicated to complement surgery in the case of an incomplete excision ,21. In aet al. [Chemotherapy consists of a combination of cisplatin and 5-FU. The choice of this protocol was based on our own experience in treatment of patients with anal cancer. This combination has been used combined with radiation with acceptable toxicity and positives responses . In patiet al.  reportedTo avoid the recurrent disease some authors suggest the administration of an autogenous vaccine after surgical excision. The lowest reported recurrence rate at 1 year was less than 5% .VC is a rare, locally aggressive tumor. Surgical complete excision of VC is advised. Other treatment modalities such as chemotherapy or radiotherapy could be used to avoid mutilating surgical interventions. Based on our case and other published reports, chemoradiotherapy should be considered in patients with malignant transformation of GCA to downsize the tumor. Decision making in regarding to the goals of surgical intervention is complex and involves palliative excision versus a curative excision which unfortunately has the potential of significant morbidity and mortality. Wide surgical excision with local flap reconstruction can significantly improve the quality of life. A regular follow-up is necessary due to frequent recurrences and possible distant metastasis.Written informed consent was obtained from the patient’s next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MA was the principal author and major contributor in writing the manuscript. YT, MFT, SM, JE, AK, and HE analyzed and interpreted the patient data and reviewed the literature. RSW, MJE, MHF, and AA read and corrected the manuscript. All authors read and approved the final manuscript.


Vascular anomalies comprise a widely heterogeneous group of tumours and malformations. Haemangioma is the most common benign tumour of vascular origin of the head and neck region. The possible sites of occurrence in oral cavity are lips, tongue, buccal mucosa, and palate. Despite its benign origin and behaviour, it is always of clinical importance to the dental profession and requires appropriate management. This case study reports a rare case of capillary haemangioma on the palatal gingiva in a 14-year-old female. Haemangioma are the most common benign vasoformative tumours of infancy and childhood , 2. TheyThe majority of haemangioma involve the head and neck. However, they are rare in the oral cavity but may occur on tongue, lips, buccal mucosa, gingiva, palatal mucosa, salivary glands, alveolar ridge, and jaw bones , 6, 9–12A female patient aged 14 years, reported with a chief complaint of a swelling and growth on the inner side of her upper front teeth since 4-5 months. She also complains of localized bleeding in that area on brushing, and there was slight pain and discomfort on eating.Dental history revealed that she had a history of gingival enlargement, one year back, which she had got excised. However, the growth recurred within two months after surgical excision. It was initially small in size, gradually increased and stabilized after 3-4 weeks till the present size. On general physical examination, it was found that the patient was normally built for her age with no defect in gait or stature, and there was no relevant medical history. Family history was also noncontributory.A comprehensive intraoral examination revealed a localized gingival mass between maxillary right central incisor and lateral incisor  on the palatal aspect . It was The other pathologic entities that were included in the differential diagnosis were malignancies, trauma, and or infection , enlargement due to drugs. Complete blood examination, urine analysis, and an intraoral periapical radiograph with respect to 11, 12 were done. The laboratory investigations of blood and urine were within normal limits that ruled out any leukemic enlargement and diabetes mellitus. HIV, HBs, VDRL, and Mantoux test were negative, ruling out any possibility of infectious involvement. Radiographically, there was no evidence of crestal bone loss, and lamina dura was intact around the roots of both maxillary right central and lateral incisor. Scaling was carried out under universal precautions, and later surgical excision of the lesion was done under local anaesthesia as a part of excisional biopsy. A thread was tied around the stalk of the pedunculated lesion and was stretched tightly so as to reduce blood circulation to the lesion. The growth was then surgically excised along with the stalk, and thorough curettage of the area was performed. The excised lesion was stored in 10% formalin and sent for histopathological examination. Periodontal dressing was applied on the operated area, and the patient was given postoperative instructions. Histopathological examination revealed stratified squamous epithelium which showed atrophy, and in some areas hyperkeratosis was seen. Beneath this, many small and large capillaries filled with blood were present. These vessels were lined by a single layer of endothelial cells and were supported by a connective tissue stroma of varying density with no inflammatory component . On the The confusing and misleading terminology has led to inappropriate grouping and classification of vasoformative tumours . The difPathogenesis and origin of haemangioma remain incompletely understood. However, various theories have been proposed to elucidate the mechanism and pathogenesis of haemangioma. Aberrant and focal proliferation of endothelial cells results in haemangioma, although the cause behind this remains unclear . The plaA variety of other lesions can resemble haemangioma in the oral cavity. The differential diagnosis includes pyogenic granuloma, chronic inflammatory gingival hyperplasia, epulis granulomatosa, telangiectasia, angiosarcoma, squamous cell carcinoma, and other vascular appearing lesions of face or oral cavity such as Sturge Weber Syndrome .In the present case, clinical features resemble that of pyogenic granuloma. However, the lesion did not show microscopic appearance of a pyogenic granuloma. It contained blood-filled capillaries lined by layer of endothelial cells in a connective tissue stroma without any evidence of inflammation.Angiosarcoma is a rare malignant tumour of vascular endothelium, and it resembles haemangioma. However, it can be differentiated from it on the basis of histopathologic findings as it is characterized by infiltrative proliferation of endothelium-lined blood vessels that form an anastomosing network. The endothelial cells appear hyperchromatic and atypical and often tend to pile up within vascular lamina .Management of haemangioma depends on a variety of factors, and most true haemangioma requires no intervention. However, 10–20% requires treatment because of the size, exact location, stages of growth or regeneration, functional compromise, and behaviour. The range of treatment includes surgery, flash lamp pulsed laser, intralesional injection of fibrosing agent, interferon alpha-2b, and electrocoagulation while cryosurgery, compression and radiation were used in the past , 19–22. Haemangioma is of benign origin and behaviour, but haemangioma in the oral cavity is of clinical importance. It often mimics other lesion clinically and requires appropriate clinical diagnosis and proper management.


Hemobilia is a rare cause of upper gastrointestinal bleeding. More than 50% of hemobilia cases are related to iatrogenic trauma from hepatobiliary procedures, and needle biopsy of the liver represents the most common cause. A minority of hemobilia cases are due to hepatobiliary disorders such as cholangitis, hepatobiliary cancers, choledocholithiasis, and vascular abnormalities in the liver. The classic presentation of hemobilia is the triad of right upper quadrant (biliary) pain, obstructive jaundice, and upper gastrointestinal bleeding. We report a rare case of hemobilia caused by a spontaneous hepatic cyst rupture, where our patient presented without the classical symptoms, in the absence of therapeutic or pathological coagulopathy, and in the absence of spontaneous or iatrogenic trauma.A 91-year-old African-American woman was referred to our out-patient gastroenterology clinic for evaluation of mild epigastric pain and intermittent melena. An abdominal computed tomography scan was remarkable for multiple hepatic cysts. Esophagogastroduodenoscopy revealed multiple blood clots at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography showed a single 18 mm-sized filling defect in the common hepatic duct wall at the junction of the right and left hepatic duct, adjacent to one of the hepatic cysts. The ruptured hepatic cyst communicated to the bile ducts and was the cause of hemobilia with an atypical clinical presentation.Hemobilia is an infrequent cause of upper gastrointestinal bleeding and rarely occurs due to hepatic cyst rupture. To the best of our knowledge, this is only the second case report in the literature that describes hemobilia due to hepatic cyst rupture. However, it is the first case in the literature of hemobilia due to hepatic cyst rupture in the absence of iatrogenic or spontaneous trauma, and in the absence of a spontaneous or pathological coagulopathy. Hemobilia is a rare cause of upper gastrointestinal bleeding. The widespread use of imaging modalities such as magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and high-resolution computed tomography (CT) have facilitated the diagnosis of hepatic disorders and increased the indication for invasive hepatobiliary procedures. These procedures in turn increase the incidence of hemobilia. A review of hemobilia cases by Sandblom indicated that trauma was the cause of hemobilia in half the cases, with one-third of these hemobilia cases being iatrogenic, and needle biopsy of the liver representing the most common cause ,2.Other factors commonly associated with hemobilia include percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, instrumental exploration of bile ducts, and biliary stent trauma. Less common causes include hepatic abscesses, cholangitis, hepatic cysts, hepatobiliary tumors, coagulopathies, and hepatic artery aneurysms that rupture -4. TableA 91-year-old African-American woman was referred to our out-patient gastroenterology (GI) clinic for evaluation of mild epigastric pain and intermittent melena. Melena had been occurring for a week. Our patient denied any history of nausea, vomiting, early satiety, weight loss, hematemesis, heartburn, or alcohol use, and had never had any previous episodes of abdominal pain. Her vital signs showed no signs of orthostasis. An abdominal examination revealed a soft, non-tender abdomen. Rectal examination revealed hemoccult-positive dark colored stool. Laboratory test results revealed anemia  and abnormal liver function tests  54 U/L, alanine aminotransferase (ALT) 188 U/L), consistent with cholestasis. Her α-fetoprotein, carbohydrate antigen (CA) 19-9, and hepatitis serologies were normal. Abdominal computed tomography (CT) studies were remarkable for multiple hepatic cysts, but malignancy could not be excluded  responsible for hemobilia and treatment modalities, such as therapeutic artery embolization, can be offered simultaneously. However, the diagnosis and evaluation of hemobilia -7 can alThe management of hemobilia is directed at hemostasis and relieving biliary obstruction ,11, whilThe term hepatic cyst usually refers to a solitary non-parasitic cyst of the liver also known as a simple cyst . HoweverIn fact, the most common hepatic cysts are simple hepatic cysts, which are generally considered benign . Simple In conclusion, hemobilia is a rare cause of upper GI bleed. Trauma and iatrogenic injuries are the most common causes of hemobilia. The absence of classical symptoms is unusual. A hepatic cyst represents an extremely unusual cause of hemobilia and is due to hepatic cyst rupture into adjacent intra-biliary ducts, which has only been reported once before in the literature. To the best of our knowledge, this is the first case of hemobilia due to a spontaneous hepatic cyst rupture in the absence of iatrogenic or spontaneous trauma and in the absence of a spontaneous or pathological coagulopathy. The diagnosis was made with a multi-modality approach using EGD, ERCP, CT, pathology, and our patient's clinical course.Written informed consent was obtained from the patient's next-of-kin for publication of this case report and any accompanying images. At the time of discharge, she was 91. Unfortunately, she passed away approximately 4 years later, due to unrelated causes to her case presentation. 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.VS performed the literature review, wrote the manuscript, and provided the revised table. VS also performed the data collection, chart review, image retrieval, and incorporated all the suggested revisions including the hepatic cyst literature addendums. VS also revised all the figures, edited the images, and incorporated them in the manuscript. SD was the gastroenterologist for our patient's care and performed the endoscopy examination along with the ERCP. SD also assisted in revision of the manuscript. DA wrote a preliminary draft of the manuscript and also provided the original table. MA reviewed the manuscript. All authors read and approved the final manuscript for publication.


Infantile myofibromatosis (IM) is the most common fibrous tumor of infancy. IM may arise in a solitary or multicentric form, with similar histopathological findings, however, the clinical features and prognoses may vary. The solitary form tends to occur predominantly in males and is typically observed in the dermis, subcutis or deep soft tissues. The reported incidence of solitary osseous myofibromatosis is rare. Furthermore, the majority of solitary IM cases of the bone occur in the craniofacial bones, while the occurrence of solitary osseous myofibromatosis on the extremities has been sporadically reported. The present study describes two cases of solitary IM involving the bones of the upper extremities in females who were over two years old. The cases show unusual symptom presentation and the tumor origin is in a rarely observed location. The study discusses the clinical, radiological and pathological features, in addition to the previously described etiology, prognosis and treatment options for this condition. Infantile myofibromatosis (IM), the most common fibrous tumor of infancy, is a mesenchymal disorder that is characterized by the proliferation of fibrous tumors in the skin, bone, muscle and viscera . The conA three-year-old female patient was admitted to Children’s Hospital of Zhejiang University School of Medicine  with a 10-day history of enlargement of a lump located in the left forearm. The girl appeared systemically healthy with a firm, well-circumscribed, subcutaneous nodule situated in the left ulna and measuring 2×3 cm in dimension. The swelling was slightly tender, but the overlying skin was not inflamed and normal in color. The family history was unremarkable. An X-ray examination exhibited a well-defined osteolytic lesion with slight marginal sclerosis and a pathological fracture in the distal left ulna . To ruleA nine-year-old female patient was sent to a local clinic following a fall. The radiological examination revealed a well-defined radiolucent lesion and a pathological fracture in the diaphysis of the right humerus. Subsequent to being transferred to Children’s Hospital of Zhejiang University School of Medicine for further treatment, the patient was in a good general condition, but was extremely vocal due to pain when the right arm was moved. The family and antenatal histories were unremarkable. The blood tests revealed a normal morphology and blood cell count. The laboratory values for calcium and phosphate were normal. Additional imaging studies failed to demonstrate any distant or visceral involvement. The patient underwent curettage with bone grafting and flexible intramedullary nail fixation on May 24, 2010. Macroscopically, fascicles of spindle cells with abundant eosinophilic cytoplasm resembled smooth muscle . The spiet al(et al(IM is a fibrous tumor of childhood and infancy that is characterized by the development of nodular lesions involving the skin, subcutaneous tissue, internal organs or bones. The tumor may arise in a solitary or multicentric form, with similar histopathological findings, but varied clinical features and prognoses . Bone leet al, one caset al and one  al(et al. In the The etiology of this disease is not well understood. One of the proposed hypotheses is the upregulation of the estrogen receptors on the fetal smooth muscles, which leaves them more sensitive to maternal estrogen and may induce their proliferation . Two othThe imaging characteristics of IM are not specific. On radiographic images, the bone lesions appear as osteolytic areas with sclerotic rims. On ultrasound scans, the masses may show either a hyperechoic or anechoic center with a surrounding rim. Computed tomography depicts the tumor as isodense or with a lower density compared with the muscles, and bone involvement often takes the shape of circumscribed lytic lesions with sclerotic margins . MagnetiHistologically, the cells have a characteristic spindle shaped fibroblast appearance with pale pink cytoplasm and elongated nuclei when stained with HE. Calcifications are frequent observations and the mitotic activity is minimally increased . The typMyofibromas are frequently confused with a number of other entities, including benign and malignant leiomyoma, leiomyosarcoma, neurofibroma, fibrosarcoma, metastatic neuroblastoma, hemangiopericytoma, desmoplastic fibroma and inflammatory myofibroblastic tumors .et al(The prognosis of IM varies according to the type . Tumors et al reportedet al reportedThe treatment for IM is determined by the location of the lesion. Although spontaneous regression is reported in a large number of cases, recurrence has also been reported ,11. SurgAlthough the incidence of solitary osseous myofibromatosis is rare, IM should be considered in the differential diagnosis for swellings and/or osteolytic lesions with pathological fractures in a child’s extremities. Subsequent to confirming a diagnosis, chest and abdominal imaging must be performed to evaluate the overall prognosis and to direct treatment . The pat


We report here the case of a 61-year-old woman who presented with hydrocephalus and cystic and solid lesions in sella turcica, suprasellar areas, and third ventricle. After ventriculoperitoneal shunt she developed cognitive changes and the cystic lesions enlarged. Magnetic resonance imaging (MRI) demonstrated multiple cysts and a solid lesion in the sella and around the anterior clinoid process. With diagnosis of neurocysticercosis she underwent craniotomy. Pathologic examination documented two different lesions: viable and dead cysticerci with inflaming infiltration and a left anterior clinoidal meningioma. At the second surgery, six weeks later via transnasal transsphenoidal approach a silent corticotroph pituitary adenoma was removed which was studied by histology, immunohistochemistry, and electron microscopy. To our knowledge, the occurrence of these three different lesions in the sellar area was not described before. Taenia solium. The embryo crosses the intestinal mucosa, enters the circulation, and reaches solid organs preferentially the brain and muscles. Neurocysticercosis refers to central nervous system infection by the parasite. It can be parenchymal or extraparenchymal. In the parenchymal form the cysticerci are within the brain parenchyma. In extraparenchymal disease the cysticerci migrate in the cerebrospinal fluid (CSF) to the ventricles, cisterns, subarachnoid space, or spinal cord [Cysticercosis is the most frequent helminthic disease of the central nervous system. It is endemic in Latin America, Asia, and Africa and it is frequently diagnosed in immigrant populations all over the world. It develops after ingestion of eggs of nal cord –3.By altering host defenses the cysticerci are able to survive in the human brain resulting in only minimal host inflammation around them. Eventually the parasite loses its ability to control the host defenses and an inflammatory response leads to the death of the cysticerci. The parasite becomes encased in a granuloma, which either resolves or leads to a scar and calcification. There is a wide variability in the immunological reaction of the host as well as in the multiple lesions induced by the parasites .A 61-year-old woman presented with two months history of headache and acute hydrocephalus with small cystic lesions in the skull base and intracranial calcifications as documented by MRI. A ventriculoperitoneal (VP) shunt was inserted and the clinical diagnosis of neurocysticercosis was made. She received albendazol for three weeks. 6 months later she developed severe cognitive decline, gait disturbances, and urinary incontinence. She complained of anorexia, malaise, and fatigue. At physical examination, visual fields showed no abnormalities and were normal. Hematological and biochemical studies revealed no changes. Hormone blood levels were growth hormone (GH) 0.32 ng/mL (<2), IGF-1 142 ng/mL (100–295), prolactin 41.4 ng/mL (2–15), luteinizing hormone (LH) 19.8 mIU/mL (40–104), follicle-stimulating hormone (FSH) 34 mIU/mL (34−96), thyroid stimulating hormone (TSH) 1.87 mU/mL (0.5–5), freeT4 1.35 ng/dL (0.7−2), and cortisol 19.2 mcg/dL (3−25). Computed tomography (CT) and magnetic resonance imaging (MRI) scan disclosed multiple intracranial cysts in the suprasellar area with extension to the third ventricle. The sella was enlarged and occupied by a mixed lesion with nonhomogeneous contrast enhancement Figures . It was The surgically removed tissues were fixed in buffered formalin and embedded in paraffin. From the first surgery one part represented the wall and epithelial lining of a simple cyst contaminated with the parasite compatible with neurocysticercosis in vesicular stage . Other pThe lesion removed at the second surgery revealed an amphophilic conclusively PAS positive pituitary adenoma with a diffuse pattern Figures . ImmunohCysticerci consist of two parts, the vesicular wall and the scolex. After entering the central nervous system, they are in a viable stage (vesicular stage) with a transparent membrane, a clear vesicular fluid, and an invaginated scolex. They may remain viable for many years or enter in a process of degeneration. The first stage of involution is the colloidal stage, in which the clear vesicular fluid becomes turbid and the scolex suffers hyaline degeneration. Thereafter the wall of the cyst thickens and the scolex is transformed into mineralized granules (granular stage) which are no longer viable. At the end the parasite remnants appear as a calcified nodule  , 4. The The presence of cysticerci in the sella is a rare occurrence. Sheehan and Summers  in theirA question may arise whether the 3 lesions which are very different in pathogenesis, clinical behavior, imaging findings, and morphology are causally related or are completely independent. As far as we know from the available literature, there is no indication to suggest that one of these lesions played a role in the development of the other lesions and it is not likely that any connection exists. Two different tumors, such as metastatic carcinoma and pituitary adenoma, or two different subtypes of pituitary adenomas may be present simultaneously but they are considered as an accidental event . Recent evidence indicates that inflammation may contribute to the development and progression of various tumors. Inflammatory cells may synthesize and release various cytokines which may affect endothelial function, vascular permeability, and the genetic profile of the tumor cells. Thus, the possibility in our case that the inflammation contributed to the development and/or progression of one of the documented tumors cannot be excluded. However, we have no evidence to suggest this possibility.


There are only nine primitive neuroectodermal tumor (PNET) cases that have arisen in lung parenchyma without pleural or chest wall involvement in the literature. Here, we present a long–term survival case of pulmonary PNET. A pulmonary mass was detected in a 19-year-old man on a chest radiograph and computed tomography image. At the three-year follow-up, the mass had enlarged in diameter by two-fold. The lesion was resected via lower left lobectomy. Histologically, the tumor was composed of uniform cells with round nuclei and scanty cytoplasm arranged in lobules with rosettes and pseudorosettes formation. Immunohistochemically, the tumor was positive for CD99, vimentin, neuron specific enolase and chromogranin A, and negative for cytokeratins, CD3, desmin, and leukocyte common antigen. Pancreatic metastasis occurred sixteen months after the first surgery, which was managed by pancreatectomy. The patient has survived seven years after the mass was initially detected, and four years after the first lobectomy.http://www.diagnosticpathology.diagnomx.eu/vs/1500847644913244The virtual slide(s) for this article can be found here:  Primitive neuroectodermal tumors (PNETs), first described by Hart and Earle in 1973 -4. ReporIn October 2005, a mass in the left lower lung lobe of a 19-year-old male was detected on a chest radiograph and a computed tomography (CT) image during a routine health examination  and the longest post-operational follow-up period (four years) of all the cases reported in the literature to date. We speculate that close follow-up with immediate surgical intervention when required may have helped to prolong the survival of our case.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 conflict of interest.SL gave the final histopathological diagnosis, performed the literature review, acquired photomicrographs, and drafted the manuscript. GZL participated in patient management and edited and revised the manuscript. WXL participated in patient management and drafted the manuscript. All authors read and approved the final manuscript.


Malignant peritoneal mesothelioma is a well-described entity in many reports in the literature in which it has been associated with asbestosis. However, there is no information describing the gross appearance and cardinal features seen during laparotomy, hence it is easy for the unwary surgeon to miss the diagnosis of this rare condition.A 49-year-old man of African descent presented to our hospital with a three-month history of weight loss, anorexia, abdominal distension, and general signs of cachexia and ascites on second presentation. At first presentation one year prior to this, he had undergone a laparotomy at our institution by a different team for intestinal obstruction secondary to adhesions with no biopsy taken. The patient's condition subsequently progressively deteriorated, and investigations including upper and lower gastrointestinal endoscopies and computed tomography of the abdomen were inconclusive, except for some free fluid in the peritoneal cavity and diffuse, mild thickening of the gut wall and mesentery. A second-look exploratory laparotomy revealed widespread nodular thickening of the visceral peritoneum with a striking, uniformly diffuse, erythematous, and velvety appearance. The peritoneal biopsy histology showed that the patient had malignant peritoneal mesothelioma. His condition deteriorated rapidly, and he died eight weeks after surgery.Our report aims to increase the diagnosing clinician's awareness of the cardinal features of malignant peritoneal mesothelioma and thus reduce diagnostic errors and delays in treatment. We present the case of a 49-year-old man with asbestos exposure to illustrate the rarity and difficulty of the diagnosis of malignant peritoneal mesothelioma (MPM). This case report focuses on the clinical appearance of the condition during exploratory laparotomy and demonstrates the striking, uniformly diffuse, erythematous, and velvety aspect of the tumor as it infiltrates the peritoneal surface. This presentation has not been described previously in the literature, and we hope that this information assists clinicians and surgeons in recognizing the condition, should they confront it in the future.At first presentation, a 49-year-old man of African descent who was a non-smoker presented with sudden onset of vomiting and abdominal distension. A clinical diagnosis of small-bowel obstruction was made based on presentation and plain abdominal radiographs. The patient underwent an exploratory laparotomy and a diagnosis of adhesions without obvious obstruction was diagnosed, but no biopsy taken.He presented on a second occasion to our unit with progressive weight loss, anorexia, abdominal distension, and general signs of cachexia and ascites three months after his first laparotomy. We performed upper and lower gastrointestinal endoscopies as well as a computed tomography (CT) scan of the abdomen. These procedures produced no positive findings except for some free fluid in the peritoneal cavity and diffuse, mild thickening of the gut wall and mesentery. A detailed social history revealed that he had been exposed to asbestos between the ages of 23 and 29 years when he worked in a pipe-insulating factory. A CT scan obtained during his second presentation illustrated a thickened gut wall and mesentery with the presence of ascites Figure , but allA second-look exploratory laparotomy revealed widespread nodular thickening of the visceral peritoneum with a striking diffusely erythematous and velvety look Figures  and 3. HMPM is a rare condition resulting most commonly from exposure to asbestos. The neoplasm manifests approximately 20 or more years after the initial exposure . PatholoMPM accounts for 20% to 33% of mesotheliomas, and histologically these may be divided into three basic forms: epithelioid (most common), sarcomatoid, and biphasic (mixed). Papillary peritoneal mesothelioma is a subdivision of the epithelioid form [Clinically, this condition may be associated with abdominal pain, abdominal distension, ascites, weight loss, and pyrexia of unknown origin . The latAt laparotomy, gross examination of the peritoneum may also reveal signs of the condition. Widespread nodular thickening of the visceral peritoneum with a striking, diffusely uniform, erythematous appearance Figures  and 3 caIn the case of our patient, the first surgeon unknowingly diagnosed adhesions without entertaining the diagnosis of MPM, probably because MPM is so rare that few surgeons would have suspected it. Therefore, no biopsies were taken during the first laparotomy.Thus, if there is widespread nodular thickening of both parietal and visceral peritoneum with marked uniformly diffuse erythema and ascites, MPM should be suspected and a biopsy should be performed. Moreover, since exposure to asbestos often occurs many years before its effects manifest as overt disease, the patient does not usually reveal it while the history is being recorded unless specifically asked.Once the diagnosis is confirmed by histology, multi-disciplinary management produces the best outcome . The proet al. [Treatment options include operative cytoreduction, followed by heated intra-peritoneal chemotherapy applied intra-operatively with doxorubicin and cisplastin . Early pet al.  highlighThis case report is important to public health, since it deals with the detection and diagnosis of MMP, which is a very important public health issue. It illustrates the vague clinical presentation of MPM, where the difficulty in diagnosis is a result of the rarity of this disease. Despite this fact, our patient presented with the most common symptoms of this condition. On the basis of the patient's history, occupational exposure to asbestos was a critical factor in the diagnosis. Furthermore, if the surgeon who performed the first laparotomy one year prior to the patient's second presentation had diagnosed MPM based on the appearance and examination of the peritoneum, this would have played a crucial role in early detection of the disease.Consequently, we wish to highlight the clinical gross appearance of this rare condition for the unwary clinician as widespread fine nodular thickening of the visceral peritoneum with a striking, uniformly diffuse, erythematous, and velvety appearance. In contrast, other considerations in the differential diagnosis of this condition could be as follows: tuberculosis may present as ileocecal inflammation, carcinomatosis appears as hard white nodules with the intervening peritoneum having a normal appearance, and endometriosis of the peritoneum and/or omentum, characterized by hemorrhagic, reddish brown, or blue nodules or cysts on the peritoneal surface .Written informed consent for publication from the patient's next of kin could not be obtained despite all reasonable attempts. The case is important to public health and every effort has been made to protect the identity of our patient. There is no reason to believe that our patient would object to publicationThe authors declare that they have no competing interests.VN operated on the patient and was the major contributor to the idea of writing the article. MJR wrote and edited the manuscript. CLL assisted in researching the literature and writing the paper.


We present super infection of an ovarian dermoid cyst with actinomyces in an infertile patient.This is a case-report study for evaluation a couple with male factor infertility, who was a goodcandidate for intracytoplasmic sperm injection (ICSI), while a 10 cm dermoid cyst was foundin the woman’s right ovary. Patient complained of pelvic pain, intermittent fever, dysmenorrhea,and dyspareunia. The cyst was extracted using laparoscopy, whilst in histopathologicalexamination, an actinomycosis super infection was reported. Actinomyc super infection of anovarian dermoid cyst is a very rare incident which can also occur in women with no history ofintrauterine device (IUD) usage or previous fertility. Dermoid cyst (mature cystic teratoma) is a prevalentovarian neoplasia which might become complicatedby torsion, rupture, or dysplasia, whereassuper infection is a rare complication of these cysts. Pelvic An infertile couple of afghan origin with lowsocio-economic and educational state came to ourcenter to treat their 10 years primary infertility.The primary cause of infertility was determined tobe azoospermia of the 28 years old male partner,and the couple was a good candidate for surgicalsperm retrieval (testicular sperm extraction/TESE)and intracytoplasmic sperm injection (ICSI).In preliminary studies before ICSI, the 26 yearsold female partner reported regular menstruationintervals, but she experienced secondary dysmenorrheaand deep dyspareunia for about a year.She also gave a history of unspecified manipulationof uterine cavity by a midwife in Afghanistanto treat her infertility before the onset of thesefindings. She also complained of intermittent pelvicpain and nocturnal fever without chills startingafter this manipulation. In examination of pelvicarea, a mobile cystic formation of about 10 cmin diameter was palpable in right adnexal region.Transvaginal ultrasound examination showed acystic formation with a size of 101×42 mm, includinghyper-echoic solid components and a muralnodule, in the right ovary, while color Dopplerexamination revealed a pulsatility index (PI) ofhigher than one, so both findings confirmed a benignovarian teratoma.In hysterosalpingography, uterine cavity was normaland both tubes were patent, but the evidence of anadnexal mass with three complete teeth was observed.All tumor markers were within the normal limits and other laboratory findings were all normal, aswell .Patient underwent laparoscopy with a diagnosisof dermoid cyst. During laparoscopic exam pelviccavity, uterus and left ovary had normal view, andboth tubes were patent. Right ovary contained abig cyst with a 5×10 cm diameter without any adhesionto surrounding tissues.Grossly, the cyst contained abundant adipose tissue,osteoid material and four well-formed teeth.Laparoscopic cystectomy was performed, and theremaining ovarian tissue was preserved. The masswas sent for histopathologic evaluation. Microscopicsections showed ovarian cyst with ciliatedstratified epithelium and foci of squamous lining.Components such as mature osseous and chondroidtissue were indentified. Some foci of acuteand chronic inflammatory cells infiltration andactinomyces like organisms were also noted. Thehistopathologic findings suggested the presence ofmature cystic teratoma with actinomycotic abscessformation . The diaPatient was treated for three months with amoxicillin500 mg/TDS and doxycycline100 mg/BIDafter consultation with an infectious disease specialist.After the treatment period, patient’s feverand pelvic pain stopped. At this time, patient hadserum follicle-stimulating hormone (FSH)=8.9and serum anti-mullerian hormone (AMH)=1.4and in ultrasonographic exam both ovaries hadnormal view.ICSI was performed following a standard longprotocol using gonadotropin-releasing hormone(GnRH) agonist test  and a combination of Fostimon andMerional . Thirty six hoursafter injection of 10000 IU human chorionic gonadotropin(hCG), three oocytes were obtainedfrom the left ovary. The right ovary remained inactiveduring the controlled ovarian hyperstimulation(COH) and no oocyte was retrieved from it. Intotal, two good quality embryos were formed andwere transferred using transcervical technique.Serum βhCG level remained negative two weeksafter embryo transfer.Mature ovarian cystic teratoma or dermoid cystis the most prevalent ovarian germ cell tumor comprising about 20% of all ovarian neoplasms.Dermoid cyst might become complicated by torsion,rupture or develop to a malignant tumor, butinfection is a rare complication accruing in only1% of mature ovarian cystic teratomas .brucella  procedurewith signs of tubo-ovarian abscess . Inrarebrucella , salmonebrucella  and schisomiasis  have beesomiasis . Actinom bacilli .Actinomyces is a normal habitant of gastrointestinaltract and is also present in 5% of cervicalsmears from healthy women (hy women . IUD mighy women  and in why women . Patienthy women . Pelvic hy women . In theshy women . Kumar ehy women .In a report of 11 cases of pelvic actinomycosis,Marret et al.  showed tHowever, it should be considered that rare casesof pelvic actinomycosis without a history of IUDusage have been reported , 15-17. Our patient did not have any history of IUD usageor previous fertility. It is possible that manipulationof uterus in a non standard setting and usingnon sterile equipment in this patient had caused thetransfer of germs into the uterus cavity and secondaryinfection of ovarian dermoid cyst.Diagnosis of pelvic actinomycosis is hard, andthe infection is mostly recognized during the surgeryor in histopathological studies . EarlydOur case shows that pelvic actinomycosis shouldbe considered in women without a history of previousfertility or IUD usage even if the signs andsymptoms are unspecific; especially the patientcomes from a low level socio economic background.The presence of unusual findings likenight fevers, chills, intermittent abdominal pain,and nonspecific digestive system signs can lead toconsider a possible super infection of benign pelvicmasses like dermoid cysts by the physician.Our case and other cases reported in the literatureindicate the importance of sending the samples ofsuspicious tissue during surgery for microbiologicalexamination in parallel with cytopathologicexamination, especially in the presence of these symptoms. Also, the long-term follow-up of patientsafter surgery has a high priority. There is aneed for further studies on the outcome of COH/ART in infertile women with pelvic actinomycosis.


Medulloblastoma is a relatively common malignant brain tumor of childhood and relatively rare in adulthood, with a propensity for neuraxial spread via cerebrospinal fluid pathways. Osseous extraneural metastasis is uncommon and when it happens, radiologic findings are of sclerotic (60%), lytic (35%), and mixed patterns (5%) ). In this paper, we present a case of medulloblastoma metastiaszing to the lumbar spine and describe the magnetic resonance appearance, with emphasis on the image findings mimicking spondylodiscitis. Due to advances in surgery, chemotherapy, and radiotherapy and differences between patients with localised and metastatic diseases, the prognosis of medulloblastoma has dramatically changed in the last 20 years. Recent series have reported that the overall disease-free survival of patients having no metastasis including the cerebrospinal fluid is 10 years. When extracranial metastases occur, most commonly it involves bone (80%), especially pelvis, long bones, and spine in order of frequency.A 34-year-old woman presented with occipital headache of sudden onset, episodic vomiting, and imbalance while walking. Neurologic examination revealed cerebellar syndrome, no sensory or motor deficit. CT and MR of the brain showed a large well-circumscribed, lobulated, heterogeneous space-occupying lesion in the right cerebellar hemisphere measuring 4.1 × 2.5 cm with a broad tentorial attachment . It was The patient underwent posterior fossa surgery. Intraoperatively the tumor was soft, easily aspirable with suction and could be clearly separated from the cerebellum. The tentorium was free of tumor, suggestive of an intraaxial lesion. Frozen section revealed malignant small round cells. Histopathological analysis showed nodules of small round cells with occasional neurocytic differentiation and surrounding collagen-rich tissue suggestive of desmoplastic medulloblastoma. Postoperatively, the patient had been given both radiotherapy and chemotherapy. She did well for 3 years with no evidence of recurrence on follow-up CT scans of the brain. She had no other complaints until she developed low back pain and sciatica. Plain radiographs of the lumbar spine showed mixed lytic and sclerotic lesions of the vertebral bodies of L5 and S1 . The desMedulloblastoma, or primitive neuroectodermal tumor of the cerebellum, accounts for approximately 20% of all childhood and 1% of all adult brain tumors . Most auThe average interval to the development of extraneural metastasis after the initial diagnosis of medulloblastoma is 18 months. In some cases, 13 years have elapsed after initial diagnosis before metastasis has developed , 8. In oBone is the most common site of extraneural spread of medulloblastoma followed by lymph nodes, peritoneum, liver, and lungs , 7, 11. This case is unique in that, to our knowledge, the MRI appearance of the extensive mixed type (both lytic and sclerotic) metastasis in medulloblastoma involving almost the lumbar disc was not described previously. MR appearance of skeletal metastases of medulloblastoma demonstrating the blastic forms has only been described in a limited number of case reports. Diffuse involvement of spine and the disc mimicking spondylodiscitis in the same patient is extremely rare. In our contest, where tuberculosis is a common cause of spondylodiscitis, only the biopsy can help make the diagnosis. In fact, we considered that chemotherapy immunosuppressed this patient and facilitated tuberculous infection. This was the reason for which tuberculous spondylodiscitis was taken into consideration as the first differential diagnosis rather than metastatic medulloblastoma, and this was supported by radioimaging, mimicking vertebral, and lumbar disc infection, that is, the same images found in tuberculosis of the spine.Although systemic metastases from primary intracranial tumors are uncommon, the onset of bone pain in patients with medulloblastoma should raise suspicion of possible bone involvement. Plain radiographs may be diagnostic, but with the multiplanar capability and high sensitivity in soft tissue contrast, MR images provide better tissue characterization and give detailed anatomic information and extent of the lesions. The MR imaging is more efficient than the bone scintigraphy in detecting vertebral metastasis, especially in the cases that bone scintigraphy is equivocal or negative for vertebral metastasis in high clinical suspicion. Furthermore, MR imaging is important for the further treatment planning such as radiation therapy or systemic chemotherapy. Although MR imaging is useful in the detection of early metastasis that is localized completely in the bone marrow cavity routinely, bone scintigraphy remains the most cost-effective method for examination of the entire skeleton.In our case, the patient underwent a second-protocol chemotherapy for medulloblastoma treatment with good outcome for two years. The survival results for medulloblastomas in adults compare favorably with those in children. However, late relapses, lateral tumor location, and desmoplastic histologic features are more frequent in adults. Spinal seeding at presentation is a poor prognostic factor for disease-free survival. A minimal dose of 54 Gy to the posterior fossa is essential for adequate tumor control. The interval between surgery and the start of RT, which was found to be a significant prognostic factor, is an interesting issue that requires further study , 9, 10.Systemic metastases of medulloblastoma occur in a minority of patients. Very rarely such metastases may involve the spine and present with features of spondylodiscitis on imaging. The treatment options for patients with extraneuraxial metastases are limited and their prognosis continues to remain poor.


We report the case of a 66-year-old woman with tumor-induced osteomalacia (TIO) caused by fibroblast growth factor 23 (FGF-23) secreting mesenchymal tumor localized in a lumbar vertebra and review other cases localized to the axial skeleton. She presented with nontraumatic low back pain and spontaneous bilateral femur fractures. Laboratory testing was remarkable for low serum phosphorus, phosphaturia, and significantly elevated serum FGF-23 level. Magnetic resonance imaging (MRI) of the lumbar spine showed a focal lesion in the L-4 vertebra which was hypermetabolic on positron emission tomography (PET) scan. A computed tomography (CT) guided needle biopsy showed a low grade spindle cell neoplasm with positive FGF-23 mRNA expression by reverse transcriptase polymerase chain reaction (RT-PCR), confirming the diagnosis of a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT). The patient elected to have surgery involving anterior resection of L-4 vertebra with subsequent normalization of serum phosphorus. Including the present case, we identified 12 cases of neoplasms localized to spine causing TIO. To our knowledge, this paper represents the first documented case of lumbar vertebra PMT causing TIO. TIO is a rare metabolic bone disorder that carries a favorable prognosis. When a lesion is identifiable, surgical intervention is typically curative. Osteomalacia is a metabolic bone disorder characterized by impaired mineralization of osteoid matrix in mature bone. Acquired forms of osteomalacia include renal tubulopathy (Fanconi's type) and FGF-23 secreting PMTs; the latter referred to as TIO or oncogenic osteomalacia (OO). TIO is a rare paraneoplastic form of renal phosphate wasting that results in phosphaturia, a defect in vitamin D metabolism, and osteomalacia –3. We reA 66-year-old female presented with nontraumatic, chronic dull-aching low back pain with worsening symptoms for the previous one year. The pain affected her walking such that she was “waddling” to avoid the pain. On occasions the pain would radiate to the right leg as well as anterior and lateral thigh but not past the knee. There were no associated paresthesias or significant weakness. She denied history of cancer, weight loss, fever, chills, or night sweats. There was no history of nephrolithiasis or bone fractures. She was being treated for diabetes and hypertension. She had history of pulmonary emboli of unclear etiology in the 1990 s. Surgical history included cholecystectomy in 1994, uterine endometrial ablation in 1996, and bilateral carpal tunnel surgeries. She had an allergy to penicillin causing a rash and an intolerance to sulfa causing abdominal discomfort. The patient reported remote history of smoking for 15 years, quitting 25 years ago. Family history was negative for bone disease. Physical exam was remarkable for her being overweight. She had a side-to-side waddle in her gait and slightly lifted her feet on walking. Straight leg raising test was negative. She did not have tenderness to percussion of the lower back but did have a gibbous at L-4. There was no back pain with movement. She had weakness at the iliopsoas and quadriceps bilaterally but no loss of sensation. An outside MRI of the lumbar spine showed an infiltrative lesion in the L-4 vertebra with collapse of the body (confirmed on repeat MRI at our institution, TIO is a rare metabolic bone disorder that in most cases carries a favorable prognosis –3. One oTo our knowledge, this paper represents the first documented case of lumbar vertebra PMTMCT causing TIO. The tumors responsible for TIO can be found anywhere in the body; however, only 11 prior cases have been described in the spine  4–14]. –14. 4–14


We report a case of a psammomatous variant of meningioma arising in a pure and mature testicular teratoma. At immunohistochemistry, the meningiomatous component showed epithelial membrane antigen, S100 protein, and vimentin positive. Benign neoplasms arising in testicular teratomas are extremely rare. To our knowledge, we have not found any such report of psammomatous variant of meningioma in a testicular teratoma and any meningioma arising in a pure and mature testicular teratoma. This is a unique phenomenon. Teratomas are composed of several types of tissues representing different germinal layers . They may be composed exclusively of well-differentiated, mature tissues or have immature, fetal-like tissues . MalignaCase Presentation. A 46-year-old man presented with right testicular enlargement. Ultrasonography performed at an outside institution showed solid-cystic testicular mass with calcifications. A right radical orchiectomy and follow-up were peformed at the outside institution. On gross description, the right orchiectomy specimen consisted of a testis measuring 5.5 × 2.5 × 3.0 cm in dimension. A solid-cystic mass with areas of calcifications measuring 2.0 cm was identified within the testicular parenchyma (2 section for every centimetre of maximum tumor diameter.renchyma . The masHistologic sections of the surgical specimen showed a teratoma composed of mature tissues epithelial-lined cystic spaces, solid areas of nervous tissue, blood vessels, and a component of numerous psammomatous bodies confluent admixed among fusiform meningothelial cells. These cells had a morphologic appearance consistent with the psammomatous variant of meningioma . TherefoFrom the tissues that comprise teratomas may arise benign and malignant neoplasms. Malignant transformation of teratoma components can be seen in 3–6% of metastatic germ cell tumors  and has It is important to recognize these malignant tumors that arise in teratomas because of the prognostic importance of their identification. Patients in whom the malignant component is localized to the testis do well, but patients in whom the nongerm cell component metastasizes do poorly .Reports of secondary benign tumors arising in teratomas are uncommon and consist of a scattering of case reports. To date, accounts of blue nevi, prolactinoma, epithelioid hemangioma, and sebaceous adenoma have been described as arising in teratomas of the ovary .Secondary benign neoplasm in testicular teratomas is extremely rare. There is a single case report in the literature of a microcystic variant of meningioma developed in mixed germ cell testicular teratoma composed predominantly of mature and immature tissues, with elements of seminoma and carcinoma embrionario .To our knowledge, this is the second case report of meningioma arising in a testicular teratoma and the first of psammomatous variant occurring in a pure and mature teratoma. This case, therefore, adds to the medical literature an interesting and distinct case of a benign tumor originating in a teratoma testicular and reaffirm, teratomas develop from totipotential germ cells, and consequently contain all three germ cell layers as well as neoplasm of all of these tissues.It is important to recognize neoplasms arising in teratomas, because some of them may have adverse clinical behavior, especially malignant components not restricted to the testis. In this case, we observe a rare benign component that represents a curiosity.


Orbital mesenchymal chondrosarcoma is a very uncommon lesion of the bone and extraskeletal tissue. To our knowledge, approximately 30 cases have been described. We present the case of a 52-year-old male who presented with a history of progressive proptosis and chemosis of the right eye caused by an orbital tumor. He underwent exenteration of the right orbit, and the histological examination revealed a mesenchymal orbital chondrosarcoma. This paper attempts to describe a rare entity that should be considered in the differential diagnosis of calcified orbital lesions, especially in young adults. Complete removal of the tumor is the mainstay of treatment, but adjuvant radiation therapy and chemotherapy should be considered. Mesenchymal chondrosarcoma of the head and neck is an uncommon tumor with potential for exhibiting highly aggressive behavior. This lesion is a malignant small round cell neoplasm with focal cartilaginous differentiation, often with a pericytomatous vascular pattern. It represents approximately 1% of all chondrosarcomas , 3. In t It is usually seen in younger age group compared to conventional chondrosarcomas .There are approximately 30 cases described in the literature. The aim of this paper is to report a case of mesenchymal chondrosarcoma of the orbit.A 52-year-old man, without any past medical illness, presented with a 12-month history of progressive proptosis of the right eye. Physical examination revealed a decreased right visual acuity, inferior displacement of the globe, severe conjunctival chemosis, and reduced corneal sensitivity . No abnoBased on this diagnosis, a right lateral orbital exenteration with excision of the mass by a craniofacial approach was performed. We found a mass that measured 7 × 8 cm with sphenoidal fissure obliteration and destruction of the roof and lateral wall of the orbit. Based on these findings, the lesion was resected, and we performed an orbital roof plasty with cyanoacrylate . There wThe patient was advised adjuvant chemotherapy and radiotherapy. He received a total of 66 Gy of external radiotherapy to the temporozygomatic region, showing no signs of toxicity or infection. He is currently on a regimen of vincristine, adriamycin, and cyclophosphamide alternating with ifosfamide and etoposide (VAC/IE), which is used in the treatment of patients with Ewing's Sarcoma. Currently, the patient is alive and without evidence of disease.The first case of mesenchymal chondrosarcoma (MCS) was described by Lichtenstein and Bernstein in 1959 , somethiClinically, these tumors tend to present with compression of the ocular globe resulting in progressive proptosis and/or visual abnormalities, such as diplopia or reduction in visual acuity. The radiological examination is relevant to help establish the diagnosis. CT scans usually reveal presence of foci of calcification in the lesion. MRI scans are helpful to delimitate the lesion margins . Our patHistologically, this tumour exhibits a biomorphic appearance of undifferentiated mesenchymal cells with islands of mature hyaline cartilage . ImmunohSurgical resection with wide margins is known as the most effective treatment modality for chondrosarcoma . Zakkak Radiotherapy might play a role when accompanied by surgery although some believe MCS to be a radioresistant tumor , 13. SomP = .005), and mesenchymal chondrosarcoma could be treated as per Ewing's sarcoma [Chemotherapy has a limited role in chondrosarcoma and should be used as an adjuvant therapy in cases with aggressive behavior with potential metastasis, rapid local recurrence, and high-grade lesions , 3, 13.  sarcoma .There are numerous active signaling pathways that have been described in human chondrosarcoma, trying to suggest potential molecular targets for directed chemotherapy. One of these is a pathway dependent on phosphoinositide-3 kinase and MEK-extracellular signal-regulated kinase (ERK) signaling. Additionally, chondrosarcoma cell proliferation and degradation is dependent on peroxisome proliferator-activated receptor-gamma (PPAR-c) activity, with a loss of PPAR-c expression and associated apoptosis in high-grade tumors. Targeting these pathways may improve control of cranial chondrosarcoma and decrease the need of recurrent operations .The prognosis of patients with MCS is extremely variable, ranging from complete tumor response and long-term survival, to rapid local tumor progression with widespread metastasis. The mesenchymal histology alone carries a nearly 10-fold increase in 5-year mortality. The overall 5- and 10-year survival for patients with mesenchymal chondrosarcoma, when considering all sites, is 55% and 27%, respectively. It has been postulated that earlier detection and diagnosis of lesions in the head and neck may in part account for improved survival for mesenchymal chondrosarcoma located in the head and neck .Orbital mesenchymal chondrosarcoma is a rare entity and should be considered in the differential diagnosis of calcified orbital lesions, especially in young adults. Complete removal of the tumor, either by orbital resection or exenteration, is the mainstay of treatment. Adjuvant radiation therapy and chemotherapy should be considered, due to the histologically aggressive nature of the tumor.


Liposarcoma is one of the most common sarcomas in adults, but only rarely presents as an esophageal primary. There have been several reports of well-differentiated liposarcoma (WDL) arising in the esophagus, but we present a case of dedifferentiated liposarcoma (DL) presenting as a large esophageal polyp. We believe this is the first reported case of DL of the esophagus with morphologic evidence of both well-differentiated and dedifferentiated components. The diagnosis was confirmed by demonstration of CPM gene amplification by fluorescence in situ hybridization (FISH). Liposarcoma is one of the most common sarcomas in adults . LiposarAn 81-year-old male presented to clinic with a 2-year history of an esophageal polyp first detected on screening endoscopy. Biopsies performed at that time were reported to be benign, and the decision was made to follow the lesion. He was relatively asymptomatic until he began experiencing trouble swallowing after a recent upper respiratory tract infection two weeks before. Physical examination revealed a well-developed, well-nourished male without any obvious oral cavity masses or abnormalities detected during routine evaluation. Flexible laryngoscopy was performed to evaluate the nasopharynx, oropharynx, hypopharynx, and larynx but showed only an elongated uvula. Computed tomography (CT) showed a large intraluminal mass extending into the upper esophagus. The imaging features were consistent with a fatty mass with an enhancing component, most suggestive of a fibrovascular polyp. The patient had no other significant past medical history and no prior history of malignancy.Because the patient was experiencing symptoms secondary to the mass, the decision was made to resect the mass endoscopically. Intraoperative findings included a lengthy polypoid lesion covered by unremarkable mucosa arising near the distal margin of the upper esophageal sphincter and extending 16 to 28 cm from the incisors. The duodenum, stomach, and remaining esophagus appeared normal. Endoscopic ultrasound confirmed that the mass did not involve the deep wall layers of the esophagus. The mass was resected at its base.CPM gene  is telomeric to the MDM2 locus on chromosome 12q15 and is consistently coamplified with MDM2, allowing it's use as a surrogate to MDM2 [DLs are biphasic malignant adipocytic tumors that contain areas of WDL with transition to nonlipogenic sarcoma . These t to MDM2 .MDM2 gene amplification per se cannot be equated with the presence of a DL, since MDM2 gene amplification by FISH can be identified in up to 40% of pleomorphic sarcomas [MDM2 amplification.Mansour et al. described the first report of a primary liposarcoma of the esophagus in 1983 . Since tsarcomas . TherefoThe behavior of DL is slightly better than other high-grade pleomorphic sarcomas . HoweverLiposarcoma of the esophagus is rare but should be considered in the differential diagnosis of large esophageal masses or polyps. We believe that our case represents the first report of DL of the esophagus with histologic documentation of both well-differentiated and dedifferentiated components, as well as confirmation with molecular analysis.


Gallbladder carcinosarcoma is one of the rarest subsets of gallbladder malignancies. The first case of carcinosarcoma of the gallbladder was reported in 1907. To date, <100 cases have been reported in the English literature. The present study reports a case of gallbladder carcinosarcoma accompanied with tumor thrombi, presenting as a soft tissue mass in the common bile duct and resulting in the obstruction and inflammation of the biliary tract. Initially, the patient was diagnosed with a gallbladder tumor and choledocholithiasis. No cases of carcinosarcoma of the gallbladder accompanied with bile duct tumor thrombus formation have been reported to date. A cholecystectomy with liver segmentectomy (S4a+S5) and a lymph node dissection were performed. The presence of a tumor thrombus in the common bile duct was confirmed by analysis of a frozen section during surgery. Resection of the extrahepatic bile duct and Roux-en-Y type hepatic cholangiojejunostomy were also performed. In addition, the gallbladder carcinosarcoma was observed to produce α-fetoprotein. The patient underwent an uneventful post-operative recovery and, to date, no clinical or radiological evidence of disease recurrence or metastasis has been identified. Carcinosarcoma of the gallbladder accompanied with tumor thrombi is extremely rare. Tumor thrombi in the common bile duct may easily be misdiagnosed as choledocholithiasis. The treatment and prognosis of gallbladder carcinosarcoma is similar to that of gallbladder carcinoma. Carcinosarcoma is a rare tumor that is characterized by malignant epithelial and mesenchymal components. These tumors have been reported in a number of different organs, including the uterus, lung, esophagus, kidney and pancreas . Carcino4 cells/mm3). The tumor marker, serum carcinoembryonic antigen, carbohydrate antigen 19-9 and α-fetoprotein (AFP) levels were elevated to 33.67 μg/l, 54.22 U/ml and 312.7 μg/l, respectively. In addition, liver function tests revealed that the serum concentrations of alanine aminotransferase and alkaline phosphatase were increased to 411 U/l and 686 U/l, respectively. In addition, the total bilirubin levels were increased to 35.3 μmol/l. Computed tomography (CT), three-dimensional reconstructions of this CT  with right upper abdominal pain and jaundice. The patient reported a past medical history of chronic cholecystitis, cholecystolithiasis and tuberculosis. A physical examination revealed a body temperature of 38.2°C and tenderness in the right upper quadrant of the abdomen. A laboratory analysis revealed leukocytosis  regards a carcinosarcoma as a collision tumor composed of the derivatives of two or more stem cells of separate epithelial and mesenchymal origin. The monoclonal theory (divergent hypothesis) proposes that carcinomatous and sarcomatous elements are derived from a single pluripotential stem cell that subsequently develops divergent differentiation along separate epithelial and mesenchymal pathways . Throughet al performeIn the present case, the patient presented with acute biliary inflammation and obstructive jaundice as the initial complaint, as a result of an obstruction of the superior segment of the common bile duct caused by tumor thrombi. This presentation has rarely been reported in previous comparable studies . In the μg/l; this decreased to within normal levels post-operatively. Hayashi et al hypothesized that AFP-producing carcinomas of the gallbladder more frequently metastasize to the liver, indicating a poorer prognosis than that of carcinomas that do not produce AFP (et al performed immunohistochemistry to investigate Ki-67 LI in 1 case of carcinosarcoma of the gallbladder and 11 cases of ordinary gallbladder adenocarcinoma classified as stage IV, to clarify the higher malignant proliferative potential of the former. The results revealed that the Ki-67 LI of the carcinosarcoma was 68, which was higher than the average level of ∼47 in the ordinary gallbladder adenocarcinomas (AFP is a clinically useful and reliable marker for the diagnosis of primary hepatocellular carcinoma, hepatoblastoma and yolk-sac tumors . Howeverduce AFP . In addiIn the current patient, the Ki-67 LI was 70, which was indicative of a higher proliferative and malignant potential and a subsequent poorer prognosis. However, the patient follow-up was uneventful and the individual remains healthy. A further detailed follow-up of this patient is vital in view of the aggressive biological behavior of this tumor.


Hydatid disease (HD) continues to be a significant health problem in areas where animal husbandry is common but no proper veterinary control exists. The involvement of the spleen in HD is rare, and isolated splenic involvement is even less common. In this case report, we present isolated splenic HD in a 26-year-old female with complaint of abdominal pain, and we discuss some of the clinical aspects of HD. Evaluation of the patient with ultrasonography, computed tomography, and magnetic resonance imaging revealed the presence of an isolated splenic HD as a multivesicular cystic mass located near splenic hilus, measuring 12 × 11 cm. No other organ or system involvement could be demonstrated. The involvement of the spleen in hydatid disease (HD) is rare, and isolated splenic involvement is even less common. We present isolated splenic HD in a 26-year-old female with complaint of abdominal pain, and we discuss some of the clinical aspects of HD.A 26-year-old female was referred to our radiology clinic with abdominal pain. The physical examination of the patient revealed splenomegaly. Serology of the patient was consistent with hydatid disease, which helped in the interpretation of the imaging findings. Other laboratory results showed no significant abnormality. We performed abdominal ultrasonography (US), contrast-enhanced abdominal computed tomography (CT), and noncontrast, contrast-enhanced abdominal magnetic resonance imaging (MRI). Chest X-rays and cranial MRI were also obtained to rule out pulmonary and intracranial involvement.In US, we observed a well-defined, multivesicular cystic mass in the location of splenic hilus, measuring 12 × 11 cm. The left kidney was compressed and displaced to the inferolateral position . On contrast enhanced CT scans, we detected an unenhancing, hypoattenuating mass located in the anterior portion of the spleen. It had well-defined borders and contained multiple, round, daughter cysts in the periphery of the lesion .T1-and T2-weighted MRI revealed a multiseptated cystic mass in the spleen which had a well-defined capsule, the mass showing no significant contrast enhancement, except some vague signal increase in the septal parts Figures , and 5. With these imaging findings, final diagnosis was made as hydatid disease of the spleen, and the patient underwent total splenectomy. The lesion was proved to be hydatic cyst pathologically. Besides surgery, the patient was also on medical treatment with albendazole. The patient was in good health in control examinations during the two years followup period.HD continues to be a significant health problem in areas where animal husbandry is common but no proper veterinary control service is given. It is a unique parasitic disease which can occur in almost any part of the body and demonstrates a spectrum of imaging features that vary according to growth stage, associated complications, and affected tissue , 2. The Echinococcus infections. E. granulosis is the more common type, whereas E. multilocularis is less common but more invasive, mimicking a malignancy. Radiologic findings range from purely cystic lesions to a completely solid appearance. Hydatid cysts (HCs) are classified on the basis of appearance. Simple cyst with no internal architecture, cyst with daughter cysts and matrix, calcified cyst, or complicated cyst can be observed [There are two types of observed . HCs can be solitary or multiple. US most clearly demonstrates the hydatid sands in purely cystic lesions, as well as floating membranes, daughter cysts, and vesicles. CT is the best modality to detect calcification and internal cystic structure behind calcification. MR imaging is especially helpful in detecting HCs of the central nervous system. Liver is the most common site of involvement. Lungs are the second most common sites of hematogenous spread in adults and probably are the most common sites in children (15%–25% of cases). The involvement of the spleen is rare. The reported prevalence of splenic involvement varies from 0.9% to 8% . SplenicIn conclusion, being familiar with imaging findings, especially in patients living in countries where this disease is endemic  and performing serological tests can help establish the diagnosis of HD, as it was in our case.


Supravesical hernias develop at the supravesical fossa between the remnants of the urachus and the left or right umbilical artery. They are exceptional and are often the cause of intestinal obstruction. We report two cases of surgically proven internal supravesical hernias presenting with small bowel obstruction. Abdominal computed tomography showed, for our first case, the relation of the incarcerated intestine anterior to and compressing the urinary bladder. We believe that the preoperative diagnosis of supravesical hernia by abdominal computed tomography is possible, as shown in our first case. Supravesical hernia is exceptional. It involves a hernia between the median umbilical ligament and the medial umbilical ligament and is classified as two types: internal supravesical hernia and external supravesical hernia. They are often the cause of intestinal obstruction. We report two cases of internal supravesical hernias presenting with small bowel obstruction. The first case was diagnosed preoperatively, but the second case was diagnosed intraoperatively.A 58-year-old woman with no relevant medical history was admitted with a one-day history of small bowel obstruction characterized by abdominal pain and vomiting. On examination, the patient was found in good general condition with a pulse rate of 80/ min, a blood pressure of 140/60 mmHg, and a temperature of 37.8°C. Physical and examination showed that the patient had abdominal distension without any peritoneal signs. Rectal examination was normal. Serum laboratory data were normal except for a white blood cell count of 12,400/ml.A scout film of the abdomen showed multiple dilated loops of small intestine with air–fluid levels. Computed tomography (CT) scan demonstrated a high-grade distal small bowel obstruction with a transitional zone in the left lower abdomen. Below the transitional zone, there was a saclike mass of clustered bowel loops within a hernia sac, indicating an internal hernia. The hernia sac was situated behind the left lower abdominal wall above the urinary bladder and passed downward into the prevesical space compressing the anterior bladder wall . SupraveA 36-year-old man was admitted to our hospital with symptoms of intestinal obstruction. He had experienced gradually increasing nausea, vomiting, and abdominal pain. He had no history of abdominal surgery. He had severe tenderness over the entire abdomen. Serum laboratory data were normal except for a white blood cell count of 14,500/ml. A scout film of the abdomen showed multiple dilated loops of small intestine with air–fluid levels .Because of severe abdominal pain, he underwent emergency surgery with a lower midline abdominal incision. The intraabdominal findings included no ascites but a generally dilated intestine. Further exploration showed an ileal segment approximately 30 cm from the ileocecal valve that entered between the median and medial umbilical ligaments. A hernia loop consisting of 15 cm of the ileum was reduced with slight traction and was found to have simple obstruction with no impairment of the blood supply to the intestine. The hernia sac was 2 cm wide and 4 cm deep. It was located anterior to the bladder and posterior to the symphysis pubis, constituting an internal supravesical hernia. The opening of the sac was removed and closed with nonabsorbable sutures, and the intestine was then decompressed through a nasogastric tube. The patient's postoperative course was good, and he was discharged on postoperative day 8.The supravesical fossa is the abdominal wall area between the remnants of the urachus  and the left or right umbilical artery  ,2. The rPre-operative diagnosis of this condition is very difficult. In patients presenting with small bowel obstruction, without any history of previous abdominal operations and no obvious external hernias are detected, pre-operative investigations may be very helpful in diagnosing this condition ,6. A CT Supravesical hernias are rare but potential causes of intestinal obstruction due to the confinement of loops in the supravesical fossa. CT findings have been reported in internal but not in external supravesical hernia. One of our cases of internal supravesical hernia indicate a possibility of preoperative diagnosis of supravesical hernia by abdominal CT.