Most commonly associated with chronic inflammatory conditions, rice bodies represent an uncommon, nonspecific, often intra-articular inflammatory process. Presumably, rice bodies represent the sequelae of microvascular infarcts of the joint synovium. However, rice bodies have been seen in pleural fluid, in the setting of bursitis, and within the tendon sheath. The etiology and prognostic significance of rice bodies are not clear. MRI is the diagnostic imaging modality of choice for the evaluation of rice body formation. Here we present a case of a 28-year-old female with a history of rheumatoid arthritis (RA) who presented to her primary care physician with a palpable mass around her right shoulder which was presumed to be a lipoma. An initial ultrasound showed a fluid filled structure with internal debris. Subsequent MRI evaluation was confirmatory for subacromial-subdeltoid bursitis with rice body formation. The salient point of this report is to highlight the importance of patient-specific differential diagnosis. While lipomas are a very common benign soft tissue tumor, patients with RA often have disease-specific sequelae that should be included in the diagnostic deliberation. Thus, when ordering diagnostic testing for patients with a palpable mass and rheumatoid arthritis, MRI--possibly preceded by conventional radiography--is the most appropriate diagnostic algorithm. Rice body formation represents an uncommon, nonspecific, inflammatory process -3. FormaA 28-year-old Caucasian female with a history of RA presented to her primary care physician with a palpable mass around her right shoulder. Her physician presumed the mass to be a lipoma and subsequently ordered a right shoulder ultrasound. Ultrasound imaging showed a well-circumscribed, mildly hypoechoic, 7.8 cm mass abutting the deltoid muscle Figure .There were multiple internal hyperechoic 'flecks' noted within this mildly hypoechoic mass. The initial imaging characteristics were nonspecific—not classic for a lipoma, but also not entirely exclusive. Also, a malignant etiology would not be ruled out by ultrasound alone. Thus, cross-sectional imaging was recommended to evaluate this solid-appearing, right shoulder mass further. The subsequent magnetic resonance imaging (MRI) showed a 10.6 cm, circumscribed, T2-weighted imaging hyperintense collection surrounding the shoulder joint with multiple hypointense internal flecks (Figure This appearance is consistent with a fluid collection with foci of internal debris most consistent with a diagnosis of rheumatoid-arthritis-associated subacromial-subdeltoid bursitis with rice body formation. Subsequently, a conventional radiograph of the right shoulder was obtained to evaluate the osseous structures, which demonstrated marked narrowing of the glenohumeral joint as well as a significant burden of erosions Figure .The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report.Regarding diagnostic imaging, MRI is the modality of choice for evaluation of rice body formation . By appeAs stated previously, rice body formation is associated with multiple inflammatory conditions including chronic arthritides, infection, and even trauma -2. HowevThe salient point of this report is to highlight the importance of patient-specific differential diagnosis. While lipomas are a very common benign soft tissue tumor, patients with RA often have disease-specific sequelae that should be included in the diagnostic deliberation. While both lipoma and bursitis should be considered in the differential diagnosis for this patient, evaluation of a shoulder mass in a patient with RA is best assessed with MRI. Thus, when ordering diagnostic testing for patients with a palpable mass and rheumatoid arthritis, MRI--possibly preceded by conventional radiography--is the most appropriate diagnostic algorithm.


Intrascrotal embryonal rhabdomyosarcoma in adults is a rare tumor with high aggression and a poor prognosis. We report our patient’s case and review the relevant literature to improve the understanding of this rare disease.A 21-year-old Han Chinese man presented to our hospital with a right intrascrotal mass of 1 year’s duration. His physical examination revealed an enlarged right scrotum containing a huge tender mass measuring about 10 × 7 cm. Ordinary and contrast-enhanced ultrasonography showed a solid mass in the right scrotum, which was suspected to be a malignant tumor. An abdominopelvic computed tomographic scan revealed metastases in the retroperitoneal lymph nodes. The patient was diagnosed with malignant testicular tumor and underwent a right radical orchiectomy by an inguinal approach. Postoperative pathological examination suggested an intrascrotal embryonal rhabdomyosarcoma.Intrascrotal embryonal rhabdomyosarcoma is a rare but highly aggressive tumor. Clinical and imaging manifestations of this tumor are nonspecific, so the definitive diagnosis depends on postoperative pathology and immunohistochemistry. Early suspicion, radical orchiectomy, accurate pathologic diagnosis, and adjuvant chemotherapy and/or radiotherapy are the keys to optimal prognosis. Rhabdomyosarcoma (RMS) is the most common soft tissue tumor in children, but it is rare in adults , 2. IntrOur patient was a 21-year-old Han Chinese man who had found a painless testicular mass in his right scrotum 1 year before presentation to our hospital, for which he had gone to another hospital for treatment. He received no definite diagnosis there but was given a 1-week Chinese herb decoction. Owing to the loss of the previous case record, the suspected diagnosis and the names of the herbs were unknown. He observed no obvious improvement. The mass remained small and unchanged during the first 9 months of the disease course and therefore did not arouse the patient’s attention enough to seek further treatment. However, over the next 3 months, the mass enlarged rapidly and led to obvious right scrotal tenderness. Ultrasonography showed a solid space-occupying lesion measuring 9.7 × 7.7 cm in the right scrotum. The patient reported no obvious fever, osphyalgia, abdominal pain, frequent micturition, urgency, dysuria, or gross hematuria.The patient was admitted to our andrology department in October 2017. On admission, we took a full medical history, including his personal and family history as well as previous treatment of his testicular mass. He had no history of hypertension, hyperlipidemia, coronary heart disease, type 2 diabetes mellitus, traumas, or surgeries, among others. He did not smoke tobacco or consume alcohol, and he had no family history of testicular tumor.The patient’s physical examination revealed unremarkable vital signs , normal heart and lung sounds, and a soft abdomen with no tenderness or organomegaly. Urogenital palpation disclosed an enlarged right scrotum with a hard, tender mass (~ 10 × 8 cm) adhering to the right testis and epididymis, but no palpable masses in the right spermatic cord or bilateral inguinal regions. The patient’s neurological examination showed no abnormalities.Color Doppler ultrasonography displayed a solid intrascrotal mass 11.5 × 8.2 × 7.6 cm) with heterogeneous inner echoes and short linear blood vessel flow signals at the mass periphery. Contrast-enhanced ultrasonography (CEUS)  showed a partial enhancement that appeared mainly in the periphery of the intrascrotal lesion during arterial phase; the lesion also showed an extensive interior filling defect. The enhanced part was irregular in form and contained coarse, twisted blood vessels Fig. -b. The C × 7.6 cmThe results of the patient’s complete blood count, blood biochemistry, and urinalysis were all normal, except for a high lactate dehydrogenase concentration (295 U/L). His α-fetoprotein  and human chorionic gonadotropin  concentrations were within normal ranges.All these findings, taken together, indicated that the right intrascrotal mass was a malignant tumor. The patient rejected retroperitoneal lymph node dissection (RPLND), but he underwent a right radical orchiectomy by inguinal approach. Intraoperative pathology suggested a small cell carcinoma of the right testis.Postoperative pathology showed a giant (10 × 7 × 6 cm) intrascrotal tumor that involved the right testis, epididymis, and paratesticular tissues Fig. . MicroscAccording to all the clinical, imaging, and pathologic evidence, the tumor was finally diagnosed as an intrascrotal embryonal RMS. Its exact origin was hard to confirm, owing to its extensive invasion of testis, epididymis, and paratesticular tissues. Because the patient rejected RPLND, we could not verify whether the tumor had metastasized to the RPLNs. The patient is now undergoing vincristine, actinomycin D, and cyclophosphamide (VAC) chemotherapy regimen, combined with abdominopelvic radiotherapy, at another hospital, which was initiated 20 days after discharge from our department. We will continue to follow-up of our patient.We present the medical history, diagnostic procedure, and treatment of an adult patient with intrascrotal embryonal RMS. Because few studies of intrascrotal embryonal RMS in adults are available, we hope that this case report and the following literature review will contribute to the understanding, diagnosis, and treatment of this rare disease.RMS is one of the most common pediatric tumors, comprising up to half of all soft tissue sarcomas , 2. HoweThe typical clinical presentation of intrascrotal embryonal RMS is a painless unilateral enlargement of the scrotum, usually over the course of a few weeks . BilaterImmunohistochemical staining is now the optimal diagnostic method for RMS , which iet al. found that CT scans for patients with intrascrotal RMS  often underestimate RPLN metastases from localized tumors, so they urged that imaging-negative adolescent patients should still undergo RPLND for further assessment of nodal involvement and to provide guidance for subsequent therapies [Because RMS rarely occurs in adults, treatments used in pediatric patients are often applied to adult cases. The standard treatment for intrascrotal embryonal RMS is radical orchiectomy combined with adjuvant chemotherapy and radiotherapy . The Intherapies .et al. suggested that chemotherapy cannot provide a significant survival benefit to patients over 21 years old [et al. retrospectively analyzed 171 adult patients with RMS and found that their rate of response to chemotherapy was 85% [Postoperative chemotherapy and/or radiotherapy can dramatically increase the survival rate of pediatric patients with RMS . Adjuvanears old , whereas was 85% . Althoug was 85% .et al. found that the 5-year disease-free survival was 97% for patients without RPLN metastases and 42% for those with metastasis [Intrascrotal RMS has a poor prognosis . The 1-ytastasis . AnotherIn our patient, CT findings suggested RPLN metastases, but because the patient rejected RPLND, we could not confirm the IRSG classification of his embryonal RMS. If the soft tissue density shadows seen by CT were metastases, the tumor would be classified as IRSG group IIA. In view of the aggressiveness and poor prognosis of adult RMS, our patient should be treated according to the therapeutic regimen proposed by the IRSG for group IIA disease. In fact, the patient is continuing to receive a VAC chemotherapy regimen with abdominopelvic radiotherapy in another hospital. A longer follow-up for him has been planned.Intrascrotal embryonal RMS is a rare but aggressive tumor, especially in adults, and therefore warrants careful attention for accurate diagnosis and appropriate treatment. Although the definitive diagnosis of embryonal RMS depends on postoperative pathology, physical examination and imaging tests can establish clinical suspicion and detect metastases. Current treatment for adult patients is based mostly on treatment for children. Early suspicion and radical orchiectomy are especially important to achieving an optimal prognosis. Adjuvant chemotherapy or radiotherapy can prolong survival and elevate the survival rate.


We describe two cases of leiomyoma in the colon that were diagnosed histologically after endoscopic resection. The first case was a 79-year-old Japanese woman who presented with a pedunculated polyp of 14 mm length at the splenic flexure. Preoperative diagnosis suggested a colonic mucosubmucosal elongated polyp. The second case was a 29-year-old Japanese woman who presented with a pedunculated polyp of 40 mm length at the hepatic flexure and had an ulcer on top of the polyp. Preoperative diagnosis suggested an inflammatory fibroid polyp. A pathological diagnosis of colonic leiomyoma was made after endoscopic resection in both cases. Both tumors were confirmed to originate, not from the proper muscle layer, but from the muscularis mucosae. These cases underscore that although colonic involvement is infrequent, leiomyomas can display pedunculated morphology in the colon rather than the typical gross appearance of gastrointestinal submucosal tumors seen with sessile morphology. Today, endoscopic examinations and interventions are extensively performed worldwide to investigate the digestive tract and to treat gastrointestinal diseases. Advances in endoscopic devices and techniques and in the understanding of typical endoscopic features of each disease enable an accurate preoperative diagnosis of various gastrointestinal lesions, even before performing the examination of biopsy samples. However, there are lesions that are not diagnosable by endoscopy.In this report, we describe two cases of leiomyoma in the colon that were presented as pedunculated polyps. We could not diagnose either case as a leiomyoma preoperatively; the final diagnosis was made after endoscopic resection of the polyps. Differential diagnosis of these two cases and morphology of the colorectal leiomyomas are discussed.α-smooth muscle cell actin  tumors, as well as others . AlthougAs pertains to the gastrointestinal tract, leiomyomas occur most frequently in the esophagus while the colorectum is a relatively infrequent site of occurrence, accounting for 3% of all the gastrointestinal leiomyomas –5. SinceColonic leiomyomas are often misdiagnosed. Several authors have noted that most colonic leiomyomas with sessile morphology mimic epithelial polyps in their gross appearance during colonoscopy , 7. ChoiColonic mucosubmucosal elongated polyp is a distinct entity that is composed of mucosa and submucosa . TypicalThe inflammatory fibroid polyp is a rare mesenchymal gastrointestinal tumor found mostly in the stomach (70%) and the small intestine (20%) . InvolveN = 10) and conventional polypectomy or endoscopic mucosal resection (N = 12) and have experienced no complications such as bleeding or perforation [Unlike the esophageal leiomyoma, colonic leiomyomas can be endoscopically removed because most of them arise from the muscularis mucosa. Choi et al. report that they have removed colorectal leiomyomas using cold forceps biopsy (foration . Miettinforation . The oveforation . Thus, eIn conclusion, we treated two cases of colonic leiomyoma presented as pedunculated polyps. Accurate preoperative diagnoses were difficult based solely on their morphology. These cases underscore that although colonic involvement is infrequent, colonic leiomyomas can display the pedunculated form, rather than the typical gross appearance of gastrointestinal submucosal tumors as in the sessile form. In addition, they can be treated with endoscopic resection alone because most of colonic leiomyomas arise from the muscularis mucosa.


Random urine protein concentration was 100mg/dL. Contrast-enhanced abdominopelvic computed tomography (CT) revealed a 36x21x30cm-sized cystic mass in the abdominopelvic cavity. The mass lesion had displaced adjacent visceral organs. Both kidneys were also displaced by this lesion. Bilateral hydronephrosis was observed, of which degree was more prominent in the right kidney (A 52-year-old woman presented with abdominal distension. The laboratory data were as follows: white blood cell count, 7.100/mmt kidney . The sert kidney .Hydronephrosis may result from multiple diseases such as urinary tract stones, uroepithelial malignancies, anatomical abnormalities, and external compression. In woman, gynecologic diseases are important causes of hydronephrosis . OvarianIn conclusion, we present a rare instructive case of hydronephrosis caused by a giant ovarian cyst. Clinicians should consider that hydronephrosis could be associated with various clinical conditions.


To the editor,We would like to make some comments about the article “Persistent mullerian duct syndrome: a rare entity with a rare presentation in need of multidisciplinary management” .The authors report a DSD case diagnosed as PMDS and review some clinical aspects of this exceedingly rare syndrome, but some unclear aspects are notable. The patient described seems to be a case of ambiguous genitalia , classified as 46,XY DSD. No gonadal biopsy was done and only the right gonad was found/described. Anti-mullerian hormone dosages are not available.In most PMDS cases the patient presents normal testes or testicles only secondarily affected by cryptorchidism. Primary testicular failure, as seen in this patient, has never been previously described. To the best of our knowledge no PMDS cases associated to streak gonads, dysplastic gonads or absent gonads have been described till this moment, despite anatomically complicated cases of cryptorchidism being common, including crossed testicular ectopy.Also, in PMDS the external genitalia is of normal male (see Table-1). The only known exception to this moment is the patient described in reference 12, but in his case two normal cryptorchidic “peeping” testes were found.From our point of view other DSD diagnoses are still possible, especially mixed gonadal dysgenesis, that may associate to a variety of karyotypes. Abnormal/absent gonads, primary and precocious testicular failure and the absence of a Fallopian tube at the left side are also compatible with this alternative diagnosis .


Inguinal hernias and colorectal cancers are common conditions, but the presentation of a loop of bowel containing cancer within a hernia is rare. Principles of surgery include oncological resection of the involved colonic segment as well as lymphatic drainage. Based on case reports of the last several decades, there have been no reports of a case where the reduction of an inguinoscrotal hernia and oncological colectomy were performed completely laparoscopically. We present the first instance of a completely laparoscopically assisted resection and hernia repair on a patient with T4 ascending colon cancer. A literature search on recent case reports over the last 30 years has also been presented with a focus on trends in treatment.An 83-year-old man presented for further investigation of his iron deficiency anaemia and was diagnosed with adenocarcinoma of the ascending colon. This was demonstrated radiologically to be found within a large right inguinoscrotal hernia. He underwent a laparoscopically assisted right hemicolectomy and laparoscopic closure of the internal ring and recovered well.Colorectal cancers within inguinal hernias are rare and can often present with complications such as perforation. As such, treatment has mostly involved an open operation. The last few years have shown feasibility of a laparoscopic approach and can be attempted safely when indicated. The combination of inguinal hernia and colorectal cancer is a very uncommon presentation with less than 40 reports found in the literature. Given its rarity, there has been no standard treatment and therefore often presents to the treating team a therapeutic dilemma. We present a rare case of inguinoscrotal hernia containing an ascending colon adenocarcinoma presenting initially as anaemia for further investigation and eventually treated completely laparoscopically. Given the variability in treatment in the literature and the increasing use of laparoscopic techniques since its introduction in the 1990s, we have also included a literature review with a focus on trends in treatment over the last 30 years.An 83-year-old man on clopidogrel for coronary artery disease presented to the emergency department of our institution with symptoms of anaemia for the past 3 weeks Table  includinHis other significant background consisted of hypertension, three previous transient ischaemic attacks, type 2 diabetes mellitus and had a permanent pacemaker for sick sinus syndrome.Colonoscopy demonstrated a large non-obstructing tumour located at the ascending colon. The tumour was confirmed as adenocarcinoma on histopathology.Further investigations included a CEA level of 2 μg/L and computed tomography of the chest and abdomen which did not demonstrate metastatic disease but that the ascending colon tumour was located in his right inguinoscrotal hernia  had an end colostomy (Hartmann’s operation). Other than this reported case, there have been two attempts at laparoscopic repair, both in incarcerated but non-perforated hernias, with Pernazza et al.  performiMost reports document performing the hernia repairs in the same operation although Kouraklis et al.  who had The benefits of laparoscopic right hemicolectomy are well known, and two recent meta-analyses , 9 of noWhile our patient presented to the emergency department, the procedure was carried out electively and was initially investigated endoscopically and thence underwent radiological and biochemical investigations allowing for planning and discussion of the planned elective procedure. Given the benefits of laparoscopic right hemicolectomy, we felt that it was in the patient’s best interest to proceed laparoscopically with an option to convert to open if required. This was discussed with the patient who agreed and consented to our approach.Given the unusual presentation of the cancer, laparoscopy allowed definition of the disease with minimal trauma and allowed the flexibility of treatment to change if required without committing to a surgical strategy dictated by an open incision.Although bowel was incarcerated within the hernia, the defect was thought to be large given the fact that the colonoscope was able to reach the terminal ileum and hence passing through the inguinal canal within bowel. As such, muscle relaxation and pneumoperitoneum might have allowed reduction of the herniated bowel which was previously non-reducible .Our case is the second known case of inguinoscrotal hernia containing an ascending colon cancer and to our knowledge the first case in which both the bowel resection and hernia repair were performed completely laparoscopically. The decision to perform the procedure laparoscopically was based on several factors.Given the risk of herniation through the large defect, it was also important that the hernial defect was repaired. With our centre’s long experience with laparoscopic hernioplasties, a trans-abdominal preperitoneal (TAPP) approach was considered. As the operation entailed a bowel resection, the wound created was considered clean contaminated, and despite significant reduction in wound infection rates in laparoscopic right hemicolectomies, they remain at 5.3% . TherefoAn open approach and tissue repair was also considered with the advantage of being able to excise the sac for histopathological analysis although the benefits remain unclear in primary intrasaccular tumours . Given tWhile it has been established that there is no benefit to screening for abdominal cancers endoscopically or radiologically in inguinal hernias , any patIt has been traditionally advocated that T4 tumours are to be resected using an open approach. Recent data have challenged that and have shown that a laparoscopic approach can be safe and is not significantly inferior to an open approach in terms of oncologic outcomes and at the same time maintaining the key advantages of laparoscopy as previously described .An inguinal hernia containing colorectal cancer is rare but serious and can often present with complications such as perforation. We have presented a case of T4 ascending colon cancer within an inguinoscrotal hernia treated completely laparoscopically. Although the data are limited, laparoscopically assisted bowel resections in this context can be safely performed and could be attempted if feasible.


Gliomas are the most common primary brain tumors in adults and invariably carry a poor prognosis. Recent clinical studies have demonstrated the safety and compelling survival benefit when tumor treating fields (TTFields) are added to temozolomide for patients with newly diagnosed glioblastoma. TTFields are low-intensity, intermediate frequency (200 kHz) alternating electric fields, delivered directly to a patient’s brain through the local application of non-invasive transducer arrays. Experimental simulations have demonstrated that TTFields distribute in a non-uniform manner within the brain. To ensure patients receive the maximal therapeutic level of TTFields at the site of their tumor, tumor burden is mapped and an optimal array layout is personalized using the NovoTAL software. The NovoTAL software utilizes magnetic resonance imaging (MRI) measurements for head size and tumor location obtained from axial and coronal T1 postcontrast sequences to determine the optimal paired transducer array configuration that will deliver the maximal field intensity at the site of the tumor. In clinical practice, physicians planning treatment with TTFields may determine that disease activity is more accurately represented in noncontrast-enhancing sequences. Here we present and discuss a series of 8 cases where a treating physician has utilized non-contrast enhancement and advanced imaging to inform TTFields treatment planning based on a clinical evaluation of where a patient is believed to have active tumor. This case series is, to our knowledge, the first report of this kind in the literature.All patients presented with gliomas (grades 2–4) and ranged in age from 49 to 65 years; 5 were male and 3, female. Each patient had previously received standard therapy including surgery, radiation therapy and/or chemotherapy prior to initiation of TTFields. The majority had progressed on prior therapy. A standard pre- and postcontrast MRI scan was acquired and used for TTFields treatment planning.This paper details important approaches for integrating clinical considerations, nonmeasurable disease and advanced imaging into the treatment planning workflow for TTFields. As TTFields become integrated into standard care pathways for glioblastoma, this case series demonstrates that treatment planning beyond the extent of contrast enhancement is clinically feasible and should be prospectively compared to standard treatment planning in a clinical trial setting, in order to determine the impact on patient outcomes. Despite significant advances in the detection, imaging and treatment planning for brain tumors, overall prognosis remains bleak and there remain no curative treatments for high-grade gliomas. There is a significant unmet need for life-extending therapies that can preserve a patient’s quality of life, given that patients with glioblastoma multiforme (GBM) have a median survival of approximately 16 months, even with aggressive therapy . Tumor t20), with a wavelength of picometers (10−19), less than the diameter of an atom [TTFields fall within the spectrum of nonionizing radiation and differ in their biologic behavior compared with radiation therapy (RT). In general, high energy gamma radiation has a frequency in the order of exahertz  are the current criteria used by the neurooncology community in the clinical practice and clinical trial settings, and these criteria have incorporated the identification of nonenhancing, infiltrative tumor into response assessment to address the limitations of using only contrast enhancing images . ConsequA 54-year-old man with a longstanding history of seizures developed new left-sided weakness and was found to have a brain tumor. He underwent a gross total resection and pathology confirmed a diagnosis of GBM with both astrocytic and oligodendroglial features, MGMT unmethylated, IDH1 wild-type and no loss of 1p19q. He was treated with conventional chemo-RT and opted to add TTFields to his maintenance temozolomide. His postradiation MRI showed no clear contrast enhancement and only minor fluid-attenuated inversion recovery (FLAIR) changes. MRI measurements for NovoTAL treatment planning were thus determined using the preoperative scans Fig. -c.Fig. 1A 49-year-old man developed left arm weakness. Imaging revealed a ring-enhancing nodule in the posterior right frontal lobe. He underwent a gross total resection with pathology confirming a GBM, MGMT unmethylated. He was treated with conventional chemo-RT, followed by 1 cycle of maintenance temozolomide. The patient experienced disease progression and was started on bevacizumab, with continuation of temozolomide. After completing 6 cycles of temozolomide, he had a further progression and underwent a repeat tumor resection, with placement of Gliadel wafers. Following the surgery, he received bevacizumab in combination with dose-intense (daily) temozolomide for 2 months. Subsequently, the patient developed new symptoms of worsening left-sided weakness. Imaging performed at that time demonstrated three areas of abnormal enhancement, including the resection cavity with Gliadel wafers, an enhancing area in the medial right frontal lobe suggestive of a subdural collection, and a new enhancing mass in the deep right hemisphere , they can often transform to a malignant phenotype. The management of anaplastic astrocytomas remains controversial, but most clinicians opt to treat patients with the same regimen used to treat glioblastoma; adjuvant chemo radiation followed by maintenance temozolomide. Although TTFields have not been prospectively tested in randomized controlled trials in low grade gliomas and are not FDA approved in this setting, they have been used off-label to treat these patients when other options have been exhausted, given the highly limited treatment options available for this population. Radiographically, low-grade gliomas tend to be nonenhancing and manifest with abnormal T2 signal or FLAIR. In these scenarios, as in Case E and F, axial and coronal FLAIR imaging was used for mapping. If coronal T2 or FLAIR are unavailable, the coronal T1-weighted imaging can be used, in which case the tumor often appears hypodense. In Case E, a diffuse astrocytoma, there was no contrast enhancement seen on MRI. Axial FLAIR images, demonstrating T2 hyperintensity in affected areas of the brain, were used to obtain mapping coordinates. No coronal T2 or FLAIR sequence was available, so the coronal T1-weighted image was used to estimate the central area of the tumor. There was some evidence of T1 hypointensity, corresponding to T2 hyperintensity.In Case F, there was no abnormal contrast enhancement seen on MRI, so the axial T2- and T1-post, as well as the coronal T1-post were used for NovoTAL mapping. The mass was T1 hypointense and T2 hyperintense to normal brain, allowing for drawing of the coordinates up to the signal change. The cases outlined above demonstrate how treating physicians can appropriately incorporate nonenhancing disease into TTFields treatment plans.A 65-year-old woman developed progressively worsening cognitive and speech impairments. Imaging revealed a large, heterogeneously enhancing left frontal mass extending to the corpus callosum. She underwent a subtotal resection, with pathology confirming a GBM, MGMT methylated, and EGFRvIII positive. She was treated with conventional chemo-RT and adjuvant temozolomide along with an investigational agent through a clinical trial. After her second recurrence while on bevacizumab, MRI demonstrated an enlarging abnormal T2 hyperintense area. This region also had significant increase in blood flow on MR perfusion Fig. .Fig. 7aA 49-year-old woman developed progressively worsening speech impairment. Imaging revealed a nodular area of DWI-hyperintense signal (restricted diffusion) in the deep left frontal lobe. She underwent a stereotactic biopsy confirming an anaplastic astrocytoma, IDH1 wild-type, and MGMT unmethlyated. She was treated with conventional chemo-RT. During the fourth week of radiation, she experienced worsening neurological symptoms, complete expressive aphasia, and right-sided hemiplegia. She was started on concurrent bevacizumab and was able to complete her course of chemo-RT thereafter continuing on bevacizumab. After 11 months of therapy, she developed new speech impairment. MRI demonstrated a new nodule of hyperintense DWI signal in the high-left frontal lobe, consistent with disease progression. It was recommended that TTFields be added as adjunctive therapy. NovoTAL mapping was performed utilizing the DWI sequence, which was correlated to the axial and coronal T1-postcontrast series Fig. .Fig. 8aIn some cases, aggressive tumor growth can be better visualized on MR-perfusion and DWI sequences. MR-perfusion represents increased blood flow to actively growing tumor, whereas DWI-hyperintensity represents a hypercellular environment. This is particularly useful in the era of antiangiogenic therapies, in which patients often have little or no contrast enhancement on MRI at the time of tumor progression. Utilization of these advanced MR modalities can guide the target of the TTFields to the area of most active tumor. In Case G, the area of increased activity on MR-perfusion narrowed the region of interest on FLAIR. In Case H, the hyperintense DWI signal, which correlated with the patient’s symptoms, defined the target on T1-postcontrast. In both cases, the treating physician used advanced MRI techniques to help target the TTFields.2-correlation coefficient for 20 individual measuring parameters exceeding 0.99. Clinicians managing patients with GBM can choose to become certified in treatment planning with NovoTAL and there are potential clinical benefits in their doing so. Unlike NovoTAL mapping performed by manufacturer, which exclusively utilizes postcontrast MRI sequences, a treating physician has access to a patient’s sequential imaging and has comprehensive knowledge of a patient’s treatment history. This can provide a better understanding of subtle changes in imaging that may or may not represent active disease. In addition, they have the discretion to integrate other MRI or advanced imaging sequences into the planning process, which may better reflect the true extent of active disease , or rely on these sequences at their discretion in instances when postcontrast sequences are missing. In addition, should a patient’s imaging change significantly from baseline while on TTFields, the managing physician can decide whether re-mapping the treatment field is warranted [The NovoTAL System is an algorithmic software program that creates optimal transducer array layouts based on patient head size and tumor location measurements obtained from an MRI . Electriarranted .Glioblastomas can have a diverse appearance within MRI images. In general, they appear as an enhancing lesion(s) on T1 post-contrast imaging. However, after treatment, not all contrast enhancement represents tumor and may actually depict treatment effect such as pseudoprogression. This needs to be taken into consideration by the treating physician, as shown by several of the cases above. Also, as demonstrated in the cases above, there are often circumstances where the active tumor is non-enhancing, and can only be visualized on FLAIR, MR-perfusion, or diffusion sequences. The lack of contrast-enhancing disease seen on MRI should certainly not preclude patients from receiving TTFields therapy. Future prospective studies may seek to understand not only the response rates of nonenhancing and other MRI sequences of glioblastoma treated with TTFields therapy, but also their correlation with molecular alterations in this tumor.Written informed consent was obtained from the patients and/or caregivers for publication of these Case reports and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


The etiology of scrotal pain is clinically classified in terms of the necessity for emergency surgery. Lately, color Doppler ultrasonography has reduced unnecessary surgeries, but there are still some cases that require immediate exploration because of an uncertain diagnosis. Here, we describe the case of a 14-month-old boy, who could not deliver his complaint accurately, presenting with a grumpy mood and a red swollen scrotum. Emergency surgery revealed that the cause was intense inflammation of the hydrocele wall, which typically does not cause acute scrotum. We also reviewed rare etiologies of scrotal pain for general physicians to develop the differential diagnosis. Acute scrotal pain includes some urgent diagnoses, such as testicular torsion and incarcerated hernia or omentum. Traditionally, an in-depth interview and color Doppler ultrasonography (US) can lead to an acute diagnosis, although some cases exist where clinicians cannot eliminate emergency etiologies because the case history and physical examination are not performed accurately or the US revealed equivocal imaging. Here, we present a case where a presurgical diagnosis compromised incarcerated omentum, and the operation revealed that intense hydrocele inflammation was the cause of the symptoms.A 14-month-old boy who had been diagnosed with a hydrocele in the right spermatic cord was referred to our department from the outpatient clinic with a right swollen scrotum. He presented to our hospital for the management of intermittent right scrotum pain for 4 days. He was in grumpy mood, his right scrotum was red and swollen, and the cremasteric reflux was absent . The uriAcute scrotum is characterized by scrotal pain that has rapid or acute onset. The most serious condition in pediatrics is testicular torsion that requires emergent surgery to avoid testicular necrosis. As the sensitivity of the US against testicular torsion is as high as 88.9–100%  and the Although the accurate etiology is uncertain, there are three reasons that suggest the painful red scrotum was derived from inflammation of hydrocele wall. First, the pathology findings revealed a thick hydrocele wall, a high number of inflammatory cells, and firm fibrin precipitation, those of which are not usually seen in typical pediatric hydroceles . Second,The reason for hydrocele inflammation is uncertain. It is widely known that incarcerated hernias sometimes cause hydroceles. In our case, however, there was no ischemia of the omentum; nor was the hydrocele communicating with abdominal cavity, suggesting other reasons exist for hydrocele inflammation. Clinically, it was reported that omentum often form adhesions to inflamed regions such as the patient's PV . In our


Primary colonic and dedifferentiated liposarcomas are both remarkably rare. This work describes a case of primary colonic well-differentiated/dedifferentiated liposarcoma and reviews the clinical characteristics and current therapies for liposarcoma tumors.A 52-year-old woman was referred to our hospital with a submucosal tumor of the ascending colon. Clinical analysis by ultrasound colonoscopy and computed tomography revealed a partially ossified tumor with irregular edges continuous with the muscular layer. High F-18 deoxyglucose uptake was detected by positron emission tomography. Radical resection with lymph node dissection was performed, yielding a tumor specimen approximately 6.5 × 4.0 × 3.2 cm. Neoplastic spindle cell proliferation was found from submucosa to subserosa. Well-differentiated adipose tissue surrounded the tumor, but contained atypical nuclei with condensed chromosomes. Immunohistochemical staining was positive for p16, CDK4, and MDM2 expression. Based on these findings, a diagnosis of well-differentiated/dedifferentiated liposarcoma was given. Dedifferentiated liposarcomas are more aggressive than their well-differentiated, low-grade counterparts. While local recurrence can occur with both tumor types, dedifferentiated liposarcomas are more prone to developing distant metastases. The patient received no postoperative therapy, and no recurrences have been observed 12 months after surgery.Here we report an extremely rare case of well-differentiated/dedifferentiated liposarcoma of the ascending colon. The dedifferentiated component was high-grade liposarcoma and well-differentiated liposarcoma was detected around the main tumor. Soft tissue sarcomas arise from skeletal or extraskeletal connective tissue in the extremities, retroperitoneum, head and neck, and subcutaneous tissues. Liposarcoma is the single most common soft tissue sarcoma, accounting for at least 20% of all sarcomas and over 50% of retroperitoneal sarcomas . The mosmax) for F-18 deoxyglucose was 2.4–3.4 as determined by positron emission tomography  and other values were normal. Colonoscopy confirmed a submucosal tumor extending from the hepatic flexure to the ascending colon Fig. , with edphy Fig. . GastroiWe performed a radical resection with lymph node dissection. General anesthesia was induced with full muscle relaxation, and a skin incision was made in the abdomen. A firm tumor was confirmed in the ascending colon, but the abdominal cavity was devoid of metastatic or disseminated lesions. The ileocolic vein and artery, as well as an accessory right colic vein, were identified, ligated, and cut, and the main lymph nodes on the anterior surface of the inferior mesenteric vein from gastrocolic trunk to ileocolic vein were dissected. We resected along the fusion fascia between the mesocolon and retroperitoneum; the resultant surgical specimen completely encompassed a firm tumor.The resected specimen was approximately 6.5 × 4.0 × 3.2 cm Fig. , the cen. No recurrences have been observed 12 months after surgery.A firm mass of dedifferentiated sarcoma was completely resected. However, there were some atypical cells in the adipose tissue around the firm tumor and these were diagnosed as well differentiated liposarcoma. The well-differentiated liposarcoma component extended to the surgical margin in places; however, only normal adipose tissue was detected at most of the surgical margin. A positive surgical margin was detected only for the parts of the well differentiated sarcoma near the firm mass. No lymph node metastasis was detected. Microscopic remnant of well-differentiated liposarcoma was confirmed according to pathological findings, but post-surgical FDG-PET CT and enhanced CT could not detect the remnant tumor around the resected lesion. The patient received no postoperative therapy. We performed follow-up evaluation with enhanced computed tomography or magnetic resonance imaging every 3 monthsThis report describes an extremely rare case of ascending colonic well-differentiated/dedifferentiated liposarcoma. PubMed was queried for articles published in English from January 1990 to September 2016 with the terms “liposarcoma” and “colon”. Seventy-six articles were returned, of which 13 and 2 described primary colonic well-differentiated and dedifferentiated liposarcoma, respectively. Primary colonic liposarcoma is rare, and only a few cases of dedifferentiated liposarcoma have been reported ; therefoDedifferentiated liposarcomas arise from their well-differentiated counterparts and thus exhibit cytogenetic similarities. Immunohistochemistry for CDK4, MDM2, and p16 expression aids in the differential diagnosis of well-differentiated and dedifferentiated liposarcoma from other adipocytic neoplasms . DespiteIn this case, the dedifferentiated liposarcoma formed a firm mass that was easily identified; however, the well-differentiated sections were soft and difficult to distinguish from the fat tissue surrounding the ascending colon during the operation. We therefore recommend that when dedifferentiated liposarcomas are resected, an adequate margin of soft fatty tissue around the solid tumor also be resected to ensure that no well-differentiated liposarcoma remains. Given that it is difficult to diagnose dedifferentiated liposarcoma preoperatively, submucosal tumors suspected of being high-grade sarcomas need to be resected with adequate margins that include soft tissue around the firm tumor.Positive margins increase the risk of local recurrence, their influence on overall survival is less clear. Positive microscopic margins (R1) are reportedly associated with higher distant recurrence rates and poorer prognoses than negative microscopic margins (R0) , but othP = 0.6) [P = 0.38) [Postoperative treatment for liposarcoma remains controversial. Adjuvant radiotherapy limits the risk of local recurrence, but no definite survival benefit has been established  and patiP = 0.6) . Recent  = 0.38) . Compara = 0.38) , 15. In The following recommendations for evaluation during follow-up of retroperitoneal sarcoma have been published by the Trans-Atlantic RPS Working Group. Because the median time to recurrence of high-grade retroperitoneal sarcoma is less than 5 years after definitive treatment, the intervals between follow-up evaluations should be 3 to 6 months for 5 years. After 5 years, annual follow-up is considered adequate. After incomplete resection of retroperitoneal sarcoma patients should be followed indefinitely because the risk of recurrence does not plateau .This report describes an extremely rare case of ascending colonic liposarcoma consisting of well-differentiated and dedifferentiated sections. Dedifferentiated liposarcomas are high-grade sarcomas; additionally, well differentiated liposarcoma was detected around the main tumor. The dedifferentiated tumor was completely resected, but the aggressive nature of dedifferentiated liposarcoma need periodic examination.


There are few reports of metastases from colon cancer to an inguinal hernia sac, and few reports of colon cancer originating in diverticula. We report a patient with carcinoma of the sigmoid colon arising in two diverticula, who presented with peritoneal seeding to an inguinal hernia sac, and a review of the literature.A 55-year-old male underwent open herniorrhaphy for a left inguinal hernia. At operation, a nodule in the inguinal hernia sac was resected and histologic examination revealed adenocarcinoma, which was suspected to be a metastasis from a distant primary lesion. Postoperative evaluation included colonoscopy and positron emission tomography which showed two suspected lesions in sigmoid diverticula. Laparoscopic subtotal colectomy was performed, and pathology revealed adenocarcinoma in two sigmoid diverticula.If a nodule is found in an inguinal hernia sac, especially in older patients, peritoneal metastases should be considered. Resection of the nodule with histopathologic evaluation is essential. Colon cancer arising in a diverticulum should be considered as a possible site of the primary lesion. Peritoneal seeding from a cancer of unknown origin may be encountered and is usually found incidentally during open or laparoscopic abdominal surgery. After evaluation to identify the primary tumor, some are found and the others remain unknown.Malignant tumors presenting in an inguinal hernia sac are extremely rare. In 1959, Yoell reported that routine histological examination of resected hernia sacs revealed approximately 0.4% contained malignant lesions [A 55-year-old male presented with a 2-week history of a bulge in the left inguinal area which was not painful but caused discomfort. The patient had no significant past medical history. Physical examinations showed that vital signs were normal, and a bulge in the left groin was soft and easily reducible, consistent with an inguinal hernia. Elective hernia repair was performed with the Lichtenstein method 1 week later. During operation, we found a white nodule inside the hernia sac, which measured 10 mm in diameter. The nodule was excised and examined histopathologically. The postoperative course was unremarkable, and he was discharged without complications. Examination of the nodule revealed moderately differentiated adenocarcinoma Fig. , b. ImmuDespite advances in the treatment of patients with a variety of malignancies, colon cancer with peritoneal metastases is still associated with a poor prognosis. Watanabe et al. reported that 5% of patients with colon cancer have peritoneal metastases at the time of diagnosis . They alOnly four patients with metastatic colon cancer in an inguinal hernia sac have been reported. All of these patients were males over 60 years of age. It remains uncertain why metastases develop within a hernia sac. Roslyn et al. suggested that the mechanism might be explained by local inflammation of the sac and gravity, in a manner similar to drop metastases to the pelvic cul-de-sac . Yu et aMalignancies can arise in colonic diverticula. The diagnosis was made based on the endoscopic finding of a tumor within a diverticulum . HoweverThere are 11 previous reports of colon cancer arising in a diverticulum. Of these, nine were in an advanced at the time of diagnosis. Eight of these lesions were in the left colon. Since colonic diverticula are thin-walled and lack a muscular layer, cancers arising within a diverticulum can easily penetrate the serosa which may facilitate early development of disseminated disease. Patients with cancers arising in a diverticulum need careful evaluation and follow-up . The preIf a nodule is found in an inguinal hernia sac, especially in older patients, peritoneal metastasis should be considered. Resection of the nodule with histopathologic evaluation is essential. Colon cancer arising in a diverticulum should be considered as a possible site of the primary lesion.


We treated a 65-year-old Japanese man with a giant penile lymphedema due to chronic penile strangulation with a rubber band. He was referred to our hospital with progressive penile swelling that had developed over a period of 2 years from chronic use of a rubber band placed around the penile base for prevention of urinary incontinence. Under a diagnosis of giant penile lymphedema, we performed resection of abnormal penile skin weighing 4.8 kg, followed by a penile plasty procedure. To the best of our knowledge, this is only the seventh report of such a case worldwide, with the present giant penile lymphedema the most reported. Wuchereria bancrofti, the most common etiology of secondary penoscrotal lymphedema, several conditions are known to be causative. In general, penile strangulation or incarceration by a foreign body, an uncommon urological emergency condition, rarely causes penoscrotal lymphedema because most cases are treated at an early stage [A penoscrotal lymphedema, also termed elephantiasis, results from obstruction, aplasia, or hypoplasia of lymphatic vessels. In addition to a filarial infection caused byly stage –4. We enA 65-year-old single Japanese man was referred to our hospital with tremendous enlargement of the penis. There was no particular psychiatric or family history, and the patient had never travelled to a tropical region. Approximately 4 years prior to admission, he began to roll a commercially available rubber band (4.5 cm in diameter) around the penile root and foreskin, and used it throughout the day and evening to prevent urinary incontinence. Two years after beginning such rubber band use, the patient noticed gradual swelling and deformity of the penis, but continued to use the rubber band, resulting in progressive enlargement.A physical examination revealed brown colored hypertrophic skin that was very large  though painless and completely covering the penis, with only the penile orifice barely observable . A normaSurgical treatment was performed to improve quality of life (QoL) and cosmetic issues. After placing a Foley urethral catheter, surgical excision of the subcutaneous hypertrophic tissues was made with carful haemostasis to expose the corpus cavernosa, that was found to be not deformed, while skin near the shaft of the penis was also found to be normal and used to cover and preserve the penis . FinallyA histopathological examination revealed that most of the excised mass consisted of proliferated collagen fibers, as well as enlarged lymphatic and capillary vessels with lymphocyte infiltration. Two months after surgery, wound healing along with acceptable cosmetic results and improvement of QoL was noted, though the patient required continuous use of a Foley urethral catheter because of loss of sensation to urinate.Penoscrotal lymphedema due to chronic penile strangulation or incarceration by a foreign body is extremely rare, with only 6 cases reported –4. The p Wuchereria bancrofti; thus it is extremely rare outside of endemic filariasis countries including Japan [Primary and secondary forms, based on etiology, are known, with the secondary form more common. The major cause of secondary penoscrotal lymphedema is a filarial infection byng Japan , 6. HoweApplication of constricting objects, such as metallic rings or rubber bands, to the penis often causes penile strangulation or incarceration and leads to painful swelling, skin ulcerations, and necrosis. Treatment in the initial stages generally consists of removal of the object and subsequent repair of any damage. However, surgical treatment is required in chronic cases such as the present, because of many problems that develop in association with hygiene, urinary incontinence, aesthetic appearance, and loss of libido, which may lead to social isolation and impaired QoL. The patients in 5 of the previously reported cases were treated with a penectomy and/or circumcision , 2, 4, wApplication of constricting objects over the penis is generally done for enhancement of sexual pleasure or curiosity  though i


Splenic artery pseudoaneurysms (PSA) are rare entities and far less common than true aneurysms of the splenic artery. The most common etiology is pancreatitis, recurrent either in the setting of chronic pancreatitis or as an episode of acute pancreatitis. Less common causes include trauma, peptic ulcer disease, or iatrogenic causes. Almost all of the trauma-related case reports have been due to blunt trauma. We believe this to be the first reported case of a splenic artery PSA presenting with massive hematemesis at a significant time frame after penetrating trauma. Successful transcatheter treatment was performed and alternative techniques are also discussed. Splenic artery pseudoaneurysms (PSA) are far less common than true aneurysms of the splenic artery. They are predominately caused by pancreatitis, either recurrent or acute, and less commonly caused by trauma, peptic ulcer disease, or iatrogenic causes. They have a higher incidence of rupture and significant morbidity when discovered as compared to true aneurysms. We present an unusual case of a splenic artery PSA presenting with massive hematemesis approximately two years after penetrating trauma of the upper abdomen. It was successfully treated with transcatheter embolization which is now accepted as the preferred approach to such cases, compared with more invasive surgical approaches.A 22-year-old-male presented to the emergency department with a one day history of abdominal pain, syncope, and three episodes of hematemesis. The patient denied any previous history of abdominal pain, gastrointestinal bleeding, or altered bowel habits. The patient had suffered multiple deep stab wounds to the left upper abdomen approximately two years earlier, resulting in emergency laparotomy, transverse colostomy, and an uneventful colostomy reversal two months later. He admitted to heavy weekend alcohol use, occasional recreational drug use, and smoking one pack of cigarettes per day for six years. There was nothing in the history to suggest any bouts of pancreatitis or gastric ulcer disease.In the emergency department the patient was hypotensive to 100/50 with a pulse of 90. Laboratory examination showed hemoglobin = 8.8 g/dL , hematocrit = 26.5% , platelets = 195 k/uL , and WBC = 20.2 K/uL . All other values including coagulation profile were within normal limits.It was decided to proceed directly to gastroenterology (GI) for upper endoscopy, which revealed a large adherent clot at the mid greater curvature of the stomach. There was no evidence for ulceration at the site of the adherent clot and a biopsy was not performed. There was fresh blood in the antrum and duodenum, consistent with recent bleed. No active bleeding site could be seen from the antrum or duodenum and no blood was seen coursing from the ampulla. It was determined that the mid greater curvature site in the body of the stomach most likely represented the source of the hematemesis.Based on the presentation of hematemesis and hypotension, the gastroenterologists recommended emergent angiography with deferment of CT imaging. Celiac and splenic arteriograms demonstrated a large wide-necked PSA from the mid-to-distal splenic artery with no active extravasation . It was The patient tolerated the procedure well with no immediate complications. The postprocedure course was uneventful as the blood pressure and hemoglobin normalized and there were no further episodes of gastrointestinal bleed reported on a return to GI clinic in 10 days. The patient was subsequently lost to followup.Splenic artery pseudoaneurysms (PSA) are rare entities and far less common than true aneurysms of the same vessel –5. They The risk of rupture is greater for splenic artery PSA compared to true aneurysms and the resultant morbidity and mortality are significant. If they are incidentally discovered it is generally accepted that prompt treatment should be instituted. Traditional open surgery either splenectomy with or without distal pancreatectomy or splenic artery ligation and PSA resection were the main forms of treatment. Over the past three decades, endovascular therapy has become the accepted and preferred treatment modality in hemodynamically stable patients.The preferred technique for endovascular treatment of splenic PSA is proximal and distal coil embolization as close as possible to the PSA –8. This Dense coil sac packing was used in our case. This method spares flow in the entire parent vessel but may be technically more challenging. Another endovascular treatment option is placement of a covered stent-graft . However H. pylori or perform biopsy of the stomach, and the appearance at endoscopy tended to rule out peptic ulcer disease. The splenic artery PSA in all likelihood developed at the time of the initial trauma was not recognized at the time of laparotomy or colostomy reversal and subsequently eroded into the body of the stomach.As mentioned, our patient was a relatively healthy young male who suffered penetrating trauma to the left upper abdomen two years prior to this admission. Although there was a history of alcohol use, there were no other hospital admissions and no history of abdominal pain to suggest that pancreatitis had ever occurred. Likewise a gastric ulcer as the inciting event is highly unlikely based on the history and the lack of chronic abdominal pain. The gastroenterologist did not request a stool examination forThe length of time from injury to presentation of two years is highly unusual. Most delays from injury to presentation have ranged from one day to four months. Patients suffering penetrating abdominal trauma requiring urgent laparotomy often do not undergo routine CT scans, which may have led to an earlier diagnosis before the complication of hematemesis in this case. It can be argued that all patients suffering significant penetrating abdominal trauma undergo CT scan of the abdomen and pelvis in attempt to rule out unsuspected vascular complication. This can be performed either prior to or after laparotomy, depending on the clinical circumstances.Several authors have described delayed presentations of splenic artery pseudoaneurysms, but these have always been related to blunt trauma, and usually intrasplenic, rather than localized to the splenic artery proximal to the spleen , 12. We


Despite the combination of aggressive treatments such as chemotherapy, debulking surgery, and whole abdominal radiation, the prognosis of DSRCT remains extremely poor.2 There are fewer than 200 cases reported in literature. We report the first case of an Australian-indigenous man with DSRCT and also describe our treatment approach for this rare cancer.Desmoplastic small round-cell tumor (DSRCT) is a rare and highly aggressive neoplasm of children and young adults that primarily arises from the abdomen with widespread peritoneal involvement and is characterized by distinct clinicopathologic features.A 20-year-old indigenous Australian man was admitted to the hospital with a 3-week history of progressive abdominal discomfort, lethargy, and weight loss, associated with nausea and occasional night sweats but no urinary or bowel symptoms. His medical history was significant for recurrent tonsillar infections, intravenous use of amphetamines, and marijuana smoking. He was not on any regular medications, and there was no family history of cancer. Clinical examination revealed a young man with a low body mass index. He was afebrile and hemodynamically stable. On abdominal examination, a firm mass was palpable in the lower abdominal region, and there was palpable inguinal lymphadenopathy, while rectal examination revealed a smooth, firm, nontender mass. Laboratory results showed mild, normocytic, normochromic anemia, with a hemoglobin level of 124 g/L and a normal white blood cell count. Results also showed acute kidney injury, with a creatinine level of 227 μmol/L, whereas liver function tests revealed a normal bilirubin level and an alkaline phosphatase level of 241 U/L, with an AST level of 66 U/L and an ALT level of 27 U/L. His inflammatory markers were within the normal range.EWSR-1 rearrangement was also detected; however, WT-1 results were negative. On the basis of this information, a final diagnosis of DSRCT was made.A computed tomography (CT) scan showed a large soft-tissue mass in the pelvis and multiple, hypodense lesions in the liver, along with porta hepatis and retroperitoneal and external iliac chain lymphadenopathy . There wThe patient’s renal function improved with intravenous hydration alone, and he showed clinical signs of improvement after one cycle of chemotherapy; therefore, the decision was made to continue with the same regimen. A repeated CT scan after three cycles of chemotherapy showed a good measurable response , and as 1 and although only a few cases have been reported in the literature, to our knowledge, it has not been described in the indigenous Australian population, making this case report unique. The tumor is composed of dense desmoplastic stroma with a nesting pattern of small, round, blue cellular growth, occasional focal rhabdoid features, and immunohistochemical reactivity for epithelial, muscle, and neural markers. DSRCT is associated with a characteristic chromosomal translocation, t, which fuses the N-terminus of the Ewing sarcoma (EWS) gene to the C-terminus of the Wilms tumor (WT-1) gene.3 The presence of this translocation provides confirmation of the diagnosis. The majority of these tumors stain positive for EWS-1, desmin, cytokeratin, vimentin, epithelial membrane antigen, and WT-1,5 which is again consistent with the immunostaining data of our patient, except for WT-1.DSRCT was first described in 1989 by Gerald and Rosai,6 This is consistent with the presentation of our patient. Because of the rarity of this tumor, misdiagnosis is common and treatment remains a challenge; despite the use of polychemotherapy and surgery, the overall survival rate is 15% at 5 years.7 One case study examined a cyclophosphamide, doxorubicin, and vincristine regimen alternating with ifosfamide and etoposide, which showed a median survival time of 19 months.8 But mostly, owing to the rarity of DSRCT, mostly different chemotherapy regimens, including anthracyclines, cisplatin, and etoposide, have been tried with limited success.11 We used the cisplatin and etoposide regimen before the immunostain results confirmed the diagnosis of DSRCT. However, both of these agents have been used in published studies,11 and our patient is currently responding to treatment, as evidenced by the follow-up imaging, leaving other polychemotherapy options, including anthracyclines, to be explored in the future.Patients are typically 5 to 30 years of age at presentation, and 90% are male. They often present with advanced abdominal disease, with large masses and/or extensive seeding into the visceral and parietal peritoneum. Most patients are asymptomatic until they have a large tumor burden, when they may present with abdominal pain or distention along with nausea and vomiting.In conclusion, DSRCT is a rare abdominal tumor in young men that is highly likely to be misdiagnosed, despite its well-defined clinicopathologic properties. Because of its aggressive nature, it is associated with a poor outcome, despite polychemotherapy regimens. The diagnosis should therefore be considered in young men, even in indigenous Australian populations, with a multifocal peritoneal soft tissue mass that is usually metastatic at the time of diagnosis, because early detection may influence management options, thereby improving survival.


Heterotopic tissue is a congenital anomaly that has been previously reported. Gastric and pancreatic heterotopia are among the most studied ones. Herein, we describe a case of a combined pancreatic and gastric heterotopia that formed a mass and caused a small intestine obstruction in a 61-year-old male. We also did a brief literature review of cases with gastric and pancreatic heterotopia in adult patients. The symptoms started one day prior to arrival to the ED. There was no report of dizziness or lightheadedness. Patient was not on any anticoagulation medications. He denied any recent use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). On physical exam, his vitals were within normal limits, and he had no orthostatic hypotension. There was abdominal distention, with mild diffuse tenderness. The initial laboratory workup showed a hemoglobin of 12.6 gm/dl with a positive stool guaiac test. The patient underwent an upper endoscopy that revealed three antral ulcers, one of which was clipped. He was also treated with Proton Pump Inhibitor (PPI). He did not require a blood transfusion as his hemoglobin remained stable. The patient continued to report nausea as well as a crampy and occasionally sharp abdominal pain with distention. He also had yellow-colored emesis. An abdominal CT was done and it showed dilated small bowel prominently within the right lower quadrant where it measured 5.2 cm and, immediately proximal to the dilated area, there was fecalization of the small bowel content with wall thickening and mesenteric edema and these findings were consistent with a partial small bowel obstruction .A surgical consultation was obtained and the patient underwent an exploratory laparotomy for this de novo obstruction. During exploration, he was found to have an obstruction with a clear transition three feet proximal to ileocecal valve. Closer inspection revealed an intraluminal mass associated with the point of obstruction.There was no diverticulum in the area. A segmental small bowel resection with an enteroenterostomy was completed. The mass measured 3.0 × 2.5 × 2.5 cm, and it contained a dense tan focally necrotic cut surface that grossly abutted the serosal border without extending into the mesenteric fat. The microscopic pathological examination revealed heterotopic pancreas, heterotopic gastric tissue, and an isolated benign mesenteric lymph node with no diverticular tissue  was done without the aid of microscopic confirmation by Jean Shultz in 1727. Nevertheless, Klop was the first one to describe it in 1859 [The most generally agreed-upon mechanism to explain the pathogenesis of HP was suggested by Hogan who proposed that it could be due to an early attachment of small pancreatic buds to the intestinal wall at different sites, and when this connection continues, even after the pancreas separates from the gut, it results in HP . As for While both heterotopias could occur at any site of the GI tract, the stomach, the duodenum, and the upper part of the jejunum were found to be the most common locations of HP . The estThe clinical manifestations depend on the site where the heterotopia is found.In one of the largest retrospective studies that was done on HP, Dolan et al. reviewed the chart of 212 patients who were diagnosed with HP at the Mayo Clinic between 1952 and 1971. The most common presenting symptom was abdominal pain followed by melena, diarrhea, gas, and bloating. The study did not find a relation between the surgical intervention and the resolution of the presenting symptom except in the case of the GI blood loss . FurtherTo the best of our knowledge, there were only 4 other cases in the literature that reported a combined heterotopia of pancreatic and gastric tissue –23. In tAlthough it is not very common, heterotopic tissue should be always considered in the differential diagnosis of adult patients presenting with a common digestive complaint.


Anal melanoma is a rare and aggressive neoplasm of the anal canal seen in the elderly population in the six or seventh decade of their lives. Presentation is usually nonspecific and diagnosis is often delayed or missed initially. The management is surgical and prognosis is poor. Here we present a case of anal melanoma in an elderly patient masquerading as hemorrhoid. Anal melanoma is a rare and aggressive neoplasm of the anal canal, comprised about 2% of anal neoplasm cases identified using the Surveillance Epidemiology and End Results (SEER) registry . FemalesAn 88-year-old woman with history of hypertension, hyperlipidemia, coronary artery disease, constipation, sedentary was referred by her primary care provider to an outside general surgery clinic with diagnosis of bleeding hemorrhoid. The patient had four weeks history of anal discomfort with defecation, sensation of protruding mass in the anal region and intermittent bleeding from her anus. No prior colonoscopy. Evaluation of the anus at that time revealed a prolapsing purple-black mass below the dentate line thought to be a thrombosed hemorrhoid. Local excision was recommended at that time however patient and daughter declined surgery because her pain had been improving and her bowel habits had been regular. She would consider surgical intervention if her symptoms got worse.The patient presented, 10 weeks later, to an outside emergency department with a complaint of enlarging perianal mass and pain, worse with seating. Surgical service was consulted. On exam she was noted to have a necrotic appearing pigmented lobulated anal mass measuring 7 cm x 5 cm. Biopsy was obtained and the patient was admitted to the surgical service. The result of the biopsy revealed malignant melanoma, ulcerated, invasive to a depth of 4.1 mm. She was then transferred to our hospital for management. Computed tomography (CT) scan of the chest, abdomen and pelvis with contrast showed perianal mass with left inguinal lymphadenopathy. The patient and daughter opt for palliative management. She was taken to the operating room and underwent exam under anesthesia, and a palliative wide local excision (WLE) was performed. The total excised tissue was 7.3 cm x 6.2 cm x 2.7 cm irregular dark brown mass . However, there has been a trend in favor of less aggressive WLE due to the high morbidity of APR and perceived lack of survival benefit ,6.Survival after WLE is similar to abdominoperineal resection, which has prompted tertiary oncology centers to recommend transanal excision over radical surgery in most cases. The result of systemic therapy for anal melanoma is disappointing. Radiation alone provides the option of sphincter preservation but does not increase survival ,6,7.Anal melanomas continue to be diagnostic challenge due to their nonspecific symptoms making early diagnosis extremely difficult. Early diagnosis and early surgical intervention are imperative. It is associated with poor prognosis, regardless of the type of intervention used. The most important role of the surgeon may be palliation of symptoms.


Chemotherapy is considered the most appropriate treatment for metastatic uterine sarcoma, despite its limited efficacy. No other treatment has been conclusively proved to be a real alternative, but some reports suggest that anti-hormonal therapy could be active in a small subset of patients. We report the case of a patient with metastatic uterine carcinosarcoma with positive hormonal receptors and a complete pathological response.A 54-year-old white woman presented to our emergency room with hypovolemic shock and serious vaginal bleeding. After stabilization, she was diagnosed as having a locally advanced uterine carcinosarcoma with lymph nodes and bone metastatic disease. In order to control the bleeding, palliative radiotherapy was administered. Based on the fact that positive hormone receptors were found in the biopsy, non-steroidal aromatase inhibitor therapy with letrozole was started. In the following weeks, her general status improved and restaging imaging tests demonstrated a partial response of the primary tumor. Ten months after initiating aromatase inhibitor therapy, she underwent a radical hysterectomy and the pathological report showed a complete response. After completing 5 years of treatment, aromatase inhibitor therapy was stopped. She currently continues free of disease, without further therapy, and maintains a normal and active life.This case shows that patients with uterine carcinosarcoma and positive hormone receptors may benefit from aromatase inhibitor therapy. A multidisciplinary strategy that includes local therapies such as radiation and/or surgery should be considered the mainstay of treatment. Systemic therapies such as hormone inhibitors should be taken into consideration and deserve further clinical research in the era of precision medicine. Uterine sarcomas are rare diseases with poor outcomes and a diverse histopathological classification. Taken together, these facts hamper a consensus on risk factors and treatment guidelines –3. DespiUterine sarcomas account for nearly 3% of all uterine cancers. Histological categorization according to the World Health Organization Classification of Tumours is represented in Table Epidemiology and prognosis are both very different according to each uterine sarcoma subgroup. Leiomyosarcoma and endometrial stromal tumor normally occur in premenopausal women and localized disease is the most common stage at diagnosis. Regardless of the stage at diagnosis, leiomyosarcoma is an aggressive illness with a poor outcome , 9 compaUterine carcinosarcoma (UCS) is typically diagnosed in post-menopausal women and usually presents extrauterine spread at the time of diagnosis. The following were suggested as prognostic factors favoring survival: age <40, white race, early stage disease, lymphadenectomy, and adjuvant radiotherapy (RT) . PatientWe present the case of a patient with an unresectable and metastatic UCS with positive hormone receptors, and a poor PS due to vaginal bleeding and a pulmonary thromboembolism, that subsequently improves radically and achieves a complete response with aromatase inhibitor therapy (AIT). Currently, the patient remains free of disease after completing 5 years of treatment.The case of a 54-year-old white postmenopausal woman with an unremarkable past medical history except for a tobacco smoking habit and a few weeks of weight loss, weakness, anorexia, and abdominal mass is described.The patient presented to our emergency room in April 2009 after a 5-day history of severe vaginal bleeding and progressive dyspnea, with hypovolemic shock, and confusional status. A physical examination showed hypoxemia, a large abdominal mass, intense abdominal discomfort, and left lower extremity edema. A hemogram showed a severe anemia (hemoglobin 5.5 g/dl). An abdominal computed tomography (CT) scan demonstrated a 20-cm ill-defined heterogeneous hypogastria mass that originated in her uterus with several inner bleeding and necrotic areas, invasion of her right ureter, and both her right iliac artery and vein Fig. , d; paraGiven the existence of metastatic disease and an Eastern Cooperative Oncology Group (ECOG) PS of 3, the illness was deemed terminal and non-curable. The patient and her closest relatives confronted the dismal prognosis and, therefore, initiation of chemotherapy was declined.Due to the presence of a large mass responsible for her vaginal bleeding and severe anemia, as well as the high risk of renal complications as a result of the extrinsic compression of her ureter, palliative radiation was considered. She was then referred to our radiation oncology department for external beam radiation therapy of the abdominopelvic mass, with hemostatic intention. Tridimensional external beam RT with parallel opposed anterior to posterior-posterior to anterior (AP-PA) fields was administered (ten fractions of 2.5 Gy) with complete control of her hemorrhagic symptoms and PS improvement to ECOG 2.Once the radiation treatment was completed, based on her immunohistochemical findings and prior reports , 20–22, Three months after AIT initiation, a hospital admission was required due to urinary infection. An abdominopelvic CT scan demonstrated a partial response Fig. , b accorTen months after the initiation of AIT, she was re-evaluated with a PET/CT scan. A decrease in the size and metabolic activity of the pelvic tumor uptake was observed (SUV max = 5.58), as well as a disappearance of metastatic lymph nodes in the para-aortic region and the uptake of L3 to L4 vertebral bodies Fig. . Her Ca-Once the excellent objective primary lesion response, the absence of secondary disease, and the significant improvement in PS were established, she was deemed to be a candidate for salvage surgery and an exploratory laparoscopy was performed. During the surgical procedure, the complete removal of the residual mass was considered feasible. The intervention was then converted to a laparotomy and a total hysterectomy with oophorectomy, external iliac lymphadenectomy, a partial cystectomy, excision of small intestine segment, as well as partial debulking of a pelvic residual mass was accomplished. Pathologic examination reported marked bleeding and necrotic changes due to prior treatment, without evidence of tumor disease, and tumor-free lymph nodes (ypT0 ypN0), along with ovarian fibrotic changes secondary to previous AIT, and small bowel atrophy and fibrosis Fig. .After the surgery, adjuvant letrozole was restarted with the plan to complete 5 years. Nine months after resection, she presented a major midline abdominal hernia. She required an abdominal eventroplasty. During surgery the right ureteral stent was also removed.In the following months, she developed a slight but progressive increase in bilirubin levels (from 1.6 to 2.2 mg/dl), which was attributed to the AIT. Therefore, her AIT dose was reduced to 50% and administered every 48 hours, with subsequent normalization of bilirubin levels Fig. . LetrozoAfter more than 7 years of follow-up, she remains free of disease, with negative Ca-125 tumor marker and without symptoms related to the prior illness or the local and systemic treatments received.We describe the case of a patient with a metastatic UCS and a dreadful medical condition who not only recovers from the critical initial situation, but also achieves a pathological complete response. Moreover, she maintained long-term disease control without limiting side effects after completing a multimodality therapy with RT, surgery, and 5 years of treatment with AIT.It must be emphasized that the RT dose administered was 25 Gy. This treatment was given with a palliative intention, and its therapeutic goal was merely hemostatic. To the best of our knowledge, such a low radiation dose has never been demonstrated to have any relevant antitumor activity in uterine sarcoma. Results from evaluation of RT in the adjuvant setting have reported superior local control rates, although no survival advantage has been demonstrated . MoreoveAfter achieving partial remission of uterine disease, our patient underwent salvage surgery. The intervention was limited to the primary uterine tumor. A pathological report did not show any residual tumor and a complete response was concluded from the resected specimen evaluation. Based on these results as well as on the metabolic response observed in the PET/CT scan, no additional RT was administered on the surgical bed, pelvic nodes, and bone metastases.In metastatic uterine sarcomas, chemotherapy is the most commonly accepted treatment, regardless of its histological type , 5, 8. OThe prognosis of our patient was dismal due to the aggressiveness of the disease and its extension. The administration of systemic chemotherapy was totally contraindicated due to her poor PS and concurrent medical condition, including bleeding, hypovolemic shock, pulmonary thromboembolism, and renal insufficiency. In this context, and given the positivity of estrogen and progesterone receptors in the tumoral cells, the option to initiate oral hormonal therapy with palliative intention seemed reasonable.Uterine sarcoma requires a multidisciplinary approach, but the gold standard in advanced disease still has to be defined. Future studies are required to elucidate whether biological and/or targeted therapy has a role in the treatment of these tumors. In the case of metastatic UCS, chemotherapy and palliative symptomatic RT might be helpful in selected cases but, as our case illustrates, aromatase inhibitors should also be considered an active option in these patients.


We reported the first case of a congenital intrapelvic presacral neuroblastoma in Puerto Rico managed in the early neonatal period. The preoperative diagnosis was a sacrococcygeal teratoma Altman stage IV classification. This case confirms the importance of a comprehensive physical examination and observation of low-risk newborn infants with a history of adequate prenatal care and an unremarkable fetal ultrasonogram during pregnancy. Neonatal tumors are rare . Around Clinical presentation of neuroblastoma is dependent upon the site of the tumor origin, disease extent, and the presence of paraneoplastic syndromes . The majMothers who delivered infants diagnosed with neuroblastoma can develop symptoms during their third trimester such as sweating, pallor, headaches, palpitations, tingling of hands and feet, and/or hypertension. This occurs by transplacental exchange of fetal tumor catecholamines into the maternal circulation .We presented a newborn with an intrapelvic neuroblastoma originally thought to be an Altman stage IV intrapelvic sacrococcygeal teratoma.2P1A0. The mother had no history of systemic illness. There was no consanguinity in the family. Prenatal screening tests  were negative; Group B Streptococcus was positive; the mother did not receive antenatal antibiotics during pregnancy. No prenatal complications were reported, and no fetal anomalies or abdominal findings were detected on antenatal ultrasound. Patient had an Apgar 8 at one minute and 9 at 5 minutes. No complications during labor and delivery were reported.This is a case of a term male born at 39 1/7 weeks of gestational age by spontaneous vaginal delivery to an 18-years-old mother GAt first day of life, the patient presented with hypoactivity, poor sucking, and cyanosis for which he was admitted to the Neonatal Intensive Care Unit due to suspected early onset of neonatal sepsis. Diagnostic studies were performed and therapeutic management was instituted, including antibiotic coverage. On day #2 of life, the patient presented with marked abdominal distention and marked bright red bloody stools. Oral feedings were discontinued, an orogastric tube was placed for gastrointestinal decompression, and metronidazole therapy was added to antibiotic therapy. The abdominal radiography revealed bowel dilation with no distal air. The clinical findings and presentation raised concern of bowel obstruction. On follow-up X-rays, a persistent radio opaque shadow in the lower abdomen raised the concern of urinary bladder obstruction. A Foley catheter was placed, obtaining 60 ml of urine. On day #4, an abdominal ultrasound was performed and revealed bilateral hydronephrosis, more prominent on the right side due to compression and a prominent parenchymal mass. A barium enema revealed a presacral soft tissue mass. On day #5 of life, an abdominopelvic computed tomography (CT) scan revealed a well-defined mass in the presacral space compressing the rectum and causing severe small and large bowel dilation. The mass was also causing compression of distal right ureter with severe hydroureteronephrosis and mild left hydroureter see . The CT The patient was taken to the operating room on day #7 of life. Through a combined intra-abdominal pfannenstiel and sacral midline approach, the intrapelvic tumor was removed completely along with the coccyx. Sacral segments four and five needed removal due to adherence of the tumor. Dissection was undertaken staying near the capsule of the tumor avoiding damage to the already stretched pelvic nerves. During dissection, tumor adherence to the sacral promontory at the level of S1 to S3 caused piecemeal removal. Postoperatively, the child could move both lower extremities well, had pinprick, sphincter muscle stimulation in the anus, and did not develop urinary retention.The tumor was received fixed in formalin and consisted of several fragments of gray tan soft tissue measuring in aggregate 8.1 × 6.5 × 1.1 cm. On section, the tumor was gray, tan, and soft with focal hemorrhages. A 1 cm segment of coccygeal bone was identified and was free of tumor. A microscopic examination disclosed a poorly differentiated neuroblastoma, with low mitotic karyorrhectic index. Few scattered ganglion cells were identified. The coccyx bone revealed no tumor involvement. Synaptophysin and chromogranin confirmed neuroblastoma. N-myc was not amplified.Congenital neuroblastoma is defined as a neuroblastoma identified within a month of birth . NeuroblPrenatal ultrasound and postnatal ultrasound are a useful screening modality in the evaluation of congenital neuroblastoma , but somIn infants less than one year of age, about 55% of the tumors are intra-abdominal and about 30% are in the chest as compared to 75% and only 15%, respectively, in older patients . This paThe initial diagnostic testing should include CT or MRI to evaluate primary tumor size and regional extent and to assess for distant spread to neck, thorax, abdomen, or pelvic sites. Brain imaging is recommended only if clinically indicated by examination or neurologic symptoms. Bilateral posterior-iliac crest marrow aspirates and core biopsies are required to exclude marrow involvement . Tumor mFew cases of sacrococcygeal neuroblastomas are reported in literature. Sunaa et al.  mentione


O angioleiomioma é uma neoplasia benigna que, a partir da nova classificação da OMS (2013) para os tumores de tecidos moles, deixou de ser considerado um tumor de origem muscular lisa, passando a ser considerado um tumor de origem perivascular. Raramente os angioleiomiomas ocorrem na cavidade oral. A lesão é tratada cirurgicamente, com prognóstico considerado favorável. Este trabalho revisa os casos de angioleiomioma oral relatados na literatura nos últimos 5 anos e descreve esse tumor em um homem de 44 anos que apresentou um nódulo assintomático localizado em lábio superior, com evolução de 6 meses. As hipóteses diagnósticas foram de adenoma pleomórfico e adenoma canalicular. A lesão foi submetida à biópsia e análise histopatológica e imuno-histoquímica  confirmaram o diagnóstico de angioleiomioma. Destacamos a imuno-histoquímica como um importante método auxiliar no diagnóstico diferencial do angioleiomioma com outras lesões e, principalmente, com o miopericitoma. Suas hiDe acordo com a OMS, os angioleiomiomas são tumores benignos dérmicos ou subcutâneos compostos de células musculares lisas bem diferenciadas que se organizam ao redor de diversas estruturas vasculares,,-Os angioleiomiomas podem ocorrer em qualquer área do corpo, porém a maioria dos casos acomete as extremidades, principalmente membros inferiores, seguidas por cabeça e tronco,,O angioleiomioma oral parece ser mais comum em pacientes do sexo masculino,Os achados clínicos do caso por nós relatado corroboram os previamente descritos na literatura. Os angioleiomiomas apresentam-se como nódulos submucosos de crescimento lento e assintomático, bem delimitados, móveis, ocasionalmente com coloração azulada, de superfície íntegra, medindo, geralmente, 2 cm de diâmetroO perfil imuno-histoquímico aqui apresentado confirma a origem muscular das células neoplásicas desse tumor, uma vez que foram notadas imunomarcações fortes e difusas para proteínas miogênicas, como α-SMA, H-caldesmon e desmina. O principal diagnóstico diferencial do angioleiomioma deve ser feito com o miopericitoma, uma vez que essas lesões apresentam achados histopatológicos sobrepostosO padrão de imunomarcação da proteína S100 também é útil para distinguir o diagnóstico do angioleiomioma de neoplasias como o neurofibroma e o neurilemoma, visto que, além do padrão morfológico dessas lesões, a falta de reação dessa proteína para as células tumorais no angioleiomioma é totalmente divergente com o que é encontrado em lesões de origem neural,A diferenciação histopatológica entre o angioleiomioma e o leiomiossarcoma de baixo grau pode ser difícil. Dentre outros parâmetros, os leiomiossarcomas podem ser identificados por apresentarem uma contagem de 5 a 10 mitoses por campo, núcleos celulares com terminação romba e focos de necrose. Assim, um cuidadoso acompanhamento dos pacientes a longo prazo deve ser realizado diante da dúvida do diagnóstico entre essas duas entidades,O tratamento de escolha para o angioleiomioma oral é a excisão cirúrgica conservadora. Raras recidivas foram descritas, provavelmente em decorrência da excisão cirúrgica incompleta da lesão. Não existem relatos de transformação maligna e o prognóstico dos pacientes é considerado excelenteSalienta-se a importância do conhecimento da reclassificação do angioleiomioma como tumor de origem perivascular, segundo a OMS ,Angioleiomyoma is a benign neoplasm that had been considered a tumor of smooth-muscle origin until the most recent 2013) World Health Organization (WHO) classification of soft tissue tumors, when it was reclassified as a tumor of perivascular origin.3 World H-,,Angioleiomyomas of the oral cavity are rare, the lips are most frequent site, followed by the palate, mucosa of the cheek, and tongue.,Clinically, oral angioleiomyoma is characterized as a submucosal nodule, with a firm consistency, slow growth and, in the majority of cases, a size of 2 cm in diameter or less.,,,Microscopically, it is a well-delimited lesion, with vascular spaces of different sizes and shapes and smooth muscle cells with varying morphology, arranged in disorganized bundles interspersed with collagen fibers.The aim of this study was to describe the clinical, morphological, and immunohistochemical findings of a case of oral angioleiomyoma and compare them with findings described in case reports published during the last 5 years in the specialized scientific literature, identified using the PubMed database.A male, 44-year-old, melanoderm patient sought care at an oral diagnosis service, presenting an asymptomatic increase in volume, with a lobulated surface, normochromic mucosal, fibrous consistency, located on the right side of the upper lip, and with duration of approximately 6 months . His medAccording to the WHO, angioleiomyomas are benign dermal or subcutaneous tumors made up of well-differentiated smooth muscle cells that organize around a variety of vascular structures.,,-Angioleiomyomas can arise on any part of the body, but in the majority of cases they occur in extremities, primarily the lower limbs, followed by the head and trunk.,,Oral angioleiomyoma is more common in male patients,,The clinical findings in our case corroborate those described in previous literature. Angioleiomyomas present as asymptomatic submucosal nodules with slow growth, that are well-defined, mobile, occasionally with a bluish color and intact surface, and generally measure 2 cm in diameter.The immunohistochemical profile described here confirms the muscular origin of the neoplastic cells in this tumor, since strong and diffuse immunostaining was observed for myogenic proteins, such as α-SMA, H-caldesmon, and desmin. The most important differential diagnosis for angioleiomyoma is myopericytoma, because these two types of lesion have overlapping histopathological findings.The profile of immunostaining for the S100 protein is also useful for differentiating a diagnosis of angioleiomyoma from neoplasms such as neurofibroma and neurilemmoma, since in addition to the morphological profile of these lesions, the fact that the tumor cells of angioleiomyomas fail to react to this protein is entirely divergent from what is observed with lesions of neural origin.,Histopathological differentiation between angioleiomyoma and low grade leiomyosarcoma may be difficult. Among other parameters, leiomyosarcomas can be identified by mitosis counts ranging from 5 to 10 per field, cell nuclei with blunt ends, and foci of necrosis. Therefore, careful long-term follow-up is necessary in view of the diagnostic uncertainty between these two entities.,The treatment of choice for oral angioleiomyoma is conservative surgical excision. Rare recurrence has been described, probably the result of incomplete surgical excision. There are no reports of malignant transformation and patients’ prognosis is considered excellent.Awareness of the WHO


Small bowel volvulus is a rare clinical entity which presents as recurrent intermittent abdominal pain after consumption of food. Although the entity is well described in the literature, diagnosis is often difficult due to its clinical presentation being similar to mesenteric ischemia. Herein we present the case of a 44-year-old male who presented to us with this condition. Small bowel volvulus (SBV) refers to the abnormal twisting of a loop of small bowel around the axis of its own mesentery . RecurreA 44-year-old male presented to the emergency with the chief complaints of recurrent postprandial epigastric pain for three days. On scrutiny of previous records, it was discovered that this was his third hospitalization for the same complaint. On all three occasions, the patient reported that his complaints were triggered after fasting for religious reasons. He had also undergone a gastroduodenoscopy three months back revealing gastric erosions for which he had been prescribed omeprazole. At the time of the admission, this was the only drug he had been taking. No history of previous abdominal surgery was noted. On examination, apart from tachycardia, other vitals were stable. The abdomen was distended but tenderness could not be elicited. On digital rectal examination, there was rectal ballooning without any soiling of the examining finger. All hematological investigations were within normal limits and an ultrasound of the abdomen was also normal. The abdominal radiograph showed multiple air fluid levels suggestive of intestinal obstruction. A computed tomography of the abdomen was also suggestive of subacute intestinal obstruction. The patient was started on intravenous fluids and a nasogastric tube was inserted. Twelve hours later, the patient underwent an exploratory laparotomy for worsening abdominal pain, signs of peritonitis and non-resolving small bowel obstruction. On opening the abdomen, the ileum had twisted along its mesenteric axis in the clockwise direction Figure .Mild distention of the stomach and proximal ileal loops was noted. The large bowel distal to the site of twisting was collapsed. No perforation or band was found. The volvulus was untwisted, and a line of rotation was seen. No fixation of the twisted segemnt was done. The bowel was slightly discoloured, but viable and started to return to its normal colour and shine Figure .  The patient was given 100% oxygen and the bowel was covered with warm moist sponges till the serosa returned to its normal color. Further examination revealed no other abnormalities like internal hernias or malrotation. The post-operative period was uneventful and the patient was discharged on the fourth postoperative day.In our patient, the diagnosis of small bowel volvulus was made in the operating room. Recurrent episode of pain and non-specific findings on computed tomography made the diagnosis even more difficult. Small bowel volvulus (SBV) is rare in western countries  but has the higher incidence in the Middle East, Asia and Africa  . ComplicA high index of suspicion is required to identify small bowel volvulus. Owing to its variable presentation and high mortality, all clinicians must consider SBV as a possible diagnosis in a patient with abdominal pain. Emergent computed tomography of the abdomen and early surgical intervention are key to avoid adverse outcomes.