Metastatic testicular cancers are rare. Primary tumor sources are prostate, lung, and gastrointestinal tract for metastatic testicular cancers. Metastasis of urothelial carcinoma (UC) to the testis is extremely rare. Two-thirds of upper tract urothelial carcinoma (UTUC) is of invasive stage at diagnosis and metastatic sites are the pelvic lymph nodes, liver, lung, and bone. We report a rare case of metastatic UTUC to the testis which has not been reported before, except one case in the literature. Testicular metastasis of UC should be considered in patients with hematuria and testicular swelling. Upper tract urothelial carcinomas (UTUC) are rare, with an incidence of 1–3/100,000 in western countries . UTUC coMetastases to the testis are rare, and such cancers are determined incidentally in orchiectomy or autopsy specimens . The mosβ human chorionic gonadotropin < 1.2 mIU/mL (N: 0–5). Ultrasonography (USG) was immediately performed to determine the presence of testicular cancer; both testes appeared normal except for a hydrocele in the left hemiscrotum , alpha fetoprotein of 2.52 ng/mL (N: 0–13.4), and iscrotum . We ideniscrotum . The radCystoscopy revealed a normal bladder and an obstructed left proximal ureter on retrograde pyelography (RGP). The contrast agent could not pass through mid-ureter to proximal segment at RGP. But we could not make differential diagnosis external compression or intraureteral mass for cause of hydronephrosis. Bladder and left ureteral cytology was benign. But we know that urine cytology has low sensitivity for UTUC even for high-grade lesions. After endoscopic investigation, we performed left radical orchiectomy and made a preliminary diagnosis of testicular cancer perioperatively. The pathological result of the left testis was a 3.8 cm malignant epithelial tumor metastasis in the paratesticular area. The tumor included multiple solid areas and lymphovascular, fat, and muscle tissue invasion. The pathology department identified the tumor as the UC metastasis to the left testis . MetastaIn two-thirds of cases, UC is of invasive grade at diagnosis , 3. The Cancer metastasis to the testis is very rare, and such cancers are identified incidentally in 2–4% of orchiectomy specimens .Swelling of the left testis and left para-aortic lymph node on CT is suggestive of testicular cancer. We performed cystoscopy and cytological examination of the bladder and separated the left ureter to exclude bladder UC and UTUC. The most important oversight in this case was the lack of ureterorenoscopy to exclude UTUC with potential testicular metastasis.Metastatic testicular tumors are observed only very rarely. Our case is the second case of testicular metastasis of UTUC reported in the literature. The most common pathway of tumor spread in UC is the lymphovascular system, and we hypothesize that malignant cells can metastasize through the lymphovascular system after lymph node invasion or through reverse blood flow in the left testicular vein, which can be caused by varicocele formation after renal or testicular vein invasion. Testicular metastasis of UC should be considered in patients with hematuria and testicular swelling.


Desmoid tumors are fibroblastic neoplasms that have an intermediate behavior with a highly aggressive infiltrative growth arising from deep muscle or aponeurosis. We present the case of a 34-year-old woman that developed a painless mass in the right popliteal fossa during pregnancy after intracytoplasmic sperm injection and hormonal therapy. The MRI scan showed a hyperintense mass of 6,7 cm × 4,7 cm × 3,8 cm surrounding the lateral head of the gastrocnemius muscle. The open biopsy was done one week after delivery, and the histology showed a desmoid tumor. We performed the resection one week later and found the common peroneal nerve completely surrounded by the tumor. The close resection due to the neurolysis was the reason why an adjuvant radiation with 56 Gy was done. The last clinical examination, 18 month later, did not show any signs of recurrence and an excellent functional outcome. This case demonstrates the possible influences of pregnancy and hormonal therapy on the evolution of desmoid tumors. The desmoid tumor is a fibroblastic one also called “deep” or “aggressive” fibromatosis that arises from deep muscle or aponeurosis. It is classified by the WHO as a fibroblastic tumor of intermediate  behavior with an infiltrative growth and a high tendency for local recurrence but no known metastasis , 2. It iIn this paper, we report the case of a desmoid tumor developing during pregnancy in the right popliteal fossa, compromising the bifurcation of the sciatic nerve.A 34-year-old woman, gravida 1, para 2, noticed a swelling and indolent mass at the back of the right lower leg and popliteal fossa during the 5th month of pregnancy. She had undergone five attempts of intracytoplasmic sperm injection (ICSI) and hormonal therapy previous to this pregnancy. The gestation had been without pathological findings to this point and the family history of the woman did not show any malignant tumors. The first medical consultation due to the swelling was in the 6th month at her general practitioner, who performed a sonography and advised an MRI scan. This was finally done at the 11th july 2012 which showed a hyperintense mass of 6,7 cm × 4,7 cm × 3,8 cm surrounding the lateral head of the gastrocnemius muscle. The X-ray of the knee was without any pathological findings.The first presentation in our clinic for musculoskeletal tumors was 7 weeks before the calculated delivery date. The clinical examination showed a firm mass at the lateral back of the right lower leg, 10 cm in length from the popliteal fossa to distal  at the 09th August 2012. The biopsy was done in a face-down position using a posterior approach to the knee. We found the communal peroneal nerve surrounded by the superficial portion of the desmoid tumor and it was mobilized to get a representative biopsy of 1 cm³. The nerve was marked with a vessel loop in preparation of the total excision that was scheduled for one week later. The histopathological findings proved the tumor to be a desmoid one and we performed the complete resection on the 16th of August 2012. The tumor was situated on the surface of the lateral head of the gastrocnemius muscle, infiltrating the top of the head of the fibula and the lateral parts of the dorsal capsule of the knee. The communal peroneal nerve was surrounded by tumor 6 cm in length and had to be dissected, even though the tibial nerve was displaced by the desmoid tumor  and the patient described no restrictions of walking. The MRI scan during the follow-ups did not show any signs of recurrence. The patient achieved a Knee Society Score of 95 points indicating an excellent postoperative function.This case shows that swelling or indurations of an extremity during pregnancy might be a sign for a tumor that need further diagnostics and treatment. The localization of desmoid tumors is generally classified as intra-abdominal in the abdominal wall or extra-abdominal. Even though pregnancy-associated desmoids typically occur in the abdominal wall, there are few cases of extra-abdominal growth during gestation . Our casAlthough the first description of a desmoid tumor goes back to MacFarlane in 1832 and Müller named the disease desmoid tumor in 1838, the exact pathology is not yet fully understood. The various etiological factors of desmoid fibromatosis, such as prior surgery, trauma, FAP, and Gardner's syndrome, have already been mentioned. In our case, however, the most likely effect seems to be due to sex hormones. It is generally accepted that women of reproductive age have an increased risk for the development of desmoid tumors especially during pregnancy , 5, 8, 9The first presentation of a patient with a new soft tissue mass should always lead to further diagnostics after completion of anamnesis and clinical examination. These include sonography and for tumors of a size above 5 cm or subfascial growth a MRI scan for accurate assessment. The two purposes are to get the diagnosis if already possible just by MRI firstly and secondly to determine the next steps in particular regarding surgical resection. X-ray or CT diagnostics are only required if the MRI shows a possible erosion of the bone and a resection and subsequent reconstruction might be necessary. In our patient, we found a very close anatomic relationship to important nerve structures, so that the biopsy was carried out as an open biopsy by us.In the treatment of desmoid tumors, new alternatives emerged especially in primary nonresectable locations in the last years. Some authors recommend, for clinically inconspicuous and stable desmoid tumors, regular check-ups and no specific treatment. However, due to the radiological not absolutely clear distinction to low-grade soft tissue sarcomas, we believe even these cases need histological confirmation of the diagnosis. Desmoid tumors with mass effects, neurological symptoms, or restricted movement range of a joint should be treated by surgical resection if possible, like in our case. Because of the high recurrence rates of 19–77%, adjuvant radiation therapy is a well-established option today and was used for our patient. The use of systemic therapies especially for nonresectable desmoid tumors has been increasing in the last years and includes cytotoxic agents, antiestrogen hormonal therapy , and imatinib , 10–12.Known prognostic factors for recurrence after surgical excision are an extra-abdominal localization, a size of more than 7 cm, and an age under 37 years [In conclusion, it must be emphasized that the desmoid tumor is a semimalignant soft tissue tumor which does not metastasize, but it unfortunately shows a very aggressive and infiltrative growth; therefore, it should not be underestimated. The standard treatment for symptomatic and growing desmoids is the surgical wide excision followed by adjuvant therapy. Particularly, in patients with a high risk of recurrence or relapse, the treatment with tamoxifen seems to be a promising option according to the recent studies.


Leiomyoma in the urethra is a rare occurrence. These are rare benign mesenchymal tumors that arise from the smooth muscle of the urethra. Such tumors often appear in females during their reproductive age (from menarche to menopause); the mean age of their appearance is approximately 41 years.We report here a case of a 52-year-old White woman who presented with complaints of sporadic hematuria, dyspareunia, and feeling of nodulation in her vagina.Histopathological studies confirmed the urethral leiomyoma, and the surgery completely resolved the original symptoms. Although the average age of occurrence of such tumors in females is about 41 years, the present case involves an older woman of 52 years. Most importantly, the mass was located in the distal urethra, an uncommon site of presentation of leiomyoma in females. Leiomyomas are benign tumors of the smooth muscles. Although the tumors tend to be relatively common in the genitourinary and gastrointestinal tracts, the occurrences are less frequent in the skin and rare in the deep tissues. In general, soft tissue leiomyomas cause little morbidity. Leiomyomas can be classified under three categories: (i) cutaneous leiomyoma (leiomyoma cutis), (ii) angiomyomas (vascular leiomyomas), and (iii) leiomyomas of deep soft tissue . UrethraHere we report a case of a distal urethral leiomyoma in a 52-year-old White woman who presented with complaints of sporadic hematuria, dyspareunia, and feeling of nodulation in her vagina. The diagnosis was confirmed on histopathology, and surgery completely resolved the original symptoms.A 52-year-old White woman presented with complaints of sporadic hematuria, dyspareunia, and feeling of nodulation in her vagina for the last 2 years. Her medical history revealed that she had two caesarean deliveries in the past, but she had no chronic disease.On physical examination, we detected a 2×2cm painless hard tumor without signs of inflammation at the level of the urethral meatus Figure . Her ureOn confirming the position, she was operated under spinal anesthesia. The tumor was resected with suburethral incision (U-shaped inverted). The urethra was calibrated with an 18-French Foley catheter, and an indwelling Foley’s catheter was kept inserted for 10 days. She was discharged from the hospital on the second day.Histopathological study of the tumor revealed spindle-shaped smooth muscle fibers in a whirling pattern Figure , confirmThe Foley catheter was removed on the 10th day. Her postoperative recovery was uneventful. She was symptom-free at the time of her last follow-up; complaints like fistula, dyspareunia, infection, and incontinence were not reported.From among all the leiomyoma cases reported to date, the most common site of occurrence has been in the genital tract (95%), while the remainder are scattered over various sites, including the skin (230 cases), gastrointestinal tract (67 cases), and bladder (five cases) . AlthougBenign neoplasms of the urethra may arise from any of its histological elements: transitional epithelium, stratified squamous epithelium, glandular epithelium, and smooth and striated muscle.Leiomyoma of the urethra is a rare benign mesenchymal tumor that affects women more often than men -4. It caDiagnosis of such tumors is primarily based on clinical history, physical examination, and imaging techniques. A careful clinical examination, urethroscopy, and radiological examination of the lower urinary tract are essential in order to distinguish the tumor from urethrocele, urethral diverticulum, and caruncle. Most importantly, the tumor must be differentiated from its malignant counterpart, the leiomyosarcoma, which shows marked pleomorphism, increased cellularity, and frequent mitoses. In females, the tumor leiomyoma originates from the genital tract, excluding the uterus. The final diagnosis should be made based on the histopathological report. The most appropriate treatment for this condition is local surgical excision or transurethral resection ,9. ThereIn the present case, the patient belonged to the 50- to 59-year-old age group. The tumor typically affects the bulbous part of the urethra (80% of cases); however, the distal segment can also be affected, as found to occur in the current case, an uncommon site for leiomyoma in females.After preoperative evaluation based on careful physical and histological examinations, leiomyomas are treated by excision, either by transurethral or open resection. In our case, the mass was located in the distal urethra, which is not the common site of presentation of leiomyoma in females. The tumor was successfully removed by resection with complete relief of her symptoms. Postoperative recovery was uneventful; subsequent complications, such as fistula, dyspareunia, infection, and incontinence were not reported.The present case of 52-year-old White woman with urethral leiomyoma is a rare case for two reasons. Firstly, the patient was older than the average age (41 years) of occurrences of such tumors. Secondly, the position of the tumor makes it a very interesting case; the mass was located in the distal urethra, an uncommon site of presentation of urethral leiomyoma in females. Her uneventful postoperative recovery without any complication suggests surgery is the best option to manage such tumors. Hence, we recommend resection of such tumors as the best possible management.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MML Jr was the major contributor in writing the manuscript, and performed the surgery. CBS analyzed and interpreted the patient data, and performed the surgery. JGT analyzed and interpreted the patient data. MML performed the surgery. FG analyzed and interpreted the patient data. All authors read and approved the final manuscript.


Background. Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) indicates a poor prognosis. Surgery is considered the only curative option for selected patients with HCC recurrence following LT. Traditionally, the preference is given to the open approach. Methods. In this report, we present two cases of laparoscopic resections (LR) for recurrent HCC after LT, performed at Oslo University Hospital, Rikshospitalet. Results. Both procedures were executed without intraoperative and postoperative adverse events. Whereas one of the patients had a recurrence one year after LR, the other patient did not have any sign of disease during 3-year follow-up. Conclusions. We argue that, in selected cases, patients with HCC recurrence following LT may benefit from LR due to its limited tissue trauma and timely start of subsequent treatment if curative resection cannot be obtained. In patients with relatively favorable prognosis, LR facilitates postoperative recovery course and avoids unnecessary laparotomy. Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer related death in the world with more than a half million new cases annually , 2.The key aspect in successful treatment of HCC is linked to proper preoperative staging. The most widely adopted staging system is the Barcelona Clinic Liver Cancer (BCLC) system, based on tumor stage, severity of liver disease, and performance status of the patients to different therapeutic alternatives. According to BCLC recommendations, the patients with early HCC are suitable candidates for radical treatment . Among these approaches, liver transplantation (LT) seems to be an attractive therapeutic option, particularly in patients with significant liver parenchymal disease (Child-Pugh B and C), as it has the potential to cure both the tumor and underlying liver disease .However LT is often limited to early stages of disease in order to ensure outcomes that are comparable to those of liver transplantation for noncancer related indications. Selection criteria, such as Milan (a single tumor ≤ 5 cm or ≤ 3 tumors ≤ 3 cm without signs of macrovascular invasion), UCSF , and up-to-seven (the sum of the number of nodules and of the diameter of the largest tumor (in cm) not exceeding seven, in absence of macrovascular invasion and extrahepatic spread), have been introduced up to date [At the same time, recurrence of HCC after LT still occurs and is to a large extent related to tumor stage. Relapse after transplantation is usually associated with poor prognosis, since in most cases it must be considered as a sign of systemic disease. Extrahepatic lesions, present in majority of these patients, are not amenable to curative treatment, thereby being considered for palliative therapy only. However, the efficacy of the latter remains unsatisfactory . SeveralToday, laparoscopic surgery is comparable to open technique for primary resection in a large fraction of patients with HCC . HoweverHospital records review revealed that 89 patients with HCC on final pathology underwent LT at Oslo University Hospital, Rikshospitalet, from 2004 to 2014. Eighteen of these patients (20.2%) had recurrence during follow-up. Of these, two with locoregional isolated recurrences and performance status of 0 according to Eastern Cooperative Oncology Group (ECOG) scale were considered eligible for curative resection. Laparoscopic approach was applied.A 62-year-old male underwent LT for multifocal HCC, combined with hepatitis C related cirrhosis. According to preoperative CT scan images, a massive lesion with greatest extent over 8 cm was found in the right lobe and 2-3 small lesions were found in segment 2. AFP level was elevated at 278 ng/mL. Histological examination of the explanted liver revealed disseminated HCC with numerous nodules in all segments and widespread vessel infiltration. In the posttransplant period the patient received immunosuppressive therapy with tacrolimus, prednisolone, and mycophenolate mofetil (MMF).Nine months after LT a routine CT scan revealed an extrahepatic, 2 cm lesion adjacent to segment 6 . UltrasoPneumoperitoneum was established through an open approach via right pararectal region, supplemented by three trocars: a 12 mm through the scar from previous incision and two 5 mm in the right flank. After complete mobilization of the right lobe, the tumor was found retroperitoneally between the right kidney and adrenal gland. Intraoperative ultrasound was carried out to determine the borders of the tumor. Despite close relation with renal capsule, no signs of infiltration to the kidney were revealed. Division of Gerota's fascia and exposing the upper part of the kidney allowed mobilization of the tumor laterally and cranially, separating it from the renal capsule. No evidence of infiltration to adjacent structures was found and the tumor was removed. No significant bleeding occurred during the surgery and the operation time was 131 min.Histological findings confirmed the presence of two (40 mm and 12 mm) extrahepatic recurrences from HCC. The postoperative course was uneventful.Surveillance for the first 8 months revealed no signs of disease recurrence, but one year after the reresection, metastases in liver, lungs, and adrenal gland were detected. Subsequent therapy with sorafenib was considered as the only possible active treatment.HCC was diagnosed in a 57-year-old male with hepatitis C and cirrhosis. A 3 cm tumor, located in segment 5, and two small hypervascular lesions, suggestive of HCC, were discovered by CT scan. The AFP level was significantly elevated (>20.000).The patient was assessed and accepted as a liver recipient and LT was performed. The postoperative course was uneventful and the patient received immunosuppression with tacrolimus, prednisolone, and MMF.An abdominal CT scan, 6 years after LT, detected two intrahepatic lesions. The larger one, measuring 2.7 cm, was located laterally in segment 6, close to the right kidney . The secThe laparoscopic approach was chosen for reresection. Pneumoperitoneum was obtained through an open access technique via umbilicus. Adhesiolysis was carried out. Afterwards, one 12 mm trocar was placed high in the midline, followed by two 5 mm trocars in the right pararectal area and more laterally. Mobilizing the right lobe of the liver, the lateral tumor was found to infiltrate into Gerota's fascia. Using LigaSure  device, the tumor was completely mobilized and separated from the fascia. Finally, both of the tumors were removed by wedge resection of the liver. Operative time was 127 min with only minor intraoperative blood loss observed.A pathological examination revealed 32 mm and 18 mm measuring moderately differentiated HCC with trabecular pattern. The postoperative course was uneventful. During further surveillance for more than 3 years, no signs of disease recurrence have been observed.P = 0.005 and 85.3% versus 22.7%; P < 0.001, resp.); hence it should be considered in patients with liver disease and cirrhosis within the various transplantation criteria [LT is associated with significantly higher 5-year overall and disease-free survival rates, compared to LR . On the other hand, the occurrence of so-called “de novo” cancer cannot be excluded in Case 2, considering the fact that the lesions developed 6 years after LT.In the light of the limited role of medical therapy in palliative treatment of recurrent HCC, patients with poor prognosis and limited survival prospects can benefit from laparoscopy due to shortened recovery period. In case of indications for subsequent therapy, laparoscopy may avoid potential delay in treatment, caused by open surgery. Conversely, the patients with favorable prognosis may also benefit from the fast recovery course, provided by laparoscopy. Extensive experience in the field of laparoscopic surgery coupled with the evaluation of therapeutic options will establish the new surgical guidelines in treatment of resectable recurrent HCC after LT.


Epithelioid angiosarcoma is a rare high-grade tumor with irregular vascular morphology. We report an unusual case of intra-abdominal epithelioid angiosarcoma affecting the omentum and peritoneal surfaces resulting in significant hemorrhagic and inflammatory changes. As in other cases of this tumor this patient had previously undergone radiation treatment for a history of cervical cancer. Epithelioid angiosarcoma is an uncommon tumor that can present in a variety of locations and occurs with higher frequency in patients who have had exposure to ionizing radiation. The following is a case of a patient who developed epithelioid angiosarcoma in the omentum after radiation treatment for cervical cancer.A 77-year-old woman with a history of cervical cancer and radiation treatment presented with fecal incontinence as well as abdominal distension and discomfort after eating. She appeared thin with a softly distended abdomen but physical exam was otherwise unremarkable. Her past medical history also included hypertension, irritable bowel syndrome, left inguinal hernia repair, and a gastric ulcer. A colonoscopy revealed rectal stricture. CAT scan  noted a The patient was taken to the operating room and a midline laparotomy incision was made. Upon entering the abdomen, two liters of ascitic fluid was identified. The small and large intestine were found to have diffuse hemorrhagic inflammatory changes as well as a bleeding and friable omentum. Omentectomy was performed and upon sending a frozen section, the patient was thought to have a high-grade adenocarcinoma. An ileostomy was then created to divert away from the strictured rectum. The patient had a postoperative course complicated by an ileus, aspiration pneumonia, and subsequent respiratory insufficiency, with ultimate referral to Palliative Care.Pathologic analysis  of the oEpithelioid angiosarcoma is a very rare, highly vascular tumor with few published reports in the literature. These sarcomas arise from a wide variety of anatomic locations with most reported cases occurring in the axial skeleton and in soft tissues –3. They Typically, epithelioid angiosarcomas have characteristic pathologic features such as irregular vascular channels with adjacent atypical pleomorphic epithelioid cells . These tIntra-abdominal epithelioid angiosarcomas are an extremely uncommon entity. One case series by Allison et al. examined the presentation and outcomes of patients with angiosarcomas of the gastrointestinal (GI) tract. These patients, in majority, presented with hematochezia or melena and anemia. They underwent tumor resection and were found to have high-grade or metastatic angiosarcoma. Only one patient's tumor could be completely resected and after receiving chemotherapy and radiation, the patient survived for 27 months. All others continued to have GI bleeding from metastatic implants and eventually expired from their disease .Other intra-abdominal cases of this highly malignant sarcoma have been reported in patients who have received prior radiation. A case of small intestinal epithelioid angiosarcoma was identified in a patient with a history of thirty years of occupational exposure to radiation and polyvinyl chloride and developed gastrointestinal bleeding . This paFactors additionally noted to influence the development of angiosarcomas include toxic chemical exposure, Thorotrast contrast media, Dacron vascular grafts, arteriovenous fistulae, and chronic lymphedema . HepaticIntraperitoneal epithelioid angiosarcoma is a rare entity. It often presents with severe bleeding secondary to diffuse spread and friability of nodules. Radiation exposure significantly increases the likelihood of development of this sarcoma. The majority of these tumors are diagnosed late and have a poor prognosis as most patients have metastatic disease or diffuse peritoneal implants at the time of discovery.


A 62-year-old female with neurofibromatosis type 1  was diagnosed with a giant, thick-walled tubular mass, mainly located in the right abdominal area on computed tomography, following an examination for intermittent abdominal pain and increasing abdominal distension. According to the clinical manifestations and imaging features, the giant tubular mass was considered most likely to be a dilated fallopian tube associated with infection, while the possibility of obstructed bowel loops was excluded. However, the subsequent laparotomy revealed a giant appendix, caused by a large neurofibroma in the root region of the appendix, which occluded the lumen. Neurofibroma of the appendix is extremely rare, even in patients with NF1. To the best of our knowledge, only three such cases have previously been reported in the English literature to date. Neurofibromatosis type 1 (NF1), also known as von Recklinghausen’s disease, is an autosomal dominant hereditary tumor syndrome, with an incidence at birth of one in 3,000 individuals, independent of ethnicity and gender , which rGastrointestinal tract involvement is observed in 10–25% of patients with NF1, but only 5% are symptomatic , usuallyA 62-year-old female with NF1 presented to The First Affiliated Hospital with intermittent lower abdominal pain, increasing abdominal distension, pelvic heaviness and tenesmus for more than one month. The patient had no history of fever, nausea or vomiting. Despite the NF1, which affected the skin, no other medical history was known, and the patient took no medication. A physical examination revealed multiple neurofibromas and café-au-lait spots on the skin , and a dAs the clinical manifestations and imaging features did not support the diagnosis of an ileus, the giant tubular mass was considered to have originated from the fallopian tube. However, the subsequent exploratory laparotomy showed that the bilateral fallopian tubes were normal. A giant, tubular, twisted mass (38×10 cm), with varicose veins on the surface, was found in the abdominopelvic cavity . A severNF is an autosomal dominant disease with two distinct forms, NF1 and NF2. NF1, which affects 85% of patients, has complete penetrance. Due to the high susceptibility of the NF-1 gene to mutation, there can be a large variation in the clinical manifestations, even within a family. Clinically, ~50% of NF1 patients have no family history of the disorder , the present literature review found that only three such cases have been reported previously (Appendiceal neurofibromatosis is an extremely rare clinical entity. By reviewing the English language literature in PubMed (eviously ,9,10. Ineviously .Pathologically, the typical features of NF1 consist of a mixture of spindle cells, with wavy nuclei and strands of collagen, as well as Schwann cells, perineural fibroblasts, endothelial cells and mast cells. In addition, positivity for S100 is indicative of a neurofibroma . Due to Although NF1 is a type of benign tumor, it also carries a certain degree of risk for malignant transformation, particularly in individuals >40 years old. Pain or rapid enlargement of a lesion should arouse suspicion of sarcomatous change . HoweverIn conclusion, NF1 is a rare multisystem genetic disease, which is characterized by the growth of noncancerous tumors, termed neurofibromas and café-au-lait spots, on the skin. However, the involvement of the appendix is extremely rare. To the best of our knowledge, only three cases of neurofibroma associated with the appendix have been reported previously in the English literature. A large neurofibroma of the appendix may result in numerous complications and may exhibit the potential for malignant transformation. Therefore, timely detection and surgical removal are extremely important. The present case indicates that appendix localization must be considered in NF1 patients.


Background: Intraoperative ultrasonography has proven to be a useful tool for tumor identification during robot-assisted laparoscopic partial nephrectomy (RALPN). However, its utility is limited in renal tumors that are completely endophytic and isoechoic in nature. We present a novel approach to intraoperative tumor identification using preoperative percutaneous intratumoral embolization coil placement that may be utilized in the management of such cases.Case Presentation: A 42-year-old Caucasian male was referred with an incidentally discovered right renal mass that was posterior and completely endophytic. He desired a RALPN; however, preoperative renal ultrasound demonstrated an isoechoic lesion. Thus, the patient underwent preoperative image-guided placement of an embolization coil within the tumor. This facilitated identification of the tumor intraoperatively using intracorporeal ultrasound centered on the coil and enabled resection with negative margins.Conclusion: Utilizing a novel approach analogous to preoperative localization of other solid malignancies, such as breast cancer, we were able to effectively identify and resect an isoechoic renal mass during RALPN. Herein we present a novel approach in which preoperative image-guided placement of an embolization coil within an isoechoic tumor was utilized to facilitate identification and subsequent resection with negative margins.TA 42-year-old male patient was referred with an incidentally discovered right renal mass. He originally presented with acute epigastric pain and was found to have acute pancreatitis on CT. The scan also demonstrated a 2.6 cm heterogeneously enhancing right renal mass concerning for neoplasm. The mass was entirely endophytic, located along the medial aspect of the upper pole . After rThe morning of surgery, he underwent coil placement by IR; a 2 × 5 mm platinum embolization coil was percutaneously deployed under CT guidance into the center of the tumor through a 22-gauge ×20-cm Chiba needle . A secon2 and he desired extirpative surgery for a more definitive oncologic result. While he accepted the possibility of requiring open surgery, he was young and active and desired a minimally invasive approach if possible.This case presented unique management challenges for partial nephrectomy in a patient with a central, endophytic, and isoechoic renal mass who strongly desired a robot-assisted laparoscopic approach. The central and deep position made ablation more problematic based on risk of injury to central structures,3 although an analogous technique has not been reported for resection of renal masses based on a detailed literature search. We believe this approach may be useful for similar masses in the future, although challenges include the need for an experienced IR team that can place a coil with a three-dimensional understanding of the tumor, as well as the need for two anesthesia settings, although the latter may not be required depending on hospital logistics. Ultimately, it was the intratumoral coil that enabled detection and resection of the tumor; the capsular coil likely dislodged during dissection within the perirenal fat. Given the limited working space of the retroperitoneum and the need for retroperitoneal dissection, a larger coil or wire was not practical; however, further investigation of capsular identifiers of endophytic tumors would be potentially useful.The particular challenge of this case was the tumor's isoechoic appearance and totally endophytic position. As mentioned earlier, the utility of intraoperative ultrasonography is limited with isoechoic tumors and renders these cases more challenging. We undertook a novel approach of preoperative CT-guided coil placement to enable intraoperative identification of the tumor. The platinum coil exhibited a characteristic hyperechoic appearance on ultrasound, aiding in identification of the otherwise isoechoic tumor. This allowed for a confident robotic resection with negative surgical margins. Our approach is analogous to localization techniques commonly used in surgical therapy of nonpalpable breast cancer,We present a novel approach in the management of a patient with an endophytic and isoechoic renal tumor who desired RALPN. The utilization of preoperative image-guided embolization coil placement within the tumor enabled identification and confident surgical resection of this patient's mass. This approach may be useful for similar cases in the future.


Sir,We would like to present an idiopathic sigmoid colon perforation revealed with a rare manifestation of pneumoscrotum. A forty two days old boy was referred to us because of agitation, progressive abdominal distention and swollen scrotum . There w On physical examination, the infant had tachycardia and tachypnea. His abdomen had distention but was soft and lax, and his scrotum had swelling with red skin that led us into a consideration of strangulated inguinal hernia. Portable CXR was normal but plain abdominal x-ray three hours later revealed bowel distention, specially in the distal colon, with free intra-peritoneal gas (Rigler's sign). A small An urgent ultrasound of the scrotum revealed only reverberation artefact, consistent with gas. Both testes were normal. An exploratory laparotomy was done through midline incision. The peritoneum was grossly contaminated and there was perforation of the descending and sigmoid colon on the antimesenteric side . Rest of the large and small bowel was normal and there were not any vesiculation or ulceration and the mucosal surfaces were intact. The mucosal biopsy specimen from the edge of perforation had a normal appearance under light microscopy, and there were not any characteristic CMV inclusions or HSV cytopathic changes. However, we had not immunohistochemistry, FISH, and PCR in our center to detect latent infection. Also multiple distal biopsies revealed normal ganglion cells and Hirschprung's disease was excluded. The incidence of spontaneous colonic perforation is extremely rare. As in one study, it was reported only ten cases, seven of ten in very-low-birth-weight (VLBW) infants and three of ten in term or near-term neonates (one with Hirschsprung disease and the two cases without clear etiology during 10 years (2000-2009), there are few reported pneumoscrotum due to procedural or pathologic processes[4]. We think that our patient was the first case which reported spontaneous colonic perforation with unknown etiology, which presented with pneumoscrotum during the last decades. Since 1912 (the first reported case) [5]. Endoscopic (upper and lower) and laparoscopic procedures were the second and third most common causes, respectively Therefore, as mentioned above, the finding of gas in the scrotal sac may be an early sign of a life-threatening condition like visceral perforation or may represent an incidental finding associated with more benign conditions like laparoscopic procedures.[9], this case presentation reminds us that eventhough pneumoscrotum is a benign, rare condition, its mere presence should signal the possibility of a severe, life-threatening disease process within the peritoneum like bowel perforation or retroperitoneum like pancreatic or renal abscess.  In conclusion, although a combination of free abdominal gas and distended abdomen usually make the diagnosis evident and surgical intervention should be the rule


Background. The diagnosis of intestinal malrotation is established by the age of 1 year in most cases, and the condition is seldom seen in adults. In this paper, a patient with small intestinal malrotation-type intraperitoneal hernia who underwent surgery at an older age because of intestinal obstruction is presented. Case. A 73-year-old patient who presented with acute intestinal obstruction underwent surgery as treatment. Distended jejunum and ileum loops surrounded by a peritoneal sac and located between the stomach and transverse colon were determined. The terminal ileum had entered into the transverse mesocolon from the right lower part, resulting in kinking and subsequent segmentary obstruction. The obstruction was relieved, and the small intestines were placed into their normal position in the abdominal cavity. Conclusion. Small intestinal malrotations are rare causes of intestinal obstructions in adults. The appropriate treatment in these patients is placement of the intestines in their normal positions. Intestinal malrotation is a congenital disorder caused by rotation of the intestines during foetal development. Embryological development and anatomical variations were described in 1923 by Dott , 5. InteμL , and the blood glucose level was determined to be 150 mg/dL. Other biochemical tests were within normal limits. Air-fluid levels localised in the upper left quadrant were determined by abdominal X-ray. Ultrasonography could not be performed because of dense intestinal gas. On abdominal tomography, small intestinal segments were observed to be dilated in the left quadrant and distal part of ileum; colon segments were collapsed . Intestinal rotation is completed within 4–12 weeks of intrauterine life. The rapid prolongation of the intestine and physiologic herniation into the umbilical cord occurs in the fifth week, a 270° anticlockwise rotation along the SMA axis and the return of herniation back into the abdominal cavity occur in the 10th week, and the location of the caecum in the right lower quadrant are completed in the 12th week . The varThe symptoms in newborn infants are intestinal obstruction findings, such as bilious vomiting . MalrotaInfants and children are diagnosed largely through upper gastrointestinal contrast studies . Adults Intestinal malrotation is not only a newborn disease. Surgeons may encounter malrotations that, in rare cases, can lead to obstruction in adults. In these cases, treating the obstruction and placing the intestines as close as possible to their normal anatomical position may be an appropriate surgical approach.


The authors report a case of an 11-year-old boy that presented with headache and vomiting that was present for several months. CT and MR imaging revealed a large prepontine mass and an obstructive hydrocephalus. A ventriculoperitoneal shunt was inserted, and in a second operation, a radiologically proven total resection was performed, using a left frontotemporal transsylvian approach. The tumour showed no involvement of the dura or clivus. Histological examination showed the characteristics of a chordoma. No further adjuvant treatment was given. The patient remained disease or tumour free after a 6-year follow-up.Intradural chordomas are extremely rare tumours that originate from notochordal remnants. Only three other cases have been reported in the paediatric population. Ecchordosis physaliphora (EP) is an ectopic notochordal remnant that has a similar biological behaviour and is difficult to distinguish from intradural chordomas. They might exist in a continuum from benign notochordal tumour to malignant chordoma. A surgical resection without adjuvant radiation therapy is suggested to be the treatment of choice in the paediatric population.The authors describe a rare case of an intradural prepontine chordoma in an 11-year-old boy that stayed disease free after a 6-year follow-up. Chordomas are rare, slow-growing tumours accounting for 1–4 % of all primary malignant bone tumours . They usAn 11-year-old boy presented with a history of headaches and vomiting that had been present for several months. Physical examination showed papilledema without the presence of any other neurological deficits. Magnetic resonance imaging (MRI) revealed a large prepontine mass with dorsal displacement of the brainstem and a secondary obstructive hydrocephalus due to compression of the aqueduct. The lesion had an inhomogeneous hypointense aspect on the T1-weighted image (T1WI) and an inhomogeneous hyperintense aspect on the T2-weighted image (T2WI). After administration of IV gadolinium, there was some inhomogeneous enhancement  are ectopic notochordal remnants that are usually asymptomatic. An incidence of 1.5–2 % in autopsy studies and approximately 1.7 % in MRI studies has been found , 17, 19.Treatment of a classic chordoma involves extensive surgery, sometimes combined with adjuvant radiation therapy . There iAlthough extremely rare, an intradural chordoma should be considered in the differential diagnosis of intradural prepontine lesions. The authors postulate that a complete surgical resection without adjuvant radiation therapy is the treatment of choice and that adjuvant radiation therapy should be avoided in the paediatric population. Additional studies are required to improve our knowledge about intradural chordomas and their treatment.


To review the epidemiological and clinical features of primary fallopian tube carcinoma (PFTC), and to illustrate the spectrum of MRI findings, with pathological confirmation.This article reviews the relevant literature on the epidemiological, clinical, and imaging features of primary fallopian tube carcinoma, with pathological confirmation, using illustrations from the authors’ teaching files.Primary fallopian tube carcinoma came under focus over the last few years due to its possible role on the pathogenesis of high-grade serous epithelial ovarian and peritoneal cancers. Typical symptoms, together with the presence of some of the most characteristic MRI signs, such as a “sausage-shaped” pelvic mass, hydrosalpinx, and hydrometra, may signal the presence of primary fallopian cancer, and allow the radiologist to report it as a differential diagnosis.Primary fallopian tube carcinoma has a constellation of clinical symptoms and magnetic resonance imaging features, which may be diagnostic. Although these findings are not present together in the majority of cases, radiologists who are aware of them may include the diagnosis of primary fallopian tube cancer in their report more frequently and with more confidence.PFTC may be more frequent than previously thought• PFTC has specific clinical and MRI characteristics• Knowledge of typical PFTC signs enables its inclusion in the differential diagnosis• PFTC is currently staged under the 2013 FIGO system• PFTC is staged collectively with ovarian and peritoneal neoplasms•  Primary fallopian tube carcinoma (PFTC) has been described as one of the rarest malignancies of the female genital tract, accounting for around 1 % of all gynaecologic malignancies, occurring predominantly in post-menopausal women at a mean age of 55 years .PFTC has come under focus in recent years, particularly in pathology and oncology scientific literature, given the likely role on the pathogenesis of ovarian cancer. This may have led to underestimate the true incidence of PFTC as ovarian cancer in the past, with significant clinical impact on the management of these patients , 8–12. SPFTC is usually not suspected pre-operatively or even intra-operatively due to its nonspecific clinical and surgical presentation, particularly when disseminated , 20–22. The purpose of this study is to review the epidemiological and clinical features of PFTC, and to illustrate the spectrum of MRI findings, with pathological correlation.PFTC is considered a rare and aggressive type of tumour, representing 0.14–1.8 % of the total gynaecological malignancies , 28. TheThe aetiology of this type of tumour has not been completely explained. Hormonal, reproductive, and genetic factors may play a role, along with the presence of chronic inflammation of the pelvis .Hydrops tubae profluens is a syndrome characterized by the relief of pain and shrinkage of the abdominal or pelvic mass by a vaginal discharge, which is caused by filling and emptying of a sub-occluded fallopian tube (seen in only 5 % of patients). Typical symptoms, however, occur in only a minority of patients with PFTC, and most women present with less specific symptoms at the time of diagnosis [PFTC may have a constellation of characteristic symptoms, namely colicky abdominal or pelvic pain and adnexal mass, relieved by intermittent, profuse, serosanguineous vaginal discharge, which constitute Laztko’s triad (seen in only 15 % of patients). iagnosis , 30–33. iagnosis . The preiagnosis .PFTC should be considered in the differential diagnosis of patients with postmenopausal bleeding with negative diagnostic curettage, cervical smear with intermittent suspicious abnormalities, and unexplained persistent vaginal discharge , 30.Pathology remains the mainstay for diagnosis of PFTC. Serous carcinoma of the fallopian tube is the most common histological type of tubal carcinoma. It is an invasive tumour growing in papillary, glandular, and solid patterns with high grade nuclear atypia. These tumours are identical to their ovarian counterparts.The second most common type of tumour is the endometrioid carcinoma, followed by undifferentiated, clear cell, mucinous, and transitional carcinomas .PFTC is graded according to its differentiation and extent of solid components, with most tumours being poorly differentiated , 36.Initial diagnostic criteria for the diagnosis of PFTC were proposed by Hu et al. in 1950 . These wDissemination of PFTC occurs through the transcoelomic route with implantation of cells throughout the abdominal cavity, similarly to ovarian cancer, and also through continuity to adjacent organs, transluminal migration, haematogenous, and lymphatic spread. Distant metastases are more common in PFTC than ovarian cancer , 36, 41,The currently accepted staging system for PFTC was developed by the International Federation of Gynecology and Obstetrics (FIGO), and currently PFTC, ovarian, and peritoneal cancers are staged collectively within the same system, although occasionally it may be impossible to attribute the tumour to a primary site . Table 1Current management of PFTC follows the same guidelines as ovarian cancer in terms of surgical staging, debulking, and adjuvant chemotherapy . The maiRoutine pelvic and para-aortic lymphadenectomy is considered to be essential by some authors due to the strong likelihood of lymphatic spread. However, this issue remains controversial, and others believe that retroperitoneal node sampling and dissection suffices , 45.Postoperatively, chemotherapy plays an important role in the management of early-stage PFTC, usually with platinum-based combination chemotherapy. The efficacy of current chemotherapy regimens has led to the abandonment of radiotherapy as a treatment option for PFTC due to its poor results and serious complications , 28.Hormonal therapies may be of value in the future, given the sensitivity and response of the fallopian tube epithelium to hormonal fluctuations, although there are no current recommendations , 28, 45.The main prognostic factors identified for increased survival include stage, age, and residual tumour after surgery, serous subtype, and elevated pre-treatment CA-125 , 36. TheSerous PFTC in advanced stage may have a better survival than its ovarian or peritoneal counterparts , 46. EarRecurrent disease, which occurs on average 2 to 3 years after initial treatment, is associated with a dismal prognosis due to the lack of alternative treatments available .Imaging diagnosis of PFTC is important because it can help planning adequate initial surgery and avoid second-look laparotomy. Imaging findings of PFTC are usually nonspecific, and a tubo-ovarian abscess or ovarian tumour may appear to be the most likely diagnosis given their higher prevalence .Similarly to other gynaecologic tumours, the imaging approach includes ultrasound as the initial modality, followed by MRI for undetermined or suspicious adnexal masses and computed tomography (CT) or MRI for complete staging. CT is only used for staging purposes and not for pelvic mass characterization due to low soft-tissue contrast in comparison to MRI , 48.On greyscale ultrasound, PFTC may be suspected in the presence of a tubular-shaped mass (or sausage-shaped) or a lobular mass with a cogwheel pattern . On DoppMRI is the modality of choice for evaluating an undetermined pelvic mass on ultrasound and also to evaluate the local burden of tumour , 53. RecThe normal fallopian tubes are usually not visualized on pelvic MRI. In the presence of intraperitoneal fluid, they may be seen as paired thin structures, extending from the ovaries to the uterine cornua, in the superior edge of the broad ligament . They exThe tubular nature of these paired organs is seen behind the sausage-shaped appearance when they are filled with solid tumour Fig. . This isHydrosalpinx forms in PFTC both due to the copious amounts of fluid produced by the tumour and to the partial obstruction of the tubes. This leads to tubular distention and can be easily observed in T2WI sequences. Frequently, one of the ends of the tube is patent, leading to decompression of the tubal obstruction with discharge and consequent shrinkage of the pelvic mass, resulting in a temporary resolution of symptoms, as described in the clinical presentation. This variability of size and shape of the mass can be seen in serial imaging. MRI can easily detect the presence of hydrosalpinx, which usually appears as a cystic, tubular-shaped, convoluted mass, with well-defined walls. The dilated tubes contain incomplete plicae or folds, producing its convoluted appearance, either seen as the “waist sign” Fig.  and 4a, PFTC can be suspected on MRI when specific fallopian-tube related signs are present. However, the likelihood to present when already spread to the ovaries or peritoneum makes this diagnosis challenging, even for the experienced radiologist.PFTC has a variety of MRI findings, which make it difficult to suspect its origin based solely on imaging. However, radiologists can be more suspicious in the presence of features related to fallopian tube disease, such as a relatively small, tubular-shaped (or sausage-shaped) mass, with homogenous signal, low signal intensity on T1WI, high signal intensity on T2WI, with mild to moderate enhancement, and associated hydrosalpinx or intrauterine fluid.Singh’s  proposal


To the Editor:Here, we report the case of a 37-year-old asymptomatic male patient who was referred because of abnormalities seen on a routine chest X-ray. The physical examination findings and laboratory test results were normal. A new chest X-ray revealed a large opacity in the left lower hemithorax. Chest CT revealed a heterogeneous pleural mass in the left lower hemithorax . The mas(-) The distribution of this tumor follows the sites of persistence of brown fat. The most common sites are the thigh, shoulder, back, neck, thorax, upper extremity, abdomen, and retroperitoneum. Intrathoracic locations include the mediastinum and the pericardium. Tumors involving the pleura are extremely uncommon. In most cases, a hibernoma manifests as a painless mass and is an incidental finding on physical examination or imaging. Although these tumors are always benign, they tend to grow to large sizes and symptoms can arise from the compression of adjacent structures. In individuals with a hibernoma, significant weight loss has been described and is attributed to excessive thermogenesis of the tumor tissue responsible for the catabolism of circulating lipids and carbohydrates into thermal energy. Complete surgical excision is the treatment of choice, and the postoperative prognosis is excellent. There have been no reports of recurrence or metastatic disease in hibernoma patients. The gross specimen typically shows a well-encapsulated, firm, tan or brown tumor. Microscopy reveals univacuolated or multivacuolated fat cells with small, central nucleoli.Hibernomas are rare benign tumors that take their name from their histological similarity to the brown fat of hibernating animals, but also seen in the human fetus and to a diminishing degree with age in adults.-3 The energy. Completatients.,2 Theucleoli.On CT scans, a hibernoma usually presents as a heterogenous low-attenuation mass (with regions of fat and soft tissue attenuation); on T1- and T2-weighted magnetic resonance imaging, it is seen as a hyperintense, heterogeneous mass. In imaging studies, the main differential diagnoses are lipoma and liposarcoma. Because of the similarity of their fat content, hibernomas and lipomas have comparable signal characteristics on magnetic resonance imaging and CT scans. Although hibernomas are more heterogeneous due to their different composition, in terms of their fibrous and vascular elements, histopathological analysis is always necessary in order to make an accurate diagnosis.


Primary dural lymphoma is a subentity of primary leptomeningeal lymphoma which represents 0.1% of all non-Hodgkin’s lymphomas. Only five cases have been reported so far. We report a very rare case of primary dural-based lymphoma in a 14 year-old boy presenting with mass effect. The patient was managed with excision of the lesion and removal of the involved bone. Post-operatively, the patient showed good recovery. He was then referred to the oncology unit for further chemo- and radiation therapy. A high index of suspicion should therefore be kept in order to diagnose the condition in a timely fashion and then plan for appropriate management since diffuse large cell lymphoma has a relatively benign clinical prognosis. The symptoms are nonspecific. The main differential diagnosis of the condition remains meningioma2. Currently there is no standard treatment due to a paucity of cases3. A high index of suspicion should be kept in order to diagnose the condition in a timely fashion and then plan for appropriate management since diffuse large cell lymphoma has a relatively benign clinical prognosis4. Here we report a case of a primary dural based DLBCL in a 14 year-old boy presenting with herniation syndrome, who improved after surgical excision and is currently on chemotherapy.Primary dural diffuse large B-cell lymphoma (DLBCL) is an extremely rare entity with only five cases reported so farA 14 year-old Tharu boy, from Siraha  presented to our emergency department with a sudden onset altered sensorium which lasted for 1 day. The patient had a history of intermittent headaches and vomiting over the last 3 months. The patient’s parents also noticed significant weight loss and the presence of scalp swelling for the last 2 months. There was no remarkable family history. Previous treatment history revealed that the patient had been taken to India 1 month back, where fine needle aspiration cytology (FNAC) of the scalp lesion in the parietal region had revealed Non-Hodgkin’s lymphoma. The patient party was told the prognosis and advised for chemo- and radiation therapy but this was refused because of their poor financial status and so the family returned back to Nepal.On initial examination at our ER room, the patient attained a Glasgow Coma Scale (GCS) of E2M4V2 with anisocoria on the left side. There were two scalp swellings on the left parietal and the frontal regions  which weBecause the child was already herniating, he was started on intravenous dexamethasone (4mg over 8 hours) and a single 100ml dose of 25% mannitol was given. Parents were counseled and written consent was taken for operative management. Surgery revealed a dural-based lesion  that wasPostoperatively, the patient improved to GCS 15. The steroids were slowly tapered off as the mass effect and edema were absent on repeat CT image and also prolonged usage would hamper healing of scalp surgical wound. The patient was thoroughly counseled and then referred for free chemo- and radiation therapy in a government oncology hospital.The patient’s GCS at 2 weeks follow-up was 4. Patient has been started on chemotherapy and is also advised for regular follow-ups.5, is an exceedingly rare disease entity. Only five cases of primary dural diffuse large B-cell lymphoma have been described so far with a median age at diagnosis of around 50 years1. Trauma, inflammation and viral infection have been postulated as probable causes6. The symptoms of the disease are variable and non-specific. The radiological findings are indistinguishable from other dural-based lesions such as meningiomas and hemangiopericytomas2. Since the prognosis of intracranial DLBCL is favourable4, it is important to make a correct and timely diagnosis. Rapid progression of the symptoms, lytic lesions on the bone and restricted diffusion in magnetic resonance imaging (MRI) may provide additional clues to the diagnosis. In cases where there are no obvious neurological symptoms, it may be advisable to take a needle biopsy of the scalp tumor as described by Ochiaiet al.7. There has been no consensus on the correct treatment protocol in the management of dural large-cell lymphoma due to a paucity of cases3. Previous cases have been treated with tumor resection followed by cyclophosphamide, hydroxy-doxorubicin, oncovin (vincristine) and prednisone (CHOP) with or without rituximab- or methotrexate-based chemo regimes. Additional radiation was also tried in some cases1. This case is the youngest age where the entity has been observed and showed good recovery despite initial presentation with herniation syndrome. Therefore, we suggest that maintaining a high index of suspicion and timely intervention is the key to better outcome in the patients.Primary dural lymphoma, first described by OberlingWritten informed consent for publication of their clinical details and images was obtained from the father of the patient. et al. have written a nice case report which highlights a rare disease. Diffuse large cell, mixed and immunoblastic lymphomas of B cell origin should be considered together as aggressive lymphomas1which unlike MALT associated primary dural lymphomas are not indolent. However certain facts need to be discussed.2, Meckel cave3,4, parasellar5,6, zygoma2,7, cerebellopontine angle8. In 2010, 93 cases with dural based lymphomas with 10 having extra CNS (systemic involvement) had been reported9.Even though rare, this case is not the sixth reported in literature. Other extra axial locations noted are orbit1. Tumor immunophenotyping using flow cytometric analysis  and by histochemical evaluation of the lymphoid cells is mandatory. These exhibit strong immunoreactivity both to leukocyte common antigen and to B-cell marker (L26). No staining should be noted for chromogranin, synaptophysin, or the epithelial markers AE1 and AE3Even though financial restriction is of concern in our country, contrast enhanced CT chest and abdomen should be the protocol to see for lymph node involvement rather than insensitive USG study.This may be a typo error, however to correct the same: Mannitol comes in 20% and not in 25% in Nepal. Image (figure 9) show a limited craniotomy causing brain herniation from the site of craniectomy and has been taken at a level lower than lesion previously shown in Figure 2. To allow comparison, it is suggested to provide CT images  of same level or plane.1,10.Differential diagnosis should include meningiomas, metastases,extradural abscesses with osteomyelitis or extradural hematomas. Clues for diagnosis include a rapid progression of symptoms with permeative growth pattern with large soft tissue component in galeal and extradural compartment, restricted diffusion on MRI, and the presence of bone lytic lesions on CT, limited periosteal reaction and an angiographically avascular lesion except for blush or vascular encasementThe treatment of choice for primary CNS lymphoma is chemotherapy (Adriamycin containing CHOP protocol) followed by radiation of the involved field and surgical excision is limited to conditions where mass effect is life threatening.Recognising this entity is important because an early diagnosis and rapid initiation of treatment, in certain cases with sole chemotherapy, is associated with a high response rates and favourable outcome10.The authors MunakomiI have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Primary dural lymphoma is the disease to most neurosurgeons and this case report provided details of a young patients' clinical treatment including diagnosis, surgery, and following chemotherapy and radiotherapy choices. It is worth indexing to improve the management of dural lymphoma.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Intraosseous lipoma is a benign bone tumor, and the tumor occurs more frequently in the lower extremities. We present a very rare case of intraosseous lipoma occurring in the lumbar vertebral arch and spinous process.A 54-year-old Japanese man presented with a three-month history of lumbar pain. Magnetic resonance imaging of the L3 vertebral arch and spinous process revealed high intensity on T1- and T2-weighted imaging, and it was suppressed on fat-suppression imaging and no enhancement showed on gadolinium contrast-enhanced imaging. Computed tomography imaging revealed an osteolytic change accompanied by marginal osteosclerosis in his third lumbar vertebral arch and spinous process, as well as a thinned and bulging bone cortex. An analgesic had been administered prior to his visit, but low back pain had persisted, so we performed curettage and filled the defect with hydroxyapatite bone. His low back pain was improved immediately after surgery, and no recurrence of tumor has been observed on computed tomography imaging as of three years postoperatively.Symptomatic intraosseous lipoma of spine is very rare, but the patient may be surgically well-treated by curettage and reconstruction of the benign tumor. Intraosseous lipoma is a benign bone tumor, and the tumor occurs more frequently in the lower extremities. We present a very rare case of intraosseous lipoma occurring in the lumbar vertebral arch and spinous process, together with a discussion of the literature.A 54-year-old Japanese man presented to our university-affiliated hospital with a three-month history of lumbar pain. He was 167cm in height and weighed 58kg. An analgesic had been administered prior to his visit, but low back pain had persisted. His physical examination showed pressure pain and tapping tenderness at the third lumbar vertebral level, but no sensory or motor disorders of his lower extremities. His blood biochemistry showed no abnormalities and his medical history was non-contributory.A plain radiography revealed the formation of a vertebral spur or narrowing of the intervertebral disc between L3 and L4 as an age-related change, but no instability was evident between vertebrae and no obvious abnormalities were evident. Magnetic resonance imaging (MRI) of the L3 vertebral arch and spinous process revealed high intensity on T1- and T2-weighted imaging  was used to fill the defect and the external lamina of the vertebral arch was replaced. Intraoperative pathological findings included hyperplasia of adipose cells and blood vessels, a small amount of trabecular bone and adipose cells of different sizes. Intraosseous lipoma was therefore diagnosed Figure .Figure 3His low back pain was improved immediately after surgery, and no recurrence of the tumor has been observed on CT imaging as of three years postoperatively Figure .Figure 4et al. [Despite the abundance of adipose connective tissue in bone marrow, intraosseous lipoma is extremely rare ; a searcet al.  reportedet al.  found thWe performed a review of the literature on intraosseous lipoma involving the spine, identifying only 14 cases (Table Even though intraosseous lipoma is a benign tumor that can be successfully treated with conservative treatment, surgery has been recommended for diagnostic confirmation, painful tumors, pathological fractures and malignant transformation -3,15,16.Symptomatic intraosseous lipoma of spine is very rare, but the patient may be surgically well-treated by curettage and reconstruction of the benign tumor.Written informed consent was obtained from the patient for publication of this case and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Benign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon.We describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation.We showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply. Benign multicystic mesothelioma is a rare pathology involving peritoneal serosa. We present the case of a benign peritoneal mesothelioma affecting cecum and pericecal peritoneum, complicating acute appendicitis in a man. In the international literature few cases are reported about this kind of neoplasm, and an acute presentation, as occurred in our case, is extremely rare . Our patA 41-year-old white man was admitted to our Emergence Surgery Department with a diagnosis of acute appendicitis and probable saccate peritonitis. He presented with a history of abdominal pain of 1 week which was localized prevalently in his right iliac fossa. At admission he was subpyretic. A clinical examination showed slight pain to abdominal palpation at right iliac fossa and flank, where a mass was appreciable, without signs of peritonism; peristalsis was preserved. Laboratory examinations showed little enhancement of inflammatory indexes  without leucocytosis or any other relevant alteration. An abdominal ultrasonography was performed; it revealed evidence of an oval lump of 72 mm diameter with hyperechogenic structure and hypoechoic-anechoic areas and septa in its contest, near to two similar less voluminous areas  is a rare pathology arising from mesothelial cells of the peritoneal serosa. This lesion usually affects women of reproductive age, but cases in men and children are reported too , 3.noxae as previous abdominal surgery or gynecologic diseases . Other authors suggest a primitive neoplastic lesion of peritoneal serosa, without strict association with coexistent chronic inflammatory insult. No correlation with asbestos exposure exists. According to a hormonal hypothesis, instead, BMPM development and progression is linked to its sex hormone sensitivity. This theory seems to be supported by the evidence of higher incidence in reproductive-aged women than in men and children, the rare insurgence after annessiectomy and in menopause, and the responsiveness to treatment with tamoxifen and gonadotropin-releasing hormone analog agonists [The etiology and pathogenesis are unclear. Three hypotheses have been proposed , 5. Someagonists .BMPM can arise in the whole peritoneum, but the most frequent site affected is the pelvis .Classically, the lesion presents as a thin-walled cystic structure that can consist in a single unilocular cyst or in a grape-like cluster of cysts of variable sizes, lined by flat or cuboidal mesothelium-like epithelium and containing serous fluid. Inflammatory cells and fibrous elements can be found within the stroma between the cysts and foci of mesothelial hyperplasia may also be present .There are problems of differential diagnosis with benign and malignant conditions such as lymphangioma, mesenteric or omental cysts, visceral cysts, echinococcal cysts, cystic adenomatoid tumors, malignant mesothelioma, cystic mesonephric duct remnants, endometriosis, endosalpingiosis, hydrosalpinx, tubo-ovarian abscess, ovarian cystadenoma or cystadenocarcinoma, cystic teratoma, pseudomyxoma peritonei, cystic smooth muscle tumors, cystic mucinous neoplasm of the pancreas, and non-pancreatic pseudocysts , 9. LympCystic mesothelioma is traditionally considered to be a benign neoplasm, but some authors underline the potential malignant behavior of this neoplasm, linked to the high local recurrence rate (about 50 %) observed after complete surgical resection .Clinical presentation of BMPM is generally aspecific. The lesion can sometimes be asymptomatic until the accidental diagnosis. The most common presenting symptoms are chronic or intermittent abdominal or pelvic pain, tenderness and distension, due to a palpable and painful mass or to mechanical compression of adjacent structures and organs. An association between BMPM and increased serum carbohydrate antigen 19–9 (CA 19–9) concentration has been described. In our case all tested neoplastic markers were negative: carcinoembryonic antigen (CEA), CA 19–9, and alpha-fetoprotein. Ultrasonography, CT scan and magnetic resonance imaging (MRI) are helpful to evaluate the localization and the size of the neoplasm, but they do not enable diagnosis of BMPM or the exclusion of other cystic lesions of the peritoneum. Laparoscopy can be considered to perform biopsies for histologic diagnosis or for surgical treatment , 12.Acute presentation is uncommon and the association with acute appendicitis, as in our case, is extremely rare, so only few cases are reported in the literature , 13.There are no evidence-based strategies of treatment for BMPM. Complete surgical removal has been advocated by most authors as the treatment of choice, but considering the high rate of recurrence and the borderline behavior of these neoplasms more aggressive approaches have been recently proposed, such as cytoreductive surgery with standard peritonectomy procedures in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) , 15. SomWe reported the uncommon case of an acute presentation of a rare benign pathology that is peritoneal multicystic mesothelioma. We underlined the difficulties that a similar presentation poses in terms of differential diagnosis and therapeutic strategy: in fact, images can provide suspicion of this kind of neoplasm, but definitive diagnosis is done only by histological examination, and there are no well-defined and evidence-based treatments.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Angiomyofibroblastoma is a benign, rare mesenchymal tumor arising from the genital tract of both men and women and was first described by Fletcher and colleagues in 1992. The tumor needs to be distinguished from other, similar lesions, such as deep and superficial aggressive angiomyxoma and cellular angiofibroma, because aggressive angiomyxoma demands much more extensive treatment. The vast majority of angiomyofibroblastomas arise from the vulva and appear as solid cystic masses on ultrasound images.We report a case of a 35-year-old Caucasian woman with an angiomyofibroblastoma arising from the vagina. She presented with a painless mass of about 5cm in diameter that had a rather homogeneous, hypoechoic appearance on ultrasound images. The patient underwent surgical resection of the mass, which was subsequently diagnosed as angiomyofibroblastoma. We present sonographic and magnetic resonance imaging findings, intraoperative and histologic images, and a thorough review of the literature.In our opinion, ultrasonography is the most valuable tool to establish a preoperative diagnosis of this tumor entity, differentiate it from other lesions of the female genital tract, and plan surgery accordingly. Even though it is a rare tumor, gynecologists should be able to recognize it and to differentiate it from other tumor entities that demand more aggressive treatment. We describe a different sonographic appearance of this tumor than previously reported.The online version of this article (doi:10.1186/s13256-015-0715-4) contains supplementary material, which is available to authorized users. Angiomyofibroblastoma (AMFB) was first described by Fletcher and colleagues in 1992 as a distinct subgroup of mesenchymal tumors histologically similar to aggressive angiomyoma (AA) that usually arise from the genital tract in both men and women [In contrast to AA, which is characterized by local destructive growth and recurrence after clear margin resection in up to 47% of cases –5, AMFB Together with cellular angiofibroma (CA) and myofibroblastoma (MFB), AMFB belongs to a group of benign stromal tumors of the lower female genital tract. These tumors, along with AA, have significant overlap in their morphological and immunohistochemical characteristics, which can pose serious diagnostic problems . Recent A 35-year-old Caucasian woman was referred to our outpatient clinic for evaluation of a neoplastic lesion located adjacent to the uterine cervix. She reported not having experienced any pain or discomfort with regard to the lesion and that she had not noticed any changes in bladder or bowel function. The lesion had come to her gynecologist’s attention during a routine pelvic examination 1 week earlier. Her history was remarkable for the excision of a melanoma from her right inner thigh about 4 years earlier. Two inguinal lymph nodes that were excised for sentinel staging at the time were reportedly without metastasis.In her gynecological examination at our clinic, no inguinal lymph node swelling was noted, and her vulva and proximal vagina appeared normal. The vaginal mucosa on the right side of the posterior fornix was bulging inward, displacing the uterine cervix laterally to the left. Underlying the mucosa was a palpable, semimobile mass of about 5cm in diameter that was of plump, elastic consistency. The vaginal mucosa overlying the tumor was smooth but not mobile relative to the tumor. There were no signs of ulceration or retraction by the tumor.Sonographically, the mass appeared homogeneous with medium echogenicity, few septations, and smooth edges Fig. , and it Histologically, the highly cellular lesion represented varying cellularity with vascularization by thin-walled blood vessels surrounded by spindle-shaped epithelioid cells with abundant eosinophilic cytoplasm and positive immunostaining for desmin and estrogen receptor Fig. .The mesenchymal cells showed a diffusely positive reaction to CD34, and 70% stained positive for desmin. There was no staining reaction to smooth muscle actin and S100. About 90% of the cells were estrogen receptor–positive. On the basis of these characteristics, a diagnosis of AMFB was made.At her follow-up examination 17 months postoperatively, the patient was doing well and without any evidence of recurrent disease or sexual or urinary dysfunction.Including our patient, 137 cases of AMFB have been reported to date (for a detailed list, see Additional file Sonographically, AMFB has been reported to be well demarcated with inhomogeneous echogenicity and multiple hypoechoic areas within an echogenic stroma . Wang anTo date, the exact pathogenesis of AMFB is not clear. Because many tumors express estrogen and progesterone receptors, it is likely that these hormones play a crucial role in the pathogenesis of AMFB. Indeed, these tumors almost exclusively occur in women of reproductive age; two cases of postmenopausal women receiving tamoxifen therapy have been reported , 15. BecAMFB is a rare, benign stromal tumor arising most commonly from the female lower reproductive tract, and ultrasonography is the most important imaging modality in its preoperative diagnosis and management. AMFB appears as a homogeneous, well-defined, vascularized lesion of medium echogenicity. AMFB needs to be distinguished from aggressive angiomyxoma because the latter demands more extensive treatment.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


The condyloma acuminatum  is a benign epithelial proliferation that occurs most frequently on the mucous membranes of the perianal and genital areas of men and women. The transmissible etiological agents of this lesion are papillomaviruses. In some rare instances these lesion can also be found in the oral cavity. In this 50-year-old woman; a wide rugose, cauliflower-like, exophytic lesion on the attached gingiva in the anterior region thought to be epulis fissuratum or a giant-cell granuloma turned out to be condyloma acuminatum following the excisional biopsy. This patient also had some genital lesions and tested positive for the human papilloma virus which is to be expected due to fact that intraoral presentation of condyloma acuminatum is a lot more frequent in patients who have anogenital lesions according to the literature. This report describes the etiology, diagnosis, treatment and follow-up an intraoral condyloma. It has been etiologically related to low-risk human papillomaviruses (HPV), mostly HPV types 6 and 11.11-3 Oral sites affected by condylomaaccuminata are the mucosa of the gingiva, cheeks, lips and hard palate or the site of the contact / traumatic event on non-keratinized tissues. Oral cavity involvement might occur without the accompanying anogenital disease.3Condyloma lesions, which are commonly considered to represent a sexually transmitted infection, frequently involve anogenital region however they might develop at oral mucosa.4The clinical appearance of condyloma acuminatum is variable and ranges from small, sessile lesions to larger pedunculated proliferations with smaller satellite growths. The differential diagnosis should also include verruca vulgaris, multiple squamous papillomas and oral mucosal lesions of Cowden’s (multiple hamartoma) syndrome.5 Koilocytosis of upper level epithelial cells is usually found. The epithelial layer itself is hyperplastic without evidence of dysplastic change and these epithelial changes might be mistaken for malignancy. The underlying stroma is well vascularized and may contain a trace of chronic inflammatory cells.1,3Pathological examinations of the infected tissues reveal some prominent clues. The papillomatous projections making up the verrucoid lesion generally show a parakerototic surface with marked underlying acanthosis.Here we report a rare case of a giant oral condyloma accuminatum coexisting with genital HPV lesions and discuss its surgical treatment.th teeth.A 50-year-old woman presented to outpatient clinic of Oral and Maxillofacial Surgery, Marmara University with the complaint of a growing lesion, which she first noticed 5 months earlier, inside her mouth. She reported no smoking history or alcohol use. In her past history, she had two operations, a myomectomy and a total abdominal hysterectomy, but no chronic illnesses or drug use. In addition, she declared to have an intraoral operation due to an epulis lesion, which at the pathological examination was reported as papillomatous lesion, in the region of maxillary 11-12Intraoral examination revealed a 2x5x4 cm in size, papillomatous, exophytic, hemorhagic and sessile lesion extending from the maxillary right second premolar region to left upper canine region . As a reSince such oral lesions might be suggestive of HIV infection, laboratory diagnostics for HIV and other causes of sexually transmitted diseases were requested. The screening test results were negative, surgical excision was arranged.ndweek, 1st, 3rd and 6th months (Following the local anesthesia of the involved intraoral region, the mass was removed with a wide excision . After th months . Patholoh months . Genitalh months .After surgical treatment, the patient was informed about possible recurrences which are common and presumably are related to the surrounding appealingly normal tissue that may act as a host for the infectious agent.6 The Centers for Disease Control and Prevention estimates that the risk of a woman acquiring genital HPV by age 50 is greater than 80 percent.7 Although HPV infection may be seen in every age groups, sexually active adults aged 15–24 account for approximately one half of new HPV infections each year.9 Nevertheless, the relation between these viruses and the pathogenic cancer in the oral mucosa remains controversial, and there appears to be more impact of HPV with other chemical and physical carcinogens such as tobacco and alcohol. In our case, as can be seen from the figures (HPV infection is the most common and widespread viral infection transmitted by close and repeated sexual contact. Transmission of HPV ordinarily requires sexual contact with the genital skin, mucous membranes or body fluids of a partner with either warts or subclinical infection. figures , patient10, the lesion in the lower lip was surgically removed. In our case we removed the intraoral lesion with a wide surgical excision. It must always be noted that primary suturing of an intraoral lesion of this magnitude might completely eliminate the vestibular sulcus depth. However, given that the bone defect present in the anterior region, it is necessary to prevent the formation of labile crest. Thus, following the bleeding in the operation area taken under control by cauterization, it seems to be a more accurate approach to suture the related region only to approximate the wound edges and to close the wound with an iodoform gauze in order to allow secondary healing. It is quite important to take complete control of bleeding in terms of minimizing any risk of hematoma and thereby wound dehiscence or its infection.Surgical excision, which may be cryosurgery, scalpel excision, electrodesiccation, or laser ablation are the most commonly preferred treatment modalities for these lesions. However they are destructive and non-specific. Condyloma lesions in the oral cavity of this size are extremely rare and in the case encountered in literatureIn the postoperative period, one of the most important issues to be aware of is oral hygiene. Our patient, due to having low oral hygiene, was called for control once every two days in the postoperative first week and the wound was irrigated with saline solution. For one week postoperatively, the patient was given antibiotics and anti-inflammatory treatments. We consider that in the postoperative period, the amount of the reduction in the vestibular depth is highly successful for a sessile mass of this magnitude. Furthermore, the formation of any labile crest is not available. As a result, in cases where surgical treatment is fulfilled with a proper postoperative care, it seems unlikely to achieve full successful treatment results.Although extra-genital condylomas are rare, such large intraoral condylomas are much rarer. In the presence of oral condylomas, the possibility of genital condylomas should be brought to mind and the patient should be re-evaluated from this perspective. Surgical removal of an oral condyloma of this size may be troublesome. Thus, it is important to make the surgical excision of such large condylomas in a tertiary medical center and to take care of some surgical points during the procedure.


Taenia solium) migrate and hatch into larvae within the central nervous system. Neurocysticercosis is the most common cause of seizures in the developing world and is characterized on brain imaging by cysts in different stages of evolution. In Canada, cases of neurocysticercosis are rare and most of these patients acquire the disease outside of Canada. We report the case of a patient with multiple intracranial lesions whose history and diagnostic imaging were consistent with neurocysticercosis. Pathological investigations ultimately demonstrated that her brain lesions were secondary to malignancy. Brain metastases are considered to be the most common cause of intracranial cystic lesions.Neurocysticercosis occurs when the eggs of the pork tapeworm (We present the case of a 60-year-old Canadian-born Caucasian woman with a subacute history of ataxia, lower extremity hyper-reflexia, and otalgia who resided near a pig farm for most of her childhood. Computed tomography and magnetic resonance imaging showed that she had multiple heterogeneous intracranial cysts, suggestive of neurocysticercosis. Despite a heavy burden of disease, serological tests for cysticercosis were negative. This result and a lack of the central scolices on neuroimaging that are pathognomonic of neurocysticercosis prompted whole-body computed tomography imaging to identify another etiology. The whole-body computed tomography revealed right hilar lymphadenopathy associated with soft tissue nodules in her chest wall and abdomen. A biopsy of an anterior chest wall nodule demonstrated high-grade poorly differentiated carcinoma with necrosis, which stained strongly positive for thyroid transcription factor-1 and synaptophysin on immunohistochemistry. A diagnosis of stage 4 metastatic small cell neuroendocrine carcinoma was made and our patient was referred for oncological palliative treatment.This case illustrates the importance of the diagnostic approach to intracranial lesions. Our patient’s diagnosis of neuroendocrine carcinoma was delayed because of her nontraditional presentation. Despite extensive metastatic burden, the lack of perilesional edema and the identification of lesions appearing to be in various stages of development led to a pursuit of neurocysticercosis as the diagnosis. The absence of constitutional symptoms should not discount the possibility of malignancy from the differential diagnosis. Taenia solium (pork tapeworm). Passage through the gastrointestinal tract dissolves the coating around the eggs, thereby allowing the cystic larvae to disseminate to different sites in the body.Cysticercosis occurs after the ingestion of eggs from Neurocysticercosis involves the migration and development of such larvae within the brain or extraparenchymal tissue. Seizures, headache, and findings of increased intracranial pressure are common manifestations of neurocysticercosis. On radiography, neurocysticercosis is characterized by multiple intracranial cysts in different stages of development. While the incidence of the disease in Canada remains low, neurocysticercosis continues to be the most common cause of seizures in developing countries .A previously healthy 60-year-old Caucasian woman presented to our hospital with a year-long history of right-sided otalgia diagnosed as otitis media. Despite multiple courses of antibiotics, the symptoms persisted. Two months prior to admission, she complained of difficulty balancing and non-specific spontaneous involuntary movements in her lower extremities. She had no history of seizure or headache. She reported no constitutional symptoms or respiratory complaints. Her past medical history was significant for a 60-pack year smoking history.Our patient was born in rural Western Canada and moved to Eastern Canada as a child. She resided with her family adjacent to a pig farm but did not work directly with livestock. She returned to rural Western Canada as a young adult and was living there at the time of admission. She has never travelled outside of North America. She had no family history of neurological conditions or malignancy.A neurological examination (including a fundoscopy) demonstrated normal cranial nerves. Sensory and motor examinations were unremarkable. Examination of her reflexes revealed hyper-reflexia (without muscle spread) throughout her lower extremities. Bilateral ankle clonus was present (greater than six beats) along with fasciculation in her right hand. A positive Romberg’s sign and a wide-based ataxic gait were also noted. Cardiovascular and respiratory examinations were unremarkable and chest radiography performed prior to admission was normal.Computed tomography (CT) of our patient’s head demonstrated multiple bilateral well-defined cystic lesions involving both her supratentorial and infratentorial regions. The cysts were mostly thin-walled of varying sizes, and some were calcified. No paralesional edema or mass effect was present Fig. .Fig. 1CoT. solium serology.Magnetic resonance imaging of her brain with gadolinium contrast confirmed the presence of over 30 intracranial cystic lesions with differing fluid levels Fig. , b. RadiResults of laboratory investigations, including renal function, hepatic enzymes, and cerebrospinal fluid analysis, were all within normal limits. When results of the cysticercosis serological tests came back negative despite an extensive burden of brain disease, whole-body CT was performed to check for other lesions that would be more amenable to biopsy.Whole-body CT revealed right hilar enlargement (2 × 3 cm) associated with soft tissue nodules in her chest wall and abdomen. Equally concerning were infiltrates with irregular density along both adrenal glands and a low-density mass arising from the lateral capsule of her left kidney.A biopsy of an anterior chest wall nodule demonstrated high-grade poorly differentiated carcinoma with necrosis Fig. . The speT. solium (pork tapeworm). The coating around the eggs is dissolved by the gastrointestinal tract, allowing them to enter the bloodstream and be distributed to other tissues of the host. The cystic larvae (cysticerci) develop in multiple sites but are commonly found in the central nervous system  and skeletal muscle. Neurocysticercosis occurs when larvae migrate and develop in the brain or extraparenchymal tissue. Seizures and headache are usually associated with parenchymal cysts whereas extraparenchymal cysts are characterized by findings of increased intracranial pressure. Neurocysticercosis is the most common cause of seizures in developing countries [Cysticercosis occurs after ingestion of eggs from ountries .Larvae remain viable for years, and multiple mechanisms of host immune tolerance have been postulated. While some larvae succumb to the host’s inflammatory reaction and form a granuloma in defense, other cysticerci do not. In the initial colloidal stage, the pathognomic finding of a cysticerci scolex within a thin-walled cystic lesion may be seen. In later stages, the walls thicken, calcify, and form a granuloma around the non-viable parasite. Imaging findings in neurocysticercosis differ depending on the stage of cyst development. Neuroimaging will commonly reveal multiple cysts in different developmental stages .There is a broad range of etiologies for intracranial cystic lesions found on imaging Table . Brain mIt is important to consider metastatic disease when intracranial lesions are identified on imaging and to commence a workup for primary pathology. In situations of unknown but suspected primary malignant processes, a chest radiograph or CT of the chest is a reasonable starting investigation . Our patIntracranial lesions have a broad differential diagnosis with brain metastases continuing to be the commonest cause in the developed world. Our case emphasizes the importance of a systematic approach when working up the etiology of intracranial lesions and of having a low threshold to investigate for malignancy.