Cystic Endometriosis in a Huge Degenerated Subserous Leiomyoma Mimicking Bilateral Multicystic Endometriomas in an Infertile Woman with Diminished Ovarian Reserve: A Rare Endometriotic Implantation.

Uterine leiomyomas are the most common pelvic tumor in women. Leiomyoma can show atypical locations and degenerations and may not be easily differentiated from adnexal masses. Uterine leiomyoma can undergo cystic degeneration and is said to be found in 4% of all types of degenerations. The commonest type of degeneration is hyaline seen in 60% of patients. Usually uterine leiomyoma does not present as clinical and radiological diagnostic challenge. However, when leiomyoma undergoes massive cystic degeneration they may become clinical and radiological diagnostic dilemmas. The MRI showed a huge cystic mass protruding up to the pelvis not differentiated from bilateral endometriomas and accompanying subserous myomas. Surgery revealed that the mass is not bilateral endometriomas but a huge pedunculated leiomyoma with cystic degeneration and cystic endometriosis. Endometriosis is a troubling gynecologic condition occurring in 10% to 15% of women of reproductive age and is associated with fertility problems. As a peritoneal disease, the locations of endometriotic lesions are predominantly the ovaries (96.4%), followed by the soft tissue (2.8%), gastrointestinal tract (0.3%), and urinary tract (0.2%) and other rare locations. The presented case is multiple sized cystic endometriosis (endometriomas) located in a huge pedunculated subserous leiomyoma in an infertile woman having a history of laparoscopic bilateral endometrioma surgery. Conclusion. To our knowledge, this is the first reported case for endometriotic cysts (endometriomas) located in a huge cystic degenerated leiomyoma. PubMed search revealed no report concerning endometriotic implantation in the leiomyomas.

A giant primary sclerosing lipogranuloma of the scrotum.

Sclerosing lipogranuloma is a rare, benign disease that can affect several organs, particularly of genitourinary system in males. The majority of the cases are secondary to exogenous foreign bodies. The masses are composed of granulomatous tissue formed around an either exogenous or endogenous lipomatous substance. We describe a 47-year-old male patient who presented with a growing, painless scrotal mass on physical examination. The mass was in 20 cm diameter and the laboratory findings were in normal limits. Pathologic evaluation confirmed the diagnosis of scrotal sclerosing lipogranuloma. To the best of our knowledge, this is the biggest scrotal sclerosing lipogranuloma case in the literature. We aimed with this presentation to keep in mind this benign lesion and also to assist the algorithmic approach.

Undifferentiated carcinoma of the epididymis.

Epididymal tumors are uncommon and usually benign, with only 25% of them being malignant. Undifferentiated epididymal carcinoma in particular is extremely rare. We report on a 54-year-old male patient presented with right testicular pain and scrotal mass for the last 6 months. Laboratory investigations were unremarkable but epididymal biopsy result was epididymal undifferentiated carcinoma. Inguinal radical orchidectomy was performed and pathological examination of the surgical specimen confirmed the presence of undifferentiated carcinoma. Then, adjuvant chemoradiotherapy (four cycles of cisplatin-etoposide chemotherapy and radiotherapy) was administered. After four months, lung metastases were detected and three doses ifosfamide-Adriamycin chemotherapy were given, but the patient died due to the disease progression. Reports of epididymal undifferentiated carcinoma are extremely rare and the present report emphasizes the need of including epididymal undifferentiated carcinoma in the differential diagnosis of an epididymal mass.

Contribution of diffusion-weighted imaging to dynamic contrast-enhanced MRI in the characterization of breast tumors.

OBJECTIVE: The purpose of our study was to evaluate the diagnostic value of an imaging protocol that combines dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted imaging (DWI) in patients with suspicious breast lesions and to determine if additional information provided by DWI improves the diagnostic value of breast MRI. MATERIALS AND METHODS: Eighty-four patients with breast tumors (37 benign, 47 malignant) underwent DCE-MRI and DWI before biopsy. Morphologic and kinetic analyses were performed on DCE-MRI and findings were classified according to the BI-RADS lexicon. Apparent diffusion coefficient (ADC) values were calculated from the DWI. The ADCs of the benign and malignant lesions were compared. For the combined MRI protocol, morphologic kinetic features and ADCs were evaluated together. Diagnostic values of DCE-MRI, DWI, and combined MRI were calculated. RESULTS: Median ADCs of the benign and malignant lesions were 1.26 × 10(-3) mm(2)/s and 0.75 × 10(-3) mm(2)/s, respectively. Cutoff value of 0.92 × 10(-3) mm(2)/s for ADC provided 91.5% sensitivity and 86.5% specificity. DCE-MRI alone showed 97.9% sensitivity and 75.7% specificity. The combination of DCE-MRI with DWI provided 95.7% sensitivity and 89.2% specificity. The specificity of breast MRI improved by 13.5% (p = 0.063) without a significant decrease in the sensitivity (p = 1.000). CONCLUSION: The combination of DWI and DCE-MRI has the potential to increase the specificity of breast MRI.

Metastatic cutaneous melanoma presented with ileal invagination: report of a case.

We herein report a case of ileal invagination secondary to metastasis of a cutaneous melanoma. A 45-year-old female was admitted with intermittent abdominal pain and nausea. The patient's medical history was remarkable for cutaneous malignant melanoma. Imaging studies showed a solid mass in the right lower quadrant and the possibility of invagination. We made a preoperative diagnosis of partial intestinal obstruction, and laparotomy was performed. Intraoperative findings revealed ileal invagination. Segmental ileum resection with wide mesenteric lymph node dissection was performed. A polypoid metastasis of melanoma into the lumen of the ileum was confirmed with pathological examination. The diagnosis and management of intestinal metastasis of cutaneous malignant melanoma are discussed together with a literature review.

Contrast-enhanced MR angiography of the breast: Evaluation of ipsilateral increased vascularity and adjacent vessel sign in the characterization of breast lesions.

OBJECTIVE: The purpose of this study was to investigate the role of evaluation of breast vascularity with contrast-enhanced MR angiography in the differentiation of malignant from benign lesions. MATERIALS AND METHODS: Contrast-enhanced 3D MR angiograms of the breasts of 102 patients with unilateral and histopathologically confirmed breast lesions were evaluated retrospectively. All images were evaluated for both ipsilateral increased vascularity and adjacent vessel sign, and the values of these signs in the diagnosis of malignancy were assessed. RESULTS: Histopathologic analysis of 102 patients revealed 50 malignant and 52 benign results. In 31 of the 50 patients with breast cancer and in 11 of the 52 patients with benign lesions, ipsilateral breast vascularity was increased. The resulting sensitivity and specificity of ipsilateral increased vascularity were 62% and 79%. The adjacent vessel sign was present in 37 of the 50 patients with breast cancer and six of the 50 patients with benign lesions. The resulting sensitivity and specificity of the adjacent vessel sign were 74% and 89%. The overall accuracies of ipsilateral increased vascularity and the adjacent vessel sign were 71% and 81%. CONCLUSION: Both ipsilateral increased vascularity and the adjacent vessel sign were found to be associated with breast cancer in a significant percentage of patients. The adjacent vessel sign is more practical and generally applicable. There is a borderline significance in favor of the higher accuracy of the adjacent vessel sign in comparison with ipsilateral increased vascularity (p = 0.043).

Recurrent lumbar spinal intradural enterogenous cyst: a case report.

Enterogenous cysts mostly present in the cervical and thoracic region of the spinal canal and have only rarely been observed in the lumbar region. We report here a case of a recurrent enterogenous cyst in the lumbar spinal canal. A 24-year old woman presented with lower back and left radicular leg pain for 1 year. She had been operated on for mass lesion at the same level 10 years ago. Lumbar spine MRI showed a large intradural cyst at L2. Other congenital abnormalities were absent. The cyst was subtotally removed and the patient recovered well. Pathological examination revealed that the lesion was a typical enterogenous cyst.

Temporalis muscle metastasis of the uterine leiomyosarcoma: a case report.

Leiomyosarcomas are malignant tumors of smooth muscle origin. These tumors are very rare in the head and neck region. The majority of leiomyosarcomas of the head and neck arise in the paranasal sinuses, oral cavity, jaws and superficial soft tissues like the scalp. A mass was observed in the right temporoparietal region of the scalp of a 76-year-old female. Two years before presentation, the patient was operated for primary uterine leiomyosarcoma. Over the ensuing years, the mass substantially increased in size. Radiologic findings revealed a mixed density mass of the right temporalis muscle. Histologic and immunohistochemical examination of the tumor showed a malignant mesenchymal neoplasm consisting of spindle-shaped atypical mesenchymal cells with marked pleomorphism and central cigar shaped nuclei arranged in fascicles. We report a rare case of uterine leiomyosarcoma metastatic to the temporalis muscle, proven by histopathology.

Dopamine-secreting adrenal ganglioneuroma presenting with paroxysmal hypertension attacks.

Adrenal ganglioneuromas are rare tumors originating from the neural crest tissue of the sympathetic nervous system. The clinical presentation for most patients is asymptomatic, and most of these tumors are hormone silent. We report a case of dopamine-secreting adrenal ganglioneuroma associated with paroxysmal hypertensive attacks in an adult patient. A 46-year-old woman was admitted to our hospital with a 2-month history of right flank pain, and a 2-year history of paroxysmal hypertensive attacks associated with headaches, palpitations, nervousness, and sweating. Abdominal CT and MRI revealed a solid round tumor approximately 4 cm in diameter on the upper pole of the right kidney. Urinary levels of dopamine and homovanillic acid were slightly elevated, although urinary levels of metanephrine and normetanephrine were suppressed. The urinary levels of epinephrine, norepinephrine, and vanillylmandelic acid were within normal limits. Right adrenalectomy was performed for treatment purposes. Histological diagnosis of the tumor was a ganglioneuroma originating from the adrenal medulla. In conclusion, this is a case of dopamine-secreting adrenal ganglioneuroma associated with paroxysmal hypertensive attacks in an adult patient.

Massive congenital intracranial immature teratoma of the lateral ventricle with retro-orbital extension: a case report and review of the literature.

Germ cell tumors comprise 0.4-3.1% of all intracranial tumors, and teratoma constitutes 9-30% of them. Congenital intracranial tumors are very rare and only account for 0.5-1.5% of all childhood brain tumors. The most common type of these tumors present at birth is teratomas, which represent 0.5% of all intracranial tumors. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. In this study, we report a neonatal intracranial immature teratoma at the lateral ventricle because of its rare location. A 5-day-old female neonate presented with a history of irritability and left eye protrusion since birth. A head computed tomographic (CT) scan and magnetic resonance imaging (MRI) disclosed a large tumor filling the left lateral ventricle and extending into the ipsilateral retro-orbital space. With left frontotemporoparietal craniotomy, a large grayish-white lobulated vascular mass was encountered, and total removal of tumor was performed. Histological examination revealed the diagnosis of immature teratoma. The prognosis of congenital intracranial immature teratoma is usually poor because the lesions are extensive when they are identified. Prenatal ultrasonography is necessary for the prenatal diagnosis. Fetal MRI should be made for the evaluation of intracranial tumor. If the tumor is detected before the 24th week of gestation, termination of the pregnancy should be considered.

Carotid body tumors and adrenal pheochromocytomas in siblings of a Turkish family.

OBJECTIVE: This is a report of 2 hypertensive siblings with a history of carotid body tumors and subsequent benign adrenal pheochromocytomas (pheos) in a family where the mother had died of possible adrenal carcinoma. CLINICAL PRESENTATION AND INTERVENTION: The first case was a 35-year-old woman with paroxysmal hypertensive attacks and a right adrenal mass. She had earlier undergone surgery to remove bilateral carotid body tumors. Investigation revealed excessive excretion of catecholamines and their metabolites in the urine. Abdominal MRI and (131)I-MIBG scintigraphy revealed a right adrenal tumor. Right adrenalectomy was performed. The second case, the 45-year-old brother of the first case, was found to have a left adrenal mass on abdominal MRI. Catecholamines and their metabolites in the urine were found to be increased. He had also had surgery to remove bilateral carotid body tumors of the neck. Left adrenalectomy was performed. Both siblings showed no evidence of other familial syndromes, such as multiple neoplasia type 2, von Hippel-Lindau disease or neurofibromatosis type 1. CONCLUSION: Although the combination of familial carotid body tumors and pheo is rare, a patient who remains hypertensive after removal of a carotid body tumor deserves a careful evaluation to exclude pheo. Such tumors may be extra-adrenal or multifocal.

Bloody nipple discharge in children: possible etiologies and selection of appropriate therapy.

An understanding of underlying causes of bloody nipple discharge (BND) is necessary to be able to advise treatment guidelines of this rare symptom in the pediatric age group. Of 11 patients with 14 breasts that had BND, data regarding age, sex, side and duration of BND, physical examination findings, laboratory values, culture reports, ultrasonography (US) findings, treatment approach, histopathologic details, and outcomes were obtained, and also, literature was reviewed. The patients were between 3 months and 12 years of age. There were six males and five females. The BND was located in the right breast in six patients, in the left in two, and it was bilateral in three. On physical examinations, seven patients had palpable cystic nodules located at the areolar area and three had a diffuse breast enlargement without skin findings. Laboratory investigations showed normal hormone levels in all patients. At US examinations, seven breasts had cystic lesions, three had hypoechoic tissue in the subareolar region, and others had normal US findings. In a girl with positive culture for Staphylococcus aureus, BND resolved after oral antibiotics. Two cases resolved spontaneously, with 6 months and 4 months follow-up periods, respectively. Surgical intervention was performed for the remaining eight patients, and mean time to operation after onset of symptoms was 10 months (range = 1-34 months). Histopathologic findings showed that the underlying cause of BND was duct ectasia in five breasts, gynecomastia in three, and fibrocystic change in two. Their follow-up periods ranged between 3 months and 6 years, and no recurrences were observed. Classification of breasts with BND for selecting appropriate therapy on the basis of results of careful physical examination, with an US evaluation in selected cases, is effective, and prevents unnecessary investigations.

Leukocytoclastic vasculitis: a rare manifestation of propylthiouracil hypersensitivity.

OBJECTIVE: We report a case of leukocytoclastic vasculitis as a manifestation of propylthiouracil hypersensitivity. CLINICAL PRESENTATION AND INTERVENTION: A 66-year-old woman with a history of a toxic adenoma was referred for evaluation of a purpuric rash on the legs and buttocks bilaterally. She was biochemically hyperthyroid. Biopsy of the skin lesions revealed leukocytoclastic vasculitis. Propylthiouracil therapy was discontinued, and methimazole started. The purpuric rash resolved and surgical treatment for toxic adenoma resulted in euthyroid state. CONCLUSION: This report indicated that leukocytoclastic vasculitis should be considered in the differential diagnosis of patients with a vasculitic rash. The discontinuation of the propylthiouracil was associated with disappearance of the lesions.

Large adrenal pseudocyst presenting with epigastric distress and abdominal distention.

OBJECTIVE: We report a patient with a large adrenal pseudocyst presenting with epigastric distress and abdominal distention. CLINICAL PRESENTATION AND INTERVENTION: A 35-year-old man presented with a 1-year history of nonspecific epigastric distress and abdominal distention. Routine laboratory tests and endocrine function tests were within the normal ranges. Magnetic resonance imaging (MRI) revealed a large left adrenal cyst. Adrenal cyst showed low intensity on T1-weighted MRI images and high density on T2-weighted MRI images. The patient underwent surgery, and the cyst was completely removed. Histological examination showed that the cyst wall consisted of hyalinized fibrous tissue without an epithelial or endothelial lining, and a diagnosis of an adrenal pseudocyst was made. Symptoms resolved after pseudocyst removal. CONCLUSION: The report showed a patient with adrenal pseudocyst, a rare and uncommon condition that was diagnosed on MR images and confirmed by histology. The epigastric distress and the abdominal distention resolved after the pseudocyst was surgically removed.

Carcinoma erysipelatoides resulting from gastric adenocarcinoma: an unusual clinical presentation.

OBJECTIVE: To report a rare case of carcinoma erysipelatoides on the laryngeal skin caused by stomach adenocarcinoma. CLINICAL PRESENTATION AND INTERVENTION: A 48-year-old male, who had undergone a gastrectomy 18 months prior to admission for stage IIIA gastric adenocarcinoma, presented with a reddish induration of the cervical skin, lymphadenopathy in both supraclavicular areas and widespread subcutaneous nodules. Abdominal computerized tomography and chest radiography did not reveal any organ metastasis or peritoneal carcinomatosis. A biopsy of the induration revealed atypical epithelial cells with edema and dilatation of lymphatics. The patient was given combination chemotherapy of etoposide, adriamycin, and cisplatin, and significant improvement was observed over the cervical area after three courses. The patient tolerated the systemic chemotherapy well and has been followed for two months. CONCLUSION: We recommend combination chemotherapy in patients with cutaneous metastasis of gastric adenocarcinoma as a safe and effective treatment.

Correlation of E-cadherin expression with clinicopathological parameters in breast carcinoma.

OBJECTIVE: To investigate the correlation between the E-cadherin (E-CD) expression and clinicopathological parameters including tumor grade, patient age, tumor size, necrosis, peritumoral lymphovascular invasion and lymph node status in breast carcinomas. METHODS: The specimens were surgically obtained from 51 female patients with breast carcinoma between 1997 and 2001 in Karadeniz Technical University Medicine Faculty Farabi Hospital, Trabzon, Turkey. Histologic grading was according to the Bloom and Richardson methods. Tumors were classified as grade I (well differentiated), grade II (moderately differentiated) and grade III (poorly differentiated). Necrosis was graded as (-), (+), (++) and (+++). RESULTS: Grade 1 breast carcinomas (n=17) showed greater immunoreactivity than grade 2 (n= 22) and grade 3 (n=12) carcinomas. None of the infiltrating lobular carcinomas expressed E-CD. Statistically, significant difference has been noticed between E-CD expression and the histological grade. In contrast, no association were found between E-CD expression and metastatic potential, tumor size, tumor necrosis and patients' age. CONCLUSION: Results in the present report suggest that E-CD expression in breast carcinoma is more related to histological type and differentiation grade than with metastatic potential, tumor size, tumor necrosis and patients' age.

Primary cerebral neuroblastoma: a case treated with adjuvant chemotherapy and radiotherapy.

Neuroblastoma is the most common extracranial solid tumor of childhood. A wide variety of tumor locations and clinical presentations have been described. However, neuroblastoma is rarely located in the central nervous system, except in the case of esthesioneuroblastoma. We report a child with primary central nervous system (CNS) neuroblastoma who admitted to the hospital in coma. The tumor could be partially removed in our patient. After surgery, we treated the patient successfully with combined radiotherapy and eight courses of cisplatin-based chemotherapy. Our patient was followed-up for 34 months without any evidence of relapse.

Intratumoral haemorrhage: a clinical study.

Although the incidence of spontaneous intracranial haemorrhage associated with meningioma is 1.3%, the incidence of intratumoral haemorrhage could not be determined. The authors report on 11 patients, six men and five women, with meningiomas that presented as spontaneous intratumoral haemorrhage, among 126 meningioma cases which were evaluated radiologically and histopathologically. The average age of patients was 58.9 years (range 45-72 years). Two (1.5%) cases showed radiological, and nine cases (7.9%) showed microscopic bleeding. Most of these cases also showed microcysts (9.7%) and necrosis (6.3%). The location, histopathological types, sex, age, blood dyscrasia, hypertension do not influence the occurrence of intratumoral haemorrhages in meningiomas. We concluded that microcysts and necrosis are important in the occurrence of intratumoral haemorrhage in meningiomas.