Misinterpretation of head and neck masses can delay the correct diagnosis. A two-step demolitive-reconstruction surgery for saving patient's life

OBJECTIVE

To present a rare case of sebaceous cyst masking skin squamous carcinoma. The delayed diagnosis made necessary a two-step (demolition and reconstruction) surgery to save patient's life.

MATERIAL AND METHODS

A 77-year-old male, suffering from persistent right hemicrania and eye pain referred to different specialists, who misinterpreted his symptoms. The man presented on the right zygomatic area a big sebaceous cyst which masked a squamous cells carcinoma (SCC) infiltrating the surrounding structures including the orbito zygomatic complex and the orbital content that was the cause of the symptoms. Patient underwent biopsy, CT thorax and MRI of the head and neck as pre-operative examinations. A two-step surgery was performed to remove the tumor.

RESULTS

The skin biopsy showed the presence of sun damaged skin contains moderately differentiated invasive SCC within the context of sebaceous cyst. While the CT chest was negative, the head and neck MRI showed a huge tumor invading the orbit and periorbital tissue, the zygomatic bone and the soft tissues up to the posterior orbital area, without presence of neck lymph nodes. Le lesion has been classified as cT4 N0 M0 (TNM 8) and a two-step surgery approach (demolition and reconstruction) was performed with successful results at 1 year-follow up.

CONCLUSIONS

The delayed diagnosis of SCC was due to the misdiagnosis of the signs of the tumor invasion. Demolitive and reconstructive surgeries allowed to preserve patient's life. The careful attention to patient's skin characteristic, the analysis of general and local clinical signs (irradiated pain, cyst and skin type) and the evaluation of the complex differential diagnosis could be the key to avoid delayed treatment in head and neck cancer.

Apocrine Hidrocystoma: A Rare Case Report

Hidrocystoma is a cystic tumor originating from a dilated sweat gland. The tumor is typically small and located predominantly on the face, particularly in the eyelid margins. They are two classical types of hidrocystomas i.e., Apocrine and Eccrine. Apocrine hidrocystomas are cystic lesions that arise from the apocrine secretory coil and Eccrine hidrocystomas represent retention cysts of the eccrine duct. Multiple apocrine hidrocystomas confined to the eyelids have been recognized as a feature of a new variant of ectodermal dysplasia. Here we present a rare case of Apocrine hidrocystoma of supraorbital area for which excisional biopsy of the lesion was performed. Histopathological evaluation proved the lesion was a unilocular cyst lined by a double-layered epithelium of the apocrine type. The purpose of this paper is to report the unique occurrence of a Supra orbital apocrine hidrocystoma which was clinically as a sebaceous cyst and to discuss its differential diagnosis with other more common supraorbital and face lesions.

Unusual presentation of epidermoid cyst mimicking breast cancer involving the areola-Case report

INTRODUCTION

Epidermoid cyst is very common benign lesion of the skin. And may appear anywhere on the surface of the body. Diagnosis is made in most cases by clinical examination, but histological evaluation may be needed in unusual cases.

PRESENTATION OF CASE

We report a rare case of a 44 year-old woman who presented with a rapidly growing inflamed mass localized to the left areola, which grew to 4 cm in diameter within a few months. The diagnosis of malignancy was ruled out following pathology examination consistent with epidermoid cyst. After a course of antibiotics, she underwent surgery with nipple sparing and reconstruction of the areola.

DISCUSSION

Preoperative diagnosis based on biopsy enable limited surgical excision and preservation of the nipple. Reconstruction of the areola by local areolar flap enable good aesthetic result.

CONCLUSION

It is important to be aware of this entity of epidermoid cyst mimicking breast cancer, and the treatment options available in these cases.

Cutaneous metastasis of renal cell carcinoma masquerading as an infected sebaceous cyst

Renal cell carcinoma (RCC) is the third most common genitourinary malignancy with an estimated one third of cases with metastatic disease at the time of diagnosis. Though rare, cutaneous metastasis from RCC is more frequent than any other genitourinary malignancy. Metastasis of RCC to skin carries poor prognosis as coexistent visceral spread is the norm. A 38-year-old man presented one year after radical nephrectomy for clear cell carcinoma of the left kidney with a submental lesion that proved to be metastatic. Clinical appearance of cutaneous RCC metastasis is varied and can closely mimic other skin lesions. It is incumbent on general practitioners, dermatologists and urologists to exercise diligence in clinical diagnosis of skin lesions in the background of previous oncological diagnosis.

Routine histological examination of epidermoid cysts; to send or not to send?

Backround

The diagnosis of epidermoid cyst is seldom in doubt, and associated malignancy extremely rare, yet it is commonplace for the lesion to be sent to the pathology laboratory for analysis. The aim of this study was to evaluate our current practice with regards to diagnostic accuracy among clinicians, and assess risk of not routinely sending suspected epidermoid cysts for histological examination. Potential cost savings were also estimated and calculated.

Methods

Retrospective analysis of clinical and pathology data on all suspected epidermoid cysts excised from a Scottish district general hospital over a 5-year period between January 2011 and October 2015.

Results

Five hundred and thirty-six suspected epidermoid cysts were excised during the study period. Three hundred and ninety-six were sent for histological examination which confirmed a diagnosis of epidermoid cyst in 303 (76.5%) cases. There was good agreement between preoperative suspicion and final histological diagnosis: 80.8% (257/318) among referring clinicians, 81.9% (289/353) among reviewing surgeons, and 88.4% (243/275) where there was preoperative agreement between both. There were no malignant lesions. An average of 80 clinically apparent epidermoid cysts were excised and sent for histology each year at a cost of £4800 per annum.

Conclusion

There was close agreement between clinical and final histological diagnosis of epidermoid cyst. Where a characteristic, odorous, toothpaste-like material is present on transection intra-operatively, the diagnosis is confirmed and the lesion can be discarded. We argue that significant cost savings can be achieved by adopting this approach.

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Epidermoid cysts are common but malignant transformation extremely rare.

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Good association between a clinical diagnosis and a final pathology diagnosis of epidermoid cyst.

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Intra-operative transection of resected specimen may improve confidence in diagnosis.

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Where classical features are present clinically and on excision, the specimens do not require histological examination.

Post Surgical Giant Epidermal Inclusion Cyst of the Lid and Orbit- A Rare Case

Epidermoid cyst within the lid and orbit is extremely rare. Epidermoid tumours are inclusion of ectodermal elements in the site not normally containing these structures. It is of two types; primary type related to implantation of ectoderm at the time of closure of the neural groove and secondary type caused by post traumatic inclusion of the surface epithelium. A 45-year-old male had complaint of swelling on the right upper lid and orbital region. It first appeared two years back. It was painless progressively increased in size and shape. There was difficulty in opening of eye lid due to large swelling, feeling of heaviness in the right upper lid and occasional headache. There was history of right eye ocular infection following vegetative matter injury three years back. Evisceration of right eye was done for aforementioned reason. USG report shows cystic encapsulated mass with calcification foci in right upper lid-orbital region with fat component. MRI right orbit shows fairly large hyperintense cystic lesion seen involving right orbit with posterior extension up to optic canal. No intracranial extension. FNAC confirmed epidermal inclusion cyst. We did upper lid reconstruction with removal of mass. We have successfully removed the mass without any complication and with one year follow-up there is no recurrence.

Case of Subcutaneous Leiomyosarcoma of the Scrotum Presenting as a Sebaceous Cyst in a 71-Year-old Man: A Case Report and Review of the Literature

Leiomyosarcoma of the scrotum is a rare genital malignancy with approximately 35 reported cases in literature. We present a case of leiomyosarcoma of the scrotum in a 71-year-old man appearing as a sebaceous cyst that later developed ulcerations. However, because the irregular mass developed ulcerations, this should trigger one to consider that lesion is potentially malignant. The pathology report demonstrated malignant spindle cell neoplasm consistent with leiomyosarcoma, which tested positive for desmin and actin stains. On literature review, a study reported a 5-year survival rate of 50%-80%. The clinical features, diagnosis, histopathologic images, and treatment are reviewed.

Cock's Peculiar Tumour

A 28 year old female presented to us with cock's peculiar tumour. This tumour is one of the complications of sebaceous cyst. Patient underwent excision for the same. We are presenting this case for rarity.

Late extrusion of a temporomandibular joint prosthesis masquerading as a sebaceous cyst

Complications of temporomandibular joint prostheses are not uncommon and have been well documented. We report a very late and rare complication following silastic TMJ replacement, believed to be the first implant extrusion through healthy skin. We are reminded that these implants can still cause problems to patients many years after initial surgery.

Cutaneous furuncular myiasis: Human infestation by the botfly

Dermatobia hominis, the botfly, is indigenous to Central and South America. Its usual host is a mammal, often a horse or cow. Cutaneous furuncular myiasis, human infestation by the botfly, has rarely been reported. Symptoms of infestation include a locally painful, firm furuncular lesion, often with a centrally located pore. Due to their infrequent occurrence, these lesions are often misdiagnosed as cellulitis, leishmaniasis, furunculosis, staphylococcal boil, insect bite or sebaceous cyst - conditions with similar presentations. The present case reiterates the need to think of 'zebras' when hearing 'hoof beats' that may have originated in a different land.