Complete resection of a giant epidermoid cyst of the occipital bone: case report and systematic review.

Key Clinical MessageThe splenic epidermoid cysts are rare benign tumors, and a definitive treatment remains unclear. Although some spleen‐preserving approaches have been reportedly used, splenic cyst recurrence usually occurs in true cyst cases, wherein the cyst is incompletely removed. In our case, partial splenectomy was performed and the giant cyst was completely removed.

The authors are reporting a rare case of giant sebaceous cysts on scalp. A neglect of patient resulting in enormous size of cyst. Local excision is modality of treatment. INTRODUCTION Several dermatosis are encountered in day to day surgical practice. The pathology vary from benign to malignant one, but very often benign cutaneous lesions are encountered.A sebaceous cyst of scalp is uncommon entity. Neglect on the part of patient sometimes leads to giant sebaceous cyst formation rarely encountered. These giant sebaceous cysts are more prone for developing malignancy CASE PRESENTATION A 60 year old male presented with two painless swellings on scalp of 15 years duration. Both of the swellings increased progressively in size and there was no positive history of trauma or infection. General and systemic examination was within normal limits. Local examination of two swellings revealed larger one 7.3× 6.9×2.4 cm, second one being 6.1×5×2 cm,in dimensions, nontender ,fixed to underlying skin but freely mobilefrom underlying structures(Fig.1) Figure 1 Figure showing two large sebaceous cysts on scalp No neck lymphadenopathy was present, Excision of these giant sebaceous cysts was done.Histopathological examination was consistent with epidermoid cysts DISCUSSION Giant sebaceous cysts are rare entity in clinical practice1 Sebaceous cysts are presently called as epidermoid cysts .These asymptomatic, dome-shaped lesions are painless smooth skin lump with thick yellowy sebum in the lump . Cysts usually vary in size from 1cm to 4cm in diameter. Most of times often arise from a ruptured pilosebaceous Giant Sebaceous Cysts of scalp: A Case Report 2 of 3 follicle. Multiple epidermoid cysts are associated with lipomas or fibromas of the skin and osteomas and should be considered as part of Gardner's syndrome, with associated premalignant colonic polyps. Pathologically, epidermoid cysts are lined by a cornified epithelium with a distinct granular layer. It contains a lamellated keratin without calcificication . Some cysts can be associated with basal cell and squamous cell carcinoma.In long standing cases in elderly ,squamous cell carcinoma arises from this type of cyst . Bowen disease, metastatic carcinoma, Merkel cell carcinoma, and mycosis fungoides have all been reported in association with epidermoid cyst.Differential diagnosis includes milia,Pilar cysts nevoid basal cell carcinoma syndrome ,pachynychia congenital,lipomas , dermoid cyst.Treatment is excision of cyst. CORRESPONDENCE TO Imtiaz Wani Post Graduate Scholar Shodi Gali ,Amira Kadal , Srinagar , Kashmir,India 190009 Email: imtazwani@yahoo.com Cell.No.9419904864

Giant Epidermal Cyst on Posterior Scalp

Epidermoid cyst (EC) is a common clinical condition and it can be filled with keratinized material. EC often represents painless, slow progressive growth, and single cyst. The cyst is usually 1 to 5 cm in size. Giant epidermoid cysts on the buttock area are extremely rare, and reports of giant epidermoid double cysts on the buttock are even rarer. This paper reports a patient with a painless mass was on the left buttock. A giant epidermoid double cysts with infection in a left buttock paranal location. The mass was surgically removed. The patient recovered well after surgical treatment and currently has no recurrence. For patients with EC, MRI is recommended as a routine examination before surgery in order to detect the variation and extent of the cyst early. This lays a foundation for the complete resection of the lesion during the operation. The review of relevant literature will hopefully be helpful to clinicians.

Mediastinal Thoracic Duct Cyst

Epidermal cysts represent the most common cutaneous cysts. They arise following a localized inflammation of the hair follicle and occasionally after the implantation of the epithelium, following a trauma or surgery. Conventional epidermal cysts are about 5 cm in diameter; however, rare reports of cysts more than 5 cm are reported in the literature and are referred as “Giant epidermal cysts.” Epidermal cysts although common, can mimic other common benign lesions in the head and neck area. A thorough clinico-pathologic investigation is needed to diagnose these cutaneous lesions as they differ in their biologic behavior, treatment, and prognosis. We report a case of a giant epidermoid cyst in the scalp area of a young female patient which mimicked lipoma on clinical, as well as cyotological examination. We also present a brief review of epidermal cysts, their histopathological differential diagnosis, and their malignant transformation.

IntroductionEpidermoid cysts are rare intracranially occurring mainly in subarachnoid spaces such as parasellar cisterns, middle fossa and cerebellopontine angle. Only few cases of infundibular/sellar epidermoid cysts have been described. We present the case of a large sellar epidermoid cyst resulting in panhypopituitarism.Case49 year old male with history of obesity and hypertension presented to the emergency department with acute onset progressively worsening headaches. He denied vision changes, nausea, vomiting or dizziness. Examination showed stable vital signs and ophthalmologic exam did not reveal any visual deficits. Further, he did not have any signs of pituitary hormone excess including hypercortisolemia or acromegaly. Brain MRI with and without IV contrast revealed a peripherally enhancing multilobulated cystic pituitary mass measuring 19.5 mm×17 mm×20.5 mm deviating the infundibulum to the left causing compression of the caudal aspect of the optic chiasm. Initial endocrinology work-up revealed noon time cortisol of 10.7 mcg/dL (range 7-23), 7 pm ACTH of 34.6 pg/mL (range 7.2-63.3), TSH of 1.71 mIU/mL (range 0.35- 4.94), free T4 of 0.93 ng/dL (range 0.5-1.39), FSH of 4.45 mIU/mL (range 1.27-19.26), LH 5.51 mIU/mL (range 1.24-8.62), IGF-1 level of 199 ng/mL (range 68-225), prolactin <0.60 ng/mL (range 2.64-13.13), and testosterone level of 186 ng/dL (range 175-800). A presumed diagnosis of non- functioning pituitary macroadenoma with compression of chiasm was made and he underwent transsphenoidal hypophysectomy after evaluation by a multi-disciplinary team including neurosurgery, ENT and endocrinology. Post-operative course was uneventful, he was started on empiric steroids which were tapered slowly. Final pathology of surgical specimen demonstrated epidermoid cyst, focal necrosis, lymphocytes and macrophages infiltration consistent with reactive granulation tissue. On subsequent laboratory evaluation, he was found to have hypogonadotropic hypogonadism with an undetectable testosterone. FT4 was also low at 0.61 ng/dL (range 0.5-1.39). He is closely following with endocrinology for management of hypogonadotropic hypogonadism and hypothyroidism.ConclusionIntracranial epidermoid cysts are uncommon benign congenital lesions arising from trapped surface of ectodermal elements. Very rarely, they are found in the sellar region. Sellar epidermoid cysts tend to present late and often after significant growth and mass effects. Complete resection is challenging and recurrence is a feared complication. Our patient presented with acute symptoms from expansion of a large epidermoid sellar cyst mimicking a pituitary macroadenoma. It also resulted in hypopituitarism. Although, a rare entity, early recognition and prompt management of such lesions is key.Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Epidermoid cysts are uncommon intracranial tumors. As one of the extradural types of epidermoid cysts, intradiploic epidermoid cysts are even rarer tumors and occur in any part of the skull. We herein report a rare case of a giant intradiploic epidermoid cyst of the occipital bone. A 57-year-old woman presented with a 1-year history of localized headache in the occipital area. CT and MRI showed an extradural mass measuring 50×70 mm in the occipital bone with bony destruction. The patient underwent surgical resection. The tumor was completely removed with its capsule. There was no extension to the intradural space. The pathological report confirmed that the tumor was an epidermoid cyst. Follow-up MRI 24 months after the operation showed no recurrence. The headache was well controlled without any medications. We report a rare case of intradiploic epidermoid cyst with clinical and radiologic features and surgical treatment. It is important to consider this diagnosis for a patient with persistent regional headache with or without a growing scalp mass.

A rare case of giant intradiploic epidermoid cyst of the occipital bone with large intracranial extension in the posterior fossa is described. The lesion was discovered when the patient presented with headache and subcutaneous swelling in the occipital region, in the absence of signs of neurological involvement. CT scan showed extensive destruction of the occipital bone, mainly of the inner table, up to the foramen magnum. On MRI the lesion was hypointense in T(1) and hyperintense in T(2)-weighted images; signal inhomogeneity was due to cellular debris and cholesterol crystals. The enhancing rim due to the thickened dura confirmed the extradural location. Complete removal of the cyst was easily accomplished despite its large size. We found only 3 documented cases in the literature of giant intradiploic infratentorial epidermoid cysts, none of which was studied by MRI. The radiological features and differential diagnosis are discussed.

Epidermoid bone cysts are rare, unilocular, and slow growing. They develop by the accumulation of ectodermal remnants, and they may be congenital or acquired. The most common locations for these bone cysts are the distal phalanges, followed by the skull. This paper documents an adult male from the Islamic (twelfth and thirteen centuries CE) burial site of Ibi in the Province of Alicante, southeast Spain. This individual had a cranial lesion in the form of a roughly elliptical hole in the posterior fossa (left occipital region). The lesion was examined macroscopically and using X-ray photography. Based on the shape of the lesion, the most likely diagnosis would appear to be a benign tumour, a so-called "hourglass" epidermoid cyst. No direct link between this tumour and the cause of death can be established.

Epidermal Cyst on the Sole

Sebaceous cysts are a prevalent form of benign cutaneous cysts that often manifest as epidermal cysts when their size exceeds 5 cm in diameter. Despite their infrequent occurrence, cases of massive epidermal cysts measuring 5 cm or larger have been documented. Malignant transformations within epidermal cysts are exceedingly rare but not impossible. Although their development into malignancies is a rare event, it is essential to acknowledge the potential for benign epidermal cysts to undergo such transformation. In clinical terminology, these cysts predominantly affect the facial, cervical, and dorsal regions. They usually remain asymptomatic, with their formation attributed to the sequestration of epithelial remnants during embryonic fusion or trauma. In this report, we present a remarkable case of a colossal epidermal cyst found on the upper back of a 75-year-old male individual, highlighting the uncommon nature of such occurrences within the medical domain. This case adds to the literature by presenting a rare case report highlighting the clinical presentation, probable consequences, and surgical therapy of larger epidermal cysts.

Epidermal or epidermoid cyst is a common lesion formed by the down growth and cystic expansion of the epidermis, or of the epithelium forming the hair follicle. It should be differentiated from trichilemmal and dermoid cysts. A six and a half years year retrospective analysis of pathological record of cases diagnosed as cases of epidermal cyst in the Department of Pathology, B. P. Koirala Institute of health sciences, Dharan, Nepal was done. A comprehensive list of clinicopathologic findings was noted and the etiology of these cysts reported previously was reviewed. Total number of cases studied was 500. The age of the patients ranged from 1.5 to 87 years. There were 289 (57.8 %) males and 211 (42.2%) females. Male to female ratio was 1.36:1. The mean age of the cases with traditional epidermal cysts was 50 years. History of traumatic episode was obtained in 9 (1.8%) cases. The mean size of traditional epidermal cysts was 1 .7 cm. Common sites were hair bearing regions. The epidermal cysts were seen at unusual site also as in breast in 2 (0.4%cases), spleen in 3 (0.6%) cases, subungual region in 1 (0.2%) case, penis in 1 (0.2%) case, palmin 3 (0.6%) cases and sole in 6 (1.2%) cases. Only in 170 (34%) cases, clinical diagnosis of epidermal cyst was considered in the present study. Of the cases of traditional epidermal cysts, 11% showed focal absence of a granular layer; and 23% revealed predominantly compact orthokeratotic cyst content. A hybrid feature, namely a combined feature of epidermal and so-called trichilemmal keratinization was noted in 11% of the cases of traditional epidermal cysts. Only 17% of the cases of traditional epidermal cysts showed parakeratosis, whereas parakeratosis was found in all cases of epidermal cysts of the sole. Foreign body reaction around the cyst wall, namely granulomatous inflammation with foreign body-type multinucleated giant cells, was observed in 1.8% cases of traditional epidermal cysts and 40% cases of epidermal cysts of the sole and 15% cases of epidermal cysts of gluteal region.

Epidermoid and dermoid cysts are benign developmental anomalies that can form anywhere in the body. Despite the rarity of incidence in the head and neck, they can arise at a variety of craniofacial locations. The purpose of this study was to analyze the clinical features of epidermoid and dermoid cysts arising in the craniofacial region with a literature review. A retrospective study was designed, and clinical features and surgical considerations were investigated from a literature review. Cases of epidermoid cysts in the scalp, temporal area, glabellar area, mouth floor, and buccal mucosa were described. Dermoid cysts in more lateral regions of the scalp are rarely associated with intracranial extension. Because temporal dermoid cysts have a high rate of intracranial extension, radiological evaluation of the lesions in the temporal area is imperative. Epidermoid cysts in the glabellar area are usually superficial. Consideration of the surgical approach for an epidermoid cyst of the mouth floor is important. Because epidermoid cysts in the buccal mucosa are extremely rare, differential diagnosis was emphasized. Epidermoid cysts in the scalp, in the temporal intradiploic area, on the glabellar area in the periorbital region, in the mouth floor, and in the buccal mucosa were surgically excised considering the depth and location. Ten cases of epidermoid cysts in the buccal mucosa were retrieved from the literature review. Consideration of the anatomic locations of epidermoid and dermoid cysts in the craniofacial region might help facilitate accurate diagnosis and treatment.

To The Editor: Epidermoid cyst is a frequent benign cutaneous tumor that could occur in any part of the human body. The pelvic cysts are uncommon and only a few cases are described in the literature. The following is a report of a rare case of a pelvic epidermoid cyst. A seventy year old multiparus lady presented with progressive swelling in the abdomen. Clinical examination confirmed a large mass in the abdomin. The ultrasound showed a giant 35 cm abdomino-pelvic echogene mass, extending from the pubis symphysis to the epigastric region, displacing the liver, spleen and the urinary bladder. The computed tomography showed similar finding (figure 1). A giant ovarian cyst was diagnosed. Median laparotomy was performed and a 30 cm retroperitoneal cyst was found. Ovaries and uterus were normal. Uneventful cyst cleavage was performed after liberation of some intestinal and epiploic adherences (figure 2). The cyst contained sebaceous matter and histological examination shows that the cystic wall was lined with flattened squamous epithelia with a distinguished granular layer. The cystic space was filled with a large amount of keratinized material. The histology was compatible with an epidermoid cyst. The post operative course was uneventful and the patient was doing well at the 5 months follow-up visit. Figure 1 Reconstruction of the image with CT scan, giant intra-abdominal mass. Figure 2 Image of the cyst after excision, size > 30cm Epidermoid cyst is a frequent benign cutaneous tumor, usually present in patients with an age range of 19 to 45 years. In children it is associated with a Gardner syndrome in 50% of cases [1]. It was described in various parts of the body including penis, spleen and brain [2–4]. It is the most frequent cutaneous cyst in the head and neck (49%) [5]. Only three cases of pelvic epidermoid cyst were reported in the literature, one was retroperitoneal [1] and the other two were retro-rectal [6, 7]. Concerning pathogenic theories, the epidermal cyst could be congenital, or post traumatic [8]. Epidermoid cysts are benign tumors with no risk of malignant transformation, but they may grow insidiously to reach a considerable sizes displacing or damaging other tissues and organs [9]. Pre-operatively, diagnosis of pelvic epidermoid cyst is difficult. Ultrasound and computed tomography often lead to a diagnosis of ovarian cyst. Magnetic resonance imaging (MRI) is more specific, as it shows epidermoid cyst as hypointense area on T1-weighted imaging and hyperintense on T2 weighted imaging without enhancement at contrast injection [10]. MRI could also help in confirming retroperitoneal localization; unfortunately it was not performed in our patient's case. The treatment of the pelvic epidermoid cyst is a surgical ablation using a cleavage to avoid any organ damage. However, in dealing with retroperitoneal space it could be difficult to avoid damaging iliac vessels and nerves [11] and if that is the case then the cyst must be punctured and drained before it is dissected. Precaution should be taken to avoid spillage of the contents out. A successful laparoscopic excision of a retro-rectal epidermoid cyst was described [7]. In conclusion, this report described a patient with a giant retroperitoneal pelvic epidermoid cyst which was successfully treated surgically. Although the pelvic epidermoid cysts are rare and difficult to diagnose pre-operatively, it should be considered in the differential diagnosis of ovarian tumors.