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Atypical fibroxanthoma is an scarce skin tumor which usually develops in exposed areas of elderly persons. It is very uncommon in the external auditory canal, where it might be wrongly diagnosed as a sebaceous cyst or carcinoma. We report a case of atypical fibroxanthoma of the external auditory canal and review the current procedure for the differential diagnosis of these lesions.
PURPOSE: In the pediatric population a broad spectrum of intrascrotal pathology ranging from congenital to neoplastic lesions present as a painless scrotal mass. The aim of our 10-year retrospective study was to review 71 pediatric cases of a painless scrotal mass to determine the overall and age specific prevalence of diseases manifesting as such masses. MATERIALS AND METHODS: From 1980-1991, 71 patients 1 day to 16 years old with a painless scrotal mass underwent evaluation using 7.5 or 10 MHz. ultrasound probes with transverse and longitudinal sections. RESULTS: The painless scrotal mass was testicular in 61 cases (86%, 28 neoplasms, 27 congenital malformations, and 6 posttraumatic/inflammatory lesions) and extratesticular in 10 (14%, 5 neoplasms, 2 hematoceles, 2 pachyvaginitis and 1 sebaceous cyst). Patient age distribution showed 2 peaks at 0 to 1-year and 13 to 14-year intervals. More than a third of the painless scrotal masses (24 cases) were found during the first year of life, predominantly congenital anomalies (in utero torsion) and neoplasia. A total of 45 patients (63%) underwent surgery (orchiectomy in 39 and conservative treatment in 6) and a pathognomonic echo pattern allowed nonsurgical treatment in 26 (37%). CONCLUSIONS: Testicular ultrasound proved to be highly reliable in differentiating intratesticular from extratesticular lesions but it demonstrated poor specificity because of extensive overlap between benign and malignant pathologies. Therefore, testicular ultrasound changed the management of a few select cases of a painless scrotal mass (epididymal cysts/spermatoceles and in utero torsion).
Pilomatrixomata are rare, benign, calcifying cutaneous tumours of the hair matrix cells. They usually present in childhood with a pre-surgical diagnosis of sebaceous cyst, because of their size and appearance. The usual sites of occurrence are the scalp, head and neck. Treatment is usually surgical excision. We report a case of unusual, multiple, benign pilomatrixomata in an Indian adult. The plastic surgeon should be aware of the various guises of pilomatrixoma and be alert to the important, although rare, occurrence of malignancy.
AIM: Children and adolescents referred to a rapid diagnosis breast clinic were analysed to study the conditions these patients were referred with, their management, and the final outcome. METHODS: All new patients aged 18 or under seen in a breast clinic over a 39-month period to June 2004 were identified and their case notes were reviewed. RESULTS: Among 6930 new referrals, 88 (1.3 %) were aged 18 or under and 86 patients were included in the study (median age 16 yrs, range 8 - 18 yrs). Five patients were aged less than 12 and were referred with physiological breast buds. In girls aged 13 - 18 years, most were referred for an apparent palpable abnormality. Thirty percent had a family history of breast carcinoma and 35 % were on the oral contraceptive pill. Thirty-three patients (38 %) had a clinical examination only. Others, in addition to the clinical examination, had an ultrasound (US) (n = 24, 28 %), fine needle aspiration cytology (FNAC)/core biopsy (CB) (n = 5, 6 %) or both US and FNAC/CB (triple assessment) (n = 24, 28 %). No malignant disease was found. No diagnostic biopsies were performed. Only 5 patients had surgery, four for fibroadenoma and one for sebaceous cyst. CONCLUSIONS: Patients aged 18 years or under do not constitute a major workload problem for rapid diagnosis breast clinics. Malignant disease remains rare. A significant proportion of patients require only clinical examination and reassurance. The diagnosis can usually be made without open biopsies and less invasively using FNAC or CB.
Clitoromegaly can be either congenital or acquired. The congenital forms are caused by hormonal disturbances or intersex states. Usually they are obvious at birth. When the clitoromegaly develops later the underlying aetiology should be explored and acquired causes should also be considered. These acquired forms of clitoromegaly are either hormonal or non-hormonal. In the hormonal causes, an androgen excess is the main contributing factor of the clitoral enlargement. Three groups should be distinguished: endocrinopathies, masculizing tumours, or self-injection of long-acting synthetic androgens. The most important endocrinopathies are non-polycystic ovarian hypertenstosteronism and polycystic ovarian syndrome. The only reported non-hormonal cause has been neurofibromatosis. We present a case in which the clitoromegaly developed during puberty. As no hormonal disturbances or other abnormalities had been found, and no signs of neurofibromatosis seen, temporary use of steroids was suspected. To our surprise a large sebaceous cyst was found.
Gardner's syndrome is a hereditary disease manifested by multiple colonic polyps that progress to malignancy at an early patient age and also manifested by multiple lesions of the different germ layers including sebaceous cysts, lipomas, fibromas, and osteomas of the facial bones. The plastic surgeon often is asked to treat these patients for the more mundane manifestations of the disease such as inclusion cysts or lipomas. At times, however, the plastic surgeon may be faced with an unusual presentation. Two such unusual cases are presented here, the first being a hemangioma of the hand, which has never been described in a patient with Gardner's syndrome, and the second being a fibroma of the left cheek requiring excision by an intraoral approach.
A female patient with Gardner's syndrome was treated with delta1-testololactone (200 mg daily) because of growth of a large desmoid tumor in the pelvis and lower abdomen and a tumor in a scar from a previous laparotomy. There was also pain and swelling of the left leg. An immediate effect of the drug therapy was complete relief of pain followed shortly thereafter by disappearance of the edema of the leg. After two months, the numerous sebaceous cysts were less prominent. The gross measurements of the diameter of the pelvic and lower abdominal tumor clearly demonstrated tumor shrinkage following therapy. Small polyps scattered over the rectal mucosa and numerous osteomata were not demonstrably affected. After one year of treatment with delta1-testololactone, a laparotomy for partial small bowel obstruction was necessary. Obstruction was caused by the involvement of small bowel mesentery and the bowel itself in a contracted residuum of dense fibrous tissue. Substitution of theophylline and chlorothiazide for the testololactone in Januray 1974 was followed by further diminution of the measurable abdominal and pelvic desmoids. All of these compounds synergize the action of 3',5'-adenosine monophosphate and at least the latter two may function by inhibiting the action of 3',5'-adenosine monophosphate diesterase.
We present 5 cases of pilar tumor, and we review the controversy over whether this tumor has a malignant potential. We feel the correct treatment is excision deep to galea, with a one to two cm margin of normal scalp. Presented with a pathology report of "pilar tumor" on a "shelled out" or ruptured sebaceous cyst, we feel the correct treatment is complete excision of the previous scar, going deep to the galea and taking a one to two cm margin of surrounding normal scalp.
The clinical importance of the gram-positive anaerobic cocci (GPAC) isolated in 1987 at St Bartholomew's Hospital, London, is assessed. Of about 800 anaerobic isolates, 209 (27%) were GPAC, of which 67 (32%) were from abscesses and 22 (11%) were in pure growth. Four species comprised 77% of the 168 isolates available for study: Peptostreptococcus magnus (55 isolates, 33%), P. micros (23, 14%), P. asaccharolyticus (24, 14%) P. asaccharolyticus (24, 14%) and P. anaerobius (27, 16%). Different species were associated with different sites, from P. magnus (usually skin-associated sites; normally cultured with aerobes, infrequently with other anaerobes), P. asaccharolyticus (distributed widely) and P. anaerobius (usually genitourinary and gastrointestinal; always below the diaphragm) to P. micros (always deep sites with other anaerobes). P. magnus was isolated from 15 abscesses and was obtained in pure culture from 11 specimens, six of them abscesses developing from infected sebaceous cysts. P. micros was usually isolated from soft tissue abscesses, never from the skin, and with a characteristic mixed flora consisting of "Streptococcus milleri" and anaerobic gram-negative rods. P. heliotrinreducens was a rare isolate from similar specimens. P. asaccharolyticus was cultured from a wide variety of sites, typically mixed with both aerobes and anaerobes, and frequently from abscesses. Most isolates of P. anaerobius came from gastrointestinal or female genitourinary specimens, never from above the diaphragm and rarely from the skin; cultures were usually heavily mixed. Isolates of P. vaginalis and the "bGAL" group made up 11% of str ains and were usally cultured from superficial sites, P. vaginalis often from post-operative wound infections with Staphylococcus aureus.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Dermatological surgery is a relatively new and expanding subspecialty within dermatology. Little information is available about complications in this kind of surgery in the European setting. OBJECTIVES: The aim of this study was to assess the incidence of anaesthetic, haemorrhagic and infectious complications in dermatological surgery and to highlight the factors associated with these complications. METHODS: Data were collected prospectively over a 3-month period for all surgical procedures performed by a network of dermatologists (n = 84 dermatologists) in France, including the excision of all benign or malignant tumours but excluding sebaceous cysts and pyodermas. Information was collected regarding dermatologists, patients, procedures and complications. RESULTS: A total of 3788 surgical procedures were available for review; 236 complications, mostly minor, occurred in a total of 213 surgical procedures (6%), bleeding being the most common (3%). Vaso-vagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Superficial suppuration accounted for 92% of surgical site infections. Only one patient had a systemic infection. Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases of 3788 (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Similarly, no link could be established between complications and surgical conditions. Multivariate analysis showed that anaesthetic or haemorrhagic complications were independent factors for infectious complications. Sex, administration of an anticoagulant or immunosuppressant, type of procedure performed and duration exceeding 24 min were independent factors for haemorrhagic complications. CONCLUSIONS: This study shows a low rate of complications associated with dermatological surgery performed by dermatologists under local anaesthesia on an outpatient basis.
Ten patients with eumycetoma were treated with oral ketoconazole in the dosage of 400mg/day for 8 to 24 months. In eight cases the foot was affected: four were due to Madurella mycetomatis and one each due to M grisea, Pyrenochaeta romeroi, Acremonium kiliense and A falciorme. One mycetoma which affected the back and perineum was due to A kiliense, and one case presented with multiple sebaceous cysts and the scalp and M mycetomatis was isolated from the lesion. Clinical and laboratory tests showed excellent tolerance to the drug, with no adverse reactions. Complete cure was obtained in six patients and two showed good responses. The cured patients were followed up for a period ranging from three months to two years without any evidence of recurrence.
BACKGROUND: To review one surgeon's experience with tumours of the inframammary crease. METHODS: Individually reviewed cases were identified from a prospective database. RESULTS: Of the 550 patients treated between January 2000 and January 2005, six patients were found to have carcinomas of the inframammary crease (IMC). The features identified from these cases included diagnostic confusion with sebaceous cysts delaying diagnosis and early involvement of the dermis and chest wall resulting in management issues related to local T staging. Lymphoscintigraphy showed drainage to bilateral, contralateral or ipsilateral axillae as well as the internal mammary chain. CONCLUSION: The anatomy and histology of the IMC are reviewed, as is the available published work on IMC breast tumours. By virtue of their location, IMC tumours invade the dermis and chest wall early. Despite this, they do not seem to behave as T4 cancers. Their lymphatic drainage is a cross between patterns observed for breast parenchymal and skin primaries, making sentinel node lymphoscintigraphy essential. The clinical cases presented highlight these peculiarities of IMC breast cancer.
BACKGROUND: Pilomatrix carcinoma (synonyms, matrical carcinoma or malignant pilomatrixoma) is a rare malignant neoplasm derived from the hair matrix first described in 1980. This neoplasm can exhibit local aggressive behavior and distant metastasis. Most pilomatrix carcinomas occur on the head and neck of elderly individuals with a predilection for males (M:F 5:1). Pilomatrix carcinoma is often clinically misdiagnosed as a sebaceous cyst and histologic difficulty can occur in differentiating this entity from the benign entity pilomatrixoma. OBJECTIVE: The objective was to describe a case of pilomatrix carcinoma encountered in a Mohs micrographic surgery practice. We present the first case of this lesion treated by Mohs surgery. METHODS: A case report and literature review are presented. CONCLUSION: Pilomatrix carcinoma is a rare malignant variant of pilomatrixoma. Given the rarity of this lesion there are no well-defined standards for surgical management. Wide local excision has been recommended given the high rate of reoccurrence. Mohs micrographic surgery may provide optimal treatment of this neoplasm given the ability to have 100% margin control.
A healthy 26 year old female underwent unsuccessful surgery for an incorrectly diagnosed sebaceous cyst in the cheek. Eventually the problem was traced to a non-vital tooth 24. When the tooth was treated endodontically, the situation resolved in one week.
The introduction of an improved anaerobic system resulted in the isolation of Bacteroides ureolyticus (B corrodens) in numbers that suggested a pathogenic role from many more clinical specimens. During a three-year period B ureolyticus was isolated from 103 fairly superficial necrotic or gangrenous lesions all of which showed evidence of active infection. These included 27 perineal or genital infections, 15 perianal abscesses, 15 other soft tissue infections such as pilonidal abscesses and infected sebaceous cysts and 16 ulcers or gangrenous lesions of the lower limb. B ureolyticus was rarely isolated in pure culture but was usually one of the predominant organisms; the other organisms were mostly anaerobes and the combination of B ureolyticus with anaerobic Gram-positive cocci was particularly noticeable. The isolation and identification of B ureolyticus is not difficult but depends upon a reliable anaerobic system and the incubation of primary cultures for at least 72 h.
Cell culture studies on adenomatosis of the colon and rectum (ACR) suggested that the clinical phenotype, colonic adenomas which become malignant recognised as a single clinical entity, may not be entirely the result of a single dominant mutation. Of the dermal cultures containing both epithelioid and fibroblastic cells established from six affected subjects from six unrelated ACR families, four showed increased tetraploidy and two did not. Of similar cultures established from four affected subjects form families with ACR associated with sebaceous cysts in consecutive generations, three did and one did not have increased tetraploidy. Irrespective of the in vivo relationship of increased tetraploidy to colonic cancer, the cultures from seven ACR patients had populations of tetraploid cells, at least in vitro, with chromosome instability. Such a difference in expression of the ACR genotype in vitro suggested genetic heterogeneity within this clinically defined group.
BACKGROUND: Merkel cell (neuroendocrine) carcinoma is a small round blue cell malignant neoplasm that primarily presents in the skin. The diagnosis of Merkel cell carcinoma in a pleural fluid is challenging because of the morphological similarity to many other malignant neoplasms. Immunohistochemical stains can be essential to establish the diagnosis of Merkel cell carcinoma. CASE PRESENTATION: A 77 year-old woman presented with a mass in her right buttock thought clinically to be a boil or sebaceous cyst. Upon histopathologic review including immunohistochemical analysis, a diagnosis of Merkel cell carcinoma was rendered. Wide-excision and sentinel lymph node biopsy revealed negative margins and no evidence of metastasis. Ten months later she complained of bone pain and a bone scan revealed multiple lesions. An abdominal CT scan revealed a T4 vertebral mass and local radiotherapy was administered. Two months later the patient presented with shortness of breath. A chest radiograph showed an effusion and thoracentesis was performed. The fluid was confirmed to contain metastatic Merkel cell carcinoma by cytology and immunohistochemical analysis. CONCLUSIONS: Merkel cell carcinoma is an aggressive neoplasm that can, despite careful surgical management, occasionally present as a malignant pleural effusion in a relatively short time period. Immunohistochemical analysis can aid in confirming this rare outcome.
UNLABELLED: Many pathologic entities in the clinical practice generate disagreements regarding its identification, not only by its likeness with other lesions but also by its semantics. BACKGROUND: The goal of this work is to clarify which disagreements are more frequent in the clinical practice, supply new knowledges to facilitate the identification of the larger pathologies controversies and to enlarge its differentials diagnosis. METHODS: We revised 1825 reports of referring biopsies to the period of 1992 up to 1999, belonging to the Laboratory of Pathological Anatomy of Unoeste, being excluded 439 lauds that did not introduce diagnostic hypothesis, or that had as signals hypothesis and clinical indications or "for clearing". We confronted the clinical hypothesis with the diagnosis Anatomic-pathological, obtaining itself 444 (32.05%) of discordant cases. RESULTS: Note that the biggest disagreements were between Hansen's disease clinical diagnosis, which in 65.7% cases were chronicles Unspecific Dermatitises, between Sebaceous Cyst, which in 80% cases were cyst of Epidermical Inclusion and Incomplete Abortion, which in 68.2% cases were complete Abortion. CONCLUSION: We conclude that an adequate concepts definition discerning an anamnese and narrow correlation of the clinical characteristics of the lesions promote a minor disagreements number among clinical diagnosis and Anatomic-pathological.