SURGICAL SHORT CASES
1.LIPOMA
2. SEBAECEOUS CYST
3.DERMOID CYST
4. KELOID
5.BCC
BY
DR.A.SASIDHARAN MBBS
Introduction
Commonest tumor of s/c
tissue.
Benign
Arising from yellow fat
Universal tumor
Karyotype 12q change
Hibernoma
Types
Encapsulated s/c lipoma
Diffuse variety
Multiple lipomas- Dercum’s
d/s
Histological types
Fibrolipoma
Neurolipom
a
Naevolipom
a
location presentation d.d. Significance
s/c Mobile, lobular, Neurofibrom Most common
edge slips under variety
palp.fingers a
subfascial Diff. to appreciate Implantation In scalp- erodes
edge & lobulation dermoid , bone
Tbtenosynovitis
Subsynovial, Knee/elbow Bursa, Intra-articular is
sweling Baker’s cyst rare
intra-articular
Intermuscular Swelling Fibrosarcoma More chance of
Hematoma devpg
liposarcoma
Parosteal Feels hard Bony tumor Very, very rare
Contd..
location presentation d.d. Significance
Submucus Asymptomatic/ Intestinal/laryngea Intussusception
stridor l tumor
Subserosal Retroperitoneal Hydronephrosis, Liposarcoma
swelling retroperitoneal
cyst
Extradural Very rare - -
Intraglandula Breast, pancreas Cystic lesions Very rare
r
Clinical features
Localized, lobular, non-
tender
Semi-fluctuant
Mobile
Slip sign
Skin free
Pedunculated +/-
Complications
Myxomatous degeneration
Saponification
Calcification
Infection
Ulceration
Intussusception & intestinal
obstruction
Liposarcoma
Common in retroperitoneum, thigh &
back
Rapid growth
Warm & vascular
Dilated veins
Restriction of mobility
Skin fixation & fungation
Hematogenous spread to lungs
Treatment
Excision
Liposarcoma- wide
excision, reconstruction, adjuvant chemo-
& radiotherapy
DISEASES OF SEBACEOUS GLANDS
sebaceous gland: Holocaine glands in the skin that secrete
sebum
usually through the hair follicles.
• Sebaceous hyperplasia
• Adenoma sebaceum (Sebaceous adenoma)
• Sebaceous cyst (Epidermoid cyst)
4 Acne
5 Sebaceous gland carcinoma
SEBACEOUS CYST (EPIDERMOID CYST)
• Epidermoid cyst originates in the epidermis and a pilar cyst originates
from hair follicles, but neither type of cyst is strictly a sebaceous cyst
• The fatty, white, semi-solid material in both cysts is not sebum, but
keratin,
and under the microscope neither entity contains sebaceous glands.
• "True" sebaceous cysts are known as steatocystomas or, if multiple, as
steatocystoma multiplex.
Steatocystoma multiplex Epidermoid cyst
Pathogenesis: formation of acne
1 Increased activity of sebaceous glands with production of
excess sebum plays an important role
2 Occlusion of the pilo sebaceous orifices plays an
important
role
1 Hormones : Increased activity of sebaceous glands and
occlusion of the cornfied hypertrophic pilosebaceous
follicles lead to retention of sebum into the follicles, which
dilate and rupture by time.
2 Anaerobes such as Corynebacterium (Propionibacterium)
acne, Pityrosporon ovale and Staphylococci cause split of
the sebum into fatty acids and triglycerides which act as
an important irritating factors & → to the formation of the
different clinical types of acne which varies from
papules, pustules ,cysts and comedones
RX : SURGICAL
EXCISION OF THE CYST
SEBACEOUS CYST
DERMOID CYST
Cyst lined by squamous epithelium
containing desquamated cells
CONTENTS
mixture of sweat, sebum,
desquamated epithelial cells, hair
CLINICAL
TYPES
CONGENITAL / SEQUESTRATION
DERMOID
SITE: along lines of embryonic fusion
(midline of body or face)
FORMATION: dermal cells sequestrated in
subcutaneous plane > proliferate & liquify
> cyst > grows & indents
mesoderm(future bone) > bony defects
MEDIAL NASAL DERMOID CYST
(root of nose at fusion lines of frontal
process)
EXTERNAL AND INTERNAL
ANGULAR DERMOID ( fusion line of
frontonasal and maxillary processes)
SUBLINGUAL DERMOID
PRE –AURICULAR DERMOID
POST AURICULAR DERMOID
CLINICAL
FEATURES
Manifests in childhood or adolescence
Typically a painless slow growing
swelling
Soft, cystic, fluctuant, yield to pressure of
finger and will not slip away
Transillumination negative
Putty in consistency
No impulse on coughing
Underlying bony defect – clue to
diagnosis
OTHER
TYPES
IMPLANTATION DERMOID
> in women, tailors, agriculturists who
sustain repeated minor injuries
> sharp injury- epidermal cells implanted
in subcutaneous plane- dermoid cyst
> fingers, palm, sole of foot
> hard in consistency ( skin is thick)
TERATOMATOUS DERMOID
> arise from totipotent cells
> ectodermal, mesodermal, endodermal
elements
> ovary, testis,retroperitoneum, mediastinum
TUBULO-EMBRYONIC DERMOID
> from ectodermal tubes
> thyroglossal cyst, post- anal
dermoid
INVESTIGATIO
NS
BLOOD – TC, DC,Hb,ESR
URINE Examination
FNAC-
X ray- subjacent bone eroded by
dermoid
Ultrasonography- mass cystic/ solid
CT scan- size , shape , local spread
TREATME
NT
Excision of the
cyst
Mass shown ( implantation Incision
dermoid) marked
Incision started ( cyst contents cyst being
leaking) removed
KELOID
History
A 23 year old female was referred by
plastic surgeons for radiotherapy to th
posterior ear lobe, following the e
development of a Keloid Scar, three
years after an ear piercing
No family history of keloids
Pathology
Keloid is a unique human dermal
fibroproliferative disorder that occurs after injury,
inflammation, surgery,a nd burn.
Commonly causes of keloids include acne,
folliculitis, chicken pox,accinations and trauma
v lacerations, or surgical
(such as, earlobe piercing,
wounds).
It is a benign growth, well-demarcated area of
fibrous tissue overgrowth that extends beyond
original defect the
Baron Jean-Louis Alibert
(1768-1837)
Described appearance
Crab-claw-like Cheloid Keloid
Effects of keloids
Compromise aesthetic Impairment of function
Itchy
Pain
Pruruti
c
How best can they be treated?
Treatment Options
Surgery
Intralesional Steroids
Radiation
Laser
Cryotherapy
Pressure
Multimodality
Therapy
Still Trying
ks
Surgery Drawbac
Painful
Difficult reconstruction with large keloids
Utilizes normal surrounding tissue – limiting later
reconstructive options
Low long term success as monotherapy
Steroids
Triamcinolone
Hydrocortisone
Dexamethasone
Methylprednisone
Laser
1980s in vogue
Proposed Mechanism
No knife Less tissue
trauma
Cryotherapy- cold treatment
Pressure Therapy
Diminishes size and induration (HTS >Keloid) when
us ed as monotherapy
<10
% Recurrence when combined with surgery
Photos Courtesy of Dr.
Radiation
Basal cell carcinoma (BCC) is a slow
progressing nonmelanocytic skin cancer
that arises from basal cells (ie, small,
round cells found in the lower layer of
the epidermis).
It is the most common skin cancer (80%)
Estimated 3.3 million cases are diagnosed per
year(US) and incidence doubles every 25 years
The incidence high in areas of ↑UV radiation
(Australia,South africa)
estimated lifetime risk of 33-39% for men
and 23-28% for women
Men >Women
It increases with age (50-80 yrs )
Rare in <40 yrs (5-15%)
Sun damage
Repeated prior episodes of
sunburn
Fair skin, blue eyes and blond or
red hair ( also affect darker skin
types)
Previous cutaneous injury,
thermal burn, disease
(eg cutaneous lupus, sebaceous
naevus)
Inherited syndromes: BCC is a particular problem
for families with basal cell naevus syndrome
(Gorlin syndrome), Bazex syndrome, Rombo
syndrome and xeroderma pigmentosum
,albinism
Other risk factors include ionising radiation,
exposure to arsenic, coal tar, smoking tanning
bed and immune suppression due
to disease or medicines
The cause of BCC is multifactorial.
DNA mutations in the patched
(PTCH) tumour suppressor gene, part of hedgehog
signalling pathway (SHH)
triggered by exposure to ultraviolet radiation
Various spontaneous and inherited gene defects
predispose to BCC
BCC is a locally invasive skin tumour and
rarely
metastatize(< 0.01%)
The main characteristics are:
Slow growing: 0.5 cm in 1-2 years
Varies in size from a few millimetres to several
centimetres in diameter
Skin coloured, pink or pigmented
Spontaneous bleeding or ulceration
Waxy papules with central depression
Pearly appearance
Oozing or crusted areas: In large
BCCs
Rolled (raised) border
Translucency
Telangiectases over the surface
Black-blue or brown areas
BCC distrubution
:
Head and neck
60%
Nose 14%
Trunk 30%
Extremities 10%
There are several distinct clinical types
of BCC, and over 20 histological growth
patterns of BCC
Nodular
Superficial
Morphoeic
Basisquamous
Fibroepithelial tumour of Pinkus
Most common type of facial BCC
Shiny or pearly nodule with a smooth
surface with telangiectases
May have central depression or ulceration,
so its edges appear rolled
Cystic variant is soft, with jelly-like
contents
Micronodular, microcystic and infiltrative
types are potentially aggressive subtypes
Most common type in younger adults
Most common type on upper trunk
and shoulders
Slightly scaly, irregular plaque
Thin, translucent rolled border
Multiple microerosions
Also known as morphoeiform or
sclerosing
BCC
Usually found in mid-facial sites
Waxy, scar-like plaque with indistinct
borders
Flat or slightly depressed, fibrotic, and
firm
Wide and deep subclinical extension
Mixed basal cell carcinoma (BCC)
and squamous cell carcinoma (SCC)
Infiltrative growth pattern
Potentially more aggressive than other forms of
BCC
Warty plaque
Usually on
trunk
Characteristics of recurrent BCC
often
include:
Incomplete excision or narrow margins
at
primary excision
Morphoeic, micronodular, and
infiltrative subtypes
Location on head and neck
Advanced BCC
Advanced BCCs are large, often neglected tumours.
They may be several centimetres in diameter
They may be deeply infiltrating into tissues below
the
skin
They are difficult or impossible to treat surgically
Nevi malignant
melanoma
Keratoacanthoma
Seborrheic keratosis
Bowen disease
Actinic keratosis
Squamous cell carcinoma
Skin biopsy
To confirm and diagnose bcc and
its subtype Shave biopsy
Punch biospy
Cytology
Histologic findings
Laser doppler (eyelids tumor
margins)
Treatment depends on size ,location and type
of
BCC
Curretage and electrosessication
Mohs micrographic surgery
Excisional surgery
Radiation
Cryosurgery
Photodynamic theray
Laser surgery
Topical medications
Curretage and electricdesiccation : The growth is
scraped off with a curette, an instrument with a
sharp, ring-shaped tip), then the tumor site is
desiccated (burned) with an electrocautery needle.
Small lesions
Leaves round whiitish scar
Not suitable for advanced bcc, in high risk sites.
Excision means the lesion is cut out and the skin
stitched up.
Most appropriate treatment for nodular,
infiltrative and morphoeic BCCs
Should include 3 to 5 mm margin of normal skin
around the tumour
Very large lesions may require flap or skin graft to
repair the defect
Further surgery is recommended for lesions that
are
incompletely excised
Cryotherapy is the treatment of a superficial
skin lesion by freezing it, usually with liquid nitrogen.
Suitable for small superficial BCCs on covered areas
of trunk and limbs
Results in a blister that crusts over and heals within
several weeks.
Leaves permanent white mark
Photodynamic therapy (PDT) refers to a technique in
which BCC is treated with a photosensitising
chemical, and exposed to light several hours later.
Topical photosensitisers include aminolevulinic acid
lotion and methyl aminolevulinate cream
Suitable for low-risk small, superficial BCCs
Results in inflammatory reaction, maximal 3–4 days
after procedure
Treatment repeated 7 days after initial treatment
Excellent cosmetic results
Radiotherapy or X-ray treatment can be used to treat
primary BCCs or as adjunctive treatment if margins are
incomplete.
Mainly used if surgery is not suitable
Best avoided in young patients and in genetic conditions
predisposing to skin cancer
Best cosmetic results achieved using multiple fractions
Typically, patient attends once-weekly for several weeks
Causes inflammatory reaction followed by scar
Risk of radiodermatitis, late recurrence, and new
tumours
Imiquimod cream
Imiquimod is an immune response modifier.
Best used for superficial BCCs less than 2 cm diameter
Applied three to five times each week, for 6–16 weeks
Fluorouracil cream
5-Fluorouracil cream is a topical cytotoxic agent.
Used to treat small superficial basal cell carcinomas
Requires prolonged course, eg twice daily for 6–12
weeks
Causes inflammatory reaction
Has high recurrence rates
SURGERY
TARGET THERAPY (SHH PATHWAY
INHIBITORS)
Vismodegib ȋ Erivedge™Ȍ
Sonidegib (Odomzo®)
Protect skin from sun exposure daily, year-round
and
lifelong.
Stay indoors or under the shade in the middle of the
day
Wear covering clothing
Apply high protection factor SPF50+ broad-
spectrum sunscreens generously to exposed skin if
outdoors
Avoid indoor tanning (sun beds, solaria)
