Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5179_Библиотеки_им_академика_М_И_Перельмана.pdf
304
Manipal Manual of Surgery
SURGICAL PROCEDURES DONE FOR
SOFT TISSUE SARCOMA (Figs 33.36 to 33.41)
Fig. 33.36: A 24-year-old lady underwent excision of a swelling
diagnosed as lipoma in a peripheral hospital which was reported
as sarcoma
Fig. 33.40: Synovial sarcoma of the toe—disarticulation being
done—highly malignant sarcoma
Fig. 33.37: The swelling was explored—as you can see it was
infiltrating the muscles—the first surgeon had not excised the
swelling completely
Fig. 33.38: Excised specimen showing skin, tumour and deeper
muscle fibres. STS was 3 cm in diameter. Histopathology reported
as synovial cell sarcoma. Margins were negative. (Courtesy: Dr Ankur
Sharma, Assistant Professor, Department of Surgery, KMC, Manipal)
Fig. 33.39: A large (8 cm) liposarcoma of the thigh being explored
with a longitudinal incision of the thigh. He had undergone an incision
biopsy earlier. The biopsy site is removed along with the skin
Section II • General Surgery
Fig. 33.41: Specimen of the growth along with the toe: Wide
excision. No nodes were palpable in the leg
SYNOVIAL SARCOMA (Fig. 33.32)
• Any rapidly growing tumour in the region of joint
or near the tendons in young patients (20–40 years),
synovial sarcoma is to be considered.
• Common site: Shoulder, wrist, knee, etc.
• Age: Young between 20 and 40 years.
• Clinical features are similar to the other sarcomas—
hard, painful mass.
• In addition to the local and blood spread, it also
spreads by lymphatic route.
• Plain X-ray: It may show characteristic calcification.
• It is aggressive, with high rates of recurrence.
• In the G-TNM staging system, they are Grade 3.
ANGIOSARCOMA (Fig. 33.33)
• 1 to 2% of soft tissue sarcomas.
• Affects elderly patients.
• They are high grade and aggressive tumours.
• They arise from skin and subcutaneous tissue rather
than deeper tissues.
• Most of them occur in the head and neck, breast and
liver.
• Surgery (excision) followed by radiotherapy/
combination chemotherapy may have to be given.
Tumours and Soft Tissue Sarcoma
305
RHABDOMYOSARCOMA
• It is the most common soft tissue sarcoma seen in
children, even though they are rare (under the age
of 15).
• It arises from striated muscle—painless enlarging mass.
• Resection/chemotherapy/radiotherapy (combination)
is tried depending on location.
• Sites: Head and neck (30%), genitourinary system
(25%), extremities (20%).
• All three varieties: Embryonal, alveolar and pleo-
morphic are considered as Grade 3 in GTNM staging.
Hence, prognosis is not good.
• Complete tumour resection should be the aim. Chemo-
therapy and RT are also used.
• Rhabdomyosarcomas have a high propensity for
lymph node metastasis.
KAPOSI’S SARCOMA
• Vulnerable section of people includes Jews, immuno-
compromised patients such as transplant recipients
and AIDS.
• Typical sites: Legs. Other sites include chest, arm,
neck in epidemic form (Africa).
• It presents as multiple pigmented sarcoma nodules
in the leg.
• It is interesting to note that Kaposi’s sarcoma is “not
seen” in transfusion related ‘AIDS
’.
• It manifests with purplish to red subcutaneous nodules
in the leg followed by ulceration and bleeding.
• Combination chemotherapy with doxorubicin,
etoposide and interferon have been used to control
the disease.
DERMATOFIBROSARCOMA PROTUBERANS (Fig. 33.31)
• Clinically presents as nodular exophytic ‘mass’
lesion—protuberans.
• Locally aggressive tumour which does not meta-
stasise.
• Wide excision should be the aim with negative
margin to prevent local recurrence.
• Mohs’ micrographic surgery such as basal cell carci-
noma has been advocated to get negative margin and
thus to get a low recurrence rates.
• Has good prognosis, if treated early.
Malignant Peripheral Nerve Sheath Tumours (MPNST)
• They are malignant form of benign schwannomas.
• They are aggressive tumours and local recurrence
rate is about 20%.
• Although arising from nerve sheath they are painless
at presentation and usually present in the 20–50 years
age group.
• MPNST may occur spontaneously or as part of NF-1
• Treatment is similar to other STS subtypes with an
aim towards margin negative resection.
USEFUL TIPS IN A CASE OF
SOFT TISSUE SARCOMA (Key Box 33.13)
In undergraduate clinical examination, students are
advised to offer soft tissue sarcoma as the diagnosis.
When asked the possible type, they only give a possible
histological type based on various clinical features
mentioned above. Ask the following questions to
yourself to get ready for the clinical examinations.
1. Is it soft tissue sarcoma? Tumour arising from soft
tissue, dilated veins, reddish skin, increase in local
temperature, firm to hard, rapidly growing swelling,
with late involvement of skin (carcinoma starts in the
skin) (Key Box 33.13).
2. What is the age of the patient?
• In children – Rhabdomyosarcoma
Undifferentiated sarcoma
Key Box 33.13
Interesting ‘Most’ to Remember in Soft Tissue Sarcoma
Most of the soft tissue sarcomas arise de novo.
Most originate in an extremity (60%).
Most common soft tissue sarcoma in adults is MFH
(28%).
Most extremity sarcomas (35%) occur in the lower
limbs.
Most occur in men (4 times more common in men
compared to women).
Most common soft tissue sarcoma in children is
rhabdomyosarcoma.
Most of the soft tissue sarcomas metastasise by blood.
Most of the extremity soft tissue sarcoma metastasise
to lungs.
Most of the retroperitoneal soft tissue sarcoma
metastasise to liver.
Most important prognostic factor for soft tissue sarcoma
is size and grade of the primary tumour.
Most accurate imaging modality for soft tissue sarcoma
is MRI.
Most effective modality of treatment is surgery.
Most effective chemotherapeutic drugs are doxoru-
bicin, dacarbazine and ifosfamide.
Section II • General Surgery
306
Manipal Manual of Surgery
• In 20–40 years – Liposarcoma
Synovial sarcoma
Kaposi’s sarcoma
• In elderly – Angiosarcoma
patients
Chondrosarcoma (bone)
Fibrosarcoma (Fig. 33.21)
3. Which site has it occurred?
• Head and neck –
Angiosarcoma
Rhabdomyosarcoma
Osteogenic sarcoma (jaw)
• Distal extremity –
Synovial sarcoma (Fig. 33.23)
(limbs) Epithelioid sarcoma (Fig. 33.34)
Clear cell sarcoma
• Retroperitoneum –
Liposarcoma (Fig. 33.27)
and mesentery MFH, leiomyosarcoma
4. Has it spread to lymph nodes?
• Rhabdomyosarcoma
• Synovial sarcoma
• Epithelioid sarcoma
5. Has it spread to lungs or liver?
• Chest X-ray
• Ultrasound
6. Can I preserve the limb? How?
• Wide excision
• Compartmental excision
• Preoperative radiotherapy combined with surgery
and postoperative radiotherapy.
A 34-year-old nondiabetic male patient had a nonhealing
ulcer right great toe of 6 months duration. History of
minor trauma was present. Examination revealed
ulceration, thickening and induration with ‘mass’ lesion.
It was MBBS examination case. The student offered
osteomyelitis, foreign body granuloma and tuberculous
synovitis as diagnosis. He qualified but he was asked to
examine the groin. The patient had 3 hard nodes in the
groin. The final diagnosis—synovial cell sarcoma with
metastasis in the groin nodes—the student had not
examined the groin!
1. When do you suspect lipoma turns into liposarcoma?
A. When lipoma gets infected
B
. When lipoma causes lymphangitis
C. When it becomes fixed
D. When it undergoes myxomatous degeneration
2. Intussusception is caused by:
A. Submucosal lipoma
B
. Subserosal lipoma
C. Retroperitoneal lipoma
D. Intraperitoneal lipoma
3. Myxomatous degeneration occurs only in which
lipoma?
A. Retroperitoneal B. Subfacial
. Submucosal D. Subcutaneous
C
4. Following are true for von Recklinghausen's disease
except:
A. It is an autosomal dominant disorder
B
. Skin pigmentation is a feature
C. Café au lait spots are characteristic
Section II • General Surgery
D. Does not turn into sarcoma
5. Following are true for schwannoma except:
A. Commonest site is acoustic nerve
B
. Sensory branches are affected more often
C. Well-encapsulated tumour
D. Highly premalignant tumour
6. Following are radiosensitive tumours except:
A. Oral cancer B. Seminoma testis
C
. Carcinoma breast D. Malignant chordoma
7. Which one of the following does not have a capsule?
A. Hamartoma B. Schwannoma
C
. Fibroadenoma D. Branchial cyst
8. Which one of the following is commonly associated
with paraneoplastic syndrome?
A. Carcinoma stomach B. Carcinoma colon
. Carcinoma pancreas D. Carcinoma lung
C
9. Which one of the following conditions is more
commonly associated with paraneoplastic syndrome?
A. Hypernatraemia B. Hyponatraemia
. Hypercalcaemia D. Hypocalcaemia
C
Tumours and Soft Tissue Sarcoma
307
10. Polycythaemia is a paraneoplastic syndrome seen
in which condition?
A. Hepatoma
B. Wilms’ tumour
C. Apudoma
D. Renal cell carcinoma
11. Post-mastectomy lymphoedema is called:
A. Stewart-Treves syndrome
. Bloom's syndrome
B
C. Fanconi’s syndrome
D. Sturge-Weber syndrome
12. Precautions to be taken while doing an open biopsy
in soft tissue sarcoma include following except:
A. Incision should be longitudinal
B
. Perfect haemostasis should be achieved
C. Drain should be kept
D. Flaps should not be raised
13. Sarcomas metastasise to lymph nodes include
following except:
A. Rhabdomyosarcoma B. Angiosarcoma
C
. Synovial sarcoma D. Liposarcoma
14. Following are true for the treatment of soft tissue
sarcomas except:
A. Surgery is the best line of treatment
. Radiotherapy is given after surgery
B
C. Chemotherapy is also given
D. Radiotherapy is the first line of treatment
15. Following are true for the treatment of retroperitoneal sarcoma except:
A. Surgery is the best line of treatment
. Radiotherapy is extremely helpful
B
C. Chemotherapy is not very useful
D. Most of them are liposarcoma
16. Following are high grade soft tissue sarcomas except:
A. Angiosarcoma
B
. Synovial sarcoma
C. Malignant fibrous histiocytoma
D. Liposarcoma
17. Following are true for glomus tumour except:
A. It can turn into malignant
. It is an angioneuromyoma
B
C. It is radio-resistant
D. It is concerned with heat regulation
Answers
1. C 2. A 3. A 4. D 5. D 6. D 7. A 8. D 9. C 10. D
11. A 12. C 13. D 14. D 15. B 16. D 17. A
Section II • General Surgery
34
Cystic Swellings, Neck Swellings
and Metastasis Lymph Node Neck
Cystic swellings
Transilluminant swellings
Differential diagnosis of midline swellings
Swellings in the submandibular triangle
Swellings in the carotid triangle
Swellings in the posterior triangle
CYSTIC SWELLINGS
A cyst is a swelling containing fluid. True cysts are lined
by endothelium or epithelium. They contain clear serous
fluid, mucoid material, pus, blood, lymph or toothpaste
like material.
The false cysts do not have lining epithelium. They
can be degenerative cysts as in the case of tumours which
undergo tumour necrosis or tumour degeneration, or
merely a collection of fluid which is walled off by coils
of bowel as in tuberculous encysted ascites or an
exudation cyst as in pseudopancreatic cyst.
Classification of Cyst
I. Congenital Cyst
• Sequestration dermoid cyst
• Branchial cyst
• Thyroglossal cyst
• Lymphangioma
• Cysts of embryonic remnants: Cyst of urachus,
vitellointestinal duct cyst.
II. Acquired Cyst
• Retention cyst: Sebaceous cyst, galactocele,
spermatocele, Bartholin’s gland cyst
• Distension cyst: Thyroid cyst, ovarian cyst
• Exudation cyst: Hydrocele
• Degenerative cyst: Tumour necrosis
• Traumatic cyst: Haematoma, implantation dermoid cyst
• Cystic tumours: Cystadenoma of pancreas, cyst-
adenoma of the ovary
AV fistula
Lymph node secondaries in the neck
Different types of neck dissections
Secondaries in the neck—occult primary
Pancoast’s tumour
III. Parasitic Cyst
• Cysticercosis
• Hydatid cyst
Clinical Examination of Cysts in General
Students are requested to follow the standard practice
of examination of the swelling in the form of inspection,
palpation, percussion and auscultation in the clinical
examination. Some important tests for cystic swellings
are given in the next page.
1. Location: Most of the congenital cystic swellings have
a typical location wherein diagnosis can be made with
fair accuracy. A few examples are as follows:
• Branchial cyst occurs at the junction of upper one-
third and lower two-thirds of the sternocleidomastoid muscle, whereas opening of branchial
fistula occurs at junction of upper two-thirds and
lower one-third of sternocleidomastoid muscle.
• Dermoid cyst: Midline, outer or inner canthus of
the eye.
• Meningocele: Swelling in the newborn at
lumbosacral region.
• Ganglion: On the dorsum of the hand and foot
2. Shape: Majority of the cystic swellings are round or
oval.
• Subhyoid bursitis: Transverse oval cystic swelling
in the midline of the neck.
• Thyroglossal cyst: Vertically placed oval swelling
in the midline of the neck.
• Sebaceous cyst: Hemispherical swelling.
308
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
309
3. Surface: Almost all the cystic swellings in the skin
and subcutaneous tissue have smooth surface.
4. Consistency: Fluctuation is positive in all cystic
swellings (Fig. 34.1 and Key Box 34.1). However,
depending on the contents, the fluctuation may be
different, which an experienced surgeon can
diagnose.
Key Box 34.1
Rules of Elicitation of Fluctuation
Mobile swelling has to be fixed.
Both hands should be used.
With the index finger and thumb of one hand, the
swelling is pressed—these are ‘active’ fingers and the
impulse is received by the thumb and index finger of
the other hand (passive fingers).
Fluctuation should be elicited in both directions, as
fleshy muscle in the thigh can be fluctuant across but
not in the longitudinal direction.
When swelling is smaller than 2 cm in size, Paget’s
test is done. Cystic swellings feel soft in the centre and
firm at the periphery. Solid swellings feel firm at the
centre than periphery.
• Soft cystic: Thyroglossal cyst, meningocele, lymph
cyst.
• Tensely cystic: Ganglion, tensely cystic swellings
in the neck may feel firm or solid, e.g. tense thyroid
cyst. Cyst in the breast may feel firm or hard.
• Yielding in cases of lipoma, as fat at body
temperature behaves like fluid (pseudofluctuation).
• Soft with firm thickened periphery: Cold abscess
• Half-filled like a rubber hot water bottle: Branchial
cyst.
• Putty or toothpaste: Sebaceous cyst (true fluctua-
tion is not found).
• Cross-fluctuation for swellings having two compo-
nents connected to each other, e.g. plunging ranula.
5. Transillumination test: Cystic swellings which contain
clear fluid show positive transillumination (Fig. 34.2).
Fig. 34.1: Fluctuation should be
elicited using both hands and in
both directions
Fig. 34.2: Transillumination
test: It should be done in a
dark room
6. Mobility: Almost all the cystic swellings in the skin,
subcutaneous tissue or in the deeper plane are benign
and as a rule, they should have free mobility. However, this is not true due to various anatomical factors.
• Branchial cyst: Restricted mobility is due to its
adherence to the sternomastoid muscle.
• Thyroglossal cyst: Transverse mobility is absent
because the cyst is tethered by remnant of the
thyroglossal duct.
• Sebaceous cyst: Limited mobility due to the
adherence to the skin.
7. Sign of compressibility: The swellings which have
communication with a cavity or with tissue spaces
give the positive sign of compressibility. Thus, a
steady pressure is applied over the swellings. The
swelling may disappear completely or may partially
disappear. However, when pressure is released the
swelling fills up slowly. Hence, it is also called the
‘sign of refilling’ (Key Box 34.2).
Key Box 34.2
Compressible Swellings
Haemangioma
Lymphangioma
Meningocele
8. Plane of the swelling
• Almost all significant cystic swellings in the neck
are deep to deep fascia. Thus, contracting sternomastoid for laterally placed swellings and bending
the chin against resistance for centrally placed swellings must be done to define the plane of swelling.
• Subcutaneous swellings become more prominent
when the underlying muscles are contracted as in
limbs.
• Swelling due to semimembranous bursitis, almost
disappears on flexion of knee and becomes more
prominent on extension of the knee.
• Sebaceous cysts are attached to the skin at the site
of punctum.
9. Pulsations
a. Expansile: Aneurysms are characterised by
expansile pulsations. When two fingers are placed
over the swelling on the sides, the fingers are not
only elevated but are also separated. Popliteal
aneurysms typically give this sign (Key Box 34.3).
b. Transmitted: When the swelling is situated over a
vessel, the fingers are raised but not separated, e.g.
pseudopancreatic cysts. When the swelling pushes
the vessel anteriorly, transmitted pulsation can be
obtained, e.g. cervical rib pushing the subclavian artery.
Section II • General Surgery
310
Manipal Manual of Surgery
Key Box 34.3
Aneurysm Tests
Expansile pulsations: Finger separation sign
Proximal compression test: Decreased size
Distal compression test: Size may increase
Thrill and bruit are present and distal pulses may be
weak
c. Pulsation can also be present in vascular tumours,
such as osteogenic sarcoma or secondaries from
carcinoma thyroid, etc.
Effects of Aneurysm (Key Box 34.4
igs 34.3 and 34.4)
and F
Some Useful TIPS
1. Thrombosis: It is one of the common effects of
aneurysm particularly aortic and popliteal, resulting
in ischaemia in the distal territory.
2. Ischaemia: Distal parts may become gangrenous
and/or can have ischaemic ulcers or claudication.
3. Pressure effects
a. Effect on bone: Erosion of the vertebral body as in
aortic aneurysm. This does not happen in TB spine.
b. Effect on nerves: Popliteal aneurysm can give rise
to foot drop due to pressure on lateral popliteal
nerve.
c. Effect on the veins: Results in congestion and
oedema of the leg.
d. On the oesophagus: Dysphagia as in aortic
aneurysm.
4. Skin changes may be in the form of oedema and
redness.
Complications of Cysts in General
1. Infection, e.g. sebaceous cyst
Calcification, e.g. haematoma, multinodular goitre
2.
with cyst, hydatid cyst
3. Pressure effects: Ovarian cyst pressing on the iliac
veins.
4. Haemorrhage within thyroid cyst.
5. Torsion: Ovarian dermoid.
6. Transformation into malignancy.
7. Ovarian cachexia: Large ovarian tumour with pedal
oedema, anorexia, loss of weight, lordosis.
DERMOID CYST
This is a cyst lined by squamous epithelium containing
desquamated cells. The contents are thick and sometimes toothpaste-like which is a mixture of sweat, sebum
and desquamated epithelial cells and sometimes even
hair.
Clinical Types of Dermoid Cyst (Key Box 34.5)
Key Box 34.4
Thrombosis, Ischaemia
Pressure, Skin changes
Fig. 34.3: Radial
artery aneurysm
Section II • General Surgery
Effects of Aneurysm: TIPS
Fig. 34.4: Radial artery aneurysm with
clot—excised specimen. (Courtesy: Prof
L Ramachandra, Professor of Surgery, KMC,
Manipal)
I. Congenital/Sequestration Dermoid
• They occur along the line of embryonic fusion, due
to dermal cells being buried in deeper plane.
• The cells which are sequestrated in the subcutaneous
plane proliferate and liquefy to form a cyst.
• As it grows, it indents the mesoderm (future bone)
which explains the bony defects caused by dermoid
cyst in the skull or facial bones.
• Even though they are congenital, they manifest as a
swelling during childhood or later in life. Often they
can be mistaken for lipoma and sebaceous cysts
(Fig. 34.5).
• They can occur anywhere in the midline of the body
or the face (Key Box 34.5).
Key Box 34.5
Origin of Dermoid Cyst
The face is developed from 5 processes—2 maxillary,
2 mandibular and 1 frontonasal.
Dermoid cyst occurs in the line of embryonic fusion of
these processes.
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
311
1. External and internal angular dermoid cyst: At the
fusion lines of frontonasal and maxillary processes
(Fig. 34.6).
2. Median nasal dermoid cyst: At the root of the nose
at the fusion lines of frontal process (Fig. 34.7).
3. In the suprasternal space of Burns
4. Sublingual dermoid cyst (Fig. 34.8)
5. Pre-auricular dermoid cyst—in front of the auricle
6. Post-auricular dermoid cyst behind the auricle
(Fig. 34.9).
Pinna is formed by the fusion of 6 cutaneous tubercles. Both
preauricular and postauricular dermoid cysts occur because of
failure of fusion of one of the tubercles with the others as they
form pinna.
Complications of Dermoid Cyst
1. Infection
. Suppuration: Abscess
2
3. Ovarian dermoid: Torsion
Clinical Features
• Though congenital, the cyst manifests in childhood
or during adolescence. A few cases also manifest in
30–40 years age group.
• Typically, the patient presents with a painless, slow-
growing swelling.
• Soft, cystic and fluctuant; transillumination is
negative.
• Rarely, it may be putty-like in consistency.
• The underlying bony defect gives the clue to the
diagnosis.
• Classical location of the cyst (along the line of fusion)
is a feature of sequestration dermoid cyst.
II. Implantation Dermoid Cyst (Fig. 34.10)
• This is common in women, tailors, agriculturists who
sustain repeated minor sharp injuries.
• Following a sharp injury, a few epidermal cells get
implanted into the subcutaneous plane. There, they
develop into an implantation dermoid cyst. Hence, it
is typically found in the fingers, palm and sole of the
foot. As the cyst develops in the areas where the skin
is thick and keratinised, it feels firm to hard in
consistency.
III. Teratomatous Dermoid Cyst (Figs 34.11 and 34.12)
• Teratoma is a tumour arising from totipotential cells.
Thus, it contains ectodermal, endodermal and mesodermal elements—hair, teeth, cartilage, bone, etc.
• Common sites are ovary, testis, retroperitoneum and
mediastinum.
A 24-year-old female patient was admitted with acute
lower abdominal pain of 2 days’ duration. There was
guarding and rigidity of the abdominal wall with rebound
tenderness. Per vaginal examination was normal. At
exploration, there was a twisted ovarian teratoma on the
left side with gangrene. It was excised. The opposite
ovary, on careful examination revealed a small
teratomatous dermoid cyst which could be enucleated.
The significance of this case report lies in the fact that
both ovaries should be examined in cases of ovarian
dermoid cysts.
Fig. 34.5: Median frontal
dermoid cyst, lipoma,
sebaceous cyst are other
differential diagnosis
Fig. 34.6: External angu-
lar dermoid cyst. Look for
bony depression—it is
pathognomonic of this
swelling
Fig. 34.7: Median frontal
dermoid cyst at the root of
the nose
impulse
.Test for cough
Fig. 34.8: Sublingual
dermoid. (Courtesy:
Dr Sreejayan, Professor
of Surgery, Calicut
Medical College)
Fig. 34.9: Post-auricular
dermoid cyst
and soft consistency
are characteristic
. Location
Section II • General Surgery
312
Manipal Manual of Surgery
Fig. 34.10: Implantation dermoid
cyst. TB synovitis and chronic
abscess are the other differential
diagnosis
Fig. 34.11: Ovarian teratomatous dermoid cyst.
Usually they are bilateral. Large ones with pedicles
are vulnerable for torsion. (Courtesy: Dr Rajesh
Bhakta, Associate Professor, Dept. of OBG, KMC,
Manipal)
IV. Tubuloembryonic Dermoid Cyst
• They arise from ectodermal tubes. A few examples
are thyroglossal cyst, post-anal dermoid cyst.
• Ependymal cyst of the brain.
Treatment of Dermoid Cyst
Excision of the cyst.
EPIDERMAL CYST (WEN)
• This is popularly called sebaceous cyst. It is a
misnomer. This occurs due to obstruction to one of
the sebaceous ducts, resulting in accumulation of
sebaceous material. Hence, this is an example of
retention cyst.
• Sites: Scalp, face, back, scrotum, etc. It does not occur
in palm and sole, where sebaceous glands are absent.
In the back, scalp and scrotum (Figs 34.13 to 34.16),
multiple cysts are often found.
Fig. 34.12: Cut open specimen of epi-
dermoid cyst showing cheesy material
Clinical Features
• They are slow-growing and appear in early
adulthood or middle age.
• Hemispherical or spherical swelling located in the
dermis. A dark spot in the centre (punctum) filled
with keratin is a diagnostic feature of this cyst. The
punctum indicates blockage of the duct (Fig. 34.17).
• In 20–30% of cases, instead of opening into the skin,
sebaceous duct opens into the hair follicle. Hence,
punctum is not seen.
• It has a smooth surface, round borders, soft and putty
consistency and is nontender.
• The cyst can be moulded into different shapes which
is described as sign of moulding.
• Sign of indentation refers to pitting on pressure over
the swelling (Table 34.1).
• The swelling is mobile over the deep structures, and
the skin is free all around except an area of adherence
at the site of punctum.
Fig. 34.13: Multiple sebaceous
cysts on the back. Troublesome
situation
Section II • General Surgery
Fig. 34.14: Multiple seba-
ceous cysts on the scrotum
calcified
. Requires excision
Fig. 34.15: Strawberry scrotum.
(Courtesy: Dr Umesh Bhat, Surgeon,
Kundapur, Karnataka, India)
Fig. 34.16: Sebaceous cyst on
the scalp. Loss of hair is a feature.
When punctum is absent, the
differential diagnosis is lipoma
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
Table 34.1 Comparison of congenital dermoid cyst and sebaceous cyst
Congenital dermoid cyst Epidermal cyst
313
• Aetiology Congenital—sequestration of the dermal cells
in the subcutaneous plane accumulation of sebaceous contents
• Location Midline of the body
• Sign of indentation, moulding Uncommon
• Punctum Absent Present in 50% of cases—diagnostic
• Skin fixation Absent Skin is fixed at the site of punctum
• Bony defect Present in majority of cases
• Intracranial communication Rare, can be diagnosed by cough impulse test
• Treatment Excision Excision or avulsion
, along the line of fusion Face, scalp, scrotum, back
Acquired—retention cyst due to
Very common
Absent
Absent
• In the scalp, loss of hair is a feature over the swelling
because of constant slow expansion of the cyst.
Treatment
• Incision and avulsion
of cyst with the wall.
Very often, during
dissection, the cyst wall
ruptures. Care should
be taken to excise the
entire cyst wall. If not,
Fig. 34.18: Sebaceous horn
recurrence can occur.
• When it is small it can
be excised along with
the skin.
Complications
1
. Infection can occur due to injury or scratch resulting
Fig. 34.17: Sebaceous punctum
is diagnostic of sebaceous
cyst
Syndrome: Gardner’s syndrome
Tumour: Cock’s peculiar tumour
Parasitic worm: Demodex folliculorum
Strawberry scrotum: Multiple sebaceous cysts of scrotum
Key Box 34.6
Interesting—Sebaceous Cyst
in an abscess. The cyst will be tender, red and warm
to touch. It should be treated like an abscess by
incision and drainage. After one to two months, the
cyst can be excised.
2. Sebaceous horn results due to slow drying of the
contents which are squeezed out, specially if a patient
does not wash the part. Thus, it is not common to
find a large sebaceous horn nowadays because of
better ways of living and sanitation (Fig. 34.18).
3. Calcification
4
. Cock’s peculiar tumour
1
refers to infected, ulcerated
cyst of scalp with pouting granulation tissue
and everted edge resembling epithelioma (Key
Box 34.6).
5. Rarely, basal cell carcinoma can arise in a long-
standing sebaceous cyst.
Meibomian cysts: They are epidermal cysts found on the free
edge of eyelid. Chronic meibomian cyst is called chalazion.
GANGLION
It is a tense, cystic swelling and which occurs due to
myxomatous degeneration of the synovial sheath lining
the joint or tendon sheath. It is common around joints
because of abundant fibrous tissue. It contains gelatinous
fluid.
Common Sites
• The dorsum of the hand is the common site, at the
scapholunate articulation.
• In the foot, dorsal or lateral aspect.
• Small ganglion in relation to flexor aspect of fingers.
1
Pott’s puffy tumour refers to osteomyelitis of the frontal bone with oedema of scalp secondary to frontal sinusitis. This and Cock’s peculiar tumour
are favourite viva voce questions.
Section II • General Surgery