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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 2  |  Page : 111-114

Giant benign skin tumors: A retrospective analysis and compilation of noteworthy characteristics


Department of Plastic Reconstructive and Aesthetic Surgery, Koç University School of Medicine, Istanbul, Turkey

Date of Submission19-Sep-2019
Date of Acceptance05-Nov-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Sedat Tatar
Koc University Hospital, Davutpasa Street No: 4 Topkap., Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_79_19

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  Abstract 


Background/Aim: Benign skin tumors are soft-tissue lesions that present with poor cosmesis along with pain, functional limitations, deformity, and hypoesthesia. Rapid progression and giant forms should be evaluated and differentiated from malignant transformation. The aim of this study is to evaluate the patients operated for giant benign skin tumors and to assess clinical experience about indications, size, location, and histopathological results and follow-up period. Materials and Methods: The present study included 16 consecutive patients who underwent surgery for giant benign skin tumors between 2015 and 2018 based on the literature definition of “giant benign skin tumors.” Demographic parameters, indications, symptoms, pathological results, and postoperative complications were evaluated retrospectively. Results: Sixteen patients (11 males and 5 females) were operated for giant benign skin tumors. The mean age of the patients was 53.38 (range: 37–72) years. Tumor locations were on the scalp for four patients, the upper extremity for three patients, lower extremity for three patients, trunk for five patients, and generalized for one patient. Pain was the most common symptom, and hypoesthesia, functional limitations, ulceration, and infection were also observed. Total excision was performed for all patients. No major complications and recurrence were observed. Conclusion: Clinical follow-up is an option for patients presenting to clinic with lesions that are small in size and asymptomatic. However, a detailed history and examination along with total excision and histopathological examination should be planned in patients with rapid progression or with benign skin tumors of giant size.

Keywords: Benign skin tumor, epithelial cyst, fibroepithelial polyp, lipoma


How to cite this article:
Tatar S, Sezgin B, Ozmen S. Giant benign skin tumors: A retrospective analysis and compilation of noteworthy characteristics. Turk J Plast Surg 2020;28:111-4

How to cite this URL:
Tatar S, Sezgin B, Ozmen S. Giant benign skin tumors: A retrospective analysis and compilation of noteworthy characteristics. Turk J Plast Surg [serial online] 2020 [cited 2020 May 27];28:111-4. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/2/111/280994




  Introduction Top


Benign skin tumors are soft-tissue lesions that frequently present with poor cosmesis along with pain, functional limitations, deformity, and hypoesthesia depending on the location.[1] Numerous histopathological subtypes, including lipomas, epidermoid cysts, fibroepithelial polyps, neurofibromas, pilar cysts, and xanthomas have been described, ranging from 1 to 2 mm to giant dimensions.[1],[2],[3] The term “giant benign tumor” is usually described and categorized individually for different tumor types. Although benign skin tumors progress slowly and are usually asymptomatic, rapid progression and giant forms should be evaluated and differentiated from malignant transformation.

The purpose of this study was to evaluate patients operated for giant benign skin tumors in our department and to compile noteworthy characteristics regarding each tumor subtype regarding surgical indications, size, location, and histopathological results and follow-up.


  Materials and Methods Top


Following the approval of the Clinical Studies Board of Ethics, this study included a total of 16 consecutive patients who underwent surgery for giant benign skin tumors between 2015 and 2018 based on the literature definition of “giant benign skin tumors.” Written informed consent was obtained from all patients, and the study protocol was compliant with the guidelines of the Declaration of Helsinki. Demographic parameters, indications, symptoms, pathological results, and postoperative complications were evaluated retrospectively.


  Results Top


Of the 16 patients, 11 were female and 5 were male. The mean age of the patients was 53.38 (range: 37–72) years. Tumor location was the scalp for four patients, the upper extremity for three patients, lower extremity for three patients, trunk for five patients, and generalized for one patient [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]. Pain was the most common symptom, whereas hypoesthesia, functional limitations, ulceration, and infection were also observed. Total excision was performed for all patients, and seven patients were operated under local anesthesia, whereas nine patients were operated under general anesthesia. Histopathological examination revealed lipomas for six patients, fibroepithelial polyp for two patients, pilar cyst for three patients, epidermal cyst for three patients, xanthoma for one patient, and benign lymphoid hyperplasia for one patient [Table 1].
Figure 1: (a) A 57-year-old female patient with 12 cm × 5 cm giant epidermal cyst on her left arm; (b) magnetic resonance imaging revealed a subcutaneous mass superiorly proceeding to the fascial plane; (c) intraoperative view; (d) surgical specimen

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Figure 2: (a) A 72-year-old male patient with a 21 cm × 13 cm giant lipoma on his left shoulder, frontal view; (b) lateral view; (c) magnetic resonance imaging view of the lesion; (d) surgical specimen

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Figure 3: (a) A 62-year-old female patient with a 6 cm × 5 cm giant pilar cyst on the occipital region of the scalp; (b) A 37-year-old female patient with a 7 cm × 4 cm cyst on the occipital region of the scalp

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Figure 4: (a) A 50-year-old female patient with a 17 cm × 4 cm xanthoma on the gluteal region; (b) postoperative 2nd-month view of the patient

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Figure 5: A 51-year-old female patient with (a) 15 cm × 5 cm pseudolymphoma on the occipital and posterior neck area (b) magnetic resonance imaging view of the lesion

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Figure 6: A 59-year-old female patient with (a) 8 cm × 4 cm giant fibroepithelial polyp on the left upper inner thigh; (b) surgical specimen

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Table 1: Allocation of patients and tumor characteristics

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The mean follow-up of the patients was 2.2 years (range: 1–3) years. We observed seromas in two patients after giant lipoma excision on the dorsal region and successfully managed treatment conservatively with drainage and compression. Recurrence and long-term complications were not observed in any of the patients.


  Discussion Top


Giant benign skin tumors evolve from existing tumors from varying degrees of proliferation. They clinically present with poor cosmesis, pain, discomfort, deformity, functional limitations, and hypoesthesia due to the compression to nerves.[1] Giant skin tumors should be assessed meticulously and malignancy should kept in mind and must be ruled out through detailed history, clinical examination, and radiological screening, and total surgical excision must be performed for definitive treatment.

Lipomas originate from mesenchyme and although they are mainly located on the upper extremity and trunk, they can arise from any part of the body where adipose tissue exists.[1],[4],[5] Lipomas are often small in size, but those that are larger than 10 cm or heavier than 1000 g are defined as “giant lipomas.”[5] Uncontrolled growth mechanisms of lipomas are not clear, but it has been proposed that the rupture of fibrous septa, which prevents the migration of fat tissue after blunt trauma may result in the proliferation of adipose tissue. It has also been assumed that local inflammation secondary to trauma may induce differentiation of preadipocytes and disrupt the normal regulation of adipose tissue.[6] Giant lipomas may affect vital structures and cause pain and hypoesthesia secondary to compression and lipedema. Sarcomatous transformation of giant tumors has been reported in the literature, and differentiation of giant lipomas from liposarcomas is required.[7],[8] Distinction between lipoma and atypical lipomatous tumor (ALT) and liposarcomas often represents a challenge. The presence of thick and irregular/nodular septa in magnetic resonance imaging is traditionally described in ALT and liposarcomas.[9]

Computerized tomography and magnetic resonance imaging as well as fine-needle biopsy or incisional biopsy can be used for selected cases. Total excision is the gold standard treatment for giant lipomas. Although liposuction is also mentioned in the literature for the treatment of lipomas, recurrence is an important issue due to residual lesion content.[10]

Fibroepithelial polyps are benign tumors that can be found on the natural creases of the body such as the groin, axilla, and neck. Dimensions usually range between 1–2 mm and 1–2 cm, but giant fibroepithelial polyps have been reported. A 40 cm × 25 cm tumor has been reported by Gupta et al.[11] Differential diagnosis include leiomyoma, sarcoma, and pedunculated neurofibromas.[12]

Pilar cysts or trichilemmal cysts (TCs) are thought to be derived from the outer sheet of hair follicles.[2] There is a female dominance in this tumor and comprises approximately 20% of epithelial cysts; the other 80% are epidermoid. Some authors have reported that trauma or inflammation may induce epithelial proliferation, especially in patients who have malfunction of p53 tumor suppression gene activity which results in proliferative trichilemmal tumors (PTTs) or malign PTTs.[3],[13],[14] As PTTs usually have more atypical behavior such as malignancy, the clinical differential diagnosis from TCs must be undertaken. Other differential diagnoses include squamous cell carcinoma, pilomatrixoma, and sweat gland tumors.[3]

Epidermal cysts or epidermoid cysts are benign tumors derived from pilosebaceous unit occlusion and migration of epidermal cells to the dermal layer. The majority, about 80% of the epithelial cysts, are of epidermal type.[15] Five centimeter or greater cysts have been describes as “giant.”[16],[17] Although malignant transformation is rarely seen, the features that would help in differentiating proliferating epithelial cyst from squamous cell carcinoma include the clinical presentation of a slow-growing subepidermal cystic tumor, origin from a preexisting cyst, and lack of evidence of origin from a premalignant epidermal lesion, such as actinic keratosis or Bowen's disease. A biopsy must be undertaken to rule out malignancy.[18] Total excision is the treatment for epidermal cyst and 3% recurrence might still be observed.

Xanthomas are often presented as a cosmetic problem but may also be a sign of more severe cardiac and metabolic problems. There are numerous entities and syndromes describing subcutaneous cholesterol deposits and xanthomas, and one of the most significant is familial dyslipidemia.[19] Xanthomas can be classified tuberous (on joint surface), tendinous, planar, palmar, and plantar based on the location.[20] Very few cases of familial hypercholesterolemia have been reported in the literature with giant xanthomas located in the gluteal region like the case of xanthoma in our report.[21]

Cutaneous lymphoid hyperplasia or pseudolymphoma occurs as a result of a benign inflammatory process against antigens. The clinical presentation is often in the form of skin-colored or red nodular lesions on the face and trunk and can be observed as multiple or diffuse lesions.[22] In addition to surgical treatment, topical steroids, intralesional steroids, cryotherapy, photochemotherapy, and local radiation therapy are among the treatment options.[23]


  Conclusion Top


Clinical follow-up is an option for patients presenting to the clinic with asymptomatic lesions that are small in size. However, a detailed history and examination along with total excision and histopathological examination should be planned in patients with rapid progression or with benign skin tumors of giant size.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nakamura Y, Teramoto Y, Sato S, Yamada K, Nakamura Y, Fujisawa Y, et al. Axillary giant lipoma: A report of two cases and published work review. J Dermatol 2014;41:841-4.  Back to cited text no. 1
    
2.
Satyaprakash AK, Sheehan DJ, Sangüeza OP. Proliferating trichilemmal tumors: A review of the literature. Dermatol Surg 2007;33:1102-8.  Back to cited text no. 2
    
3.
Khaled A, Kourda M, Fazaa B, Kourda J, Ben JilaniS, Kamoun MR, et al. Malignant proliferating trichilemmal cyst of the scalp: Histological aspects and nosology. Pathologica 2011;103:73-6.  Back to cited text no. 3
    
4.
Harrington AC, Adnot J, Chesser RS. Infiltrating lipomas of the upper extremities. J Dermatol Surg Oncol 1990;16:834-7.  Back to cited text no. 4
    
5.
Sanchez MR, Golomb FM, Moy JA, Potozkin JR. Giant lipoma: Case report and review of the literature. J Am Acad Dermatol 1993;28:266-8.  Back to cited text no. 5
    
6.
Meggitt BF, Wilson JN. The battered buttock syndrome – Fat fractures. A report on a group of traumatic lipomata. Br J Surg 1972;59:165-9.  Back to cited text no. 6
    
7.
Phalen GS, Kendrick JI, Rodriguez JM. Lipomas of the upper extremity. A series of fifteen tumors in the hand and wrist and six tumors causing nerve compression. Am J Surg 1971;121:298-306.  Back to cited text no. 7
    
8.
Takagi H, Kato K, Yamada E, Suchi T. Six recent liposarcomas including largest to date. J Surg Oncol 1984;26:260-7.  Back to cited text no. 8
    
9.
Brisson M, Kashima T, Delaney D, Tirabosco R, Clarke A, Cro S, et al. MRI characteristics of lipoma and atypical lipomatous tumor/well-differentiated liposarcoma: Retrospective comparison with histology and MDM2 gene amplification. Skeletal Radiol 2013;42:635-47.  Back to cited text no. 9
    
10.
Rubenstein R, Roenigk HH, Jr., Garden JM, Goldberg NS, Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol 1985;11:1070-4.  Back to cited text no. 10
    
11.
Gupta R, Smita S, Sinha R, Sinha N, Sinha L. Giant fibroepithelial polyp of the thigh and retroperitoneal fibromatosis in a young woman: A rare case. Skeletal Radiol 2018;47:1299-304.  Back to cited text no. 11
    
12.
Lim R, Jaramillo D, Poussaint TY, Chang Y, Korf B. Superficial neurofibroma: A lesion with unique MRI characteristics in patients with neurofibromatosis type 1. AJR Am J Roentgenol 2005;184:962-8.  Back to cited text no. 12
    
13.
Al-Khateeb TH, Al-Masri NM, Al-Zoubi F. Cutaneous cysts of the head and neck. J Oral Maxillofac Surg 2009;67:52-7.  Back to cited text no. 13
    
14.
Muslu Ü, Şenel E, Güney G. A case with a giant trichilemmal cyst. J Surg Dermatol 2018;3:173.  Back to cited text no. 14
    
15.
McGavran MH, Binnington B. Keratinous cysts of the skin. Identification and differentiation of pilar cysts from epidermal cysts. Arch Dermatol 1966;94:499-508.  Back to cited text no. 15
    
16.
Patel S, Tsoi KY, Joseph G. Giant epidermal cyst of the arm: A rare presentation. BMJ Case Rep 2018;11. pii: e227615.  Back to cited text no. 16
    
17.
Low SF, Sridharan R, Ngiu CS. Giant epidermal cyst with intramuscular extension: A rare occurrence. BMJ Case Rep 2015;2015. pii: bcr2013202534.  Back to cited text no. 17
    
18.
Sau P, Graham JH, Helwig EB. Proliferating epithelial cysts. Clinicopathological analysis of 96 cases. J Cutan Pathol 1995;22:394-406.  Back to cited text no. 18
    
19.
Pietroleonardo L, Ruzicka T. Skin manifestations in familial heterozygous hypercholesterolemia. Acta Dermatovenerol Alp Pannonica Adriat 2009;18:183-7.  Back to cited text no. 19
    
20.
Song JW, Ersahin D, Much MA, Thomson JG, Smitaman E. An exceptional case of xanthomatous infiltration of the musculoskeletal and integumentary systems. Skeletal Radiol 2015;44:1181-7.  Back to cited text no. 20
    
21.
Dwivedi S, Aggarwal A, Sharma V, Dwivedi G. Images in cardiovascular medicine: Giant gluteal xanthomas. Circulation 2010;121:1866-7.  Back to cited text no. 21
    
22.
Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998;38:877-95.  Back to cited text no. 22
    
23.
Albrecht J, Fine LA, Piette W. Drug-associated lymphoma and pseudolymphoma: Recognition and management. Dermatol Clin 2007;25:233-44.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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