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Differential diagnosis of soft scalp lumps

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Lawrence Leung at University of Ottawa
Lawrence Leung
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A 56-year-old man presented with a painless cyst on the top of his head which has been increasing in size in the last 6 months. Due to his learning disability, he could not be dissuaded from his belief that the lump was a sign of brain prolapse which led to increasing agitation in the next 2 weeks. A provisional diagnosis of benign lipoma was made and prompt excision was performed in his best interests. The lesion was more cystic and fluctuant than that of a lipoma and hence it was sent for histological diagnosis. The report came back as a trichilemmal cyst with no signs of proliferation. Cosmetic outcome was reasonable at follow-up after 3 months. The patient was scheduled for regular review every 6 months.
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BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4492 1 of 4
BACKGROUND
Painless soft tissue masses on the scalp are commonly
encountered in clinical practice. The most likely diag-
noses still remain as epidermoid cysts, sebaceous cysts and
benign lipomas. However, clinicians should be cognisant
of other possible, though uncommon, pathologies as dif-
ferential diagnoses. We hereby present a case of soft scalp
mass which was mis-diagnosed as benign lipoma until
clarifi ed by histological confi rmation to be trichilemmal
cyst, a relatively common condition known to carry prolif-
erative and malignant potential in rare cases.
CASE PRESENTATION
A 56-year-old patient with learning disability presented
with a lump at top of his head. Due to problems in com-
munication, history was obtained from his mother who
had been living together with the patient since his birth.
The lump appeared when patient was in his late teens, and
had never been painful, infected or bled. It remained the
size of a cherry and it had increased in size in the last 6
months. Patient was unaware of the lump until someone
commented on it. Despite repeated assurance from his
mother, patient became nervous with frequent agitation,
thinking that it is a punishment from God and he would
soon meet his demise. He had no history of trauma or
developmental defect to his head and he takes losartan
and hydrochlorothiazide for his hypertension. He had no
personal or family history of solid tumours. On examina-
tion, there is a solitary 4×4 cm spherical mass arising from
the vertex of his skull. The mass is soft and fl uctuant and
partially trans-illuminable. The surface consisted of normal
looking skin of the near-alopecic scalp with no discoloura-
tion, cicatration or punctum. The mass was non-pulsatile
and non-tender on palpation ( fi gure 1 ). A provisional diag-
nosis of lipoma was made and when the benign nature of
the lesion was explained to the patient; his mother elected
to observe the lesion. Two weeks later, patient returned
in an extremely distressed state and pleaded for an opera-
tion to prevent ‘his brains from sticking out’. In view of
the patient’s inability to comprehend the situation, it was
decided that the mass be removed in the best interests of
the patient. The patient was offered the choice between
Reminder of important clinical lesson
Differential diagnosis of soft scalp lumps
Lawrence K Leung
Department of Family Medicine, Queen’s University, Kingston, Canada
Correspondence to Dr Lawrence K Leung, leungl@queensu.ca
Summary
A 56-year-old man presented with a painless cyst on the top of his head which has been increasing in size in the last 6 months. Due to his
learning disability, he could not be dissuaded from his belief that the lump was a sign of brain prolapse which led to increasing agitation in the
next 2 weeks. A provisional diagnosis of benign lipoma was made and prompt excision was performed in his best interests. The lesion was
more cystic and fl uctuant than that of a lipoma and hence it was sent for histological diagnosis. The report came back as a trichilemmal cyst
with no signs of proliferation. Cosmetic outcome was reasonable at follow-up after 3 months. The patient was scheduled for regular review
every 6 months.
Figure 1 Soft fl uctuant cystis mass measuring 4×4 cm arising
from the vertex of the scalp.
Figure 2 Elliptical excision of skin marked out to facilitate better
wound closure.
BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4492
2 of 4
a plastic surgery procedure (guaranteed cosmesis), or an
offi ce procedure (possible cicatration). Due to the long
waiting time (up to 12 months) for plastics referral, patient
opted for the latter.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis of trichilemmal cysts includes epi-
dermoid cysts, benign lipomas, spindle cell lipoma, hiber-
nomas and liposcarcoma. Epidermoid cysts broadly refer
to cystic lesions that rise from invagination of the epi-
dermis into deeper layers either accidentally or iatrogeni-
cally, as a complication of hair transplantation.
1 Though
considered benign and slow-growing, epidermoid cysts
of the scalp are known to be associated with perforation
of the skull
2 and even the dura and the brain.
3 Sebaceous
cysts arise from cystic dilatation of the secretory glands
of the hair follicles and in fact should be distinct from
epidermoid cysts. However, in our medical literature,
epidermoid cysts are often used synonymously and inter-
changeably with sebaceous cysts. Due to the semisolid
contents, both epidermoid cysts and sebaceous cysts are
often fi rmer to touch and less spherical in shape then
truly fl uid fi lled cysts. Due to the intrinsic anatomy of
the scalp and face, benign lipomas are relatively uncom-
mon with a case prevalence of 2%–14%.
4 They are usu-
ally slow-growing and often ellipsoid rather than round
on the scalp. Spindle cell lipoma is a variant of common
lipomas which consists of signifi cant fi brous tissue com-
posing of spindle cells among the mature adipocytes.
5
Most spindle cell lipomas are under 5 cm in diameter but
can exceed 40 cm.
6 Hibernomas are rare tumours thought
to arise from the developmental remnants of brown
adipose tissues. They often present as non-tender slow-
growing masses with increased localised temperature.
7
Hibernomas can grow to sizes of 5–10 cm in diameters
with a preferred site at the thighs, interscapular area, the
neck and the scalp.
8
9 Although rare, liposarcomas of the
scalp have been reported which were mostly the myxoid
subtypes.
10
11 They can mimic infected benign sebaceous
cysts with their rapid growth and possible tissue necrosis.
Diagnosis with fi ne-needle aspiration or local biopsy is
known to be diffi cult as well-differentiated liposarcomas
may look similar to benign lipomas.
12
13
TREATMENT
The lesion was infi ltrated with 2% lidocaine containing
1:10 000 norepinephrine. Due to ballooning effect of the
lesion, an elliptical strip of skin was excised as the cyst was
removed en bloc ( fi gures 2 and 3 ). There was moderate
tethering of the base to the underlying fascia which upon
separation, led to profuse bleeding initially. Using elec-
trodessication from a hyfrecator and subsequent prompt
suturing, adequate haemostasis was eventually achieved.
There was moderate tissue and cutaneous swelling when
the suture was complete ( fi gure 4 ). The wound was given
a light dressing, and patient was observed in the waiting
room for an hour before being sent home.
OUTCOME AND FOLLOW-UP
Sutures were removed after 10 days with satisfactory heal-
ing of the wound. When reviewed after 3 months, there
was mild degree of cicatration at the site of excision ( fi gure
5 ). Nevertheless, patient was not concerned by the cos-
metic effects and repeatedly expressed gratitude to us for
‘putting his brains back in’! Given the cystic nature of the
lesion and the obvious lack of lobulation in appearance, the
author queried the diagnosis of lipoma, hence the lesion
was sent off for histology. Indeed, histology report con-
fi rmed the diagnosis of trichilemmal cyst with no signs of
active cell proliferation. In view of the low risks of malig-
nancy for this patient, no further action was considered
necessary. Patient was scheduled for routine review every
6-months thereafter.
DISCUSSION
Trichilemmal (pilar) cysts and the commoner epidermoid
(sebaceous) cysts are the two types of cutaneous cysts
found in the hair bearing area that arise from different parts
of the hair follicle unit, with a prevalence ratio of 1:4.
14 In
earlier days, all cutaneous cysts were erroneously referred
to as sebaceous cysts until Pinkus
15 pointed out in 1969 that
trichilemmal cysts arise from the outer root sheath of the
isthmus of the follicle, whereas sebaceous cysts arise from
the follicular infundibulum and hence are distinct entities.
Trichilemmal cysts usually occur in the hair bearing areas
with a predisposition for the scalp, neck, trunk and gluteal
Figure 3 Cystic mass removed en bloc with the ellipse of skin. Figure 4 Wound closed with adequate haemostasis albeit
moderate degree of cutaneous oedema.
BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4492 3 of 4
region. They have a female dominance and with an age
preponderance of over 60 years
16 and occasionally reached
extreme sizes of over 8 cm in diameter.
17
18 Trichilemmal
cysts are usually solitary lesions and can increase in size
over time. They may partially rupture leading to low-grade
infl ammation due to the cystic contents. Though rare, pro-
liferative forms of trichilemmal cysts have been reported
which mimic squamous cell carcinomas histologically
19
20
and may eventually progress to true local malignancy
20
–
22
and even metastases.
23
24 Some studies even suggested that
the metastatic potential of proliferative trichilemmal cysts
may even exceed that of squamous cell carcinomas.
14
25 In
our case, whether the preoperative diagnosis was a lipoma
or trichilemmal cyst would in fact make no difference in
our surgical management of excision. However, it would
be necessary to confi rm if there is a proliferative or malig-
nant potential if it is turns out to be a trichilemmal cyst, as
it would affect the postoperative management and overall
prognosis.
Learning points
▶ Soft tissue masses of the head and neck are
commonly encountered in general practice.
Benign lipomas, epidermoid cysts and sebaceous
▶
cysts remain as the most common diagnoses.
Excision of lesions from the scalp can lead to profuse
▶
bleeding and adequate haemostasis must be ensured.
Trichilemmal cyst usually presents as a slow-growing
▶
painless lump with cystic fl uctuant consistency.
Though rare, proliferative forms of trichilemmal cysts
▶
have been reported which mimic squamous cell
carcinomas.
Practising clinicians should be aware of trichilemmal
▶
cysts as a possible differential diagnosis when
approaching soft tissue masses of the head and neck,
and to exclude malignant potential which will affect
prognosis and management.
Competing interests None.
Patient consent Obtained.
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Figure 5 Review of patient after 3 months with mild cicatration
at site of cyst excision.
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... The scalp mass was removed en bloc after preparing an elliptical design in the same way as for the removal of a benign cystic mass [13]. In contrast to the resection of a benign cystic mass, fibrous tissues around the scalp mass were removed until fresh tissue was obtained when removing the mass en bloc. ...
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Article
  • Jun 2001
Hibernoma, an uncommon tumor of brown fat, has been described only in a few case reports and small series. The authors reviewed 170 cases of hibernoma and evaluated the morphologic features and the behavior of this tumor. The records from the Soft Tissue Registry of the Armed Forces Institute of Pathology from 1970 were searched for cases coded as "hibernoma." Clinical information and available slides from 170 hibernomas were reviewed. Immunohistochemical staining for S-100 and CD34 was performed on select cases. Follow-up information was obtained from the patients' medical records, the patients' physicians, and the patients themselves. Of 170 patients with hibernoma, 99 were men and 71 were women. The tumor occurred most commonly in adults, with a mean age of 38.0 years (age range, 2-75 years). Nine tumors occurred in pediatric patients. The most common anatomic locations included the thigh (n = 50), shoulder (n = 20), back (n = 17), neck (n = 16), chest (n = 11), arm (n = 11), and abdominal cavity/retroperitoneum (n = 10). The average duration of the tumor was 30.6 months. Tumor size ranged from 1 to 24 cm with an average dimension of 9.3 cm. All tumors were composed partly or principally of coarsely multivacuolated fat cells with small, central nuclei and no atypia. Four morphologic variants of hibernoma were identified: typical, myxoid, spindle cell, and lipoma-like. "Typical" hibernoma (n = 140) included eosinophilic cell, pale cell, and mixed cell types based on the tinctorial quality of the hibernoma cells. The myxoid variant (n = 14) contained a loose basophilic matrix. Spindle cell hibernoma (n = 4) had features of spindle cell lipoma and hibernoma; all occurred in the neck or scalp. The lipoma-like variant (n = 12) contained only scattered hibernoma cells. Immunohistochemically, 17 of 20 cases (85%) were positive for S-100 protein. Only one hibernoma of 20, a spindle cell variant, was positive for CD34, whereas other hibernoma variants were negative. Follow-up was obtained for 66 cases (39%) over a mean period of 7.7 years (range, 6 months-28 years). None of the patients with follow-up had a recurrence or metastasis, including eight with intramuscular tumors. No patient died of disease. Hibernoma is a tumor found most often in adults and most commonly in the thigh, with several morphologic variants. It is a benign tumor that does not recur with complete excision. Hibernomas should not be confused with atypical lipomas or well-differentiated liposarcoma.
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Epidermoid cyst with perforation of the skull
Article
  • Nov 2003
  • J AM ACAD DERMATOL
A rare case of an epidermoid cyst associated with a skull defect is reported. The patient was a 59-year-old healthy woman from Japan who exhibited an elastic, soft, subcutaneous tumor on the left side of the parietal scalp for approximately 10 years without a history of trauma. On radiographic findings, a punched-out lesion was shown. Computed tomography of the cranium revealed a mass on the left parietal side that adhered to the cerebrum through the bone defect. Surgical excision resulted in remission. The tumor was peridurally located and showed no adhesion to the dura mater encephali. Histopathologically, a hybrid epidermoid cyst with no malignant features was seen. We hypothesized that long-term continuous pressure by the cyst resulted in a bone defect called scalloping.
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Giant Trichilemmal Cyst at the Neck Region
Article
  • Jun 2009
  • J CRANIOFAC SURG
To compare the extensiveness and the effectiveness of anterograde and retrograde dissections in superficial parotidectomy for pleomorphic adenoma of the parotid gland, a review of medical records and pathology reports of consecutive patients who underwent superficial parotidectomy has been performed. The sizes of the overall pathologic specimen, the tumor within the specimen, and the normal parotid tissue obtained by anterograde and retrograde approaches have been compared. Mann-Whitney and χ2 tests have been used to reveal significant differences. Sixty-four patients were included in the study, 32 who underwent anterograde (standard) parotidectomy and 32 who underwent retrograde parotidectomy. Anterograde dissection resulted in a significantly larger size of the overall pathologic specimen as compared with retrograde parotidectomy (P = 0.019). The size of the tumor was nonsignificantly larger for patients undergoing standard parotidectomy (P = 0.174). Patients undergoing anterograde parotidectomy also had a significantly much larger volume of normal tissue removed in the course of extirpating the adenoma, as compared with patients undergoing retrograde parotidectomy (P = 0.008). Despite extracapsular dissection and partial superficial parotidectomy being proposed in the last years as conservative techniques, the optimal treatment of pleomorphic adenoma remains the superficial or total parotidectomy with facial nerve primary identification and preservation. Retrograde parotidectomy, reducing the extent of normal parotid gland removal, may permit a more conservative approach than standard parotidectomy, with the same complication rates and surgical effectiveness.
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Cervical hibernoma
Article
  • Sep 1976
The hibernoma is a rare neoplasm derived from vestigal remnants of brown fat left from early embryologic development. Review of the world literature reveals only 40 cases to which we are adding a report of a tumor arising in the posterior cervical triangle of a 20-year-old man. The distribution, histology and cytochemistry of brown fat and the hibernoma are discussed, and evidence supporting its histogensis is presented.
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The natural history of trichilemmal cysts
Article
  • May 1976
The histological features of 149 trichilemmal cysts removed from sixty-five patients are reviewed and related to the clinical findings. These cysts, which may be solitary or multiple, gradually increase in size and number, and may produce daughter cysts by budding. When a breach occurs in the wall, inflammatory cells pour in but do not replace the cyst wall. This event may be followed by healing from the margins of the breach, by marsupialization to the overlying epidermis and thus natural resolution, or by proliferation to produce a pseudo-epitheliomatous change which can be confused with a well differentiated squamous cell carcinoma.
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Facial and Scalp Lipomas: Case Reports and Study of Prevalence
Article
  • Nov 1985
  • J Dermatol Surg Oncol
Lipomas of the face and scalp are reportedly rare, comprising less than 2% of lipomas. Three such cases have recently been diagnosed in our clinic. Among 110 lipomas in our files, a total of 16 (14.5%) involved the face and scalp. The clinician rarely considered lipoma as the primary preoperative diagnosis. Often mistaken clinically for epidermal cysts, face and scalp lipomas appear more common than the literature would indicate.
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