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 Table of Contents  
IMAGES IN ACADEMIC MEDICINE
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 325-327

An image of cutaneous squamous cell carcinoma derived from complex epidermoid cyst in a 65-year-old male


Department of Family Medicine at Warren Hospital, St. Luke's University Health Network, Phillipsburg, New Jersey, USA

Date of Web Publication9-Jan-2018

Correspondence Address:
Dr. Kristine V Cornejo
St. Luke's Warren Family Medicine Residency, St. Luke's University Health Network, 755 Memorial Parkway, Suite 300, Phillipsburg, New Jersey 08865
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_23_17

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  Abstract 


An epidermal cyst is a benign intradermal lesion and may occur anywhere in the body. Carcinoma arising in a preexisting epidermal cyst is uncommon. Cutaneous squamous cell carcinoma is the second most common form of nonmelanoma skin cancer. A 65-year-old male with light skin pigmentation presented with chronic lower back pain secondary to a large “cauliflower-like” mass over his left flank, which started out as a “cheesy tumor” 20 years ago. The patient reported that the mass had recently begun to drain foul-smelling mucous and bloody discharge and was growing in size. This image illustrates the importance of proper comprehensive biannually or annually history and physical examination as screening tools for skin cancer. Primary care physicians are encouraged to educate their patients on the use of sunscreen containing zinc oxide and conducting regular self-examinations.
The following core competencies are addressed in this article: Medical knowledge, Patient care.

Keywords: Cutaneous squamous cell carcinoma, epidermoid cyst, preventive medicine, skin cancer


How to cite this article:
Cornejo KV, Anmolsingh R, Liang N, Chu CH, Buch RS. An image of cutaneous squamous cell carcinoma derived from complex epidermoid cyst in a 65-year-old male. Int J Acad Med 2017;3:325-7

How to cite this URL:
Cornejo KV, Anmolsingh R, Liang N, Chu CH, Buch RS. An image of cutaneous squamous cell carcinoma derived from complex epidermoid cyst in a 65-year-old male. Int J Acad Med [serial online] 2017 [cited 2019 Jun 27];3:325-7. Available from: http://www.ijam-web.org/text.asp?2017/3/2/325/222468




  Introduction Top


65-year-old male with light skin pigmentation presented with chronic lower back pain secondary to a large “cauliflower-like” mass over his left flank which started out as a “cheesy tumor” 20 years ago. The patient reported that the mass had recently begun to drain foul-smelling mucous and bloody discharge and was growing in size. He stated that he had not been seen by a medical professional in over 20 years. The patient reported an extensive history of sun exposure due to his occupation as a farmer. He also reported a history of hypertension but had not been noncompliant with his medication. He reported a history of alcohol (EtOH) abuse (12 pack of 12oz beer daily for 20+ years) and smoked 2 PPD cigarettes for 50+ years. On a review of systems, he reported 1-month history of light-headedness, visual disturbances, unstable gait, and slurred speech.


  Image Presentation Top


On physical examination, a foul-smelling, ulcerated fungating mass was found over the left flank area, measuring 3 cm × 8 cm × 7 cm with hyper-pigmented edges and serous drainage, which was tender to touch [Figure 1]. Computed tomography of the abdomen showed a 3.1 cm × 8.3 cm × 7.7 cm cutaneous mass in the left posterior abdominal wall that extended into the subcutaneous fat [Figure 2]. The diagnosis of invasive squamous cell carcinoma (SCC) well-differentiated (Grade I; Stage II-pT2, pNX) arising from proliferative epidermal cyst was made from the biopsied tissue [Figure 3]. The tumor was subsequently resected measuring 8.2 cm × 8.1 cm × 3.3 cm and the resected margin was 1.1 mm. He was subsequently referred to radiation oncology with the goal of reducing the risk of recurrence.
Figure 1: Fungating villous mass with mucopurulent discharge

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Figure 2: Left flank mass tissue resection hematoxylin and eosin stain demonstrating well-differentiated squamous cell carcinoma with keratinized pearls (black arrow)

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Figure 3: Computed tomographic scans showed 3.1 cm × 8.3 cm × 7.7 cm cutaneous mass (red circle) in the right posterior abdominal wall, extending into the subcutaneous fat

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  Discussion Top


An epidermal cyst is a benign intradermal lesion and may occur anywhere in the body.[1],[2] A carcinoma arising in a preexisting epidermal cyst is uncommon.[2],[3] Reported rates of malignant transformation of an epidermal cyst into cutaneous SCC (cSCC) range from 0.011% to 0.045%.[1],[2],[3] Most reported cases occurred on the head and neck, while other lesions were on the trunk or limb.[4],[5]

In this case, the patient's repeated exposure to ultraviolet (UV) light is the likely risk factor in the development of his cSCC. The second most common form of nonmelanoma skin cancer is cSCC, and nonmelanoma skin cancer is the most common cancer affecting humans.[6],[7] The major risk factor for cSCC development is exposure to UV radiation.[8] UV-B radiation from sunlight is predominantly responsible with UV-A contributing an added risk.[6],[7],[8] UV light causes mutations to develop in DNA typically in the p53 tumor suppressor gene.[3] A comprehensive history and physical examination are screening tools that a primary care physician should be conducting biannually or annually, according to patient's potential risk.[6],[8] Information pertaining to UV sunlight exposure during childhood, occupational exposure to carcinogenic materials, prior history of cutaneous cancer, and prior UV radiation exposure or history of immunosuppressive therapy should be elicited from patients.[8] Primary care physicians are encouraged to educate their patients on the use of sunscreen containing zinc oxide and conducting regular self-examinations.[8],[9] Furthermore, the site, size, and rate of tumor growth, differentiation and presence of neurologic symptoms among other features, differentiate between low- and high-risk lesions.[6],[8],[9] Treatment options for resectable masses include surgical excision, cryotherapy, topical therapy, radiation, or photodynamic therapy.[8],[9] Unresectable and metastatic cSCC is challenging in the absence of targeted therapies and associated with poor prognosis. Recently, dasatinib, a tyrosine kinase inhibitor, has been associated with significant reduction in viable cSCC cells in a time- and dose-dependent manner.[10]

Teaching points

  • Conduct comprehensive history and full body physical examinations on patients with increased risk of the development of skin cancer
  • Regularly monitor preexisting nonmalignant lesions yearly
  • Educate patients on the use of sunscreens containing zinc oxide and the performance of regular self-examinations
  • Emphasize that all resected cystic skin specimens should undergo further microscopic examination to avoid any misdiagnosis.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lin CY, Jwo SC. Squamous cell carcinoma arising in an epidermal inclusion cyst. Chang Gung Med J 2002;25:279-82.  Back to cited text no. 1
[PUBMED]    
2.
Chiu MY, Ho ST. Squamous cell carcinoma arising from an epidermal cyst. Hong Kong Med J 2007;13:482-4.  Back to cited text no. 2
[PUBMED]    
3.
López-Ríos F, Rodríguez-Peralto JL, Castaño E, Benito A. Squamous cell carcinoma arising in a cutaneous epidermal cyst: Case report and literature review. Am J Dermatopathol 1999;21:174-7.  Back to cited text no. 3
    
4.
Bhatt V, Evans M, Malins TJ. Squamous cell carcinoma arising in the lining of an epidermoid cyst within the sublingual gland – A case report. Br J Oral Maxillofac Surg 2008;46:683-5.  Back to cited text no. 4
[PUBMED]    
5.
Cameron DS, Hilsinger RL Jr. Squamous cell carcinoma in an epidermal inclusion cyst: Case report. Otolaryngol Head Neck Surg 2003;129:141-3.  Back to cited text no. 5
[PUBMED]    
6.
Brougham ND, Dennett ER, Cameron R, Tan ST. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol 2012;106:811-5.  Back to cited text no. 6
[PUBMED]    
7.
Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283-7.  Back to cited text no. 7
[PUBMED]    
8.
Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med 2001;344:975-83.  Back to cited text no. 8
[PUBMED]    
9.
Chartier TK, Aasi SZ. In: Stern RS, Robinson JK, Corona R, editors. Treatment and Prognosis of Cutaneous Squamous Cell Carcinoma. Wolters Kluwer; 2015. Available from: http://www.uptodate.com/contents/treatment-and-prognosis-of-cutaneous-squamous-cell-carcinoma. [Last accessed 2016 Apr 20].  Back to cited text no. 9
    
10.
Farshchian M, Nissinen L, Grénman R, Kähäri VM. Dasatinib promotes apoptosis of cutaneous squamous carcinoma cells by regulating activation of ERK1/2. Exp Dermatol 2017;26:89-92.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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