|Year : 2021 | Volume
| Issue : 3 | Page : 151-152
Squamous cell carcinoma arising in a verrucous cyst-like lesion: A case report
Chi-Hsuan Chen, Chao-Chun Yang, Yu-Yun Lee, Yin-Yu Ho
Department of Dermatology, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
|Date of Submission||26-May-2021|
|Date of Decision||10-Jun-2021|
|Date of Acceptance||16-Jun-2021|
|Date of Web Publication||20-Sep-2021|
Dr. Yin-Yu Ho
Department of Dermatology, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chen CH, Yang CC, Lee YY, Ho YY. Squamous cell carcinoma arising in a verrucous cyst-like lesion: A case report. Dermatol Sin 2021;39:151-2
Follicular infundibular cysts or epidermoid cysts are the most common cutaneous cysts, accounting for 85%–90% of all cysts that were removed for histopathology. However, only a small number of epidermoid cysts undergo malignant transformation. A limited number of clinical cases have reported malignant transformation of epidermoid cysts into squamous cell carcinoma (SCC), basal cell carcinoma, Paget's disease, Bowen's disease, mycosis fungoides, Merkel cell carcinoma, Bowenoid papulosis, and melanoma.,,
We presented a 69-year-old healthy male with a nodular lesion on the right flank for about 20 years. The lesion became erythematous, accompanied by pain, swelling, local heat, and pus discharge over the past 2 years. Therefore, the patient sought medical treatment at our dermatology clinic. The symptoms totally subsided after oral antibiotic therapy. One year later, pain recurred locally. Physical examination revealed a movable, round, skin-colored subcutaneous tumor on the right flank, measuring 3 cm in diameter [Figure 1a]. The clinical diagnosis was epidermoid cyst. The lesion on the right flank was excised. The histopathology showed irregular hyperplasia of the cyst wall with proliferation of atypical keratinocytes containing enlarged hyperchromatic vesicular nuclei and prominent nucleoli, as well as focal dermal invasion [Figure 1b-d]. Based on these findings, well-differentiated SCC arising in a verrucous cyst-like lesion was diagnosed. A wide excision was then performed with 5 mm surgical margin and histopathology showed that the malignant tumor was completely removed. The patient had been followed every 3 months for 1 year, and no signs of recurrence or metastasis were found.
|Figure 1: (a) One 3 cm round, coin-sized, poorly-defined and skin-colored nodule over the right flank for 20 years. (b-d) The histopathology reveals a cystic tumor characterized by irregular hyperplasia of the cyst wall with proliferation of atypical keratinocytes with enlarged hyperchromatic vesicular nuclei and prominent nucleoli. Part of the cyst wall shows hypogranulosis and hints of koilocytosis. Focal dermal invasion of the atypical keratinocytes is visible in the underlying dermis where there is a dense mixed inflammatory infiltrate consisting of small lymphocytes, plasma cells, eosinophils and neutrophils.|
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Both epidermoid cysts and SCC are common. However, it is rare for epidermoid cysts to undergo malignant transformation to SCC. The most popular theory is that a continuous chronic inflammatory process can stimulate malignant transformation.,,,,, A statistical report shows that the incidence of SCC originating from epidermoid cysts is 0.011%–0.045%., Twenty relevant cases (SCC originated from epidermoid cysts) from 14 reports in the literature from 2007 to 2019 and the present case (total of 21 cases) were reviewed and summarized in [Supplementary Table 1]. The average age of the patients, when malignant transformation of epidermoid cysts was diagnosed, was 64.4 years (ranges from 41 to 89 years), with males accounting for 66.7% of the cases. The most common location was the head and neck (47.6%). The average size of the tumor was 3.3 cm in diameter (range from 0.4 cm to 13 cm). The lesion persisted from 2 weeks to 40 years. Most SCCs were well-differentiated; only two were moderately differentiated. All the patients underwent wide local excision. Histopathological examination confirmed that there were no residual malignant tumors. Most of the patients had no recurrence during the follow-up period and only 1 patient had metastasis to the lung 5 months later.
The primary treatment for epidermoid cysts with malignant transformation is wide local excision. The margin of excision depends upon the depth of tumor invasion, tumor size, degree of differentiation, perineural invasion, and the presence of metastasis. For high-risk tumors, current guidelines recommend surgical excision with margins of 4–6 mm.,
It is uncommon for benign epidermoid cysts to transform into malignant SCC, and there is no specific diagnostic clue to identify the malignant change in an epidermoid cyst. However, the following clinical changes can be considered as risk factors or warning signs for possible malignant transformation, including human papillomavirus infection, immunosuppression, actinic damage, large epidermoid cysts, recurring lesions, a rapid increase in size, fistula formation or continuous pus discharge, no improvement after medical treatment, and heterogeneous components found in the cyst.,,,, Primary SCC combined with cystic changes should be differentiated from an epidermoid cyst undergone malignant transformation by the connection to overlying epidermis. In our case, the malignant change was confined to the cystic lesion in the dermis and not connected to the epidermis, indicating that the SCC arised from the epidermoid cyst. Physicians, especially dermatologists, should be aware of the possible malignant transformation in an epidermoid cyst and a prompt excision of the suspicious lesion is recommended.
This study was approved by the institutional review board of National Cheng Kung University Hospital (approval number: B-EC-110-002, approval date: 2021/01/22).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
Prof. Chao-Chun Yang and Prof. Yu-Yun Lee, editorial board members at Dermatologica Sinica, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
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