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Epidermoid cyst of the cecum
Epidermoid By Fatih Andiran,
An epidermoid cyst girl who presented ultrasound scan During operation, wall
of the
cecum
Sabriye
of the cecum is reported with vague abdominal
showed a mass that was a subserosal cystic mass and
confirmed
Cyst of the Cecum
Day, Muzaffer Caydere, Ankara, Turkey
cystic in nature. was found in the
J Pediatr Surg 34:1567-7569. Saunders Company.
to be an epidermoid
cyst
CASE REPORT An S-year-old girl complained about periumbilical abdominal pain of 2 days’ duration. She had no vomiting, dysuria, or fever and normal bowel habits. On physical examination, there was no sign of acute abdomen. No mass within the abdomen could be palpable. Her white blood cell count was 9700/mm3, hemoglobin and hematocrit values were 13.2 g/dL and 40%, respectively. Her urine examination and plain abdominal radiographs were normal. Abdominal ultrasound scan showed a cysttc mass of approximately 3 cm in diameter in the right lower quadrant without connection to the adnexa. The patient underwent laparotomy. The exploration of the cecum showed a subserosal mass of 3 X 3 X 2 cm. in dimension on the antimesenteric side (Fig 1). The mass was excised totally without any connectton to the lumen (Figs 2 and 3). Appendectomy was performed. The histopathologic examination was confirmatory for an epidermoid cyst containing only keratin without any appendages of skin (Figs 4 and 5). The appendix was normal histopathologically. The postoperative recovery was uneventful.
DISCUSSION
Epidermoid cyst of the abdominal viscera is an uncommon condition. Except for cysts affecting the ovary, epidermoid lesions have been reported involving the spleen, kidneys, mesentery, tunica vaginalis, appendix, and the cecum.l-12 However, there has been no previous report of an epidemroid cyst of the cecum in children in the literature. Epidermoid cysts are lined by well-differentiated stratified squamous epithelium and enlarged by cellular proliferation and by desquamation of keratinized debris into the center of the cyst. Dermoid cysts are similar but
Surgery,
Vol34,
No 10 (October),
and UQur Dilmen
histopathologically. This is the first case of epidermoid the cecum in children reported in the literature.
PIDERMOID CYST of the cecum is extremely rare. The unpredicted origin and the nature of epidermoid and dermoid cysts in the pericecal region have been discussed in a few case reports.1-7 An epidermoid cyst of the cecum was encountered in an &year-old girl. We report the present case to discuss the origin and the peculiarity of this entity. To the best of our knowledge, this is the first case of an epidermoid cyst of the cecum in a child described in the literature.
of Pediatric
Dilmen,
in an 8-year-old pain. Abdominal
E
Journal
GijlCin
1999: pp 1567-1569
INDEX
WORDS:
Epidermoid
cyst,
Copyright
cyst
of
o 1999 by W.B.
cecum.
include dermal structures such as hair follicles, sweat, apocrine, and sebaceous glands, and may also contain hair and sebum. Epidermoid and dermoid cysts are neither inflammatory in nature nor true neoplasms. These cysts are generally accepted to be sequestration cysts that may be either congenital or acquired.13 The congenital epidermoid cysts relate to inclusion of ectodermal elements at the time of closure of the neural groove such as pericranial, intradiploic, intracranial, and intraspinal epidermoid cysts or when epithelial surfaces coalesce such as anorectal epidermoid cysts and ones found in head and neck. Acquired epidermoid cysts are either traumatic or iatrogenic or occlusive in origin and are caused by implantation of epidermis in locations favorable to growth. Sebaceous cysts are the occlusive type of epidermoid cysts that occur within the skin and subcutaneous tissues after plugging of the orifice of a hair follicle or sebaceous gland. However, there has been much controversy concerning the origin of these cysts in the cecum, which is an unlikely location for the occurrence of epidermoid and dermoid lesions. Two cases described in the literature have been attributed to iatrogenic implantations during an appendectomy of fragments of epidermis via scalpels, needles, or clamps at the time of the surgical procedure.1,3 However, in some other cases as in the current instance, no previous iatrogenic etiology can be found.2+7 The theories of metaplasia of the serosa caused by chronic inflammatory stimuli and heterotopic inclusion
From the Departments of Pediatric Surgery Radiology, and Pediatrics, Fatih University, Medical Faculty, and the Department of Pathology, Ankara Hospital, Ankara, Turkey. Address reprint requests to Fatih Andwan, MD, Fatih Universiry Medical Faculty, Depaninent of Pediatric Surgery, Ciftrik Cad. No: 57 Emek, Ankara. Turkey, 06510. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3410-0033$03.00/O
1567
ANDIRAN
Fig 1.
The subserosal
mass
of the cecum
Fig 2. The cystic mass of the cecum any connection to the lumen.
Fig 3. The cut surface material as keratin.
of the cyst
within
Fig 4. Stratified squamous epithelium of the cyst containing keratin without any skin appendages confirmed to be an epidermoid cyst of the cecum (H&E, original magnification x200).
is shown.
was excised
containing
totally
e very
ET AL
without
friable
within the organ remain insufficient to explain the occurrences of these cysts in the cecum.12J4-16There must also be another explanation for their predilection for the cecum instead of other portions of the intestines. Epidermoid and dermoid cysts of the cecum may arise from the right ovary. Remnants of ovarian tissue may well have been displaced to the region of the cecum during its embryogenic development. 1,4However, the occurrence of these cysts in boys without any acquired etiology refutes this theory.3J-7 So, a common etiologic event for the development of these congenital epidermoid or dermoid cysts peculiar to the cecum must have taken place in one of the embryological steps. Therefore, we propose that these congenital epidermoid or dermoid cysts of the cecum may have taken origin while the cecum re-enters the abdominal cavity as the last part of the gut in the process of intrauterine rotation17 and any inclusion or closure line of epidermal or dermal structures may result
Fig 5. Higher of the cyst with tion x400).
magnification congestion
of the stratified squamous in the vessels (H&E. original
epithelium magnifica-
CECAL
EPIDERMOID
1569
CYST
in the later development of these cysts. The fact that most occur in a subserosal location in the cecum also supports this concept. Because an epidermoid cyst of the cecum has now been
encountered in a child, pediatric surgeons also should consider this entity in the differential diagnosis of cysts within the abdomen, and the cecum must be explored carefully during laparotomies.
REFERENCES 1. Pan A, Rogers AG, Klass AA: Epidermoid cyst of the cecum. Can Med Assoc J 84:1075,1961 2. Chandreviotis N: Epidermoid cyst of the cecum. JAMA 192:425426,1965
3. Pear BL, Wolff JN: Epidermoid cyst of the cecum. 207:1516-1517, 1969 4. Gowdy JM: Dermoid cyst of the cecum. Gastroenterology
JAMA 31:447-
450,1956
5. Finlay-Jones LR, Singh A, Minchin E: Dermoid cyst of the cecum. Med JAust 21377.378, 1973 6. Piserchia NE, Davey RB: Epidermoid cyst of the appendix. J Pediatr Surg 15674-675, 1980 7. Cotton MH, Blake JR: Dermoid cyst: A rare tumour of the appendix. Gut 27:334-336, 1986 8. Spencer NJ, Arthur RJ, Stringer MD: Ruptured splenic epidermoid cyst: Case report and imaging appearances. Pediatr Radio1 26:871-873, 1996
9. Panossian DH, Wang N, Reeves CD, et al: Epidermord cyst of the spleen presenting as a generalized peritonitis. Am Surg 56:295-298, 1990 10. James JF: Dermoid cysts of the mesentety. Am J Surg 65: 116,194I 11. Straube A: Mesenteric dermoid cysts. Chirurg 21:177, 1950 12. King ESJ: Metaplasia in tunica vaginalis. Aust NZ J Surg 24: 13 1, 1954 13. Pear BL: Epidennoid and dermoid sequestration cysts. Am J Roentgen01 Radium Ther Nucl Med 110: 148- 155, 1970 14. Teoh TB: The structure and development of Walthard nests. J Path01 Bacterial 66:433, 1953 15. Harding HE: A large inclusion cyst in a spleen. J Path01 36:485, 1933 16. Willis RA: Borderland of Embryology and Pathology. London, England, Butkroutz, 1962 pp 333-334 17. Williams PL, Warwick R: Gray’s Anatomy. Edinburgh, Churchill Livingstone, 1980, p 201
An epidermoid cyst girl who presented ultrasound scan During operation, wall
of the
cecum
Sabriye
of the cecum is reported with vague abdominal
showed a mass that was a subserosal cystic mass and
confirmed
Cyst of the Cecum
Day, Muzaffer Caydere, Ankara, Turkey
cystic in nature. was found in the
J Pediatr Surg 34:1567-7569. Saunders Company.
to be an epidermoid
cyst
CASE REPORT An S-year-old girl complained about periumbilical abdominal pain of 2 days’ duration. She had no vomiting, dysuria, or fever and normal bowel habits. On physical examination, there was no sign of acute abdomen. No mass within the abdomen could be palpable. Her white blood cell count was 9700/mm3, hemoglobin and hematocrit values were 13.2 g/dL and 40%, respectively. Her urine examination and plain abdominal radiographs were normal. Abdominal ultrasound scan showed a cysttc mass of approximately 3 cm in diameter in the right lower quadrant without connection to the adnexa. The patient underwent laparotomy. The exploration of the cecum showed a subserosal mass of 3 X 3 X 2 cm. in dimension on the antimesenteric side (Fig 1). The mass was excised totally without any connectton to the lumen (Figs 2 and 3). Appendectomy was performed. The histopathologic examination was confirmatory for an epidermoid cyst containing only keratin without any appendages of skin (Figs 4 and 5). The appendix was normal histopathologically. The postoperative recovery was uneventful.
DISCUSSION
Epidermoid cyst of the abdominal viscera is an uncommon condition. Except for cysts affecting the ovary, epidermoid lesions have been reported involving the spleen, kidneys, mesentery, tunica vaginalis, appendix, and the cecum.l-12 However, there has been no previous report of an epidemroid cyst of the cecum in children in the literature. Epidermoid cysts are lined by well-differentiated stratified squamous epithelium and enlarged by cellular proliferation and by desquamation of keratinized debris into the center of the cyst. Dermoid cysts are similar but
Surgery,
Vol34,
No 10 (October),
and UQur Dilmen
histopathologically. This is the first case of epidermoid the cecum in children reported in the literature.
PIDERMOID CYST of the cecum is extremely rare. The unpredicted origin and the nature of epidermoid and dermoid cysts in the pericecal region have been discussed in a few case reports.1-7 An epidermoid cyst of the cecum was encountered in an &year-old girl. We report the present case to discuss the origin and the peculiarity of this entity. To the best of our knowledge, this is the first case of an epidermoid cyst of the cecum in a child described in the literature.
of Pediatric
Dilmen,
in an 8-year-old pain. Abdominal
E
Journal
GijlCin
1999: pp 1567-1569
INDEX
WORDS:
Epidermoid
cyst,
Copyright
cyst
of
o 1999 by W.B.
cecum.
include dermal structures such as hair follicles, sweat, apocrine, and sebaceous glands, and may also contain hair and sebum. Epidermoid and dermoid cysts are neither inflammatory in nature nor true neoplasms. These cysts are generally accepted to be sequestration cysts that may be either congenital or acquired.13 The congenital epidermoid cysts relate to inclusion of ectodermal elements at the time of closure of the neural groove such as pericranial, intradiploic, intracranial, and intraspinal epidermoid cysts or when epithelial surfaces coalesce such as anorectal epidermoid cysts and ones found in head and neck. Acquired epidermoid cysts are either traumatic or iatrogenic or occlusive in origin and are caused by implantation of epidermis in locations favorable to growth. Sebaceous cysts are the occlusive type of epidermoid cysts that occur within the skin and subcutaneous tissues after plugging of the orifice of a hair follicle or sebaceous gland. However, there has been much controversy concerning the origin of these cysts in the cecum, which is an unlikely location for the occurrence of epidermoid and dermoid lesions. Two cases described in the literature have been attributed to iatrogenic implantations during an appendectomy of fragments of epidermis via scalpels, needles, or clamps at the time of the surgical procedure.1,3 However, in some other cases as in the current instance, no previous iatrogenic etiology can be found.2+7 The theories of metaplasia of the serosa caused by chronic inflammatory stimuli and heterotopic inclusion
From the Departments of Pediatric Surgery Radiology, and Pediatrics, Fatih University, Medical Faculty, and the Department of Pathology, Ankara Hospital, Ankara, Turkey. Address reprint requests to Fatih Andwan, MD, Fatih Universiry Medical Faculty, Depaninent of Pediatric Surgery, Ciftrik Cad. No: 57 Emek, Ankara. Turkey, 06510. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3410-0033$03.00/O
1567
ANDIRAN
Fig 1.
The subserosal
mass
of the cecum
Fig 2. The cystic mass of the cecum any connection to the lumen.
Fig 3. The cut surface material as keratin.
of the cyst
within
Fig 4. Stratified squamous epithelium of the cyst containing keratin without any skin appendages confirmed to be an epidermoid cyst of the cecum (H&E, original magnification x200).
is shown.
was excised
containing
totally
e very
ET AL
without
friable
within the organ remain insufficient to explain the occurrences of these cysts in the cecum.12J4-16There must also be another explanation for their predilection for the cecum instead of other portions of the intestines. Epidermoid and dermoid cysts of the cecum may arise from the right ovary. Remnants of ovarian tissue may well have been displaced to the region of the cecum during its embryogenic development. 1,4However, the occurrence of these cysts in boys without any acquired etiology refutes this theory.3J-7 So, a common etiologic event for the development of these congenital epidermoid or dermoid cysts peculiar to the cecum must have taken place in one of the embryological steps. Therefore, we propose that these congenital epidermoid or dermoid cysts of the cecum may have taken origin while the cecum re-enters the abdominal cavity as the last part of the gut in the process of intrauterine rotation17 and any inclusion or closure line of epidermal or dermal structures may result
Fig 5. Higher of the cyst with tion x400).
magnification congestion
of the stratified squamous in the vessels (H&E. original
epithelium magnifica-
CECAL
EPIDERMOID
1569
CYST
in the later development of these cysts. The fact that most occur in a subserosal location in the cecum also supports this concept. Because an epidermoid cyst of the cecum has now been
encountered in a child, pediatric surgeons also should consider this entity in the differential diagnosis of cysts within the abdomen, and the cecum must be explored carefully during laparotomies.
REFERENCES 1. Pan A, Rogers AG, Klass AA: Epidermoid cyst of the cecum. Can Med Assoc J 84:1075,1961 2. Chandreviotis N: Epidermoid cyst of the cecum. JAMA 192:425426,1965
3. Pear BL, Wolff JN: Epidermoid cyst of the cecum. 207:1516-1517, 1969 4. Gowdy JM: Dermoid cyst of the cecum. Gastroenterology
JAMA 31:447-
450,1956
5. Finlay-Jones LR, Singh A, Minchin E: Dermoid cyst of the cecum. Med JAust 21377.378, 1973 6. Piserchia NE, Davey RB: Epidermoid cyst of the appendix. J Pediatr Surg 15674-675, 1980 7. Cotton MH, Blake JR: Dermoid cyst: A rare tumour of the appendix. Gut 27:334-336, 1986 8. Spencer NJ, Arthur RJ, Stringer MD: Ruptured splenic epidermoid cyst: Case report and imaging appearances. Pediatr Radio1 26:871-873, 1996
9. Panossian DH, Wang N, Reeves CD, et al: Epidermord cyst of the spleen presenting as a generalized peritonitis. Am Surg 56:295-298, 1990 10. James JF: Dermoid cysts of the mesentety. Am J Surg 65: 116,194I 11. Straube A: Mesenteric dermoid cysts. Chirurg 21:177, 1950 12. King ESJ: Metaplasia in tunica vaginalis. Aust NZ J Surg 24: 13 1, 1954 13. Pear BL: Epidennoid and dermoid sequestration cysts. Am J Roentgen01 Radium Ther Nucl Med 110: 148- 155, 1970 14. Teoh TB: The structure and development of Walthard nests. J Path01 Bacterial 66:433, 1953 15. Harding HE: A large inclusion cyst in a spleen. J Path01 36:485, 1933 16. Willis RA: Borderland of Embryology and Pathology. London, England, Butkroutz, 1962 pp 333-334 17. Williams PL, Warwick R: Gray’s Anatomy. Edinburgh, Churchill Livingstone, 1980, p 201