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\begin{document}

\title{An Unusual Presentation of Gaint Sebaceous Cyst over the Back: A Case
Report.}



\author[1]{Neel Doshi}%
\author[1]{Pratik Gond}%
\author[2]{Tanisha Prasad}%
\author[3]{Abhigan  Shrestha}%
\affil[1]{Pravara Institute of Medical Sciences (Deemed to be University)}%
\affil[2]{Royal College of Surgeons in Ireland}%
\affil[3]{M Abdur Rahim Medical Medical College Hospital}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\emph{Introduction:}

Sebaceous cysts, often known as epidermoid cysts, are keratin-containing
unilocular retention cysts. It frequently appears on the head, neck,
scalp, scrotum, earlobe, and breast, and can range in size from a few
millimetres to less than a few centimetres. When an epidermal cyst
exceeds more than 5 cm in diameter, it is considered a giant cyst. The
development of cancer is more likely in giant epidermal cysts, which are
uncommon.\textsuperscript{1}

Conventional sebaceous cysts are typically small, slowly expanding,
non-sensitive lesions with a dome shape. Unless it becomes infected or
enlarges to the point where it damages nearby anatomical structures, an
epidermal cyst is typically asymptomatic. Authors have previously
described enormous epidermal cysts with diameters greater than 5
cm.\textsuperscript{2,3}

A well-developed granular cell layer lines epidermoid cysts, which are
also lined by stratified squamous epithelium. On rare occasions, the
cyst wall may also contain pseudostratified ciliated columnar
epithelium. The cyst wall may have calcification of a dystrophic type.
The preferred course of action is excision. Studying the occurrence of
enormous sebaceous cysts was the goal.\textsuperscript{4}

Epidermal inclusion cysts, ganglion cysts, neurogenic tumors, myxoid
tumors, nodular fasciitis, and dermatofibrosarcoma protuberans are among
the possible diagnoses. The reported incidence of malignant degeneration
to squamous-cell carcinoma is 2.2\%. \textsuperscript{5}

The present study reported a case of a giant sebaceous cyst over the
posterior upper back in a 75-year-old male.

\emph{Case Report:}

A 75-year-old male patient came to the outpatient surgery department at
Pravara Rural Hospital in Loni complaining of a 5-year-old swelling that
had been gradually getting worse over the left upper back and shoulder
region. History showed that the swelling was approximately 1 cm in size
when he first noticed it a few months ago but gradually grew in size
until it reached a large one. For six months, he also experienced
discharge from the swelling.

An extensive multi-lobulated soft cystic swelling measuring 20 cm by 17
cm by 10 cm was found during a clinical examination of the swelling over
the left upper back and shoulder (Figure 1). There was a cream-coloured
discharge that had the consistency of butter and was oozing from the
swollen punctum.

The patient's ultrasound results showed a large, well-defined,
lobulated, heterogeneous hypoechoic lesion with numerous small
calcifications on the left upper back region (Figure 2). The Doppler
study revealed no internal vascularity or a solid component within the
swelling's underlying aetiology. In the subcutaneous plane of the
cervical region and upper back region on the left side, there was a
multi-lobulated area of altered signal intensity that measured roughly
8.5 10.4 14.8 cm (AP TR CC), appeared hyperintense on T2W and STIR
images, and appeared hyperintense on T1W images. DWI showed diffusion
restrictions in these regions. Indistinct fat planes with the trapezius
are visible anteriorly. The trapezius was displaced laterally,
anteriorly, and posteriorly over the skin as a result of this lesion. A
thin peripheral enhancement was discovered during the post-contrast
study. Fat in the vicinity seems normal. Findings that could point to
sebaceous cysts.

\emph{Management and Outcome:}

The specimen's histopathology revealed a cyst with a stratified squamous
epithelium lining that contained keratin (Figure 3). Histopathology has
not revealed any malignant changes. The patient was intubated under
general anaesthesia an oblique elliptical incision was made around the
swelling. Incision deepened up to the cyst wall and a total skin flap
was excised from the cyst and underlined muscle and haemostasis was
achieved. Romovac drain was inserted and the skin was closed with
Ethilon 2-0 mattress sutures(Figure 4). After the cystic mass has been
removed, excess skin is removed to promote primary closure and aesthetic
improvement. A day after surgery, the patient was released, and on the
third day of follow-up, there were no complaints. On the tenth
postoperative day, the stitches were removed after the wound healed
without any complications. At the follow-up examination at regular
intervals of 15 days, the authors found no local recurrence of the
lesion.

\emph{Discussion:}

Epidermoid cysts are benign, slow-growing, high, round, firm,
subcutaneous, or intradermal cysts that typically grow 1-5 cm in
diameter and are usually asymptomatic. It is noteworthy that an
epidermoid cyst with a diameter [?]5 cm is rare. \textsuperscript{6}

Rarely do giant sebaceous cysts or epidermoid cysts appear in surgical
practises. These are rare before puberty but can happen at any age.
Young adult males are the most common age of presentation. The face,
trunk, neck, scalp, scrotum, ear lobe, and breast are the most frequent
sites of occurrence, but occurrence at an unusual site is cause for
concern. \textsuperscript{4}

Epidermoid cysts with increased sizes are more brittle and prone to
secondary infection. Another crucial point is that the patient may
experience depression and anxiety due to the lesion's aesthetic
appearance if these enormous cysts appear in the head or neck due to the
high visibility of these areas. \textsuperscript{7}

A massive epidermal cyst, which is uncommon in surgical practice.
According to pathology, the cornified epithelium-lined epidermal cyst
has a distinctive granular layer, and lamellated keratin, and is not
calcified. There are three different types of lesions: 1) congenital
sequestration of surface ectoderm, 2) pilosebaceous unit occlusion, and
3) implantation of epidermal cells into the dermis as a result of
surgical intervention and puncturing injury.\textsuperscript{8}

In our case, there were no clinical indications of infection. Since
there was no nodal involvement and the lesion was benign, neoplastic
conditions were ruled out. Lipomas and salivary vascular lesions are
additional conditions to consider, but with the aid of a thorough
physical examination and additional tests like ultrasound, and MRI we
were able to rule out these other pathological conditions. Importantly,
there are reports of malignant changes in epidermoid cysts in the
literature. In our case, the pathology-analysed specimen revealed no
malignancy.

Although epidermoid cysts have a benign clinical course, there have been
a few isolated reports of basal cell carcinoma, squamous cell carcinoma,
epithelioid carcinoma, and other malignancies being linked to these
cysts. In order to ensure complete removal and prevent recurrence,
complete surgical removal is the preferred course of treatment. To get
good aesthetic results for giant epidermal cysts, redundant skin must be
removed.\textsuperscript{8}

A sebaceous cyst is completely removed along with its capsule as part of
the treatment. In one of the few cases to date presented in the
literature, the authors describe a rare instance of a massive epidermal
cyst that covered the back and required total excision. FNAC typically
makes a diagnosis. In order to establish the diagnosis in unusual
locations, MRI is a helpful adjunct. Simple excision is the preferred
procedure in uncomplicated cases, but regional perforator island flap
reconstruction has been used in patients with large epidermal cysts and
underlying medical conditions. The outcome of these flaps is determined
by the underlying illness and any coexisting
diseases.\textsuperscript{4,9}

\emph{Conclusion:}

Despite being a benign, slow-growing tumour, the epidermal cyst can make
diagnosis challenging. In this case, the authors show that a giant
epidermal cyst can grow for a long time and have negative effects on the
surrounding structures as well as serious cosmetic issues that may call
for mental health counselling. Therefore, for patients with a giant
epidermal cyst, early surgical excision is advised. We thus hope to add
to the existing body of scientific literature.

Data availability statement: Not applicable.

Funding statement: No funding was received for this study.

Conflict of interest disclosure: None declared.

Ethics approval statement: Not applicable.

Patient consent statement: Formal written consent was obtained from the
patient's parents for drafting this manuscript.

Permission to reproduce material from other sources: Not applicable.

Clinical trial registration: Not applicable.

Consent statement: Informed written consent has been taken from the
patient and will be provided on request.

Acknowledgement: No authors have been funded for this manuscript.

\emph{Author contribution:} All authors contributed equally.

\emph{References:}

\begin{enumerate}
\tightlist
\item
  1.Wani I, Jawaid H, Mir SR, Wani AM, Shah PS, Peerzada AH, et al.
  Giant epidermoid cysts OA Case Reports. 2013; 2(7):65
\item
  2. Kang SG, Kim CH, Cho HK, Park MY, Lee YJ, Cho MK. Two cases of
  giant epidermal cyst occurring in the neck. Ann Dermatol.
  2011;23(Suppl 1):S135--S138.
\item
  3. Golshan Momeni M, Anavim A, Lin F, Tehranzadeh J. Giant epidermal
  inclusion cyst of buttock. Skeletal Radiol. 2006;35:864--866.
\item
  4. Bansal N, Vergadia A, Mashke AN, Datey A. A rare case of a giant
  epidermal cyst over the back. Int J Res Med Sci 2020;8:1169-71.
\item
  5. Haflah MN, Kassim MA, Shukur HM. Giant Epidermoid Cyst of the
  Thigh, Malaysian Orthopaedic Journal. 2011; 5(3):17-9.
\item
  Gaetti Jardim, E. C., Masocatto, D. C., Oliveira, M. M., Macena, J.
  A., \& Teixeira, F. R. (2017). Epidermoid Cyst: Clinical and Surgical
  Case Report. Annals of Maxillofacial Surgery, 7(1), 151-154.
\item
  Park TW, Kim JK, Kim JR. Giant epidermal cyst in the posterior neck
  developing over 40 years: A case report. Exp Ther Med. 2014;7:287--9.
\item
  Kereh, David and Septiman, Septiman (2019) ''A Rare Presentation of A
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  The New Ropanasuri Journal of Surgery: Vol. 4 : No. 2 , Article 9.
  DOI: 10.7454/nrjs.v4i2.1052
\item
  Houdek MT, Warneke JA, Pollard CM, Lindgren EA, Taljanovic MS. Giant
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\end{enumerate}

Figure legend:

Figure 1: Multi-lobulated soft cystic swelling measuring 20 *17 *10 cm
swelling over the left upper back and shoulder

Figure 2: ultrasound results showed a large, well-defined, lobulated,
heterogeneous hypoechoic lesion with numerous small calcifications

Figure 3: histopathology revealed a cyst with a stratified squamous
epithelium lining that contained keratin.

Figure 4: Romovac drain was inserted and the skin was closed with
Ethilon 2-0 mattress sutures

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