Lipoma

Lipomas are the most common subcutaneous soft tissue tumors, with an annual incidence of
nearly 1 in 1000 persons. Lipomas are benign aggregates of slowly growing adipocytes.
These tumors usually occur on the trunk and extremities but can occur anywhere on the body.
Solitary lesions are the most common, but multiple lesions can occur, with higher frequency
in young males.

Lipomas present as soft, rubbery masses that can sometimes be well-circumscribed and other
times have indistinct palpable borders. They are usually not painful or tender, unless they
grow to compress an underlying nerve. They are noncompressible and do not transluminate,
making them easily distinguishable from a fluid-filled cyst. Most lipomas appear to be small,
smooth protuberances of the skin (1-2 cm), but they can present larger than 20 cm in diameter
and up to several kilograms.

The etiology of lipsomas is unclear. The tendency to develop a lipoma is not necessarily
hereditary, although hereditary conditions, such as familial multiple lipomatosis, may lead to
lipoma development. Controversy exists over the so-called posttraumatic lipoma (reported
cases in which minor injuries are alleged to have triggered the growth of a lipoma). However,
whether the trauma caused the lipoma or simply led to the detection of a preexisting lipoma is
unclear.

Lipomas are benign mesenchymal tumors derived from adipocytes. Microscopically, they are
composed of fatty tissue with interlacing muscle fibers. Fine-needle aspiration biopsies of a
lipoblastoma contain multivacuolated lipoblasts, myxoid areas, and a plexiform capillary
network.Several variants have been described. Adenolipomas, a variation of lipomas that may
occur in the breast, often have a marked fibrotic component. They are best regarded as
hamartomas. Angiolipomas contain many small vessels.

Small, asymptomatic lipomas require no treatment. However, definitive treatment is surgical

excision. Indications to excise lipomas vary but are largely performed for cosmetic reasons;
to evaluate their histology, particularly when liposarcomas must be ruled out; when they
cause symptoms; or when they grow and become larger than 5 cm (because larger lipomas
hold a small but increased risk of liposarcoma development). In certain cases, liposuction has
been used to remove large lipomas in anatomically sensitive locations.

Background
Lipomas are the most common soft-tissue tumor. These slow-growing,
benign fatty tumors form soft, lobulated masses enclosed by a thin, fibrous
capsule. Although it has been hypothesized that lipomas may rarely
undergo sarcomatous change, this event has never been convincingly
documented. It is more probable that lipomas are at the benign end of the
spectrum of tumors, which, at the malignant end, include liposarcomas (see
Pathophysiology).
Because more than half of lipomas encountered by clinicians are
subcutaneous in location, most of this article will be devoted to that
subgroup. Additional information about other locations (eg, intramuscular,
retroperitoneal, gastrointestinal [GI]) will be included as appropriate.
Pathophysiology
Lipomas are common benign mesenchymal tumors. They may develop in
virtually all organs throughout the body. The anatomy depends on the
tumor site. Subcutaneous lipomas are usually not fixed to the underlying
fascia. The fibrous capsule must be removed to prevent recurrence.
In the GI tract, lipomas present as submucosal fatty tumors. The most
common locations include the esophagus, stomach, and small intestine.
Symptoms occur from luminal obstruction or bleeding.
Duodenal lipomas are mostly small but may become pedunculated with
obstruction of the lumen. They may cause pain, obstructive jaundice,
or intussusception in younger patients. [1] Mucosal erosion over the lipoma
may lead to severe bleeding (see the image below). Small intestinal
lipomas occur mainly in elderly patients. They tend to be pedunculated
submucosal lesions. They are more common in the ileum than in the
duodenum or jejunum. As with duodenal lipomas, severe hemorrhage
or intussusception may occur.

Pathophysiology
Lipomas are common benign mesenchymal tumors. They may develop in
virtually all organs throughout the body. The anatomy depends on the
tumor site. Subcutaneous lipomas are usually not fixed to the underlying
fascia. The fibrous capsule must be removed to prevent recurrence.
In the GI tract, lipomas present as submucosal fatty tumors. The most
common locations include the esophagus, stomach, and small intestine.
Symptoms occur from luminal obstruction or bleeding.
Duodenal lipomas are mostly small but may become pedunculated with
obstruction of the lumen. They may cause pain, obstructive jaundice,
or intussusception in younger patients. [1] Mucosal erosion over the lipoma
may lead to severe bleeding (see the image below). Small intestinal
lipomas occur mainly in elderly patients. They tend to be pedunculated
submucosal lesions. They are more common in the ileum than in the
duodenum or jejunum. As with duodenal lipomas, severe hemorrhage
or intussusception may occur

Etiology
Speculation exists regarding a potential link between trauma and
subsequent lipoma formation. [9] One theory suggests that trauma-related
fat herniation through tissue planes creates so-called pseudolipomas. It has
also been suggested that trauma-induced cytokine release triggers pre-
adipocyte differentiation and maturation. To date, no definitive link between
trauma and lipoma formation has been prospectively demonstrated.
While the exact etiology of lipomas remains uncertain, an association with
gene rearrangements of chromosome 12 has been established in cases of
solitary lipomas, as has an abnormality in the HMGA2-LPP fusion gene. [10]
Epidemiology
Lipomas occur in 1% of the population. Most of these are small
subcutaneous tumors that are removed for cosmetic reasons. These
subcutaneous lipomas will be considered separately from lipomas in other
locations in the discussion below. In the intestine, lipomas constitute 16%
of benign, small neoplasms; this percentage is lower than that of
leiomyomas (18%) and higher than that of adenomas (14%).

Prognosis
The outcome and prognosis are excellent for benign lipomas. Recurrence
is uncommon but may develop if the excision was incomplete.
Pang et al compared outcomes in 238 patients who underwent total or
near-total (T/NT) resection for dorsal, transitional, or chaotic spinal cord
lipomas (with 16-year follow-up), along with complete reconstruction of the
neural placode, with results from 116 patients who underwent partial
resection for spinal cord lipomas (with 11-year follow-up). [11, 12]
Although in the T/NT and partial resection groups the rate of immediate
symptom stabilization or improvement was similar (more than 95%), the
combined cerebrospinal fluid leakage and wound complication rate was
only 2.5% for T/NT resections, compared with 6.9% for partial resections.
Moreover, the overall progression-free survival probability (Kaplan-Meier
analysis) was 82.8% for T/NT resection patients at 16 years postoperative,
compared with 34.6% for partial resection patients at 10.5 years post
operation. Evidence indicated that the superior results in the T/NT resection
patients were associated with the fact that lower cord-sac ratios were
achieved in these patients than in the partial-resection group. [11, 12]

History and Physical Examination

Lipomas are most often asymptomatic. When they arise from fatty tissue
between the skin and deep fascia, typical features include a soft, fluctuant
feel; lobulation; and free mobility of overlying skin. A characteristic
"slippage sign" may be elicited by gently sliding the fingers off the edge of
the tumor. The tumor will be felt to slip out from under, as opposed to a
sebaceous cyst or an abscess that is tethered by surrounding induration.
The overlying skin is typically normal.
Symptoms in other sites depend on the location and can include the
following:
 Lipomas in the major airways can cause respiratory distress related to
bronchial obstruction; patients may present with either endobronchial
or parenchymal lesions
  Previously undiagnosed lipomas of the oropharynx may also lead to
airway difficulty at the time of intubation
 Patients with esophageal lipomas can present with obstruction,
dysphagia, regurgitation, vomiting, and reflux; esophageal lipomas can
be associated with aspiration and consecutive respiratory infections
 Cardiac lipomas are located mainly subendocardially, are rarely found
intramurally, and are normally unencapsulated; they appear as a
yellow mass projecting into the cardiac chamber
 Intramediastinal lipomas may impinge on the superior vena cava,
thereby leading to superior vena cava syndrome
 Intestinal lipomas may manifest as classic obstruction,
intussusception, volvulization, or hemorrhage
 Lipomas arising from fat in the intramuscular septa cause a diffuse,
palpable swelling, which is more prominent when the related muscle is
contracted
 Lipomas in intra-articular joint spaces or intraosseous sites, such as
the calcaneus, may lead to joint dysfunction and pain that preclude
normal ambulation
 Lipomas may also arise in the dural or medullary components of the
spinal cord, thereby leading to cord compression and attendant
sequelae [7]
 Lipomas occur frequently in the breast but not as frequently as
expected considering the extent of fat that is present
 Lipomas may arise from the subcutaneous tissues of the vulva; they
usually become pedunculated and dependent

Complications
Subcutaneous lipomas are primarily cosmetic issues. Lipomas in other
locations may cause luminal obstruction or hemorrhage. The images below
show a duodenal lipoma that caused gastrointestinal hemorrhage and
required removal.
Duodenal lipoma resected through a duodenotomy. Overlying mucosa with central
ulceration removed and lobulated fatty tumor shelled out intact with capsule. The
mucosa was then sutured closed, and the duodenotomy closed. The stitch was
placed to orient the specimen for pathologic examination.

Diagnostic Considerations
Lipomas must be differentiated from other masses or tumors.
In the subcutaneous location, the primary differential diagnosis is a sebaceous cyst
or an abscess. Sebaceous cysts are also rounded and subcutaneous. They can be
differentiated from lipomas by their characteristic central punctum and the
surrounding induration. Treatment requires removal of a small ellipse of overlying
skin to avoid entering the cyst. Abscesses typically have overlying induration and
erythema. Incision and drainage is the appropriate management.
Hibernomas are uncommon tumors that arise from brown fat. They are also benign
but with a slightly greater tendency to bleed during excision and to recur if
intralesional excision is performed.
Atypical lipomatous tumors are considered to be well-differentiated liposarcomas.
They have a predilection for local recurrence but do not generally metastasize. This
diagnosis should be suspected when a fatty tumor is encountered in an
intramuscular or retroperitoneal location.
Liposarcomas are malignant tumors that arise from adipocytes. They may recur
locally and may metastasize. Fatty tumors of the retroperitoneum or in intramuscular
locations should be considered to be potential liposarcomas until proven otherwise.
In the breast, a lipoma will be mammographically radiolucent. It must be
differentiated from a similar benign tumor, a mammary hamartoma, and a
pseudolipoma (a soft-tissue mass that may surround a small, scirrhous cancer).
Conversely, lipomatous lesions in the adrenal gland that have calcifications on
radiologic examinations have been confused with teratoma. Many of these are
angiomyolipomas.
In the spermatic cord, a finger of retroperitoneal fat termed a "lipoma of the cord" is
frequently encountered during hernia repair. Removal is advocated to allow the
internal inguinal ring to be tightened around the cord and to minimize the risk of
recurrence of the hernia. During laparoscopic exploration for a palpable inguinal
mass, no identifiable peritoneal orifice may be found if the inguinal mass purely
consists of a lipoma of the cord.

Imaging Studies
For most subcutaneous lipomas, no imaging studies are required.
Lesions in the gastrointestinal (GI) tract may be visible on GI contrast
studies (see the image below).
Imaging studies for lipomas in atypical locations (or those for which the differential
diagnosis includes sarcoma) include ultrasonography, computed tomography (CT),
and magnetic resonance imaging (MRI). [14]
In a retrospective review of the use of ultrasonography by two musculoskeletal
radiologists to evaluate 714 superficial soft-tissue tumors, Hung et al reported a
sensitivity of 95.2% and a specificity of 94.3% for lipoma. [15]

When CT is employed, a radiodensity of less than 50 Hounsfield units is indicative of

a soft-tissue tumor composed of fat, though no reliable distinction can be made
between a benign lipoma and a malignant liposarcoma. [6]
MRI has been recommended as a reliable preoperative investigation. [16, 17, 18, 19, 6] It
has been employed in intramuscular lipoma, pediatric lipoblastomas, and others. The
findings of intramuscular lipomas, for example, range from small, homogeneous
masses to large, inhomogeneous lesions with infiltrative margins. However, like CT,
MRI does not allow an absolute, reliable distinction between a lipoma and a
liposarcoma. [20] A study by Thornhill suggested that the addition of computer-
assisted diagnosis may improve the ability of MRI to make this distinction. [21]
Because all lipomas are radiolucent, soft-tissue radiography can be diagnostic, but it
is indicated only when the diagnosis is in doubt.
Biopsy
Biopsies are normally not indicated for small subcutaneous lesions,
because the entire tumor is usually removed. All imaging techniques have
been combined with fine-needle aspiration (FNA); this combination
increases the accuracy of diagnosis. Obtaining tissue samples from
different tumor components is important, because it provides samples for
histopathologic analysis by means of various techniques, including
fluorescence in situ hybridization (FISH).

Histologic Findings
Lipomas are benign mesenchymal tumors derived from adipocytes. Several
variants have been described, including the following:
 Adenolipomas, a variation of lipomas that may occur in the breast,
often have a marked fibrotic component; they are best regarded as a
hamartoma
 Angiolipomas contain many small vessels
 Cardiac lipomas may calcify following fat necrosis; microscopically,
they are composed of fatty tissue with interlacing muscle fibers
FNA biopsies of a lipoblastoma contain multivacuolated lipoblasts, myxoid
areas, and a plexiform capillary network.

Approach Considerations
Lipomas are removed for the following reasons:
 Cosmetic reasons
 To evaluate their histology, particularly when liposarcomas must be
ruled out
 When they cause symptoms
 When they grow and become larger than 5 cm
Obtain biopsies of large lipomas or of those tethered to fascia to rule out a
liposarcoma.
No contraindications to removing a lipoma exist, unless the patient is unfit
for surgery or anatomic location makes removal unfeasible (as in the case,
for example, of an intraspinal lipoma). Benign lipomas are simply "shelled
out," with complete removal of the capsule in an extracapsular plane. This
is an inadequate operation for a liposarcoma, and hence, performing an
initial biopsy to exclude this lesion may be considered for large fatty tumors
or for those in the retroperitoneum or the intramuscular spaces.

Endoscopic Therapy
Nonsurgical therapy includes endoscopic excision of tumors in the upper
gastrointestinal (GI) tract (ie, esophagus, stomach, or duodenum) or the
colon. Colonoscopic snare removal has been described but may be
associated with perforation if the base is broad. Japanese authors reported
a safe technique in which a bipolar snare was used and the mucosa of the
defective region was clipped. [22] Otherwise, surgical removal is indicated.

Surgical Therapy
Complete surgical excision with the capsule is advocated to prevent local
recurrence, whether the lipoma in question is subcutaneous or intracardiac
in origin. These lesions may be lobulated, and it is essential that all lobules
be removed.
Specific therapy depends on the location of the tumor. [23]
Subcutaneous lipomas are removed for cosmetic reasons, and hence, a
cosmetically pleasing incision should be used. [24] The incision is usually
placed directly over the mass and is oriented to lie in a line of skin
tension. Liposuction is an alternative that allows removal of the lipoma
through a very small incision, the location of which may be remote from the
actual tumor. [25, 26, 27, 28] The lesion may also be approached by means of
advanced, minimal-access tissue dissection methods, with the use of a
dissecting balloon. [29] The latter two methods allow the incision to be
placed in an inconspicuous location. For example, axillary incisions may be
used to remove lipomas from the back.
Liposuction may be employed more often in small facial lipomas, because
favorable aesthetic results have been obtained through strategically placed
incisions. Liposuction is indicated for the treatment of medium-sized (4-10
cm) and large (>10 cm) lipomas; in small lipomas, no advantage has been
reported, because these tumors can be extracted through small
incisions. [25, 26, 27, 28]
Lipoma formation has been reported as an unusual complication of
liposuction and has also been found to occur following trauma. [9, 30] The
mechanism in these cases is unknown. Research on genetic markers of
atypical lipomatous tumors and liposarcomas is ongoing. These tumors
have been shown to express receptors for leptin. [31]
For more unusual locations, the method of removal must be tailored to the
site and may require the expertise of a consultant, as follows:
 Local removal is indicated in intestinal lipomas causing obstruction or
hemorrhage; uncertainty of diagnosis for an intramural intestinal mass
also warrants resection, because liposarcomatous disease of the
bowel has been described
 If esophageal lipomas cannot be endoscopically removed, surgical
excision is indicated, whether by a transhiatal or a transthoracic
approach
 Lipoma-related narrowing of the major airways warrants removal of the
instigating mass; likewise, intraparenchymal lipomas of the lung may
require thoracotomy and the expertise of a thoracic surgeon
  Breast lipomas are excised if their nature is in doubt, whether by
means of wire or ultrasonographic localization or by means of direct
palpation
 Vulvar lipomas may be locally excised
 Lipomas in critical locations, such as the heart, may require a more
physiologically and technically demanding procedure for removal,
including median sternotomy with bypass
 Intraosseous lipomas may be removed by means of endoscopy in
combination with orthopedic expertise
Tumors can usually be enucleated. They may recur if not properly
removed, which should include removal of the capsule. Hibernomas tend to
be highly vascular. Lipomas in other locations may present unique
difficulties during removal; for example, in a person presenting with a
frontalis-associated subfascial lipoma as a protruding mass on the lateral
forehead, the lipoma may be difficult to dissect because of the highly
vascular muscle that invests it. Lipomas of the GI tract can frequently be
shelled out of their submucosal location.

Epidermoid cystc

Background
Epidermoid cysts represent the most common cutaneous cysts. While they
may occur anywhere on the body, they occur most frequently on the face,
scalp, neck, and trunk. [1]
Historically, epidermoid cysts have been referred to by various terms,
including follicular infundibular cysts, epidermal cysts, and epidermal
inclusion cysts. The term epidermal inclusion cyst refers specifically to an
epidermoid cyst that is the result of the implantation of epidermal elements
in the dermis. Because most lesions originate from the follicular
infundibulum, the more general term epidermoid cyst is favored. The term
sebaceous cyst should be avoided because it implies that the cyst is of
sebaceous origin. Finally, the term milia refers to very small, superficial
epidermoid cysts.
Epidermoid cysts are benign lesions; however, very rare cases of various
associated malignancies have been reported. [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]

Pathophysiology
Epidermoid cysts result from the proliferation of epidermal cells within a
circumscribed space of the dermis. Analysis of their lipid pattern
demonstrates similarities to the epidermis. In addition, epidermoid cysts
express cytokeratins 1 and 10, which are constituents of the suprabasilar
layers of the epidermis. The source of this epidermis is nearly always the
infundibulum of the hair follicle, as evidenced by the observation that the
lining of the 2 structures is identical. [13]
Inflammation is mediated in part by the horny material contained in
epidermoid cysts. Extracts of this material have been shown to be
chemotactic for polymorphonucleocytes.
Studies have suggested that human papillomavirus (HPV) and exposure to
ultraviolet light (UV) may play a role in the formation of some epidermoid
cysts, particularly verrucous cysts with coarse
hypergranulosis. [14, 15, 16, 17, 18, 19, 20, 21, 22, 23,24, 25]
The manner in which carcinomas may arise within epidermoid cysts is
unclear. In a series of epidermoid cysts with carcinoma,
immunohistochemical results for HPV were negative, suggesting that HPV
is not likely to play a role in the development in squamous cell
carcinoma (SCC) in epidermoid cysts. Chronic irritation or repetitive trauma
to the epithelial lining of the cyst has been suggested to play a role in
malignant transformation; however, this relationship has not been
established.

Epidemiology
Race

No racial predilection has been identified. Pigmentation of epidermoid cysts

is common in individuals with dark skin. In a study of Indian patients with
epidermoid cysts, 63% of the cysts contained melanin pigment. [26]
Sex

Epidermoid cysts are approximately twice as common in men as in women.

Age

Epidermoid cysts may occur at any age; however, they most commonly
arise in the third and fourth decades of life. Small epidermoid cysts known
as milia are common in the neonatal period.

Prognosis
Epidermoid cysts are usually asymptomatic; however, they may become
inflamed or secondarily infected, resulting in swelling and tenderness.
Rarely, malignancies, including basal cell carcinoma, Bowen disease, SCC
(most common of these rarities), mycosis fungoides, and melanoma in situ,
have developed in epidermoid cysts. [13]

History
Epidermoid cysts are usually asymptomatic. Discharge of a foul-smelling
“cheeselike” material may be described. Less frequently, the cysts can
become inflamed or infected, resulting in pain and tenderness. In the
uncommon event of malignancy, rapid growth, friability, and bleeding may
be reported.

Physical Examination
Epidermoid cysts appear as flesh–colored-to-yellowish, firm, round nodules
of variable size. A central pore or punctum may be present. Note the image
below.
Reportedly, epidermoid cysts are most common (in descending order of frequency)
on the face, trunk, neck, extremities, and scalp. Rare cases of epidermoid cysts
occurring in bone, breast, and various intracranial locations have been
reported. [33]Epidermoid cysts in the breast and genital area are not uncommon in the
general population. The ocular and oral mucosae can also be affected and, cysts
have been reported on the palpebral conjunctivae, lips, buccal mucosa, tongue, and
uvula.
Epidermoid cysts can manifest in various ways on the extremities. Epidermoid cysts
on the distal portions of the digits may extend into the terminal phalanx. These
lesions may produce changes in the nails such as pincer nails, erythema, edema,
tenderness, and pain. [34]

Laboratory Studies
Laboratory studies are typically unnecessary; however, with recurrent
infection or lack of response to antibiotics, a culture and sensitivity may be
obtained.

Imaging Studies
If an epidermoid cyst is suspected in an unusual location, such as breast,
bone, or intracranial locations, imaging with ultrasonography, radiography,
CT scanning, or MRI is appropriate.

Histologic Findings
Epidermoid cysts are lined with stratified squamous epithelium that
contains a granular layer. Laminated keratin contents are noted inside the
cyst. An inflammatory response may be present in cysts that have ruptured.
Older cysts may exhibit calcification. Pilomatrical differentiation may be
noted, especially in patients with Gardner syndrome. [35]
Note the images below.

Medical Care
Asymptomatic epidermoid cysts do not need to be treated. Intralesional
injection with triamcinolone may hasten the resolution of inflammation. Oral
antibiotics may occasionally be indicated
Surgical Care
Epidermoid cysts may be removed via simple excision or incision with
removal of the cyst and cyst wall though the surgical defect. [36] If the entire
cyst wall is not removed, the lesion may recur. Excision with punch biopsy
technique may be used if the size of the lesion permits. [37, 38] Minimal-
incision surgery, with reduced scarring, has been reported. [39, 40]
Incision and drainage may be performed if a cyst is inflamed. Injection of
triamcinolone into the tissue surrounding the inflamed cyst results in faster
improvement in symptoms. This may facilitate the clearing of infection;
however, it does not eradicate the cyst.

Complications
Complications are rare, but they can include infection, scarring from
removal, and recurrence. Malignancies in epidermoid cysts are very rare.

Prevention
When the cutaneous portion of a myocutaneous flap is to be buried, a
dermatome should be used to remove the epidermis.

LIPOSARCOMA

History
Liposarcomas are most commonly found in the extremities; in the
retroperitoneum; and, less often, in the head and neck area. These tumors
are most likely to arise from deep-seated, well-vascularized structures than
from submucosal or subcutaneous fat. Myxoid liposarcoma is usually
evident as a deep-seated mass in the lower extremity of adults, but it may
be less commonly be first evident as a primary subcutaneous mass. [14]
Liposarcomas of all subtypes can occur in the cutis and the subcutis;
however, their primary occurrence in the skin is rare. Clinically, all cases of
liposarcomas in the skin tend to grow in an exophytic manner, presenting
as either dome-shaped or polypoid lesions. In all patients, the neoplasm is
centered in the dermis, and it has a minimal tendency to grow downward
into the underlying subcutaneous adipose tissue.
Most patients with liposarcoma have no symptoms until the tumor is large
and impinges on neighboring structures, causing tenderness, pain, or
functional disturbances. In the retroperitoneal area, where liposarcoma is
detected at a late stage, the tumor may grow to a substantial size, weighing
several pounds at the time of diagnosis. In general, liposarcoma grows
silently, and the patient's estimation of the clinical duration is often
unreliable. The patient eventually becomes aware of a swelling or a mass
and reports this finding to the physician.
Patients may report the following:
  Associated episode of trauma to the region containing the mass
 Painful swelling (occurs in one third of cases for as long as 6 mo)
 Decreased function (ie, range of motion)
 Numbness
 Enlargement of varicose veins
 Fatigue
 Abdominal pain
 Weight loss
 Nausea
 Vomiting
Physical Examination
The three most common locations of involvement are the thighs, the
retroperitoneum, and the inguinal region.
Liposarcoma usually appears as a well-circumscribed palpable mass as
large as 10 cm in diameter. The mass tends to grow slowly over time. The
lesion is commonly not tender on palpation. Diffuse abdominal enlargement
may be observed in patients with retroperitoneal disease. Liposarcoma that
resembles a skin tag has been reported but is an exceptionally rare
event. [15]
Fascial compartmentalization may cause liposarcomas to have awkward
discoid and fusiform shapes rather than smooth, round forms. Thus,
liposarcoma can appear with an array of clinical morphologies and
manifestations. Other aspects to note on physical examination are
neurologic involvement and lymphadenopathy.
Pleomorphic liposarcoma is both uncommon and rarely occurs in the skin
and subcutis. [13]They are most often located on an extremity, trunk, and
head and neck and more often involve the subcutaneous, less so the
subcutis or dermis. It may be evident as a painless pedunculated pink
papulonodule. [16]
Complications
A case report describes liposarcoma complicating pregnancy. [17]

Laboratory Studies
Cytogenetics may be of value when diagnosing lipomatous tumors because
different tumor types have different more or less specific chromosomal
abnormalities. [24] The lipoblastoma, for example, often exhibits
rearrangements of bands 8q11-13, and the gene PLAG1 has been
implicated as the target of these chromosomal changes.
Imaging Studies
CT scanning (see image below) is superior to MRI in detailing cortical bone
erosion and tumor mineralization, whereas MRI is useful in providing views
of the long axis of the limb and in depicting the fatty nature of the tumor.
Most liposarcomas have well-defined and mostly lobulated margins. The
well-differentiated liposarcomas are composed of mainly fat with septa or
nodules. These tumors are hyperintense on T2-weighted images, and they
demonstrate faint enhancement or no enhancement after the intravenous
administration of contrast material.
Myxoid liposarcomas are homogeneous or mildly heterogeneous, and a
pseudocapsule can be present. Pleomorphic types have a markedly
heterogeneous internal structure. Both myxoid and pleomorphic lesions
have moderate or marked heterogeneous enhancement after the
administration of contrast material. Well-differentiated liposarcomas may be
distinguished from the other types by their largely lipomatous appearance.
The malignancy grade increases with the degree of tumor heterogeneity
and contrast enhancement.
Angiography may demonstrate tumor malignancy on the basis of prominent
vascularity; thus, angiography may be of value in planning surgical
resection.
Chest radiography may be used as an initial screening for pulmonary
metastases; however, the definitive test for detection of pulmonary
metastases is chest CT scanning.
An early-phase bone scan may show a marked increase of radioisotopic
uptake.
Risk assessment in liposarcoma patients can be based on
[(18)F]fluorodeoxyglucose (FDG) PET imaging. [25] Although tumor grade
and subtype are considered standard parameters for risk assessment in
patients with liposarcoma, pretherapy tumor standardized uptake values
obtained by FDG PET imaging was found to be a more useful parameter
for risk assessment in liposarcoma compared with tumor grade or subtype.
A maximum standardized uptake value of more than 3.6 was associated
with significantly reduced disease-free survival and identified patients at
high risk for developing early local recurrences or metastatic disease.
Also see Liposarcoma Imaging.
Procedures
The diagnostic procedure of choice for liposarcoma is open biopsy. With
superficial, small, fatty tumors, excisional biopsy is recommended for
diagnosis. In large (>3 cm) and deep tumors, diagnosis and treatment may
involve open incisional biopsy followed by definitive resection.
Fine-needle aspiration or biopsy should be followed by histologic and
immunohistochemical examination. Adjunctive tests for MDM2 (murine
double minute 2) may be helpful to distinguish liposarcoma from benign
fatty neoplasms, but cutaneous and subcutaneous pleomorphic
liposarcoma is less likely to demonstrate
amplification. [26, 27] Immunohistochemical examination aids in excluding
other sarcomas. Lipid staining may be helpful, although Sudan black or oil
red O stains are generally insufficient for diagnosis. Helpful stains include
the following:
 S-100 - Positive results in fat cells and lipoblasts
 Alpha-1-antitrypsin - Positive results in malignant fibrous histiocytomas
 Desmin - Positive results in leiomyosarcomas
 Myoglobin - Positive results in rhabdomyosarcomas
 Adipophilin stain to document lipid content in the cytoplasm of the
neoplastic cells using formalin-fixed paraffin-embedded issue [28]
Histologic Findings
The recognition of lipoblasts is the key finding in the diagnosis of
liposarcoma. A lipoblast has the ability to produce and accumulate non–
membrane-bound lipid within its cytoplasm. The key morphologic features
are well-demarcated cytoplasmic lipid that shifts, causes indentations in an
irregular hyperchromatic nucleus, and creates a characteristic scalloping of
the nuclear membrane.
The stage and further differentiation into 1 of the 4 major types affect the
prognosis.
Well-differentiated liposarcomas usually contain a predominance of mature
fat cells with relatively few, widely scattered lipoblasts. A misdiagnosis of
lipoma can result from inadequate sampling. In the sclerosing subtype of a
well-differentiated liposarcoma, collagen fibrils that encircle fat cells and
lipoblasts make up a prominent part of the matrix.
Myxoid liposarcoma, the most common type, is diagnosed by the
observation of a delicate plexiform capillary network that is associated with
both primitive mesenchymelike cells and a variable number of lipoblasts.
The stroma contains a large proportion of myxoid ground substance (ie,
hyaluronic acid), in which numerous microcysts may form.
In the round-cell type, lipoblasts are interspersed among sheets of poorly
differentiated round cells.
Poorly differentiated pleomorphic liposarcoma is recognized by a mixture of
bizarre, often multivacuolated lipoblasts and atypical stromal cells, many of
which contain highly abnormal mitotic figures. Hemorrhagic and necrotic
areas are common. Lipoblasts are present.
Staging
The Enneking oncologic staging system defines the biologic behavior of
primary tumors. This system has proven to be effective in planning surgery
for limb lesions (eg, intralesional, marginal, wide, radical) and in evaluating
its results. Note the following:
 The Enneking staging system divides benign tumors into 3 stages: S1,
S2, and S3.
 Localized malignant tumors are divided into 4 stages: IA, IB, IIA, and
IIB.
  Two other stages include metastatic high-grade intracompartmental
tumors, or stage IIIA tumors, and extracompartmental malignant
tumors, or stage IIIB tumors.
 This classification scheme was formerly used to describe long-bone
tumors.
 This staging system is based on a complete preoperative workup that
includes an assessment of the clinical features; the radiographic
pattern and CT and MRI data regarding the extension of the tumor; the
peculiar imaging features of the tumor and its relationship to the
neighboring tissues; the findings from isotopic scanning, which
provides information about local aggression and systemic diffusion;
and the histologic findings obtained at biopsy.
Surgical staging is appropriate only after the diagnosis is established and
the oncologic stage is determined.

Medical Care
Liposarcoma has a number of different subtypes (ie, well differentiated,
dedifferentiated, myxoid/round cell, pleomorphic), and their response to
chemotherapy is not well documented. [29] Thus, the response rates to
chemotherapy of the different histological subtypes and overall and
progression free survival were investigated; survival according to
histological grade was also assessed. This retrospective analysis
suggested that myxoid liposarcoma is relatively chemosensitive in
comparison to a combination of other liposarcomas, in particular
dedifferentiated and well-differentiated tumors.
In the case of well-differentiated liposarcoma, grade provides no
incremental information over other histological subtypes in terms of
response to therapy. In myxoid/round cell liposarcoma, the presence of a
round cell component may be an adverse prognostic sign. Tumor site, a
high proliferative fraction noted with MIB-1 labeling, and TP53 missense
mutations are also adverse prognostic factors in myxoid/round cell
tumors. [30]
For liposarcomas, radiation therapy may be a valuable adjunct to surgery,
especially in those of the myxoid variant.
The use of chemotherapy in liposarcomas remains experimental.
Although surgical resection is the mainstay of curative treatment, patients
with large high-grade liposarcomas may benefit from multimodality
treatment with chemotherapy and radiation. [31]
Treatment of an atypical lipoma using liposuction has been described. [32]
Trabectedin (Yondelis) was approved in November 2015 in the United
States for unresectable or metastatic liposarcoma or leiomyosarcoma in
patients who have received a prior anthracycline-containing regimen. It is
an alkylating drug that binds guanine residues in the minor groove of DNA.
Approval was based on a phase 3 trial (n=518) that showed a statistically
significant improvement in progression-free survival compared with
dacarbazine (4.2 mo vs 1.5 mo; P<.0001). No improvement in overall
survival was observed. [33]
In January 2016, eribulin (Halaven), a microtubule inhibitor, [34] was
approved by the US Food and Drug Administration (FDA) for unresectable
or metastatic liposarcoma in patients who received a prior anthracycline-
containing regimen. The FDA approval is based on the results from the
subgroup of 143 patients with liposarcoma. In this subgroup, the results
show a 7-month improvement in survival (15.6 months with eribulin
compared with 8.4 months with dacarbazine). The median progression-free
survival, a secondary endpoint, was 2.9 months with eribulin compared with
1.7 months with dacarbazine. However, eribulin was more toxic than
dacarbazine. Treatment-emergent adverse events included neutropenia
(44% vs 24%), pyrexia (28% vs 14%), peripheral sensory neuropathy (20%
vs 4%), and alopecia (35% vs 3%) for eribulin compared with dacarbazine,
respectively. [35]

Surgical Care
The rationale for wide surgical excision of atypical lipomatous tumors is the
prevention of recurrence and dedifferentiation.
Wide and deep surgical excision, along with local radiation and/or
chemotherapy, may be necessary for high-grade lesions.
Given the favorable outcome with wide surgical excision alone, regardless
of the histologic type of the tumor, some authors believe that adjuvant
radiation therapy is unjustified.
Sebaceous cysts are common noncancerous cysts of the skin. Cysts are abnormalities in the body
that may contain liquid or semiliquid material.

Sebaceous cysts are mostly found on the face, neck, or torso. They grow slowly and aren’t life-
threatening, but they may become uncomfortable if they go unchecked.

Doctors usually diagnose a cyst with only a physical examination and a medical history.

In some cases, a cyst will be examined more thoroughly for signs of cancer.

Sebaceous cysts form out of your sebaceous gland. The sebaceous gland produces the oil (called
sebum) that coats your hair and skin.

Cysts can develop if the gland or its duct (the passage from which the oil is able to leave) becomes
damaged or blocked. This usually occurs due to a trauma to the area.

The trauma may be a scratch, a surgical wound, or a skin condition, such as acne. Sebaceous cysts
grow slowly, so the trauma may have occurred weeks or months before you notice the cyst.

Other causes of a sebaceous cyst may include:

misshapen or deformed duct

damage to the cells during a surgery

genetic conditions, such as Gardner’s syndrome or basal cell nevus syndrome

Small cysts are typically not painful. Large cysts can range from uncomfortable to considerably
painful. Large cysts on the face and neck may cause pressure and pain.

This type of cyst is typically filled with white flakes of keratin, which is also a key element that makes
up your skin and nails. Most cysts are soft to the touch.
Areas on the body where cysts are usually found include:

scalp

face

neck

back

A sebaceous cyst is considered unusual — and possibly cancerous — if it has the following
characteristics:

diameter that’s larger than five centimeters

fast rate of reoccurrence after being removed

signs of infection, such as redness, pain, or pus drainage

Doctors often diagnose a sebaceous cyst after a simple physical examination. If your cyst is unusual,
your doctor may order additional tests to rule out possible cancers. You may also need these tests if
you wish to have the cyst surgically removed.

Common tests used for a sebaceous cyst include:

CT scans, which help your doctor find the best route for surgery and to spot abnormalities

ultrasounds, which identify the contents of the cyst

punch biopsy, which involves removal of a small amount of tissue from the cyst to be examined in a
laboratory for signs of cancer

Your doctor can treat a cyst by draining it or by surgically removing it. Normally, cysts are removed.
This isn’t because they’re dangerous but rather for cosmetic reasons.

Since most cysts aren’t harmful to your health, your doctor will allow you to choose the treatment
option that works for you.
It’s important to remember that without surgical removal, your cyst will usually come back. The best
treatment is to ensure complete removal through surgery. Some people do decide against surgery,
however, because it can cause scarring.

Your doctor may use one of the following methods to remove your cyst:

Conventional wide excision, which completely removes a cyst but can leave a long scar.

Minimal excision, which causes minimal scarring but carries a risk that the cyst will return.

Laser with punch biopsy excision, which uses a laser to make a small hole to drain the cyst of its
contents (the outer walls of the cyst are removed about a month later).

After your cyst is removed, your doctor may give you an antibiotic ointment to prevent infection.
You should use this until the healing process is complete. You may also be given a scar cream to
reduce the appearance of any surgical scars.

Sebaceous cysts are generally not cancerous. Cysts left untreated can become very large and may
eventually require surgical removal if they become uncomfortable.

If you have a complete surgical removal, the cyst will most likely not return in the future.

In rare cases, the removal site may become infected. Contact your doctor if your skin shows any
signs of infection such as redness and pain or if you develop a fever. Most infections will go away
with antibiotics, but some can be deadly if untreated.

https://www.healthline.com/health/sebaceous-cys

They appear as lumps or bumps under the skin, elastic to pressure and free to move in relation to
the deeper structures. Most common localization is on the head, back, chest, genitals but they can
appear on any other region of the body, except for palms and soles. The unpleasant odour coming
from it is a consequence of keratin, a protein produced in the sebaceous gland itself. They go into
infection fairly often, and then pain and swelling occur, with a development of a purulent process
which finally results in formation of an abscess
Sebaceous cysts are formed by blockage of the sebaceous gland ducts or by swelling of the hair
follicle which then disrupts the emptying of the sebaceous gland through the pore.

It is usually noticed as a small painless lump that can be felt under the skin. When they last longer
(sometimes for years), those lumps can reach the size of hazelnuts or be even bigger. Often they
develop purulent infections inside.

Signs of developing purulent infection are .

redness,

swelling,

local increase in temperature of the skin,

leaking of smelly, dirty-cheesy like content or pus,

pain

Diagnosis is usually made on the basis of the look of the lesion itself (by eye) and on the basis of
information acquired by palpation of the lesion. Biopsyis rarely needed.

In cases of infection development, a purulent abscess is formed, and very rarely, when not treated,
necrosis can develop.

Sebaceous cysts that don’t impose any esthetic or functional problems are usually left untreated.

If they disrupt the esthetic appearance and especially of they get infected, they need to be treated in
some of the manners :

Incision and drainage. In cases of infections, an incision of the skin, in order to drain the purulent
content and subside the inflammation, is made. After the inflammation process is resolved, a radical
excision is recommended because there is a significant probability of renewing the process.

• Total radical excision. This surgical procedure is advised as a permanent solution, but only in
cases where there’s no infection present. Radical excision entails the removal of the cyst itself and
the surrounding tissue, thus creating a skin defect slightly larger than the cyst itself, and then
requires the suture of such wound. Removal of the sutures is done in 7 to 14 days after.

Minimal excision. This is a method where a small incision about 5mm in size is made, and the cyst is
removed through it, part by part. The wound heals with no sutures, and the scar is minimal.

Removal through puncture. This is a special method used primarily for sebaceous cysts on the head.

Sebaceous cysts are most common to appear:

• After puberty, very rarely they occur before puberty

In men, in all regions except for the head (the head is more common for women)

• In persons who have had acne during puberty

• After extensive sun tanning or sun bed tanning

• After trauma to the skin. Usually it’s microtrauma, followed by crusting.

Formation of sebaceous cysts is impossible to prevent. But, persons who already had them are
advised to avoid using skin care products that contain oils, as oils can increase the risk of sebaceous
duct blockage, and by so, to increase the risk of developing sebaceous cysts.

http://orshospital.rs/en_aterom.asp

sebaceous Cysts, sometimes misspelled as Sebacous Cysts, are firm, dome-shaped sacs or lumps
appearing beneath the skin. These sacs are filled with a white oily substance known as the keratin,
the fibrous protein found in hairs and nails which often emit a foul odor. The bumps are found in
many areas of the body like the face, scalp, chest, neck, ears, upper back and even private parts like
the genitals.

The condition affects about 200000 people in the United States alone.

CAUSES OF SEBACEOUS CYSTS

Sebaceous or Epidermal cysts are formed due to a number of factors. These include :

SWOLLEN HAIR FOLLICLES

When hair follicles suffer an inflammation due to acne or some other cause, it may lead to the
accumulation of keratin compounds under the skin.

SKIN INJURY OR TRAUMA

When the skin suffers an injury, the affected cells block hair follicles located deep inside the skin.
The epidermis is implanted into the dermis and results in an inflammation that is visible in the form
of Sebaceous Cysts.

IMPAIRED SEBACEOUS GLAND

When the Sebaceous gland, the gland near the hair follicles, fails to perform normally due to a
defect or blockage the keratin may accumulate in a particular spot and form a lump.

BACTERIAL INFECTION

In some cases, cysts may be formed in skin areas affected by bacteria.

SYMPTOMS OF EPIDERMAL CYST

Epidermal Cysts are accompanied with several symptoms, most of which are visible to the naked
eye. These include :

LUMPS

Small lumps or sacs formed on the skin are the most visible symptoms of this condition. These are
the Sebaceous Cysts, also known as Epidermoid Cysts.

TENDERNESS

The Sebaceous Cysts are generally non-painful. However, patients with an infected cyst can
experience a feeling of tenderness in the affected region.
DRAINAGE

In some cases, a foul-smelling grayish white substance may drain from the cyst.

REDNESS

If the cysts swell, there may be redness in the area.

HOTNESS

Sufferers may also feel an increase in temperature in the affected region of the skin.

MOVABLE

In many cases, the cysts are freely movable beneath the skin.

DIAGNOSIS OF SEBACEOUS CYSTS

Doctors mostly diagnose Sebaceous Cysts by judging their appearance. The medical history of the
patient is also often taken into consideration. The sufferer is asked about the symptoms to make a
proper diagnosis. Physical tests are also conducted to ascertain the reason behind the condition.
Occasionally, a biopsy is needed to prevent misdiagnosis and make sure that the cysts have not
developed due to any other skin condition.

SEBACEOUS CYST TREATMENT

Sebaceous Cysts treatment includes home remedies as well as professional medical care.

TREATMENT FOR SEBACEOUS CYST (MEDICATION AND REMOVAL)

Painless Epidermal cysts are normally harmless and need no treatment. These appear and normally
go away after a few days. But if the cysts get infected they may swell to be large enough or drain
from time to time. The bumps may become a cause for embarrassment in such cases and require
medical attention. You should ideally visit a dermatologist, a doctor who specializes in treating skin
problems.
Doctors normally use steroid medications such as corticosteroid injections to reduce the pain and
swelling in the cysts

An oral antibiotic may be prescribed in case of an infected cyst. This reduces the chances of an
infection after drainage or surgical removal of the cysts.

Cysts draining from time to time need surgical drainage. This involves cutting the cyst open by
surgical means, draining its contents and removing the upper wall. This may give temporary relief
but the cyst will eventually come back. This is the only disadvantage of this procedure.

If the cyst becomes too large or swollen, Epidermal Cyst removal may be the only option. Complete
removal of Sebaceous Cysts is done to prevent their recurrence. Cysts that go by themselves also
have a chance of coming back. Sebaceous Cyst removal is done by a small surgical operation done
performed in the doctor’s chamber.

SEBACEOUS CYST TREATMENT (HOME OR NATURAL)

Want to know how to get rid of Sebaceous Cyst at home? Most people with painless Sebaceous
Cysts are looking for Sebaceous Cyst remedy at home. Here are some ways you can treat Sebaceous
Cysts by yourself.

Applying a warm, moist cloth over the cysts for a few types during the day can make them subside
after a period of time.

If a cyst drains at home, you should carefully expose the area and wash it with cotton moistened
with antiseptic. This will prevent bacterial infection till you see a doctor. You should not try to open
or remove a Sebacous Cyst by yourself. This can lead to an infection that will bring on more severe
complications.

PREVENTION OF EPIDERMAL CYSTS

Unfortunately, there is no way to prevent the occurrence of Sebaceous Cysts. The cysts are actually
diagnosed after a person notices their presence in the skin and informs a doctor about it. As
aforementioned, cysts may come back even after surgical drainage.
this is especially true if any of the cyst walls gets left behind after the drainage. If home treatment
and medications do not work, Sebaceous Cyst surgery or excision may be the only foolproof way to
get rid of the unwanted bumps. SEBACEOUS CYSTS PICTURES If the condition seems difficult to you,
you can refer to some of these pictures of Sebaceous Cysts. We have collected some Sebaceous Cyst
photos to help you understand the condition. These Sebaceous Cyst images will help you get a
comprehensive idea about this peculiar syndrome. The Epidermal Cyst pictures cover some of the
main areas in the skin commonly affected by the condition.

https://www.primehealthchannel.com/sebaceous-cyst-epidermal-cyst-pictures-causes-treatment-
and-removal.html