Head and neck pilomatricoma in the pediatric age group: a retrospective study and literature review

Applications of indocyanine green (ICG) fluorescence technology in open surgery: preliminary experience in pediatric surgery

Background

Indocyanine green fluorescence technology (ICG) in pediatric minimally invasive surgery has undergone an important improvement in the last 5 years. However, its use in open surgery is still limited. In this paper, we aim to report our preliminary experience with Rubina® lens ICG fluorescence technology in combination with the IMAGE1 S™ system from KARL STORZ in open excision of masses in children.

Methods

The records of 18 patients undergoing open surgery for head, neck and thorax masses between September and November 2022 were retrospectively reviewed. Rubina® lens ICG fluorescence technology system was used in all the cases. In 10 cases we adopted the holding arm system and in 8 cases the hand-held technique. Data about patients' demographics, surgery and outcomes were collected and analyzed through the following criteria: mass localization, intraoperative time (min), ICG administration (ml), intraoperative complications, postoperative complications.

Results

A total of 18 patients were operated: 4 thyroglossal duct cysts, 3 supraorbital cysts, 2 neck masses, 2 pre-auricular and 2 scalp cysts, 2 gynecomastias, 2 lymphangiomas, 1 nose mass. In all the cases, intralesional injection of 0.5-1 ml of ICG solution was performed peri-operatively. Mean operative time was 58.4 min (35-134 min). Postoperative complications included seroma formation in 2 cases. Surgical pathology reports confirmed complete mass excision in all the cases.

Conclusion

Based on our preliminary experience, ICG fluorescence guided surgery using Rubina® lens system was very helpful also in open surgery procedures. Rubina® lens system permits to have a very low complication rate, a time-saving surgery, a real time reliability of anatomic structures and an excellent clinical safety. In our experience, holding arm system seems more comfortable than hand-held system. However, further cases need to be performed to evaluate the exact role and to identify new indications of this technique in open pediatric surgical procedures.

Giant Pilomatrix Carcinoma of the Thorax: An Uncommon and Clinically Misdiagnosed Tumor

Pilomatrix carcinoma is an unusual and aggressive malignant tumor deriving from follicular matrix cells and exhibiting a metastatic potential to lungs and regional lymph nodes in 10% of cases. We report the case of a 54-year-old male patient who presented with a biopsy-proven malignant pilomatrixoma of the thoracic region, which recurred multiple times after previous excisions. Due to the size of the tumor (28 by 22 cm), wide excision and axillary lymphadenectomy of levels I and II were performed, followed by reconstruction with a free deep inferior epigastric artery perforator flap and adjuvant radiotherapy. Owing to its rarity, this tumor can initially be misdiagnosed, resulting in delayed treatment and recurrences if inadequately excised. Also, large tumor size is correlated with a higher incidence of metastasis. High index of clinical suspicion and wide excision are recommended, along with the need of establishing oncological guidelines for better prognosis.

Cytological Diagnosis of Pilomatrixoma and its Diagnostic Pitfalls

Background

Pilomatrixoma (PMX) is a relatively uncommon benign cutaneous neoplasm arising from skin adnexa. It presents as a subcutaneous asymptomatic nodule mostly in the head and neck region and is frequently misdiagnosed by the clinicians. Although easily diagnosed on histopathology, the cytologic features of PMX are less distinctive, depending on the stage and evolution of disease and may mimic other benign or even malignant lesions.

Aim

To study the cyto-morphological features of this uncommon neoplasm and identify its potential diagnostic pitfalls on fine needle aspiration cytology (FNAC).

Material and Methods

Archival records of histopathologically diagnosed Pilomatrixoma were analyzed during study period of 2.5 years. Clinical diagnosis, preoperative FNA characteristics, and histopathological details were studied in each case. Cytologic pitfalls resulting in misdiagnosis of PMX cases on FNAC were evaluated in discordant cases.

Results

The series showed male preponderance, with head and neck being the commonest site. Out of 21 histopathologically proven cases of PMX, cytological correlation was available in 18 cases. A correct cytologic diagnosis of PMX/adnexal tumor was rendered in 13 cases. Erroneous diagnosis was given in 5 cases mainly because of the predominance of one component over the other or non-representative-aspirated material.

Conclusion

The present study highlights the importance of careful screening of FNAC smears keeping in mind the variability in the relevant cytologic features of PMX and creates awareness about the lesions that can mimic Pilomatrixoma resulting in diagnostic dilemma.

Cancer and Myotonic Dystrophy

Myotonic dystrophy (DM) is the most common muscular dystrophy in adults. Dominantly inherited CTG and CCTG repeat expansions in DMPK and CNBP genes cause DM type 1 (DM1) and 2 (DM2), respectively. These genetic defects lead to the abnormal splicing of different mRNA transcripts, which are thought to be responsible for the multiorgan involvement of these diseases. In ours and others' experience, cancer frequency in patients with DM appears to be higher than in the general population or non-DM muscular dystrophy cohorts. There are no specific guidelines regarding malignancy screening in these patients, and the general consensus is that they should undergo the same cancer screening as the general population. Here, we review the main studies that investigated cancer risk (and cancer type) in DM cohorts and those that researched potential molecular mechanisms accounting for DM carcinogenesis. We propose some evaluations to be considered as malignancy screening in patients with DM, and we discuss DM susceptibility to general anesthesia and sedatives, which are often needed for the management of cancer. This review underscores the importance of monitoring the adherence of patients with DM to malignancy screenings and the need to design studies that determine whether they would benefit from a more intensified cancer screening than the general population.

Cranial pilomatricoma: a diagnosis to consider

Pilomatricomas are benign tumors of the hair follicle that occur frequently in the scalp region. They occur most often in children. We describe a case of pilomatricoma in a teenager, referred to neurosurgery for excision. This diagnosis should be considered in the workup of scalp lesions, and this case report should serve to draw attention to this entity.

Benign Pilomatricoma With Osseous Metaplasia: A Rare Case

Pilomatricomas are frequently misdiagnosed benign neoplasms of the skin derived from hair matrix cells. Pilomatricomas may undergo calcification and ossification although the latter is rare and poorly documented, with only eight cases reported since 2006. We present a case of pilomatricoma with osseous metaplasia arising from the scalp in an 87-year-old female patient. She was referred by her general practitioner via the two-week cancer referral pathway, for a suspicious lesion. On examination, there was a 2 x 1cm nodule, with protruding hardened yellow material, on the right side of the patient’s occipital scalp. The lump was hard, non-tender and had been present for 17 years. The surrounding area was bleeding and slightly ulcerated. A clinical diagnosis of a ruptured epidermal cyst was made, and the patient was prepared for excision under local anaesthesia. The excised lesion of 23 x 18 x 10mm with 22 x 9mm of skin was sent for histology. This revealed a partially ulcerated dermal lesion composed of islands of keratin with ‘ghost cell’ outlines. Foreign body granulomas, transition to mature lamellar bone, and foci of calcification were noted. There were no definite populations of basaloid cells and features of malignancy were not seen. These findings are consistent with benign pilomatricoma with osseous metaplasia. The patient was discharged 4 weeks later with satisfactory wound healing. Differentiating this tumour from other commonly encountered benign masses remains a challenge, as seen in this case which was initially misdiagnosed as a ruptured epidermal cyst.

Unexpected diagnosis of a pilomatrixoma in an infant: a case report

Pilomatrixomas are a benign tumour of the hair follicle.1–4 Prevalence is estimated to be less than 1 per cent of all benign skin tumours.1,3 Pilomatrixomas present as small, solitary, slow-growing subcutaneous nodules.1,3 Lesions present on the head and neck, with the face the most commonly affected.3 They are more common in adolescent years, and have a female predominance.3 Less than 10 per cent of pilomatrixomas present in patients younger than two years2 with a recent systematic review of 2189 pilomatrixomas revealing an age range of five months to 97 years.3 This case report reaffirms the need for a vigilant approach when managing paediatric skin lesions, particularly those that do not follow the expected course.

Pilomatrixoma of the Left Scapular Region in a Young Male: A Rare Case Report

Pilomatrixoma is a benign and rare neoplasm derived from the cortex of the hair follicle. The head and neck region's involvement is relatively common and occurs in the upper extremity, trunk, and lower extremity in decreasing tendency. It is usually encountered in younger age groups, usually in children and adolescents. Management of the pilomatrixoma involves surgical excision of the mass. A 15-year-old male presented with a history of an isolated left scapular mass. The lesion had appeared two weeks before the presentation. His parents brought him to the emergency department due to continued bleeding from the mass. He denied any pain, fever, night sweats, weight loss, chills, appetite changes, and numbness to the area. Physical examination revealed a bleeding non-tender mass measuring about 2.5 x 3 cm, with the fluctuant inferior surface. Baseline investigations were normal. Cyst, abscess, and neoplasm were the initial differentials. Ultrasound findings were suggestive of neoplasm, and contrast-enhanced MRI was highly suspicious for progressive neoplasm. The surgical team was consulted, and surgical excision of the mass was carried out. Biopsy results confirmed pilomatrixoma. In conclusion, the pre-surgical diagnosis of pilomatrixoma is difficult. Hence, this case report's main objective is to raise awareness among clinicians about this rare diagnosis and its clinical features. Furthermore, our case highlights the need to consider pilomatrixoma in the differentials of the head, neck, and back masses in children and adolescents.

Optimal Timing of Surgical Excision in Pediatric Pilomatricoma: Association between Clinicopathological Features and Cosmetic Outcomes

Background

The treatment of choice for pilomatricomas is surgical excision; however, data for the optimal timing of treatment and cosmetic outcomes are limited.

Objective

This study aimed to investigate the optimal timing of treatment in pilomatricomas by considering clinicopathological findings and cosmetic outcomes.

Methods

Seventy-three pilomatricomas patients aged ≤15 years were retrospectively reviewed. Patients were classified into early excision (disease duration ≤12 months, group A) and delayed excision groups (disease duration >12 months, group B). Tumor characteristics, and histopathological features with evolutionary stages were assessed. Cosmetic outcomes were evaluated by the Modified Vancouver Scar Scale (MVSS), 5-point patient satisfaction score, and complication rates.

Results

Group A showed better cosmetic outcomes than group B in the MVSS (1.53±1.22 vs. 3.68±1.84), 5-point patient satisfaction score (4.08±0.89 vs. 3.18±1.01), and complication rates (11.8% vs. 36.4%), respectively (p<0.05). Secondary anetoderma, tent sign, calcification, and late regressive stage (evolutionary stage IV) were more common in group B, (p<0.05). Moreover, evolutionary stages showed a positive correlation with mean MVSS (r=0.670, p<0.05).

Conclusion

Early excision (disease duration ≤12 months) provides superior cosmetic outcomes compared to delayed procedures. Early recognition, diagnosis, and management for pediatric pilomatricomas is important to improve overall cosmetic outcomes.

Pilomatrixoma: a common tumour of head and neck, but rarely reported

Pilomatrixoma is a benign subcutaneous tumour arising from the sebaceous glands. Mutation in the CTNNB1 gene is seen, suggesting beta-catenin misregulation may be the cause of pilomatrixoma. The preoperative diagnosis may be improved by the awareness of the fact that pilomatrixoma is a common and benign skin tumour of the head and neck region. It presents as a well-defined mass, which may be firm to hard in consistency, usually attached to the skin, but not to the underlying tissue. The colour of overlying skin appears a reddish-brown tinge, indicating that it could be a case of pilomatrixoma. Here, we report a case of pilomatrixoma of the cheek in a woman along with the CT findings and histopathological appearances. Dental surgeons should consider it as one of the differential diagnosis in superficial head and neck swelling with calcification.

Bilateral Cervical Pilomatricoma: A Diagnostic Dilemma for the Pediatric Otolaryngologist

Pilomatricomas are benign skin tumors often encountered by otolaryngologists but frequently misdiagnosed. Although they can occur at any age, they commonly present in children as a discolored superficial lesion adhered to the overlying skin. Accurate preoperative diagnosis is crucial for appropriate management, which is surgical in most cases. Here, we present bilateral pilomatricomas mimicking features of several other diagnoses in a pediatric patient. The patient was successfully treated with surgical excision. This case presented a unique diagnostic challenge, as the lesions exhibited features of several common diagnoses. In general, surgical management of pilomatricoma is curative, and recurrence is rare.

Pilomatrixoma of the right thigh: Sonographic-pathologic correlation in a young man

Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a histological type of benign subcutaneous tumor arising from the cutaneous adnexa. We present our experience and the characteristic findings of a pilomatrixoma of the right thigh in a young healthy man. The lesion had grown slowly in size over the past year and this was the reason for referral to the Department of Plastic Surgery. Ultrasound imaging was performed and, through the use of B-mode, color-Doppler, and elastosonography, the lesion was depicted. The patient was therefore scheduled for surgery.

Pilomatrixomas at times can pose a diagnostic challenge, especially when the location is unusual. Ultrasound and its tools, that is, color-Doppler and elastography, can assist the clinician arising the suspicion of pilomatrixoma.

Multiple pilomatrixomas: Case report and literature review

Pilomatrixoma is a rare, benign, circumscribed, calcifying epithelial neoplasm that is derived from hair matrix cells. Multiple pilomatrixomas are uncommon. We describe a case of multiple pilomatrixomas in a 23-year-old black woman who presented with lesions on her face and back. Based on the results of the clinical examination, she was provisionally diagnosed with either calcified sebaceous cysts or calcified lymph nodes. She underwent surgical excision of the masses. On histopathology, the lesions were identified as pilomatrixomas. We attribute our original failure to diagnose this condition to our lack of familiarity with it. We discuss the presentation, differential diagnosis, and other characteristics of pilomatrixomas.

Benign tumors in myotonic dystrophy type I target disease-related cancer sites

Objectives

Recent evidence showed that myotonic dystrophy type I (DM1) patients are at increased risk of certain cancers, but the risk of benign tumors is unknown. We compared the risk of benign tumors in DM1 patients with matched DM1‐free individuals and assessed the association between benign tumors and subsequent cancers.

Methods

We identified 927 DM1 patients and 13,085 DM1‐free individuals matched on gender, birth‐year, clinic, and clinic‐registration year from the UK Clinical Practice Research Datalink, a primary care records database. We used Cox regression models for statistical analyses.

Results

DM1 patients had elevated risks of thyroid nodules (Hazard Ratio [HR] = 10.4; 95% Confidence Interval [CI] = 3.91–27.52; P < 0.001), benign tumors of the brain or nervous system (HR = 8.4; 95% CI = 2.48–28.47; P < 0.001), colorectal polyps (HR = 4.3; 95% CI = 1.76–10.41; P = 0.001), and possibly uterine fibroids (HR = 2.7; 95% CI = 1.22–5.88; P = 0.01). Pilomatricomas and salivary gland adenomas occurred almost exclusively in DM1 patients (Fisher's exact P < 0.001). The HR for colorectal polyps was elevated in DM1 males but not in females (HR = 8.2 vs. 1.3, respectively; P‐heterogeneity < 0.001), whereas endocrine and brain tumors occurred exclusively in females. The data suggested an association between benign tumors and subsequent cancer in classic DM1 patients (HR = 2.7; 95% CI = 0.93–7.59; P = 0.07).

Interpretation

Our study showed a similar site‐specific benign tumor profile to that previously reported for DM1‐associated cancers. The possible association between benign tumors and subsequent cancer in classic DM1 patients warrants further investigation as it may guide identifying patients at elevated risk of cancer. Our findings underscore the importance of following population‐based screening recommendations in DM1 patients, for example, for colorectal cancer.

A skin tumor from an orthopedic oncology perspective: Pilomatrixoma in extremities (11 years experience with 108 cases)

Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a benign skin neoplasm originating from hair follicle matrix cells. Pilomatrixoma is a common skin neoplasm that is often misdiagnosed as another type of skin condition. The aim of our study is to review 11 years' worth of experience in examining clinical and histopathological presentations, imaging findings, management approaches, and treatment outcomes of pilomatrixoma at a tertiary hospital. A review of the pathology database revealed that 108 extremity pilomatrixomas were excised between 2007 and 2018. Hospital charts, and pathology and orthopedic clinic records, were reviewed for patient data such as age, gender, clinical and histopathological presentations, preoperative diagnosis and imaging results, management approach, recurrence, and treatment outcomes. The main presenting symptom was a hard, subcutaneous, slowly growing mass. The preoperative diagnosis was accurate and consistent with the pathological diagnosis of pilomatrixoma in only 35 cases (32%). The optimal diagnostic tool for pilomatrixoma seems to be ultrasound imaging of superficial tissue, and the optimal first-line treatment might be surgical excision with clear margins. However, pilomatrixoma is a benign tumor, with atypical forms, and there no tumor-specific diagnostic tool is available other than careful histopathological examination.

Preauricular Pilomatricoma Manifesting as an Aggressive Mass

Pilomatricoma is an uncommon benign skin tumor arising from the hair follicle. It usually occurs in the head and neck region and is typically found in the pediatric age group particularly girls. The tumor has inconsistent clinical features and may manifest as a small superficial lesion with benign features or a large and seemingly aggressive lesion with local invasion. Due to its variable clinical presentations, it can occasionally be misdiagnosed as a malignant tumor. We encountered a case of pilomatricoma in a 12-year-old girl with a left preauricular swelling for two years, which became progressively larger and more painful in the few weeks before presentation. Clinically, the swelling resembled a malignant parotid tumor. Multiple fine-needle aspirations were performed, but the cytology results were all inconclusive. Subsequent computed tomography scan revealed a well-defined calcified subcutaneous mass with suspicious parotid involvement. The case was posted for tumor excision and superficial parotidectomy. Intraoperatively, however, the mass could be easily separated from the parotid gland. Histopathological examination of the excised specimen showed characteristic ghost cells, basophilic cells, and ossifications typical of pilomatricoma. In conclusion, preauricular pilomatricoma may pose a diagnostic dilemma. A heightened knowledge of the disease is needed for early recognition of its clinical and imaging features to prevent aggressive therapy than is required.

Idiopathic scrotal calcinosis - A case report

INTRODUCTION

Idiopathic scrotal calcinosis is a rare benign condition which presents with asymptomatic multiple nodules on the scrotal skin.

PRESENTATION OF CASE

Our patient, a 64-year-old Indian male with Fitzpatrick skin type 4, presented with multiple nodules, which were completely surgically excised with no complications. Histological examination reveals extensive intradermal deposition of calcium surrounded by histiocytes and without cystic structure.

DISCUSSION

Numerous theories about the pathogenesis have been proposed and the evidence presented suggests this is a continuum.

CONCLUSION

The nature of idiopathic scrotal calcinosis is still unknown and it is up to debate whether the term "idiopathic" is appropriate for the condition.

Calcifying epithelioma of malherbe (Pilomatrixoma): Clinical and sonographic features

PURPOSE

The purpose of this study was to describe the clinical and sonographic features of calcifying epitheliomas (pilomatrixomas).

METHODS

We retrospectively reviewed the clinical data and sonographic appearances of 59 cases of calcifying epitheliomas in 58 patients that were confirmed pathologically.

RESULTS

The mean age of the patients was 26 years (range, 5-69 years) and the female-to-male ratio was 1.2. All masses were located in subcutaneous soft tissues. Overall, 76.3% of the cases were located in the head and neck; the mean tumor size was 13 mm, and 72.9% of the cases were between 10 and 20 mm in size. Of the lesions, 62.7% were hypoechoic masses with internal calcifications, and 74.6% of them showed low or moderate internal vascularity on Doppler imaging.

CONCLUSIONS

The diagnosis of calcifying epithelioma should be considered in a patient with a painless, circumscribed, oval-shaped hypoechoic mass with internal calcifications and internal vascularity in the subcutaneous soft tissues of the head or neck. The mass may be small and have well-defined margins, with hypoechogenicity. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:3-7, 2018.

Preauricular pilomatricoma: An uncommon entity in a dental pediatric patient

•

Pilomatricomas are common lesions although rarely encountered in dental practice. Dental professionals especially oral surgeons and pediatric dentists should be aware of the condition during their practice.

•

Common differential diagnosis of preauricular pilomatricoma does not involve temporomandibular joint disease. This condition should be added to differential diagnosis.

•

Meticulous examinations should be made and misdiagnosis with temporomandibular joint disease should be eliminated.

Introduction

Pilomatricomas are benign follicular skin appendage tumors, commonly occurring in children and young adults. Most patients admit to dermatologists to seek treatment and are well known by them; however, dental professionals, especially pediatric dentists are not familiar with these tumors.

Presentation of case

This report presents a 16-year-old female with preauricular pilomatricoma, located beneath the overlying skin of the temporomandibular region. Clinical examination revealed an asymptomatic lump, the overlying skin revealed no abnormalities. Patient was unaware of the lesion.

Discussion

Pilomatricomas are commonly encountered in the maxillofacial region, although not considered in differential diagnosis by dental professionals. They usually present as, asymptomatic, subcutaneous masses; although symptomatic cases have been reported. In literature, common differential diagnosis for head and neck pilomatricoma includes sebaceous cyst, ossifying hematoma, giant cell tumor, chondroma, dermoid cyst, foreign body reaction, degenerating fibroxanthoma, metastatic bone formation, and osteoma cutis. We are of the opinion that temporomandibular joint disease should also be considered in differential diagnosis for preauricular pilomatricoma.

Conclusion

Pediatric dentists should be aware of the condition and consider it in the differential diagnosis of pediatric conditions involving the temporomandibular joint.

[Pilomatricoma: a study of 22 cases]

Pilomatricoma is a common and benign skin tumor of childhood arising from the hair follicle matrix. It is an often misunderstood adnexal tumor, confused with other skin lesions. The most common sites of pilomatricome are the head and the neck. The aim of this study was to report a series of 22 cases with unusual forms collected in the dermatology department from January 2006 to May 2015. The study included 16 women and 6 men. The average age was 23.3 years (4- 80 years). Cervicofacial location was observed in 12 cases, 2 patients had multiple locations, a 4 year-old boy had frontotemporal location, a 14 year-old girl had face and forearm location and a 48 year-old patient had subungual location. Clinical features were typical in all cases, with subcutaneous nodules with a stony-hard consistency. All patients underwent excision of nodules under local anesthesia. Histological study supported a completely excised Malherbe's mummified tumor without malignancy. No patients relapsed. The originality of our study lies in the presence of exceptional locations in laterovertebral region, on limbs and in the subungual region and of unusual age of onset (80 year-old) as well as the presence of multiple tumor locations reported in 2 children.

Common Pediatric Skin Lesions: A Comprehensive Review of the Current Literature

The timely diagnosis and treatment of dermatologic disease in the pediatric population can be challenging. A basic, yet comprehensive knowledge of common lesions is essential for a successful practice in plastic surgery. In this article, the authors describe vascular, cystic, and pigmented cutaneous lesions that are commonly encountered in the pediatric population. Epidemiology, pathogenesis, clinical course, and management options are discussed for each.

Dermoid Cyst of Submental Region Mimicking Pilomatricoma

Diagnosis of midline neck swellings may give a myriad of options, ranging from ranula, thyroglossal duct cyst, cystic hygroma, cystic lymphangioma, epidermoid, dermoid and teratoid cysts to benign or malignant neoplasms of the mucosa or salivary glands and also rare skin appendage tumours like pilomatricoma or pilomatrix carcinoma. Various pitfalls are encountered in diagnosing these midline swellings as most of the features are overlapping. Careful history and examination have to be complemented with other diagnostic aids such as conventional radiography, ultrasonography, aspiration cytology and computed tomography to arrive at a correct diagnosis. Dermoid cysts in the head and neck are relatively uncommon, present in the midline either above or below the mylohyoid muscle thus differentiating it into sublingual and submental dermoids and can grow to a massive size before presenting symptoms if it breaches the mylohyoid muscle. Pilomatricoma is a skin appendage tumour which presents as midline swelling and is usually diagnosed with careful history and certain pathagnomonic features on fine needle aspiration cytology and ultrasonography. Hereby we are presenting a case of a submental swelling which was diagnosed as a dermoid cyst upon excision but which initially posed a diagnostic challenge because of features of pilomatricoma seen on FNAC.

Review of pediatric head and neck pilomatrixoma

INTRODUCTION

Pilomatrixoma is a benign skin tumor, which is commonly found in the head and neck region. It usually presents as an isolated lesion and rarely undergoes malignant transformation. It is not uncommon for these tumors to be misdiagnosed.

OBJECTIVE

To review the clinical characteristics of head and neck pilomatrixomas in the pediatric population.

METHODS

A systematic review was completed by searching ten databases to identify studies reporting findings on pilomatrixoma in the pediatric population. Eligible articles were independently assessed for quality by two authors.

RESULTS

A total of 17 studies met the inclusion criteria totaling 318 pediatric patients. The age of diagnosis ranged from 3 months to 17 years of age. The female to male ratio was 1.65:1. In 14 articles, in which pilomatrixoma was located in the head and neck region, 76 (25%) lesions were found in the neck while 229 (75%) were present in the head region. Three articles exclusively described ophthalmologic pilomatrixoma. Even though pilomatrixoma presents with classical features, the clinical diagnostic accuracy when confronting this lesion averaged 43%. The definitive treatment was surgical excision with a very low recurrence rate.

CONCLUSION

Head and neck pilomatrixoma in the pediatric population has a typical presentation with a low clinical diagnostic accuracy. Awareness of this lesion and its clinical appearance can improve its diagnosis. We hereby suggest a management algorithm for suspected pilomatrixoma.

Uncommon benign tumour of the skin: infraorbital pilomatricoma

Pilomatricoma is a relatively rare tumour of the skin derived from primitive basal cells of epidermis that differentiate into hair matrix cells. It comprises approximately 1% of all benign skin tumours. The most common sites for pilomatricomas are the head, neck and upper extremities. A 44-year-old woman, admitted to our department, underwent an orthopantomography examination, which revealed a well-circumscribed 1.6×1.4 mm radiopaque mass superimposed between the medial wall of the right maxillary sinus and lateral wall of the nasal cavity. Clinically, it was firm and mobile, and remained attached to the underlying skin when palpated. A cone beam CT scan was performed to ascertain its location and anatomic relations. Subsequently, it was totally excised under local anaesthesia. Histopathological evaluation of the lesion reported it to be a pilomatricoma.

The Epidemiology of Non-Melanocytic Benign and Malignant Skin Tumors in Pediatric Patients Attending to the Dermatology Department

Background

Non-melanocytic skin tumors are rarely seen in pediatric patients; although they are mostly benign, they remain to be elucidated by histopathological examination. The objective of the study was to describe the epidemiology of non-melanocytic skin tumors in children attending to our dermatology department.

Method

The histopathologic studies of all skin punch and excisional biopsies of children up to 16 years old referred to our dermatology department between January 2007 and January 2012 were reviewed retrospectively. Melanocytic tumors and cystic and infectious lesions were excluded. Age, sex, location, and histopathologic diagnosis were recorded. The skin tumors were categorized.

Results

A total of 4,126 skin tumors were analyzed histopathologically, and 203 of the lesions were from children up to 16 years of age. Ninety-seven of the lesions from 91 patients were non-melanocytic skin tumors. Forty-seven (51.64%) were male, 44 (48.36%) were female, and mean age was 10.55 ± 4.31 years. Malignant tumor was 1.03% (one tumor) and benign tumors were 98.97% (96 tumors) of all. The most frequent non-melanocytic skin tumor was pilomatricoma with 22 lesions (22.68%), followed by pyogenic granuloma with 18 lesions (18.54%), and nevus sebaceous with 10 (10.3%) lesions. Cutaneous leukemic infiltrate was found to be the only malignant skin tumor in the study group. The most frequently affected age group was children aged > 13 to ≤ 16 years, which included 38 patients (41.7%). The majority of lesions were on head and scalp (32 tumors, 32.96%), followed by trunk (28 tumors, 28.84%) and upper limbs (22 tumors, 22.75%).

Conclusion

The ratio of malignant to benign skin tumors in pediatric patients is found to be small. Pilomatricoma, pyogenic granuloma and nevus sebaceous are found to be the most frequent non-melanocytic skin tumors of children. The ratio of malignant tumors is very rare.

Congenital lesions of epithelial origin

Defects of embryologic development give rise to a variety of congenital lesions arising from the epithelium and are among the most common congenital lesions of the head and neck in the pediatric population. This article presents several congenital lesions of epithelial origin, including congenital midline cervical cleft, pilomatrixoma, dermoid, foregut duplication cysts, and preauricular sinuses and pits. In addition, the management of these lesions is reviewed.

Let's face it - 13 unusual causes of facial masses in children

Facial swelling is commonly encountered in paediatric patients and is typically related to an underlying infection. The spectrum of possible causes, however, is wide, and includes traumatic, inflammatory, nutritional and neoplastic aetiologies. In this pictorial essay we present 13 examples of rare conditions selected from a total of 136 MRI examinations performed at our institution between April 2007 and May 2013. These include HIV-associated malignancies such as a case of plasmablastic lymphoma, parotid gland tumours including a parotid hamartoma, rare congenital lesions such as a thyroid fetiform teratoma, and infective lesions including tuberculosis of the mandible. In many cases, only minimal information could be gleaned from the literature, particularly with regard to imaging findings. An analysis of the spectrum of masses and specific clinical presentations allowed for the construction of a diagnostic flowchart which may serve to assist in unusual cases.

TEACHING POINTS

• Facial swelling is commonly encountered in paediatrics, with a wide spectrum of possible aetiologies. • MRI is the favoured imaging modality for accurate assessment. • Facial swelling is typically infectious in nature, but includes various benign and malignant causes. • This pictorial essay presents 13 examples of rare conditions with corresponding imaging.

Idiopathic facial aseptic granuloma

Idiopathic facial aseptic granuloma (IFAG) is a condition that is commonly encountered in clinical practice, but is rarely reported. It appears in childhood and its pathogenesis is still unknown. It has a benign course with resolution within a few months without aggressive treatment. Microbiological tests are negative and histological findings are nonspecific. It is possible that this condition is part of the spectrum of granulomatous rosacea in childhood. We present two cases in which diagnosis of IFAG was established and resolved without sequelae following topical antibiotic treatment.

Pilomatrixoma masquerading as metastatic adenocarcinoma. A diagnostic pitfall on cytology

Pilomatrixoma (Px) is a relatively uncommon slowly growing, benign skin appendageal tumor with a wide morphological spectrum, and can pose diagnostic difficulties especially in cases with unusual clinical presentation. We report a case of young male who presented with a nodule over anterior abdominal wall, fine needle aspiration cytology (FNAC) revealed predominantly small cells in focal acinar pattern suggestive of metastatic carcinoma; however, histopathological diagnosis was Px. The case highlights the diagnostic pitfalls on cytology due to limited morphology.

Cyto-histopathological and Clinical Correlation of Pilomatricomas: A 4 Year Study

Aim:

The aim of the following study is to characterize the cytological features of pilomatricomas (PMXs) on fine-needle aspiration (FNA) and correlate with the histopathological features.

Materials and Methods:

FNA, histopathological and clinical diagnosis of 12 cases of PMXs were analyzed. Clinical, aspiration findings and histopathological features were correlated with histopathological diagnosis which was taken as the gold standard. A written consent was taken from patients or parents as appropriate. Morphological features of both aspiration as well as histopathological features were graded. The study was duly approved by the Hospital Scientific Review Committee.

Results:

Out of the 7600 cases studied retrospectively over a period of 4 years, only 12 cases were diagnosed as PMXs. These tumors were mainly located in the head and neck region and mostly affected young females (median age 9.5 years). The mean size of these lesions was 0.9 cm. Out of the 12 histopathologically proven cases of PMX, the correct clinical diagnosis was given in only one case while cytopathological diagnosis was achieved in four cases.

Conclusion:

PMX is a rare tumor, which is mostly found in the pediatric age group. The clinical features should be keenly observed. Keeping in mind the diagnostic pitfalls a cytopathologist may encounter, histopathology should be regarded as the gold standard for diagnosis.

Pilomatricoma of the pinna

A 4-year-old boy presented with a painless swelling over the right pinna of 4 months' duration. Histopathologic examination of the excised mass revealed features of pilomatricoma-a rare, benign skin neoplasm arising from hair follicle matrix cells. The unusual location of the lesion over the pinna, despite its frequent occurrence in the head and neck, prompted this article. We discuss the etiology, clinical presentation, and management of pilomatricoma of the auricular region.

Characterizing pilomatricomas in children: a single institution experience

BACKGROUND/PURPOSE

Pilomatricomas, or calcifying epitheliomas of Malherbe, are among the most common superficial cutaneous soft tissue lesions in children. Familiarity with the presenting signs and symptoms allows for the diagnosis to be made on physical examination alone in most patients, avoiding expensive and unnecessary diagnostic imaging.

METHODS

A retrospective IRB-approved review of surgical pathology archives and medical records of all patients undergoing excision of pilomatricomas between 1982 and 2010 was performed to determine the characteristics of the pilomatricoma tumors. Data regarding gender, age, location, size of tumor, and histopathology were collected.

RESULTS

There were 916 pilomatricomas resected in 802 patients. Fifty-five percent of the patients were girls (441 patients). The median age at the time of resection was 6 years (range 5 months to 18 years). Multiple lesions were found in 43 patients (5%). The most common location was head and neck (n = 529, 58%), followed by upper limbs (n = 214, 23%), trunk (n = 130, 14%), and lower limbs (n = 43, 5%). Information on size was available for 674 lesions; mean lesion diameter was 14.0 ± 7.4 mm. Twenty-eight patients (3%) had either recurrent (n = 11) or metachronous (n = 17) lesions resected at our institution, with a median interval of 12 months after initial resection (range 5 weeks to 5 years). No cases of pilomatrix carcinoma were observed.

CONCLUSION

The majority of pilomatricomas occur in the head and neck, although they can present in any location. Approximately 5% of children have multiple lesions. Pilomatricomas occur slightly more commonly in girls, and 66% of lesions occur in children < 10 years of age. Complete surgical excision is necessary to prevent recurrence. Recurrences and pilomatrix carcinoma are very rare if complete excision is achieved.

Cystic pilomatrixoma of the wrist mimicking a ganglion cyst in a child

We describe a patient with a cystic pilomatrixoma mimicking a ganglion cyst on ultrasound. A 9-year-old boy had a subcutaneous mass on his left wrist. Ultrasound displayed a well-defined, multilobulated anechoic mass containing a few internal septa between the extensor pollicis longus and the extensor carpi radialis longus tendons. Sonographic findings suggested that the mass was a ganglion cyst. After excisional biopsy, histopathologic examination confirmed the diagnosis of pilomatrixoma.

A 5-year-old girl with an enlarging mass at the elbow

Pilomatrixoma is a rare benign neoplasm that presents as a solitary, hard, mobile, subcutaneous mass. Pilomatrixomas can be found on any hair-bearing region of the body, with the upper extremity being the second most common location. Pilomatrixomas are common in children, and have a higher frequency in girls. We present a case of left-arm pilomatrixoma in a 5-year-old girl. Surgical excision was curative. Pediatric orthopedic surgeons should be familiar with this benign tumor when evaluating a calcified soft-tissue mass in the extremities of a child.

Facial dermatologic lesions in children

This article briefly reviews some of the most common skin lesions in the head and neck of a child. Benign "lumps and bumps" are very common in children and it is prudent for the pediatric maxillofacial surgeon to be familiar with their presentation, workup (including radiographic studies), and definitive surgical management. Inflammatory and infectious lesions require prompt treatment to avoid more serious sequelae of progressive infection and scarring.

Imaging and review of a large pre-auricular pilomatrixoma in a child

A 10-year-old girl presented with a mildly tender mass in the right preauricular region. The mass became larger, and the overlying skin turned purple. There was no clinical response to a course of either cephalexin or clarithromycin. The remainder of the head and neck examination was normal including normal facial nerve function. Lyme titers and a computed tomographic (CT) scan with contrast of the facial region were obtained. The CT scan demonstrated the lesion to be superficial to the parotid gland. The lyme titer was elevated and doxycycline was begun. The mass appeared to reduce in size after doxycycline treatment, but then grew and turned erythematous. The lesion was surgically excised and was vascular with calcification and cheesy inclusions. The mass was quite close to the skin and the clinical diagnosis at the time of surgery was a pilomatrixoma, which was corroborated on pathological evaluation.

Pilomatricoma as a diagnostic pitfall in clinical practice: report of two cases and review of literature

Pilomatricoma (PMC) is a relatively uncommon benign skin neoplasm arising from the skin adnexa. Since the first description of PMC in 1880, there has been a gradual increase in understanding of the morphologic features and clinical presentation of this tumor. However, difficulties still persist in making clinical and cytologic diagnosis. We report the clinical and histopathological findings of two cases of pilomatricoma. In case 1, a 10-year-old girl presented with a right upper back mass. In case 2, a nine-year-old girl presented with a left ear lobe mass. The clinical findings in both the cases were suggestive of epidermoid/dermoid cyst. However, subsequent histopathologic examination confirmed these cases as pilomatricoma. This report reveals that pilomatricoma is a frequently misdiagnosed entity in clinical practice. The purpose of this article is to create awareness among clinicians on the possibility of pilomatricoma as a cause of solitary skin nodules, especially those on the head, neck or upper extremities.

Diagnosis of pilomatricoma using an otoscope

Pilomatricoma is a benign tumor that presents as a 3-30-mm, firm, solitary, deep, dermal or subcutaneous tumor on the head, neck, or upper extremities. The clinical diagnosis is often made by the firm, sometimes rock-hard texture of the skin. The diagnosis can be confirmed by a skin biopsy or excision of the lesion. We have recently noted that pilomatricomas appear as a black mass in the skin when the lesion is transilluminated by placing the light of a fiberoptic otoscope adjacent to the skin lesion. To our knowledge, this is the first report demonstrating preoperative diagnosis of pilomatricoma by transilluminating the lesion with an otoscope.

[Insulated leg pilomatrixoma: a rare localization]

Pilomatrixoma is a benign skin neoplasm of the hair follicle. It's common in the pediatric population. It's usually misdiagnosed and confused with other skin lesions. Head and neck represent the usual locations. The extremity remains an exceptional location. Through an observation of a pilomatrixoma of the leg in an adult patient treated surgically without recurrence, different diagnostic and therapeutic aspects of this pathology will be recalled.

Pilomatricoma in children: a frequently misdiagnosed superficial tumor

Pilomatricomas are the most common superficial tumors in children, but they are frequently misdiagnosed preoperatively. There are some characteristic features of pilomatricomas that can help clinicians differentiate it from other tumors. The authors report 3 children with head and neck pilomatricomas, one with multiple tumors. They emphasize some clinical features that may help in differential diagnosis to avoid unnecessary investigations before surgical removal.

Pilomatrixoma in an infant: diagnostic challenges of fine-needle aspiration

Fine-needle aspiration biopsy (FNAB) is a well-recognized minimally invasive tool in the diagnosis of neoplasia of various organ systems. Several reports in the literature suggest that FNAB can be an accurate method for the preoperative diagnosis and treatment planning. We describe a case to caution the interpretation from a FNAB that contains suboptimal contents (basaloid cells only) and highlight a clinical-pathologic-based algorithm that can provide the appropriate management for the patient when the cytopathologic diagnosis does not fit the clinical impression.