Images for surgeons

tively, altered flow patterns associated with anatomic derangements such as bicuspid aortic valves may be thought to cause stressinduced degenerative changes.9 It is speculated that multiple processes underlie the development of the large aneurysm presented in this case. This case presents intra-operative images of severely thinned aortic wall tissue and associated rare 11.5-cm ascending aortic aneurysm.

References 1. National Center for Injury Prevention and Control. WISQARS Leading Causes of Death Reports, 1999–2010. [Cited 27 Jul 2013.] Available from URL: 2. Okura T, Kitami Y, Takata Y, Fukuoka T, Arimitsu J, Hiwada K. Giant unruptured aneurysm of the thoracic aorta: a case report. Angiology 1999; 50: 865–9. 3. Gupta N, Mohammad N, Bajaj S, Shah P, Bikkina M, Shamoon F. Asymptomatic giant dissecting aortic aneurysm. Chest 2012; 142 (4_MeetingAbstracts): 124A. 4. Coady MA, Rizzo JA, Hammond GL et al. What is the appropriate size criterion for resection of thoracic aortic aneurysm? J. Thorac. Cardiovasc. Surg. 1997; 113: 476–91.


5. Dapunt OE, Gall JD, Sadeghi AM et al. The natural history of thoracic aortic aneurysms. J. Thorac. Cardiovasc. Surg. 1994; 107: 1323–32. 6. Bonser RD, Pagano D, Lewis ME et al. Clinical and patho-anatomical factors affecting expansion of thoracic aortic aneurysms. Heart 2000; 84: 277–83. 7. Elefteriades JA, Farkas EA. Thoracic aortic aneurysm: clinically pertinent controversies and uncertainties. J. Am. Coll. Cardiol. 2010; 55: 841–57. 8. El-Hamamsy I, Yacoub MH. Cellular and molecular mechanisms of thoracic aortic aneurysms. Nat. Rev. Cardiol. 2009; 6: 771–86. 9. Russo CF, Cannata A, Lanfranconi M, Vitali E, Garatti A, Bonacina E. Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease? J. Thorac. Cardiovasc. Surg. 2008; 136: 937–42. 10. Yuan S, Jing H. Cystic medial necrosis: pathological findings and clinical implications. Braz. J. Cardiovasc. Surg. 2011; 26: 107–15.

Dean E. Page, MBBS Andrew Newcomb, MBBS, FRACS Cardiothoracic Surgery, St Vincent’s Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12469

How peculiar: the case of a rare tumour Cock’s peculiar tumour, first described in 1852 by Edward Cock,1 is a rare growth that has been commonly misdiagnosed clinically ever since its initial discovery.2 This tumour has been described as a granuloma that is the result of chronic irritation on the surface of an epidermal cyst, typically identified on the scalp and scrotum.3 However, it can appear anywhere epidermal cysts exist.4 In this article, we present a case and update the limited literature that describes the Cock’s peculiar tumour, such as that seen in the seminal publication of Bailey & Love’s Short Practice of Surgery.4 A 23-year-old man presented with a 12-month history of increasing right medial thigh cystic mass with recurrent episodes of bleeding that was difficult to be managed. A computed tomography scan of the right thigh revealed that the mass measured 54 × 43 mm (Fig. 1). It was a well-encapsulated mass in subcutaneous adipose tissue but did not arise from underlying muscles. No adjacent lymphadenopathy was found. The patient had suffered a traumatic blow to the site a month prior to presentation, which caused a haematoma to form on the superficial surface of the lesion. This has since caused the lesion to bleed on occasions. The patient was admitted on emergency surgical care for a complete excision of the mass after an acute episode of bleeding (Fig. 2). The operation was conducted under general anaesthesia and the mass was dissected out with an elliptical incision, using diathermy to prevent excessive bleeding. It was considered at this point that the tumour may be a vascular tumour. Pathological examination revealed that the mass was cystic and lined by stratified squamous epithelium with a granular layer (Fig. 3). The cavity of the cyst was filled with keratin. There were multiple patches of haemorrhages underneath the cystic lining. The post-operative period was uneventful without any further complications. © 2013 Royal Australasian College of Surgeons

Fig. 1. A computed tomography scan of the right thigh demonstrating the mass as being separate from the underlying musculature. The lesion here appears encapsulated and non-invasive.

Since the lesion was first described in 1852, it has also been referred to as proliferative pilar cyst, proliferating trichilemmal tumour, pilar tumour and proliferating follicular cystic neoplasm, as well as being commonly mistaken for squamous cell carcinoma.2 The Cock’s peculiar tumour is a complication of long-standing epithelial cysts,5 completely benign and is well encapsulated, often being found on the scalp growing to significant sizes. This tumour has been demonstrated to have a pathogenesis that initiates from a blockage to the duct of a sebaceous gland, which subsequently results in infection. Due to regular escapes of purulent material at the surface of the lesion, chronic irritation results in the formation of a mass, which is then recognized as the Cock’s peculiar tumour.3


Images for surgeons

Fig. 3. Microscopic picture of the mass showing that it is cystic and lined by stratified squamous epithelium with keratin-filled cavity. Fig. 2. View of the Cock’s peculiar tumour on the inner right thigh. Bleeding can be seen from the superior aspect of this large lesion.

The patient reported here has had no recurrences, which is typical for the tumour type. Although a vast majority of the Cock’s peculiar tumours are benign, lesions with high mitotic rate, severe nuclear polymorphism and invasion of adjacent tissue may be found on pathology. The peculiar tumour may also give the appearance of a squamous cell carcinoma,6 and atypical cases should be treated with immediate excision.2 Indeed, even for benign cases wherever it is practical, removal of the peculiar tumour is preferred.

References 1. Cock E. A few remarks on a peculiar follicular disease. Guys Hosp. Rep. 1852–1853; 8: 151–74. 2. Affleck A, Varma S. Cock’s peculiar tumor. Arch. Dematol. 2010; 146: 68. 3. Ray MD. Gateway to Success in Surgery. New Delhi, India: Jaypee Brothers Medical Publishers, 2012.

4. Mann CV, Russell RCG (eds). Bailey & Love’s Short Practice of Surgery, 21st edn. London: Chapman & Hall Medical, 1992. 5. Bolbandi A, Krishnappa P, Arunchandra B. Varied presentations of epithelial cysts. Int. J. Case Rep. Images 2012; 3: 1–4. 6. Perks G. Cysts and benign tumours of skin. Surgery (Oxford) 2002; 20: 150–2.

Elliot Dolan-Evans,* BAppSc (Hons) Alfred King Yin Lam,† PhD, FRCPA Errol Maguire,‡§ AM, FRACS *Department of Medicine, Griffith University School of Medicine, Gold Coast, Queensland, Australia, †Department of Pathology, School of Medicine and Griffith Health Institute, Gold Coast, Queensland, Australia, ‡Department of Surgery, Griffith University School of Medicine, Gold Coast, Queensland, Australia and §Department of Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia doi: 10.1111/ans.12448

Sinister cause of abdominal wall bruising A 60-year-old man represented to the emergency department with a non-resolving cough and increasing abdominal wall bruising (Fig. 1). He had a past history of hypertension, chronic back pain and alcoholic pancreatitis, was a non-smoker, and was not taking any regular antiplatelet or anticoagulant medications. He initially presented with a 5-day history of left-sided pleuritic chest pain and productive cough. Subsequent investigations including a computed tomography (CT) pulmonary angiogram demonstrated minor collapse of the left lower lobe of the lung consistent with a lower respiratory tract infection. He was discharged back to the community with oral antibiotics. The patient then represented 3 days later with extensive abdominal wall bruising and abdominal wall pain. There was no history of trauma however his productive cough had persisted. A surgical opinion was sought and physical examination revealed an afebrile and haemodynamically stable patient who was alert and conversant. The cardiopulmonary examination revealed decreased

air entry in the left basal lung field with crackles. The abdomen was soft but distended. The abdominal wall depicted bruising around the left flank with extension medially indicative of Grey Turner’s sign. There was mild tenderness in the peri-umbilical region but without guarding or rigidity. Provisional diagnoses include the possibility of rupture of the rectus muscle as a result of excessive coughing, retroperitoneal bleeding and acute pancreatitis. Bedside ultrasound was performed on the abdomen and did not identify any free fluid or an expansile mass to suggest an aneurysm. His haemoglobin returned at 9.9 g/dL and white cell count was 36 × 109/L. Liver function test and pancreatic enzyme serology excluded pancreatitis. A CT of the chest and abdomen revealed left-sided lung herniation through the eighth intercostal space, leftsided pleural effusion, consolidation with pulmonary and pleural contents extending through the hernia into the left postero-lateral chest wall, and a fluid collection between the rib cage and latissimus dorsi muscle with secondary truncal oedema (Figs 2,3). © 2013 Royal Australasian College of Surgeons

How peculiar: the case of a rare tumour.

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