Case 39: enlarging forehead "bump"

posted: February 7, 1999

Resident: John Ratliff, MD
Attendings: Deepak Awasthi, MD; Steve Metzinger, MD; Paul Friedlander, MD

CLINICAL PRESENTATION: This 66 year white man presented with a progressively increasing "bump" on his right lateral forehead. He denied any neurological symptoms. He denied any headache, seizures, nausea/ vomiting. The patient was overall a healthy man. His past history is significant for a craniofacial approach and resection of an adenocarcinoma arising from the maxillary sinus (approximately 7 months prior to admission). This tumor abutted the cribiform plate. There was no dural penetration. The pateint had a gross total en bloc resection (including the cribiform plate) with negative margins. During this procedure a bifrontal craniotomy was performed. The patient did well postoperatively. He received focal radiation to the facial area for 6 weeks. The head was not part of the radiation field. The patient tolerated the radiation well until approximately one week after the RT, the patient first noticed the 'bump" on his forehead. Subsequently, this "bump" doubled in just 2 weeks. Of note, patient does not have systemic cancer.

EXAMINATION: The clinical examination showed no focal neurological deficits. The right forehead mass was 3cm x 4cm in size; it was non-mobile, firm, non-tender. There was no evidence of scalp erosion. A view of the "bump" is shown below:

Note the right forehead mass outlined by the purple-marker. The black marking represents the previous scalp incision for the bifrontal craniotomy during the craniofacial approach.

DIAGNOSTIC STUDIES: A cranial CT scan and MRI scan of the brain (with and without contrast) were performed. Select MR images are shown below:

Coronal T1-weighted contrast-enhanced MR image on the left shows an epidural homogeneously enhancing mass (purple marker). This same mass (purple marker) can be seen on the axial T2-weighted MR image on the right.

STEPS TAKEN AT LSUHSC: Given the fact that the patient had no systemic disease nor local recuurence at the site of the previous operation, it was felt that the best course of action would be to resect this mass en bloc (including scalp, bone and dura). This was accomplished without difficulty. Duraplasty (with artifical dural graft) and cranioplasty (with mesh and BoneSource) were performed after the removal of the lesion. Select intraoperative picts are shown below:

Left: en bloc resection of mass. The mass was infiltrating the craniotomy cut of the previous surgery. Right: en bloc resection sample (scalp, bone and dura). The white marker indicates the previous craniotomy cut. Note the tumor infiltrating through this cut.

Postoperative course was uneventful. The final pathology was adenocarcinoma (similar to the one resected 7 months ago). The scalp, bone and dural margins were negative. There was no tumor in the subdural space. It was our feeling that the tumor was iatrogenically implanted at this site during the previous procedure.

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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