Giant Proliferating Pilar Tumor of the Scalp: A Minimal Risk Approach

A 61-year-old man presented with a large scalp mass of more than 30 years duration. He reported recent rapid growth, leading him to seek medical attention. On examination the lesion was approximately 20 cm in diameter with a wide base and a bulky protuberant appearance; the patient described himself as having a horned or “Viking helmet” appearance. CT imaging showed no abnormality of the underlying calvarium but was suggestive of extension of tumor through the galea in some areas. Biopsy was suspicious for proliferating pilar cell tumor. Given this rare but benign neoplasm diagnosis, the size of the disfiguring tumor, and the patient's comorbid status (anticoagulation for cardiac disease), we decided to resect the mass with limited margins to rule out malignancy definitively and treat the bulky lesion. Raney clips proved instrumental to maintaining hemostasis during the resection in this anticoagulation-requiring patient. The periosteum was preserved except for a few small areas where the tumor appeared to be very close to it. Because we needed to finalize the tumor type and assess margin status, we opted to avoid committing to a definitive flap or skin graft reconstruction and reconstructed the large scalp wound with an INTEGRA dermal regeneration template (Plainsboro, NJ) as a temporizing measure. Ultimately, all margins were negative, the diagnosis confirmed to be benign, and the patient was counseled regarding definitive reconstruction. In the short interim between the resection and his postoperative visit, remarkable wound healing had occurred and the decision was made to observe the wound without further reconstruction. Indeed, the patient opted to forgo additional reconstructive procedures as he was pleased with his result and did not want to miss further time at work.

The unique aspects of managing this case are presented in keeping with the theme of the meeting, Minimizing Risk. Our management of this high comorbidity patient with a massive rare neoplasm led us to investigate other conservative measures in such patients with scalp lesions and various lesions at other sites in the head and neck.