11. LUMPS IN THE SKIN

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1 , 11. LUMPS N THE SKN Skin lesions in the United Kingdom account for 1318%' of outpatient surgical referrals. The majority of these cause no great concern, but malignant lesions of the skin are increasing in incidence and therefore an accurate knowledge of the various guises of skin neoplasia is essential. Many types of skin lesion may ulcerate and these are discussed in Chapter 12, This chapter should also be read in conjunction with Chapters 9, 10 and 13. Break in the continuity 01the epithral suriace 11.1 NTAL ASSESSMENT 7 When the skin is moved he lump mres wilhit Skin can be moved overtr lump AMELANOTC AND AVASCl{LAR ULCER brad bill NDTNASCAR Red/purple VASCULAR /GRANULATON TSSUE bill] LUMP S N THE SKN Brown/black pigment MELANOTC b. Proliferates beyond wound margin Usually itches Especially black skin KELOD SCAR Steroid injection and/or excision LUMP S UNDER THE SKN b. NASCAR nside wound margin Red Wide HYPERTROPHC or pressure garment SCAR

2 11. LUMPS N THE SKN Congenital or hairy f the affected area covers more than 1% of body surface. excision because of risk of malignant change 11.2 LUMP N SKN (1) MELANOTC MOLE/NAEVUS Overgrowing keratin layer KERATOSS Acquired adolescent/adult t may be very dillicuilio distinguish a benign from a malignant lesion Features suggestive of malignancy are listed below, bul these characteristics are nol definitive and a tissue diagnosis is therefore required Features suggestive of malignancy include: ncrease in pigmentation ncrease in size Bleeding Ulceration or crusting Spread of pigmentation Red halo around lesion Satellite lesions Pain O',ilChing ;/. EXCSON BOPSY Greasy, warty Raised lesion SEBORRHOEC KERATOSSW ART or curretlage lor cosmesis Scaly Crumbling surface On exposed areas ACTNC/SOLAR KERATOSS (premalignant) Topical chemotherapy. cryolherapy or excision Benign DYSPLASTC NAEVUS Malignant i.e there is loss of differentiation of the cells. but no invasion of the surrounding tissues MALGNANT MELANOMA A lew may be amelanotic Palros 01 hands Horizontal growth phase Vertical growth phrase Frequently arises Soles 01feet in Hutchinson's freckle Nail beds Therefore we'" prognosis Ughtexposed areas ACRAL LENTGNOUS Behaves like superficial spreading SUPERFCAL SPREADNG NODULAR LENTGO MAUGNA MELANOMA Least malignant Malignant melanoma is best staged by Breslow's method, which measures the thickness of the lesion in millimelres: the thicker the lesion the worse the prognosis and the wider the resection should be with a margin of normal tissue (of variable size) lymph node dissection is the normal treatment Chemotherapy is for palliation only mmunotherapy (interleukin2) may have a role

3 11. LUMPS N THE SKN Raised 11.3 LUMP N SKN (2) VASCULAR/GRANULATON TSSUE Slightlyelevaledtrlat soft/comressib,e Young people Soft Compressible STRAWBERRY NAEVUS Leave it as mosl will eventually disappear Rounded Granulation tissue Bleeds frequently History of penetrarg injury PYOGENC GRANULOMA KAPOS'S Multifocal Sluish.red SARCOMA Consider HV status and appropriate workup Single lesions are excised Radiotherapy for multiple sites Painful 13 mm Under nail GLOMUS TUMOUR Painless 23 mm Multiple Brightrr spots Especially on face, neck and scalp Present from birth AsymmeTa,outiine Central arteriole serving capillaries CAMPBELL DE MORGAN SPOTS Leave them PORT WNE STAN SPDER NAEVUS or T1ELANGECTASA Laser for cosmetic defect Seen in: liver disease hereditary haemorrhagic telangiectasia Up to five may be normal Usually no treatment required f necessary, electrodesiccation ll... [] '"".. :

4 11. LUMPS N THE SKN 11.4 LUMP N SKN (3) AVASCULAR AND AMELANOTC located at embryological sites of fusion in midline of scalp, neck and lower jaw or al outer angle of eyebrow (external angular dermoid) NCLUSON DERMOD CYST NOT NFECTED / Following a traumatic More mobile in one direction puncture wound Pressure may cause tingling Usually on extremities MPLANTATON DERMOD CYST NEUROMA! NEUROFBROMA Red, swollen, ho, tender, loss of function NFECTED Most commonly on lace, ABSCESS neck, trunk and scalp Punctum may be visible Mobile over deeper skin SEBACEOUS OR EPDERMOD CYST Exision f multiple with caftauait spots Consider: Von Recklinghausen's neurofibromatosis Complete excision f infected, antibiotic therapy prior to excision or incision and drainage Staphylococcal abscess in a hair follicle Patient may be diabetic FURUNCLE Multilocular abscess draining via mulliple sinuses Usually on back of neck Palient may be diabetic CARBUNCLE nfected sweat gland Multiple recurrent sepsis of axillas or perineum HDRADENTS SUPPURATVA Antibiotic therapy and drainage of pus fj.s for furuncle but also excision with primary closure or split skin graft

5 PULSATLE 11.5 LUMP UNDER THE SKN Machinelike murmur on auscultation Collapsing pre distal to it ARTEROVENOUS MALFORMATON May be a history of surgery (especially vascular or trauma) ANEURYSM Rarer differential diagnoses requiring histology for diagnosis, e.g. Angioma Fibroma Neuroma Angiosarcoma Rhabdomyosarcoma Fibrosarcoma Osteosarcoma Chondrosarcoma or grafting n some instances the diagnosis of these lumps depends on their anatomical location, 8.g. Lumps in groin or scrotum see Chapter 9 Lumps in the neck see Chapter 24 Any subcutaneous tissues or structures may form benign or malignant tumours Most of these that present as lumps in the skin require histology to make the diagnosis; a few, however (listed separately below) are characteristic f a soft tissue malignant tumour is suspected, an incision biopsy is taken via a small, carefully placed incision that is unlikely to compromise subsequent definitive surgery Dorsum of the wrist, hand and around the ankle Hemispherical Hard, fluctuant consistency Weakly transilluminable GANGLON \ Can present Lobulated/soft LPOMA anywhere jf inconvenient or unsightly f multiple and painful MULTPLE L1POMATOSS/ DERCUM'S DSEASE Can rarely undergo malignant change POSARCOMA