Lumps

A lump or swelling is a common presenting problem. A lump may also be found by the examining clinician in the course of routine examination. A methodical approach to history and examination, with particular emphasis on inspection and palpation, are usually important in the correct description and initial diagnosis of a lump. This initial diagnosis will enable a management plan to be formulated and discussed with the patient. Management may range from explanation and reassurance to urgent referral for surgery.

Generally lumps fall into one of the following aetiological categories:

• Congenital or acquired:
• Traumatic
• Inflammatory (acute or chronic)
• Neoplastic (benign or malignant, primary or secondary)
• Other (degenerative, metabolic, parasitic, hormonal disorder)

• Where was the lump found? Common sites are:
  • Neck
  • Breast
  • Groin
  • Axilla
  • Wrist, hands and feet
  • Scrotum
  • Perianal
  • Scalp
  • Skin
  • Chest wall
  The site will give important clues from experience and a knowledge of anatomy as to the origin of the swelling and the underlying pathology.
• When was the lump first noticed?
• Has it changed in size since?
• Is it painful?
• Any other lumps or associated symptoms?
• Any history of travel?
• Any history of trauma?
• Any history of illness present or past?

It will usually suffice to succinctly describe the size, shape and consistency of the lump, but the following is a more thorough outline of the examination.
It is important to try and ascertain the anatomical plane or origin of a lump. It may be in the skin, subcutaneous tissue, muscle, tendon, bone, or arise from an internal organ. This can be attempted by:

• Inspection and palpation. Initial inspection should identify the position, size, shape and any unusual colour of the lump. These features and others can be remembered as 'the Ss':
  • Site or position:
    • This should be accurately defined anatomically. It may be easy to define (as with lumps in the breast, thyroid or parotid) or more difficult (as for example with abdominal masses).
    • Where it is difficult to ascribe an anatomical origin other features should then be described.
  • Size:
    • This should be measured and recorded with a diagram showing dimensions, position and shape.
    • It can be misleading to describe size by comparisons with other things, familiar or otherwise. For example, 'it is about the size of a quail's egg, sir'!
  • Shape:
    • Some swellings have a characteristic shape.
    • For example the two lobes of the thyroid, the parotid (fills the hollow between posterior border of mandible and the mastoid process), the enlarged spleen or liver, the uterine fundus in pregnancy, and a distended bladder.
  • Surface
    • This may be uniform and smooth or very irregular.
    • For example the liver, prostate and thyroid may have either a smooth or irregular surface depending on the underlying pathology.
    • The margins of the lump may be similarly described as regular or irregular, well or ill-defined, sharp or rounded.
  • Surroundings
    • Examination around the lump may reveal associated swellings.
    • For example lymph nodes, breast nodules, neurofibromatosis and lipomatosis.
    • Examine the regional lymph nodes, or if this lump may be a lymph node, examine its drainage area.
    • Examine the corresponding area on the other side of the body as appropriate.
  • Structure or consistency:
    • The lump may be solid, fluid, or gaseous.
    • Lumps may be described as soft and fluctuant, firm or even 'stony hard'. Fluctuation indicates a fluid swelling and this is elicited by compression of the swelling with displacement in two planes.
  • Stability:
    • It is important to define if the lump is mobile, attached or fixed to other structures.
    • Fixation may be to skin in, for example 'peau d'orange' dimpling of the skin.
    • Fixation may be to deeper structures, for example breast lumps to underlying muscle and thyroid indirectly to larynx.
  • Sound:
    • This would usually be detected at auscultation (below).
    • For example venous hum over a vascular swelling.
  • Secretion:
    • There may be evidence of a punctum (with sebum secretion).
    • For example this can help differentiate a lipoma from a sebaceous cyst.
  • Sensation:
    • Temperature - the skin over inflammatory lesions may be raised, red and warm (increased blood flow).
    • Tenderness- Inflammatory lesions are often tender to touch. Tumours are often non tender.
    • Pulsatile swellings- Distinguish between transmitted and expansile pulsation.
  • Sign of Emptying:
    • When compressed the swelling diminishes in size or disappears and slowly refills when pressure is released
    • For example cavernous haemangioma, lymphangiomata and meningocoeles.
  • Sign of indentation:
    • On compression the lump remains indented.
    • For example some sebaceous cysts.
• Percussion:
  • Usually of little value in defining a mass with the exception of some abdominal swellings.
• Auscultation:
  • Vascular sounds may be detected. For example a systolic murmur or 'bruit' may be heard over large tumours, vascular goitres and arterial aneurysms.
  • Fetal heart sounds from about week 28 in the pregnant uterus.
  • Bowel sounds over a hernia containing bowel.
  • Friction rub over an enlarged spleen or liver when there is perisplenitis or perihepatitis.
• Transillumination:
  • This will differentiate between a solid and a fluid filled swelling.
  • Find a dark room and a bright, thin 'pencil' torch, and place it on the lump, from behind, so the light is shining through the lump towards your eye. If the lump glows red it is said to transilluminate.
  • Fluid-filled lumps such as hydrocoeles are good examples of transilluminable swellings.

The record of findings may include the following (the 4 Ds) :

• Date. It may be important to plot change over time.
• Define the site and record dimensions.
• Describe any features as above.
• Draw a diagram or even photograph with a ruler (a picture paints a thousand words).

Diagnosis can be made clinically with some lumps and investigations are often not required.

• Excision biopsy may be all that is required, when it is not clinically contraindicated.
• Full blood count, blood glucose and microbiological investigations may be appropriate for suspected infection.
• Aspiration followed by microscopy, culture and cytological examination may be indicated for some cystic swellings.
• Fine needle aspiration for cytological examination may be used for some solid tumours.
• Ultrasound and doppler studies may be used for suspected vascular lesions.
• CT and MRI may be necessary to clarify the anatomy and diagnosis of some lumps, particularly where deeper structures may be involved with or without organ involvement.

The most likely diagnoses will be determined by the features of the lump, the anatomical site and the suspected aetiology. The following selection serves to illustrate this point.

• Neck lumps:
  • Most often caused by enlarged lymph nodes (consider sources in head and neck, chest, abdomen, lymphoma)
  • Thyroid disease
• Groin and scrotum:
  • Indirect inguinal hernias
  • Testicular swellings (possible to 'get above the swelling')
  • Epididymal cysts
  • Hydrocoeles
  • Sebaceous cysts in the scrotal skin
• Breast lumps:
  • Fibroadenomas (mobile, 'the breast mouse')
  • Simple cysts
  • Fat necrosis
  • Fibroadenosis (lumpy breasts)
  • Breast abscesses
  • Breast carcinoma
• Groin, neck and axilla:
  • These are sites of known lymph node collections (see Assessing Lymphadenopathy)
  • Sebaceous cysts
  • Abscesses
• Abdominal lumps or masses:
  • Pregnancy
  • Hepatomegaly
  • Splenomegaly
  • Other organ enlargement and tumours
  • Abdominal aortic aneurysms (pulsatile and often with bruits)

This will depend on a number of factors such as the site of the lump, the features of the lump, and ultimately the suspected diagnosis. Discussion with the patient will enable the patient to make choices about treatment. The following options may be considered:

• Reassurance and no treatment (for example dermatofibromas, lipomas, some sebaceous cysts).
• Routine investigation to confirm a diagnosis (for example hydrocoeles, goitre and other benign conditions).
• Routine excision biopsy (for example sebaceous cysts, troublesome lipomas, persistent ganglia).
• Urgent referral for investigation and/or treatment (two week rule to apply where malignancy suspected). Examples include:
  • Any lump with features of malignancy:
    • Hard, fixed and irregular lumps (often painless)
    • Lumps with a history of rapid growth
  • Breast lumps
  • Testicular lumps (not obvious epididymal cysts)
  • Abscesses (for incision and drainage)

The management of some lumps (particularly some sites and clinical findings) may be usefully discussed with consultant colleagues. A typical example is lymphadenopathy in the neck. Benign pathology can present in an alarming fashion with hard, fixed and rapidly growing lumps which suggest malignancy. Urgent referral for further investigation is needed to make a diagnosis and, hopefully, allay anxiety.

• Lipomas:
  • Benign fatty lumps, occurring wherever fat can expand (not scalp or palms).
  • Have smooth, imprecise margins and some fluctuance.
  • They cause symptoms from their size and pressure on surrounding structures.
  • Malignant change is very rare (suspect if rapid growth, hardening or vascularisation occurs).
• Sebaceous cysts:
  • These are intradermal (skin cannot be drawn over them).
  • Confirm diagnosis by identifying the characteristic punctum.
  • Infection is quite common. Pus may then exude through the punctum.
  • Treatment is by excision. Volkmann spoon useful for this as sharp instruments burst and fragment the cyst wall.
• Lymph node enlargement- There are many causes of lymphadenopathy which can be generalised or localised. Examples include:
  • Viral infection (for example glandular fever, HIV,cytomegalovirus).
  • Bacterial infection (for example tuberculosis, brucellosis, syphilis, actinomycosis)
  • Other infections (for example toxoplasmosis)
  • Malignancy (for example secondary carcinoma, lymphoma).
  • Inflammatory (for example sarcoidosis, connective tissue disorders, autoimmune disease).
• Cutaneous abscesses:
  • Staphylococci are the most common causative organisms.
  • Haemolytic streptococci are common in hand infections.
  • Proteus is a common cause of non-staphylococcal axillary abscesses.
  • Below the waist faecal organisms are common (aerobes and anaerobes).
  • Treatment is by incision and drainage.
• Boils:
  • Furuncles are abscesses which involve a hair follicle and its associated glands.
  • A carbuncle is an area of subcutaneous necrosis which discharges itself on to the surface through multiple sinuses.
• Rheumatoid nodules:
  • These are collagenous granulomas which appear on the extensor aspects of joints, especially the elbows.
  • They occur in established cases of rheumatoid arthritis.
• Ganglia:
  • These are degenerative cysts from an adjacent joint or synovial sheath commonly seen on the dorsum of the wrist or hand and dorsum of the foot.
  • They may transilluminate. 50% will disappear spontaneously.
  • Excision may be required.
• Dermatofibromas:
  • Very common and have characteristic dimpling of overlying skin.
  • These may occur anywhere in the body, but most commonly they are under the skin of the legs.
  • Remove where cosmetically disliked, symptomatic or diagnostic uncertainty.
• Dermoid cysts:
  • These contain dermal structures.
  • They are often found in the midline.
  • Treatment is (for diagnosis) by excision biopsy.
• Malignant tumours of connective tissue:
  • These are rare but important to identify clinically. They require urgent referral.
  • Suspicion will be aroused generally speaking by rapid growth and the hard consistency of these tumours.
  • These include the fibrosarcoma, liposarcoma, leiomyosarcoma (smooth muscle), and rhabdomyosarcoma (striated muscle).
  • Sarcomas are staged using a modification of the TNM system which includes tumour grade.