PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Lumps

History

• When was the lump first noticed?
• Has it changed in size since?
• Is it painful?
• Any other lumps or associated symptoms?
• Ever been abroad?
• Preceded by trauma?
• Otherwise well?

Physical examination

• Remember the eleven Ss: site, size, shape, smoothness, surface, surroundings (eg nodes), structure (solid, fluid, or gas), stability (eg fixed to deeper structures), sound (eg venous hum), secretion (eg through a punctum), sensation (eg temperature, tenderness, pulsatility - this may seem to be a minor detail until faced with a surprise on a minor operations list. ).
• Does it transilluminate (ie fluid filled)?
• 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.

Differential diagnosis
Generally lumps fall into one of the following categories:

• Abscesses
• Lymphadenopathy
• Cysts
• Solid tumours
• Vascular formations
• Organ hypertrophy
• Foreign bodies and rarities

Some common sites with important differentials are:

• Neck lumps
• Groin and scrotum
• Breast lumps
• Sites of known lymph node collections - see Causes of lymphadenopathy.

Investigation and Management
Depends on the diagnosis and severity, but some general points are:

• If infection suspected - FBC, glucose, then antibiotics for likely organisms (often staph/strep. species) ± incision and drainage.
• If cystic - aspiration for microscopy/culture/cytology.
• If solid - biopsy/FNA for cytology/pathology, relevant blood tests, +/- appropriate surgery and medical therapy.
• If vascular - USS/Doppler.
• CT/MRI

Notes on a few possibilities

• Transilluminable lumps 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.
• Lipomas These benign fatty lumps, occurring wherever fat can expand (not scalp or palms), have smooth, imprecise margins and a hint of fluctuance. They only cause symptoms via pressure. Malignant change is very rare (suspect if rapid growth, hardening or vascularization occurs).
• Sebaceous cysts
  • These are intradermal, so you cannot draw the skin over them. Look for the characteristic punctum marking blocked sebaceous outflow.
  • Infection is quite common, and foul pus exits through the punctum.
  • Treatment: Shelling them out whole can be tricky: learn from an expert. After achieving haemostasis, close with subcuticular catgut.
• Causes of lymph node enlargement
  • Infections: glandular fever; brucellosis; TB; HIV; toxoplasmosis; actinomycosis; syphilis.
  • Others: malignancy (carcinoma, lymphoma); sarcoidosis.
• Cutaneous abscesses
  • Staphylococci are the most common organisms.
  • Haemolytic streptococci are only 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: Incision and drainage alone usually cures.
  • 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. For the rest, the treatment of choice is excision rather than the traditional blow from your bible! (the Oxford Textbook of Surgery).
• Fibromas These may occur anywhere in the body, but most commonly they are under the skin. These whitish, benign tumours contain collagen, fibroblasts, and fibrocytes.
• Dermoid cysts contain dermal structures; often found in the midline.
• Malignant tumours of connective tissue
  • 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.
  • Incisional biopsies of large tumours precede excision.
  • Any lesion suspected of being a sarcoma should not be simply enucleated in what might erroneously be considered a 'conservative' operation.

Last issued 30 Aug 2006