OVERVIEW• Definitions – Lump , Swelling and Tumor• Differences Between Benign And Malignant Swellings• Evaluation of a swelling – History• Evaluation of a swelling – Physical Examination• Benign Skin Swellings• Congenital• Inflammatory• Traumatic• Miscellaneous• Neoplastic• Special Investigations and Treatment Options
Swelling: enlargement or protuberance in thebody due to any cause. A swelling maybe: - Congenital -Traumatic - Infalmmatory - Neoplastic -Miscellaneous
Tumor: growth of new cells which proliferateindependently. - Benign tumour proliferates slowly with littleevidence of mitoses and invasiveness- Malignant tumour proliferates fast withinvasiveness and mitosis.
Benign Occurs at a younger age Malignant Usually seen above 40 years or might occur at a younger ageDuration: Slow growth Duration: Rapid growthPain: Usually absent Pain: May be painfulLoss of weight: Never Loss of weight: PresentseenLoss of function: Not seen Loss of function: Seen quite early
Mobility: Freely mobile Mobility: Fixed due to infiltrationSurface: Usually smooth Surface: Usually irregularMargin: Definite and smooth Margin: Not definite and irregularConsistency: Usually firm Consistency: Hard or varyingPressure effects: Absent Pressure affect: PresentLymph nodes: Not enlarged Lymph nodes: EnlargedDistant metastasis: Not seen Distant metastasis: Seen in late stage.Recurrence: Never recurs after excision Recurrence: Often recurs after excisionSecndary changes: Not seen Secondary changes: Often present
History1. Duration2. Mode of onset3. Associated symptoms4. Progress of the swelling5. Exact site6. Fever7. Presence of other lumps8. Secondary changes9. Impairment of function10.Recurrence of the swelling11.Loss of body weightPast historyPersonal historyFamily history
General ExaminationLocal examination:Inspection:Situation- Few swellings are peculiar in their positionsColourShapeSizeSurfaceEdgeNumberPulsationPeristalsisMovement with respirationImpulse on coughingMovement on deglutitionMovement with protrusion of the tongueSkin over the swellingAny pressure effect
Palpation• Important part of local examination – collaborate findings of inspection and explore other findings• BE GENTLE• Temperature – MUST BE DONE FIRST !!!• Tenderness – Look at facial expression , be gentle• Size, shape and extent : try to find whole extent of swelling• Surface – smooth (cyst) , lobular (lipoma) , nodular(matted lymph nodes), irregular and rough (carcinoma)• Edge – well defined or indistinct, elicit SLIP SIGN• Consistency – uniform or variable uniform ( soft – lipoma, cystic – cyst, firm – fibroma, hard, but yielding – chondroma, bony hard – osteoma, stony hard – carcinoma)
• Consistency – In gaseous swellings ( gas gangrene, surgical emphysema) ; crepitus may be heard• Variable consistency – carcinoma or sarcoma• Also check – if swelling getting moulded to pressure –( ex: sebaceous cyst , dermoid cyst ) or pitting on pressure ( indicates edema – inflammatory swellings ) • FLUCTUATION TEST - swelling fluctuates when containing gas or liquid • Mechanism • Always perform in two planes • How to do fluctuation for 1. freely movable , 2. Very small (Pagets test) 3. Very large swelling REMEMBER FALSE POSITIVE FLUCTUATION!!!
• FLUID THRILL – swellings containing fluid• mechanism – Percussion wave is conducted to the other pole when one pole is tapped• - Fluid thrill in small swelling ? Large swelling ?• TRANSLUCENCY- Swelling containing clear fluid (even highly refractile fat) transmits light• A swelling may be fluctuant BUT NOT translucent ( sebaceous cyst – pultaceous material )• How to elicit ?• COUGH IMPULSE – Swellings which are In communication with the abdominal ( eg hernia), pleural or spinal or cranial cavity• Mechanism and how to elicit?• In children it is performed when they CRY
• REDUCIBILITY – Hernia ( also lymph, varix, meningocele may reduce partly or completely• Swelling reduces and ULTIMATELY DISAPPEARS WHEN PRESSED UPON.• COMPRESSIBILITY – Swellings donot usually have communication with abdominal ,pleural or other cavities• Liquid filled , usually from vascular malformations like capillary or cavernous hemangiomas.• Contents reappear when pressure is taken off• PULSATILITY – Maybe expansile ( arising from an artery) or transmitted ( near an artery )• - How to differentiate ??
• FIXITY TO THE OVERLYING SKIN : Swellings which originate from skin will move with skin ( except malignancies )• Other swellings – how to know attachment to overlying skin?• RELATIONS TO THE SURROUNDING STRUCTURES• Swelling arising from subcutaneous tissue – free from overlying skin and underlying contracted muscle ( can be freely moved )• Arising from deep fascia – Not be mobile as the one arising from S/C tissue• Arising from muscle – it will be mobile when muscle is relaxed• Ask patient to contract muscle – if swelling ARISES from muscle it will diminish in size , if it is arising from S/C tissue but attached to muscle , it will become more prominent and cannot be moved along line of muscle fibres..if it arises deep to the muscle, virtually disappear
State of the regional lymph nodesPercussion: Not much of importance in case of aswelling. Its sole place is to find out the presenceof gaseous content within the swelling. Ex.Resonant note in herniaAscultation: All pulsatile swellings should beascultated to exclude presence of any bruits ormurmursMeasurementMovement- In case of a swelling you mustexamine the movements of the nearby join toexclude any impairment.
Examination for pressure effect: swellings may inevitably exertpressure on the surrounding structures:1. Arterial pulse distal to the swelling is felt. Sometimes the swelling may press on the main artery of the limb and cause weak pulse distally.2. The nerves may be affected by the pressure of the swelling. This will cause wasting, paresis or paralysis of the muscles supplied by the nerve.3. The swelling may exert pressure on the subjacent bone by eroding it. Example: Dermoid cyst on the skull
• Capillary hemangioma • Cavernous hemangioma• Usually flat • Soft , spongy• Bright red or purple • Bluish swelling patches • Blanches on• Blanches on pressure pressure • Compressible• Plexiform hemangioma• Network of interwoven dilated arteries• Bag of earthworms
Acute Inflammatory Chronic Inflammatory All signs of acute inflammation – rubor , All signs are present BUT SUBDUEDcalor, dolor, tumor and functio lesiaPain , redness and heat predominate Swelling is more predominate Brawny induration and edema Brawny induration and edema ABSENTconspicuously PRESENT• Some sarcomas like Tenderness , Brawny induration osteosarcoma MIMICS and edema acute inflammatory Fluctuation – ( pus ) swelling with pain , redness, swelling and Acute lymphadenitis of related heat . How to lymph nodes differentiate ?? Leucocytosis
• Chronic inflammatory Occasional dimunition in the size swellings may sometimes of the swelling ( tumor never recedes ) mimic malignancy . How to differentiate ??- Localized accumulation of PMNL with tissue necrosis in the dermis and Subcutaneous tissue- Commonest organism – Staphylococcus aureus
- CLINICAL FEATURES- Erythematous swelling, tenderness , pain- Pus draining from it- Erythematous surroundings- May / may not be fluctuant ( parotid abscess is not fluctuant ) THREE MAIN TYPES : - Pyogenic Abscess - Pyaemic abscess - Cold abscess
Pyogenic Pyaemic Cold (most common )-Source of infection Cellulitis or acute infective emboli – Sequel to lymphadenitis lodge in different TUEBRCULAR places -- MULTIPLE INFECTION of lymph ABSCESSES nodes and bone- Clinical features - red hot and tender - commonly occur in - NON-REACTING ( - pus pain SUBFASCIAL PLANE NOT hot or painful ) becomes THROBBING - Brawny induration - Acute features I,e - Caused by the and EDEMA ( redness etc. caseation of lymph pitting) ABSENT nodes - Fluctuation +/- - Constitutional (parotid) symptoms like high fever, rigor etc.Common sites anywhere (eg.liver) in the SUBFASCIAL Neck and axilla plane ; multiple arise May originate from when one has been ends of bones coe incised to surface through fascial planes
- Infection of hair follicle by Staphylococcus aureus- Clinical Features- Starts as PAINFUL and INDURATED SWELLING- TENDERNESS and EDEMA +++- After some days softening at the centre - PUSTULE rupture spontaneously discharge GREEN- Then, DEEP CAVITY lined by granulation tissue heals by itself- COMMON SITES – Back and the neck- Complications ??? - Bigger ; same causative organism ; common in males >40 and DIABETICS - Starts similar fashion to boil – spreads rapidly progress similar to boil - PATHOGNOMONIC FEATURE – Sieve like or cribriform appearance - Multiple openings coalesce ULCER with ashy-grey slough base slough separates granulation tissue
Erysipelas Cellulitis ( MORE FATAL)- Spreading cuticular lymphangitis - Spreading inflammation of Subcutaneous tissue and fascia- Organism – Str. Pyogenes Str. Pyogenes- Predisposing factors – debilitation or poor DIABETICS or debilitated statehealth- Features – RAISED RASH HAS SHARPLY No DEFINITE EDGEDEFINED MARGINStarts as rosy-red rash – disappears on redness, itching and stiffness at site ofpressure innoculation ; Red streaks (lymphangitis) acute lymphadenitis or regional nodes Vescicles contain SEROUS FLUID Vescicles contain PUS
Traumatic:Traumatic swellings arising from the skin andsubcutaneous tissue are rare. Hematoma following atrauma may give rise to swelling.
Sebaceous Cyst:- cyst of the sebaceous gland due to blockage of the duct of this gland which opens intp the hair follicle. The gland becomes distended by its own secretions.- Contains sebum and always has a black spot on the swelling, which is the obstructed opening known as, “punctum”.- Common in scalp, face, scrotum- Single or multiple- Smooth and round shape whose margin yields to the palpating finger- Fluctuation test is positive- Transillumination test is negative
Condyloma: - Hypertrophy of the epidermis occurring at the mucocutaneous junction ex. angle of the mouth, anus, vulva etc. - Fungating, sessile raised but flat growth with moist and sodden surface.Warts: patches of overgrown skinwith hyperkeratosis- Found in hands, face, knees, sole of the feet, axilla- Firm and covered with rough surface and filiform excrescences- Painful when they are repeatedly rubbed or become infected
- LIPOMA ( UNIVERSAL TUMOR ) – Commonest tumor of the subcutaneous tissue- Benign tumor of the adipocytes- COMMON SITES-Other places – Intermuscular, Subfascial , Submucosal , Intra-articular etc.
VARITIES OF LIPOMA – ENCAPSULATED , DIFFUSE and MULTIPLE - Skin overlying – Slowly growing and PAINLESS usually normal Can occur at any age – RARE IN But in LARGE Skin CHILDREN may be stretched - Freely mobile over deeper structuresUsually SMALL , mayattain large sizes - Skin can be pinched up SOFT and LOBULATED consistency
- DIFFUSE LIPOMA - Does not possess features of lipoma – PSEUDOLIPOMA- Subcutaneous and Intermuscular tissue of neck – extending into cheek- NO CAPSULE- Seen in Persons taking EXCESSIVE ALCOHOL- MULTIPLE LIPOMAS - Called LIPOMATOSIS- Painful often contain NERVE TISSUE ( NEUROLIPOMATOSIS )- Seen in limbs and Trunk - COMPLICATIONS - DECRUMS DISEASE - Myxomatous degeneration - ( Adiposis Dolorosa ) - Saponification – Tender lipomatous - Calcification swellings - Infection - Seen in TRUNK - Ulceration - Affects Women - MALIGNANT CHANGE - Complications mainly – S/c tissue of thigh, buttock and Retroperitoneal tissue
Pedunculated with Central fibrovascularOvergrowth of all layers of branched villous core lined by epitheliumskin processes - Sometimes, surface may be hard - Swelling – HORNY PAPILLOMA - Papilliferous, pedunculated or sessile - Usually Soft and solid - Complications- ulceration , - Moves with the SKIN bleeding , malignacy - Other sites lip, tongue, colon , rectum, kidney etc.
- Tumor of the fibrous tissue - True fibroma rarely occurs ; mostly combined with mesodermal tissues – Fibrolipoma, fibromyoma, neurofibroma etc.- Painless, Firm , WELL CIRCUMSCRIBED- Freely mobile on underlying structures- According to consistency maybe SOFT or FIRM ( usually FIRM ) depending on amount of fibrous tissue - DESMOID TUMOR ( Paget’s recurrent fibroid) - Unusual - Arises in rectus sheath - Recurrence - Potential for malignancy
Lymphangioma: localized cluster of dilated lymhsacs in the skin and subcutaneous tissues whichcannot connect into the normal lymph system.3 types: a) Simple or capillary b) Cavernous c) Cytic hygromaSimple or capillary:- Presents as small vesicle or blister- Present on the inner side of thigh, buttock, axilla- 0.5-4mm in diameter- Lesion is soft and spongy- Multiple cysts or one or two large cysts- Fluctuation, fluid thrill and translucency are positive- Swelling is not compressible- Lymph nodes are not enlarged- Margin of the swelling is indistinct.
Cavernous :- Present as bigger lymphatic swellings which are situated deep.- Commonly occurs on the face, mouth, lips, axilla- Lesion is soft and lobulated- Single or multiple communicating lymphatic cysts- Fluctuation and translucency positiveCystic Hygroma:- Common form of lymphangioma- Collection of lymphatic sacs- Large cyst like cavities containing clear watery fluid- Found in axilla, mediastinum, groin, pelvis- Soft swelling, compressible- Fluctuation and translucency test are positive- No lymph node enlargment
Neurofibromma: tumour contains both neural and fibrouselements.Local neurofibromma:- Occur at any age but commonly seen in adults- Present in subcutaneous tissue- Firm, smooth swelling, slightly painful- Cannot be moved in the direction of the nerve from which it arises- Parasthesia and tingle sensation is commonGeneralized neurofibrmatosis- Involve the cranial spinal and peripheral nerves- Multiple nodules present all over the body- Found in subcutaneous tissue and can become pedunculated- Nodules vary from being firm to soft
Plexiform Neurofibromatosis:- Occurs in connection with the branches of the 5th cranial nerve- Enormous swelling which hangs down and folds- Mostly affects upper limb and may be associated with generalized neurofibromatosisElephentiasis Neurofibromatosis- Affected skin becomes coarse, dry thick and resembles an elephant’s skin- Subcutaneous tissue is replaced by fibrous tissue which is thick and oedematous
Moles: contain excess quantity of melanin derivedfrom melanocytesHairy mole:- Flat and slightly raised above the level of skin- Smooth or slightly warty epidermal covering- Hair grow from its surfaceSmooth mole:- Surface is not elevated- Epithelium is smooth and there is no hair growth- Pigment is deeperBlue naevus- Occurs deep in the dermis as the thick overlying layers of the dermis and epidermis mask the colour of the melanin and make it look blue.- Overlying skin is smooth and shiny- Commonly seen on face, feet, buttock of children
Junctional naevus: clusters of cells of variousstages of maturity in the epidermis and dermiswhen the growth and movements of melanocytesstop before they have migrated into the dermis.- Centered around the junctional or basal layer ofthe epidermis- immature, unstable and can turn malignant- Smooth or elevated naevus of all shades- Found in the palms, soles, digits, genetaliaCompound Naevus- Two distinct varieties of mole are present- intradermal and junctionalFreckle- Area of dark pigmentation found on face and neck- Smooth surface however there might be junctional activity and may turn malignant
- Routine – Blood, Urine, Aspiration- Fine Needle Aspiration Biopsy / Cytology – To avoid extensive open biopsy Fine needle (22 or 23 gauge ) fitted with a tight syringe tissue aspirated is examined microscopically, chemically and bacteriologically- X –ray : Mainly to check for erosions by a cyst ( eX dermoid cyst)- Ultrasound –- CT scan- MRI- Angiography- BIOPSY – Most important investigation of swelling ( suspected malignant tumors)- NEEDLE BIOPSY- DRILL BIOPSY (done for breast masses)- PUNCH BIOPSY ( mainly for hollow viscus – tissue taken from margin of tumor along with surrounding normal tissue- OPEN BIOPSY Incisional or excisional