35-Year-Old Male with an Expanding Lump in the Thigh (Case 17)

Chapter 28 35-Year-Old Male with an Expanding Lump in the Thigh (Case 17)



Robin M. Ciocca, DO, Ned Z. Carp, MD




Differential Diagnosis











Lipoma Hematoma
Soft tissue sarcoma Sebaceous cyst



Speaking Intelligently


Dx of the common “lump” or “bump” on the extremity is usually pretty obvious. Nonetheless, I always ask myself if an extremity mass could possibly be a sarcoma. Should I be suspicious for sarcoma, my initial approach differs. Since the tx for a sarcoma of the extremity is a wide excision with clear margins (not simple enucleation of the mass), it is vital for proper planning to make the dx prior to definitive surgery. Hence the appropriate approach to a suspicious soft tissue mass of the extremity of greater than 3.0 cm is incisional biopsy or rarely core biopsy.



PATIENT CARE



Clinical Thinking



• In your career, you will encounter many “lumps” and “bumps,” but few sarcomas; nonetheless, sarcoma should be kept in your “lump” and “bump” differential dx.

• Sebaceous cysts, lipomas, and hematomas will usually be recognized by inspection and palpation. The tests and imaging studies noted below are applicable when there is suspicion for sarcoma.

• Patients will frequently present with a small mass consistent with a lipoma, which has been present for a “long time.” Excision is warranted if the lesion is tender, expanding, or of concern to the patient, or for cosmetic reasons.

• When a sarcoma is suspected, incisional biopsy (or rarely core biopsy) allows proper preoperative planning for more definitive surgical excision.


History



• How long has the mass has been present? associated symptoms of pain? limited range of motion?

• Did the appearance of the mass relate to recent trauma or skin infection?

• Has the mass changed in size or consistency since initial presentation?

• Remember to ask family hx: sarcomas may be associated with familial syndromes such as neurofibromatosis, familial adenomatous polyposis, and Li-Fraumeni syndrome.


Physical Examination



• Measure the size of the mass and document it in the chart.

• Check the mobility of the surrounding skin and subcutaneous tissues.

• Determine proximity to surrounding neurovascular structures and bony structures.

• Evaluate texture: soft fleshy subcutaneous masses are usually benign; firm hard masses are suspicious for malignancy.


Tests for Consideration


















• Biopsy: If sarcoma is suspected, core needle or open incisional biopsy (rather than fine-needle biopsy) will give a sufficient amount of tissue for proper histologic examination. If sarcoma is suspected, orient the open biopsy incision in the longitudinal plane of the extremity in order not to compromise a more definitive resection, should the lesion prove malignant.
 Core biopsy $425
Incisional biopsy $725

• Incision and drainage for infected sebaceous cyst
 $325

• Excision sebaceous cyst
 $425

• Excision lipoma
 $425



IMAGING CONSIDERATIONS















→ CT: Performed with IV contrast in thinner sections to allow for 3-D reconstructions. Calcifications, bony integrity, and vascular supply can all be determined.
 $450

→ MRI: Preferred imaging tool of soft tissue pathology. MRI with gadolinium contrast is valuable to evaluate vascular structures.
 $750

→ Angiography: Catheter angiography is no longer used diagnostically but can provide preoperative embolization of vascular tumors.
 $1,650























Clinical Entities Medical Knowledge
Lipoma
PΦ A lipoma is a benign soft tissue tumor of mature adipocytes.
TP Many patients have a hx of a lipoma that has been present for several years. The lesion is usually soft, mobile, subcutaneous, and nontender. When a patient states that a small mass has been present for a long time, excision is generally warranted if the lesion is tender, expanding, or of any concern to the patient.
Dx The dx of lipoma is made through hx and physical examination. Suspicious masses (e.g., firm, rapidly growing) require excision to exclude sarcoma. Incisional biopsy should be performed for larger masses greater than 3.0 cm in order to exclude the possibility of sarcoma prior to definitive surgery.
Tx Complete excision of a lipoma is usually curative. Care must be taken to excise the entire mass; a small piece left behind may regrow in the same area.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on 35-Year-Old Male with an Expanding Lump in the Thigh (Case 17)

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