Lumps and Ulcer

Ask the following questions

• Onset
• what do you first notice it?
• what made you notice it?
• were there any predisposing events

•
• Continuing symptoms
• How does it bother you?
• Has it changed since first notice it?
• Have you noticed any other lump?
• Has it ever disappeared or healed
• Treatments and cause
• what treatments have you had in the past?
• What do you think cause of the lump/ulcer
Inspection
• Site
• Size
• Shape (6 S )
• Skin changes
• Symmetry(margin)
• Scars
• Colour
• tenderness
Palpate

• Surface
• Edge (SEC)
• Consistency
• Temperature
• Tenderness
• Transillumination
• Pulsatility
• Compressibility
• Fluctuation FFP
• Fluid thrill
• Fixation-skin or muscle
Palpation(SEC FFP TR )

• Surface- Rough or smooth

• Edge - Irregular, infiltrative or well defined
• Consistency-Hard-feels like nasal bridge
• Firm-feels like nasal tip
• Soft-feels like nares
• Fixed -Fixed to skin
• Fixed to underlying tissue
• Fixed to muscle surface
• within the muscle
• Fluctuant
• Pulsatile/Expansile
• Trans illuminable
• Reducible

• Percussion-Fluid filled lumps may have a fluid thrill or be stony dull on

• percussion
• Auscultation-Auscultate for bowel sound or bruit
• Percuss-dull or resonance
• Auscultate
• Completion
• draining lymph nodes
• neurovascular status
• look for similar lumps elsewhere
• perform general examination
Transillumination of a ganglion of the
thumb.
• A benign proliferation of the normal constituent cells of the skin
(Naevi ) is classified as follows
• Melanocytic-
congenital,junctional,intradermal,compound,blue,becker’s,dysplastic
• Vascular –port wine stain, salmon patch, strawberry naevus
• Epidermal-warty naevus
• Connective tissue-shagreen patches
 Ulcer
• Ulcer should be examined similar way to a lump but important additional points to look
for
• Base
• Edge
i. sloping (BEDS)- Base and Floor, Edge, Discharge, Surrounding Skin
ii. punch out
iii. undermined
iv. rolled
v. everted
• Describe the structure visualized at the base
• discharge
Mnemonic:
Spure (da pakhto
lughath)
 Basal cell carcinoma
• Most common skin tumour –can occur any where on the skin down to to anal
margin.
• 90% face above a line from the angle of the mouth to external auditory
meatus.
• Aetiology
• sunlight
• X rays
• Arsenic
• Immunosuppression
• Basal cell naevus Syndrome
Features of Basal cell
• Non melanocytic skin cancer(i.e. epithelial tumour )that arises from
basal cells.
a) A nodulocystic basal carcinoma (BCC). Note the
characteristic pearly surface with telangiectasia. (b) An ulcerating
BCC on the lower eyelid. (c) A recurrent morphoeic BCC.
Basal cell carcinoma
Basal cell carcinoma
A large keratoacanthoma on the face
Seborrheic keratosis (usually brownish, this
example is unusually dark).
 Clinical features of BCC
• Waxy papules with central depression
• Pearly nodules with visible blood vessels
• Erosion or ulceration. Often central and pigmented
• Bleeding: Especially when traumatized
• Oozing or crusted area
• Rolled and raised border
• Translucency
• Telangiectasia over the surface
• Slowing growing 0.5 cm in 1-2 years
• Black blue or brown area
 BCC types
• 1)Superficial basal cell carcinoma-some might consider to be In-
Situ.it very responsive to topical chemotherapy such as imiquimod or
5 FU.
• The only BCC can be treated effectively with topical chemotherapy
• 2)infiltrative basal cell carcinoma-which often encompasses micro
nodular basal cell cancer.
• Nodular BCC-most common and classic BCC
 Spread of BCC
• Slow but steady local infiltration and destruction of surrounding
tissues including face, nose ,skull and eye, considered malignant’
• Termed rodent ulcer
• Blood and lymphatic spread is extremely rare.
 Treatment
• Excision-margins vs cosmetic
• 6mm margins from large BCC has 95% cure rate
• Mohs micrographic surgery-margins examined straightaway and
more excision can be made if margins insufficient
• Radiation
• Topical fluorouracil for early /superficial BCC
 Squamous cell carcinoma
• Common invasive malignant epidermal cell tumour with low but
significant potential for metastasis
• Men> Woman, common in elderly>70s
• Sun exposed area, face and back of hands
• Spread via lymphatics and may metastasise
• Human papilloma virus (HPV)has been associated with SCC of the
oropharynx, lung ,fingers and anogenital region.
 Aetiology of SCC
• Exposure to sunshine or irradiation
• Carcinogens(pitch,tar,betel nuts,papilloma virus)
• Lupus vulgaris
• Immuno suppressive drugs
• Chronic ulceration(Marjolin’s ulcer-malignant change in long standing
scar, ulcer or sinus-typically chronic varicose ulcer, unhealed burn,
sinus of chronic osteomyelitis.
 Risk factors
• Fair skin
• Excessive sun exposure
• Use of tanning beds
• A history of Sun burns
• A personal history of precancerous skin lesions
• actinic keratosis or Bowen ‘s disease
• SCC in the past
• Immunosuppression –e.g. leukaemias or lymphoma
• Rare genetic disorder-E.g. ,xeroderma pigmentosum
 Clinical features
• Scaly red patches(Bowen's disease)
• Open sores, everted edges
• Elevated growths with a central depression or warts
• They may crust or bleed
• A new sore or raised area on an old scar or ulcer
• Can occur in genital areas
(a) A squamous cell carcinoma (SCC) on the face. (b) A recurrent SCC arising in a
previously skin-grafted area of the scalp. (c)
SCC arising on the dorsum of the hand in a renal transplant recipient on
immunosuppressive therapy. (d) SCC arising on the lip of a smoker
Squamous cell carcinoma behind the ear.
A fungating squamous cell carcinoma
Characteristic ulceration in a patient with
squamous cancer of the facial skin.
 Treatment
• Surgical excision
• Mohs surgery
• Radiation: reserved for large SCC not amenable for excision. Patient may need 15
to 30 radiation treatments.
• Small or early SCC lesions can be treated:
Curettage and electrodessication: early SCC plaques are scraped off. Then electricity
is used to destroy any remaining cancer cells. These two steps are repeated.
• Photodynamic therapy
• Laser treatment
• Chemotherapy cream-5-FU
• High risk squamous cell carcinoma , as defined by those occurring around
the eye , ear or nose, is of large size , is poorly differentiated , and
grows rapidly , requires more aggressive multidisciplinary management.
• Nodal spread are treated with
• 1)Surgical block dissection
• 2)Radiotherapy
• 3)Adjuvant therapy with Imiquimod may be considered in high risk SCC
even in the absence of local metastasis.
• Close follow up and regular skin check for high risk SCC
• Premalignant lesions for SCC
Actinic (solar) keratosis
In situ or intraepidermal squamous cell carcinoma (Bowen’s
disease)
Actinic keratosis.
Bowen’s disease – squamous cell carcinoma
in situ
Erythroplasia of Queyrat – squamous cell carcinoma in
situ on the glans penis; also called Paget’s disease of the penis
Naeves
• Condensations of melanocytes form a naevus or mole that can be
congenital or acquired.
• Acquired naevi are of three types: junctional, compound or
intradermal depending upon the depth of the melanocytes within the
skin.
Features of pigmented skin lesions
suspicious of malignancy
• Loss of normal surface markings around the lesion
• Presence of ulceration
• Bleeding from the lesion
• Marked variation of colour within the lesion
• Presence of halo of brown pigment in the skin around the lesion
• Presence of satellite nodules of tumour around the lesion
• Examine the draining lymph nodes.
• The clinician must always be on the lookout for any changes in a lesion suggesting malignant
change. The clinical signs of malignant transformation can be remembered using ABCDE:
• • A – Asymmetry (note whether one side is larger than the
• other).
• • B – Border (jagged borders are suggestive of transformation).
• • C – Colour (multiple colours within a naevus should raise
• suspicion).
• • D – Diameter (any naevus that has grown to more than
• the size of the pencil eraser or 6 mm in diameter should be
• examined).
• • E – Evolution (a lesion that is changing with time should be
• checked).
• Another easy method is the ‘ugly duckling’ sign, where patients’ naevi are examined and
moles that show changes that are not present in most others are considered for biopsy.
Malignant melanoma
• Found commonly on the legs of young woman and trunk of middle
aged man.
• Presence of naevi is the most common predictor of risk of malignant
melanoma
• Commonest cancer of young adults aged between 20 and 39 years
• Commoner in woman than men
• Four common types of MM(Malignant Melanoma)
• (1)Superficial spreading
• most common type(70%)
• Red ,white and blue colour,
• Irregular edge
• Usually palpable but thin
Superficial spreading melanoma
• (2)Nodular
• Second most common(15 t0 30%)
• Occur most common on the trunk
• Polypoid in shape and is raised, smooth surface, irregular
edge,freaquently ulcerated.
• Nodular melanoma
 Acral lentiginous melanoma on the sole of
the foot
Differential diagnosis
• Benign skin lesion
• Moles
• Freckles
• Lentigo
• Pigmented seborrhoeic keratosis
• Dermatofibromas
• Thrombosed hemangiomas
• Malignant skin lesion
• pigmented basal cell carcinoma
Predisposing factors for MM
• Xeroderma pigmentosa
• Dysplatic naevus syndrome
• Large congenital naevi
• Family history in first degree relatives
• Acquired
• Sunlight
• preexisting skin lesion
• Previous melanoma,increase the risk three and half times
• Malignant melanoma
• The main diagnostic features(Major criteria)
• change in size
• change in shape
• change in colour
• Secondary features(minor criteria)
• Diameter>6mm
• inflammation Oozing or bleeding
• Altered sensation
• Suspicious lesions should undergo excisional biopsy. The lesion
should be removed completely.
How do you stage malignant melanoma
• Ckark’s level
• Breslow’s thickness
• Margins of excision-Related to Breslow thickness
• lesions 0-1mm thick -1cm
• lesions 1-2mm thick -1-2 cm
• lesions 2-4mm thick - 2-3cm
• lesions >4 mm thick -3 cm
• Further treatments such as sentinel lymph node mapping, isolated limb
perfusion and block dissection of regional lymph node group should be
selectively applied.
Treatments options
• Surgical excision
• main lesion
• Nodal spread-therapeutic block dissection
• Palliative/adjuvant therapies
• Immunotherapy
• Monoclonal antibody therapy, cytokine interferon therapy
Sebaceous cyst
• The skin is kept soft and oily by the sebum secreted by the sebaceous
glands. When an opening of one of these glands becomes blocked, it
distends with its own secretion, and ultimately becomes a sebaceous
cyst.
• Examination
• Site Most sebaceous cysts are found in the hairy parts of the body.
The scalp, scrotum, neck, shoulders and back are the common sites,
but they can occur wherever there are sebaceous glands.
• Shape and size Most sebaceous cysts are tense and spherical
• Surface The surface of a sebaceous cyst is smooth.
• Edge The edge is well defined.
• They are occasionally so tense that it is not possible to elicit
fluctuation.
• They do not transilluminate because they are full of sebum.
• Only one-half of the cysts that you will see have a visible punctum,
but when one is present it is a useful diagnostic sign. All sebaceous
cysts are attached to the skin even if there is no punctum.
A punctum of a sebaceous cyst.
Lipoma
• This is a cluster of fat cells that have become overactive and so
distended with fat that they have become palpable lumps.
• Duration They usually grow slowly for months or years before being
noticed. They rarely regress.
• Multiplicity Patients often have many lipomas.
• This condition is called lipomatosis, Multiple lipomatosis (Dercum’s
disease).
A large lipoma overlying the scapula.
• Most lipomas are lobulated, as fat in the body is in the form of
lobules. The lobules can be seen and felt on the surface.
A lipoma in the subcutaneous tissues of the
upper arm. Note the lobulation
• Edge The edge is not circular but soft, compressible,described as the ‘slip sign’.
• Evidence of lobulation on the surface and at the edge is the most significant
physical sign.
• Composition
• lipomas contain a soft but solid jelly-like fat ,often give the impression of
fluctuating.
• Fat at body temperature is solid, not liquid.
• Lipomas do not transilluminate.
• They do not have a fluid thrill, and they do not reduce or pulsate.
• the diagnostic importance of finding lobulation.
• Subcutaneous lipomas are not attached superficially or deeply, and
can be moved in all directions.
• Lymph drainage The regional lymph glands are not be enlarged.
• Local tissues The surrounding tissues are normal, but other lipomas
may be present.
Dermoid cysts are either congenital or
acquired.
• This cyst lies beneath the skin and is lined by ‘skin’ is called dermoid
cyst.
• The two ways in which a piece of skin can become trapped deep to
the normal skin are:
• ●● as an accident during antenatal development;(Congenital dermoid
cyst)
• ●● following an injury, which implants some skin into the
subcutaneous tissue.(implantation dermoid cyst)
• History
• Duration They may be present at birth, but usually become obvious a
few years later when they begin to distend. They are rarely multiple.
• Symptoms Most congenital dermoid cysts occur in the head and neck,
and parents are therefore concerned about their ‘unsightliness’ as
well as the diagnosis. They rarely become very large or infected.
• Examination
• Site-inner and outer ends of the upper eyebrow
A right external angular dermoid cyst, so
called because it lies beneath the outer end of the
eyebrow over the external angular protuberance of
the skull. This is a congenital dermoid cyst.
• Shape and size They are usually ovoid or spherical and 1–2 cm in
diameter.
• Surface Their surface is smooth.
• Composition Cysts on the face often feel soft, not tense and hard.
They fluctuate, but only transilluminates if they contain clear fluid,
instead of the usual thick, opaque mixture of sebum, sweat and
desquamated epithelial cells. They are not pulsatile, compressible or
reducible.
• Relations Dermoid cysts lie deep to the skin, in the subcutaneous
tissue. Unlike sebaceous cysts, they are not attached to the skin.