This presentation is part of the PEER Liberia Radiology Lecture Series. It provides an overview for clinicians about the diagnosis and ultrasound of lumps, bumps and other soft tissue lesions in the skin

Harris, Robert D.

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University of Massachusetts Medical School eScholarship@UMMS PEER Liberia Project UMass Medical School Collaborations in Liberia 2021-02-25 Ultrasound of Superficial Lumps and Bumps Robert D. Harris RAD-AID Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/liberia_peer  Part of the Diagnosis Commons, Family Medicine Commons, Medical Education Commons, and the Radiology Commons Repository Citation Harris RD. (2021). Ultrasound of Superficial Lumps and Bumps. PEER Liberia Project. https://doi.org/10.13028/ryen-7q98. Retrieved from https://escholarship.umassmed.edu/liberia_peer/74 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in PEER Liberia Project by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. Professor of  Clinical Radiology,  USC-KeckSection of Abdominal Imaging, Radiology Dept.USC-LAC Med Centers, LA, CAFebruary, 2021Radiographics 2006; 26, 1289-1304Epidermis and DermisSubcutaneousDeep FasciaMuscleBone ABCDEShah and Callahan, Pediatric Radiology 2013; 43:S23-40¡ Epidermis§ Thinnest layer§ Keratinocytes§ Merkel cells, melanocytes¡ Dermis§ Fibroblasts, endothelial and neural cells§ Collagen¡ Subcutaneous§ Lipid cells, blood vessels, septa¡ History-especially for post-trauma pts.¡ Physical exam is mandatory (MD)¡ Scan with highest frequency transducer (> 8-12 MHz)¡ Lots of gel/stand-off pad/light touch¡ Color Doppler-optimized for slow flow¡ ** Use contralateral side for comparison-Dual imaging mode **from  J. Wagner, Ultrasound Clinics, 2014POSSIBLE MASSCLINICAL EXAM AND USNO US ABNORMALITYSPECIFIC DIAGNOSISforeign bodyMASS-LIKE LESION herniaMRI or CT IF SUSPICIOUS ganglion cystlymph nodeSUPERFICIAL AND < 5 CM. >5 CM OR DEEP bone/calcsepidermal incl cystCHARACTERISTIC OF LIPOMA NOT CHARACTERISTIC OF LIPOMA MRI (OR CT) abscesshematomaCHOICE OF EXCISION OR CLINICAL F/U EXICISION, NEEDLE BX, OR MRI¡ Anechoic¡ Imperceptible walls¡ Smooth, round shape¡ Increased through transmission¡ Rarely, simple cysts in the skin or subQ tissue¡ Foreign Bodies¡ Cellulitis/Abscess¡ Sensitivity, PPV– both > 95%¡ Wood, thorns, glass, plastic, metal: all well shown¡ Echogenic structures +/- shadowing¡ If Hyperechoic rim surrounding hypoechoic center, + compressibility, think = abscessWooden splinter¡ Cellulitis/Phlegmon§ infection of skin and soft tissues¡ Ultrasound Findings § Skin thickening§ Hyperemia (color Doppler)§ Subcutaneous edema¡ Classic cobblestoning§ Fluid tracking between fatty lobules in SubQ¡ Dirty shadowing§ think gas from infectionSonosite 180 , Kigali, RwandaSubQEdemaSkin/fat thickening                MRI  with contrast                         Frank abscessShah and Callahan, 2013¡ Abscess§ Early-difficult clinically to distinguish from cellulitis§ Complex (int. echoes) fluid collection with thick, irregular (+/ - hyperemic) wall§ May be pockets of gas-echogenic foci§ US allows for easy aspiration, drainageUW bx 5/18– granulation tissueNo biopsy or f/u imaging-presumed hematoma¡ Among most common superficial nodules/lumps¡ Children-95% are benign, reactive, hxinfection/inflammation¡ Lymphadenitis on U/S§ Hypervascular cortex, loss of fatty hilum, adjacent cellulitis, indurated fat§ +/- Necrosis and abscess*§ *Hard to differentiate from cancerBenign in 8 yo male neck Malignant in 72 yo woman w/ breast CAShah and Callahan, 2013Oval Shape, wider than high, uniform cortical thicknessFocal  cortical bulge, CA finding + FNATuTUBERCULOSIS¡ Infantile hemangiomas (IH) / Vascular lesions§ Hemangioma, vascular malformation (low or high flow), lymphangioma, or AVM ¡ fibromatosis colli¡ ectopic breast tissue¡ Contracture of SCM¡ Head tilt to ipsilateral side¡ Chin rotates to contralateral side¡ Right side 75%¡ Frequent  traumatic breech or forceps delivery HX¡ Occurs ~ age 4-6 weeks, regresses over 4-8 months¡ Treat conservatively¡ US-fusiform swelling of SCMContralateral SCM Trans neck viewRTLTTransverse view of the neck anteriorlySCMSCM¡Failure of regression of embryologic tissue ¡Puberty-becomes more prominent¡Palpable, tender lesion(s) in axilla¡Echogenic tissue similar to breast tissue¡ Generally ill- defined¡ Multiple small, hypoechoic areas¡ May mimic lymph nodes¡ Comparison to contralateral breast or area helpful¡ Lipoma¡ Hernia¡ Epidermal inclusion cyst¡ Ganglion cyst¡ Popliteal cyst¡ Morton’s “neuroma”¡ Fat necrosis¡ Neurofibroma¡ Uncommon-Sarcoma/malignancy¡ Common in adults§ > 50% or more of superficial lesions on U/S§ 2-4%  prevalence overall¡ Rarer in children§ 10% of all lesions¡ Variable in appearance-Hypo- to hyperechoic, well-defined to vague borders¡ Difficult to separate from surrounding fat¡ Asymmetry of soft tissues¡ Hard to see--Look at contralateral body part¡ Ultrasound usually pathognomonic¡ 7 of 31 (23%) echogenic masses (lipoma or lipoma- like) in subQ fat had blood flow on color Doppler US¡ Most were in upper arm, mean size 1.7 cm.¡ Second most common site: trunk and chest¡ Well-circumscribed¡ Half homogeneous, half heterogeneous echogenicitySkeletal Radiol (2012) 41:1055–1059¡ Most common subcutaneous “cyst”¡ Most common over trunk & scalp¡ Rarely extremities¡ Often clinical diagnosis¡ Congenital or post-traumatic etiology¡ Inclusion of squamous epithelium into dermis¡ Hypoechoic rim¡ Varying internal echoes¡ No vascularityIf in doubt, always exclude color Doppler twinkle artifact with spectral Doppler—if it is artifactual, only see noiseShah and Callahan, Pediatric Radiology 2013; 43:S23-40Pilonidal Cyst¡ 5 % of palpable masses¡ Fluid in bursa behind knee§ Postero-medial to the joint§ Usually anechoic fluid, may contain debris or septa§ Usually reflects knee joint pathology§ May see septa in R.A., inflammatory processes¡ Hand and wrist most common--near articular joints¡ Pain and/or palpable abnl. -often feel hard¡ 10-40 years of age¡ 2nd most common soft tissue lesion after lipoma¡ U/S appearance§ Anechoic or mildly complex  cystic§ Generally round or oval§ Often, lobulated or septated§ No blood flow§ Connection to tendon sheath or joint capsule¡ 2nd-3rd web space of foot -most common site¡ Bilateral in 10%¡ Multiple in up to 30% of pts¡ Middle aged¡ Female¡ US appearance§ Hypoechoic§ Well-defined§ Ovoid, ~ 5-7 mm. diameter¡ Etiology§ S/p blunt trauma (but pt may not recall, often minor)§ Sickle cell dz, vasculitis§ Autoimmune disease (SLE, Wegener’s)§ Hypothermia§ Medication injection¡ PE-Firm, non-tender¡ US§ Hyperechoic, in subcutaneous tissues§ Indistinct, hypoechoic margins§ Little vascularityShah and Callahan, Pedi Radiology, 2013¡ Benign lesion of nerve /nerve sheath (Schwann cells)¡ Age ~ 20-50¡ Most in deep locations¡ Rarely superficial-dermal¡ Tenderness, numbness frequent symptoms¡ Smooth, well-defined¡ Optimally-see nerve at either end of lesion13 yo male, Congo-Brazzaville, 2013*Med NBicepsHLarge groin hematoma-confirmed by MRI, no tumorProbable hematoma, no therapy given¡ Benign much more statistically common (~ 50:1)¡ No single US predictor very accurate¡ Margins  & Vascularity “important”¡ Clinical hx important¡ PE-not so important (cysts or LN can feel fixed and solid & malignancy feel somewhat soft, mobile!)Looks malignant, path: benign!Shah and Callahan, Pediatric Radiology 2013; 43:S23-40¡ Size > 5 cm., or intramuscular location¡ Involvement of the deep fasciallayers¡ Lesion heterogeneity¡ Poorly defined margins  ¡ Increased vascularity +/-¡ rapid growth ¡ clinical predisposition ¡ syndromes ¡ family historyJournal of  Ultrasound in Medicine, 1999, 18: 89-93Type Benign ( total 100 %) Malignant (total 100 %)I 86 9II 14 0III 0 50IV 0 41N = 71 lesions (39 benign, 32 malignant)Giovagnorio, JUM 1999, 18:89¡ Incidence - 1: 100 palpable soft tissue tumors in adults¡Uncommon in pediatrics¡Height : Length > 0.5¡Loss of hilar fat sign¡Cortical thickening¡Hypervascularity¡ 1 percent of all adult malignancies and 12percent of pediatric cancers ¡ 80 percent of sarcomas originate from soft tissue, and the rest from bone¡ ~12,000 new cases of soft tissue sarcoma diagnosed each year in the United States, with 4,740 deaths¡ Thigh, buttock, groin- ~ 50% casesSurgery- intramuscular myxoma¡ Superficial soft tissue bumps are common, malignancy rare (1-2%)¡ Diff Dx based upon age, clinical  hx, US appearance-get good  history¡ Know “leave-alone” lesions-fibromatosis coli, lipomas, cysts, hematomas¡ Color Doppler very helpful- ~25% of lipomas may show Color Doppler flow¡ Size  > 5 cm. or deep location suggests malignancy (needs MRI or CT)¡ If heavy Ca++ or bone, get plain filmsfrom  J. Wagner, Ultrasound Clinics, 2014POSSIBLE MASSCLINICAL EXAM AND USNO US ABNORMALITYSPECIFIC DIAGNOSISforeign bodyMASS-LIKE LESION herniaMRI or CT IF SUSPICIOUS ganglion cystlymph nodeSUPERFICIAL AND < 5 CM. >5 CM OR DEEP bone/calcsepidermal incl cystCHARACTERISTIC OF LIPOMA NOT CHARACTERISTIC OF LIPOMA MRI (OR CT) abscesshematomaCHOICE OF EXCISION OR CLINICAL F/U EXICISION, NEEDLE BX, OR MRIThank you for your attention….

Ultrasound of Superficial Lumps and Bumps

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Ultrasound of Superficial Lumps and Bumps

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