Lumps and Bumps in Children Thomas C. Putnam Pediatrics in Review 1992;13;371 DOI: 10.1542/pir.13-10-371
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/13/10/371
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
-
S
Lumps Thomas
and C. Putnam,
FOCUS
QUESTIONS
1. What
superficial
subcutaneous
Bumps MD*
the skin moves freely over the mass, the nature of the lesion is not so readily apparent. If the mass moves over the underlying fascia, the lesion lies in the subcutaneous tissue and is essentially benign. However, if the lesion is fixed to the underlying fascia, or the examiner cannot be sure, then the possibility of malignancy does exist. The location of the lesion on the body affects the risk of malignancy. A submandibular node is usually not worrisome, but a supraclavicular node is always alarming and requires urgent biopsy (Fig 1). Most malignant superficial lesions in children involve lymph nodes. Masses involving deeper layers may represent sarcomas.
cutaneous and lesions do not have for anatomic
a predilection location? 2. What superficial or deep cutaneous lesions have a predilection for specific anatomic locations, and in what location(s) is each most likely to be found? 3. What are the indications for rapid biopsy of a skin lesion? & What risk factors predict malignancy in 80% of the malignant skin lesions seen in children?
S
Many lesions involving the skin or subcutaneous tissues alarm parents and, often fearing cancer, they bring their child to a physician. Most lesions are benign and rarely lifethreatening. The physician faces the problem of determining which characteristics suggest only observation of a lesion and which make biopsy necessary. Because many lesions have a predilection for certain areas of the body, this is a useful form of categorization (Table 1). On first inspection of a superficial lesion, several questions must be asked, including the known duration, change in size, presence of pain or other signs of inflammation, and any noted multiplicity. The examination includes an accurate measurement of the size and, most importantly, a determination of the level of the lesion. This will help establish the diagnosis and help to determine whether the possibility of malignancy exists. Essentially all lesions originating in the skin of children are benign. Some are obvious, such as a wart, while others may not be so clear-cut, especially if the epidermis is not altered in appearance. Upon palpation of a cutaneous mass, the skin does not move over the surface and puckers when the adjacent skin and tissues are compressed and elevated. If *ChnwaJ
S
Associate
Professor,
Departments
in Review
VoL
13
No.
Lesions Without Predilection for Anatomic Location Many superficial lesions occur on the body without a preference for a particular area. Lesions attached to the skin include nevi, warts, sebaceous cysts, capillary hemangiomas, and pyogenic granulomas. Subcutaneous lesions involve cavernous hemangiomas, fibromas, neurofibromas, and lipomas. Lesions arising from tissues deep to the subcutaneous layer include fibromatoses, foreign bodies, hematomas, and benign and malignant tumors of neural or musculoskeletal origin. CUTANEOUS
of
Rochester andSchool Surgery Pediatrics, of Medicine University and Dentistry, of Rochester, N}’ Requests for reprints should be addressed to: 125 Laulmore Road, Suite 270, Rochester, NY 14620.
Pediatrics
in Children
10
LESIONS
Sixty-two percent of the white population has nevi; affected individuals have an average of 15 per person. Darkly pigmented races have fewer moles. Cutaneous melanoma, the concern of physician and parent alike, rarely is found in infants and young children. However, 0.3% to 0.5% of all cutaneous melanomas are diagnosed in children younger than 13 y. Preexisting pigmented lesions at the site of a melanoma have been reported in 18% to 85% of patients, representing a widely variable incidence. Two types of nevi are considered precursors of melanoma: congenital and dysplastic. Congenital nevi are
October
recognized at birth. These moles range from 2 to 10 mm in diameter and are similar in appearance to benign acquired nevi. Compared with acquired nevi, however, congenital nevi carry a 21-fold greater relative risk of becoming melanoma. This means that 1 in 20 patients who have a congenital nevus will develop a melanoma in the nevus if the individual lives to be 60 y of age. Therefore, surgical excision of congenital nevi is recommended. Dysplastic nevi usually develop during the second decade of life. They vary in color from deeply pigmented to a haphazard coloration with irregular or poorly demarcated borders (Fig 2). One third of adults who have a melanoma have preexisting dysplastic nevi. In patients with a family history of melanoma (an autosomal dominant trait), 90% also have dysplastic nevi. Dysplastic nevi are seen in 40% of relatives who do not have melanoma. Such patients require education and careful yearly evaluation by a physician familiar with dysplastic nevi. Nevi that appear dysplastic should be excised and submitted for pathologic evaluation. A melanoma is characterized by an irregular border with deeply pigmented or variedly colored areas. Ulceration or satellite lesions may be present, and growth usually occurs (Fig 3). Acquired nevi are not present at birth, by definition. The average number of acquired nevi in the white adult is 15, although some studies have reported up to 40. In contrast, the average number in the black adult is two, and in the East Indian adult, six. These lesions are 3 cm in diameter Fixation to or location deep to fascia Onset in neonatal period Rapid or progressive growth Skin ulceration
nant viously
lesions noted
SUGGESTED
not suggested five
risk
by the prefactors.
PIR QUIZ
S
6. Superficial lesions of the head and neck that require biopsy for diagnosis are:
READING
Bingul 0, Graham JH, Helwig EB. Pilomatrixomas (calcifying epithelioma) children. Pediatrics. 1962;30:233-240 Hoss DM, Grant-Kels JM. Significant
A. B. C. D. E.
in
melanocytic lesions in infancy, childhood, and adolescence. Der,natol Clin. 1986;4:2944 Knight PJ, Hamoudi AF, Vassy LE. Midline neck masses in children. Surgery. 1983;93:603-61 1 Knight Pi, Mulne AF, Vassy LE. When is lymph node biopsy indicated in children with enlarged peripheral lymph nodes? Pediatrics. 1982;69:391-396 Knight Pi, Reiner CB. Superficial lumps in children: What, when, and why? Pediatrics. 1983;72: 147-153 Muhlbauer MD. Granuloma annulare. J Am Acad Dermatol. 1980;3:217-230 Pollard ZF, Robinson HD, Calhoun J. Dermoid cysts in children. Pediatrics. 1976;57:379-382 Rhodes AR. Pigmented birthmarks and precursor melanotic lesions of cutaneous melanoma identifiable in childhood. Pediatr Clin North Amer. 1983;30:435-463 Spraker MK. The vascular lesions of childhood. Dermatol Clin. 1986;4:79-87
Dermoid cysts. Exostoses. Histiocytosis X. Thyroglossal duct cysts. Congenital torticollis.
7. Common
benign
subcutaneous
lesions of the skin include of the following, except. A. Cavernous
each
hemangiomas.
B. Lipomas. C. Neurofibromatoses. D. Aggressive fibromatoses. E. Ganglion cysts. 8. On first inspection of a superficial skin lesion, it is essential to determine each of the following, except: A. Duration.
B. C. D. E. 9.
10.
Size. Pain. Determination of level. Age of patient.
Each of the following changes in acquired nevi indicate a need for biopsy, except: A. Sudden darkening. B. 1-lymphocyte invasion in the surrounding area. C. Change in size. D. Itching. E. Pain.
S
of warts may include each of the following, except: A. Liquid nitrogen.
Treatment
B. Electrofulguration. C. Laser. D. Excision. E. Radiography.
malignant superficial lesions in children involve: A. Thyroglossal ducts. B. Lymph nodes. C. Cavernous hemangioma.
11. Most
D. Neurofibromas. E. Nevi.
S 378
Pediatrics
in Review
VoL
13
No.
10
October
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
1992
Lumps and Bumps in Children Thomas C. Putnam Pediatrics in Review 1992;13;371 DOI: 10.1542/pir.13-10-371
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/13/10/371
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/13/10/371
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
-
S
Lumps Thomas
and C. Putnam,
FOCUS
QUESTIONS
1. What
superficial
subcutaneous
Bumps MD*
the skin moves freely over the mass, the nature of the lesion is not so readily apparent. If the mass moves over the underlying fascia, the lesion lies in the subcutaneous tissue and is essentially benign. However, if the lesion is fixed to the underlying fascia, or the examiner cannot be sure, then the possibility of malignancy does exist. The location of the lesion on the body affects the risk of malignancy. A submandibular node is usually not worrisome, but a supraclavicular node is always alarming and requires urgent biopsy (Fig 1). Most malignant superficial lesions in children involve lymph nodes. Masses involving deeper layers may represent sarcomas.
cutaneous and lesions do not have for anatomic
a predilection location? 2. What superficial or deep cutaneous lesions have a predilection for specific anatomic locations, and in what location(s) is each most likely to be found? 3. What are the indications for rapid biopsy of a skin lesion? & What risk factors predict malignancy in 80% of the malignant skin lesions seen in children?
S
Many lesions involving the skin or subcutaneous tissues alarm parents and, often fearing cancer, they bring their child to a physician. Most lesions are benign and rarely lifethreatening. The physician faces the problem of determining which characteristics suggest only observation of a lesion and which make biopsy necessary. Because many lesions have a predilection for certain areas of the body, this is a useful form of categorization (Table 1). On first inspection of a superficial lesion, several questions must be asked, including the known duration, change in size, presence of pain or other signs of inflammation, and any noted multiplicity. The examination includes an accurate measurement of the size and, most importantly, a determination of the level of the lesion. This will help establish the diagnosis and help to determine whether the possibility of malignancy exists. Essentially all lesions originating in the skin of children are benign. Some are obvious, such as a wart, while others may not be so clear-cut, especially if the epidermis is not altered in appearance. Upon palpation of a cutaneous mass, the skin does not move over the surface and puckers when the adjacent skin and tissues are compressed and elevated. If *ChnwaJ
S
Associate
Professor,
Departments
in Review
VoL
13
No.
Lesions Without Predilection for Anatomic Location Many superficial lesions occur on the body without a preference for a particular area. Lesions attached to the skin include nevi, warts, sebaceous cysts, capillary hemangiomas, and pyogenic granulomas. Subcutaneous lesions involve cavernous hemangiomas, fibromas, neurofibromas, and lipomas. Lesions arising from tissues deep to the subcutaneous layer include fibromatoses, foreign bodies, hematomas, and benign and malignant tumors of neural or musculoskeletal origin. CUTANEOUS
of
Rochester andSchool Surgery Pediatrics, of Medicine University and Dentistry, of Rochester, N}’ Requests for reprints should be addressed to: 125 Laulmore Road, Suite 270, Rochester, NY 14620.
Pediatrics
in Children
10
LESIONS
Sixty-two percent of the white population has nevi; affected individuals have an average of 15 per person. Darkly pigmented races have fewer moles. Cutaneous melanoma, the concern of physician and parent alike, rarely is found in infants and young children. However, 0.3% to 0.5% of all cutaneous melanomas are diagnosed in children younger than 13 y. Preexisting pigmented lesions at the site of a melanoma have been reported in 18% to 85% of patients, representing a widely variable incidence. Two types of nevi are considered precursors of melanoma: congenital and dysplastic. Congenital nevi are
October
recognized at birth. These moles range from 2 to 10 mm in diameter and are similar in appearance to benign acquired nevi. Compared with acquired nevi, however, congenital nevi carry a 21-fold greater relative risk of becoming melanoma. This means that 1 in 20 patients who have a congenital nevus will develop a melanoma in the nevus if the individual lives to be 60 y of age. Therefore, surgical excision of congenital nevi is recommended. Dysplastic nevi usually develop during the second decade of life. They vary in color from deeply pigmented to a haphazard coloration with irregular or poorly demarcated borders (Fig 2). One third of adults who have a melanoma have preexisting dysplastic nevi. In patients with a family history of melanoma (an autosomal dominant trait), 90% also have dysplastic nevi. Dysplastic nevi are seen in 40% of relatives who do not have melanoma. Such patients require education and careful yearly evaluation by a physician familiar with dysplastic nevi. Nevi that appear dysplastic should be excised and submitted for pathologic evaluation. A melanoma is characterized by an irregular border with deeply pigmented or variedly colored areas. Ulceration or satellite lesions may be present, and growth usually occurs (Fig 3). Acquired nevi are not present at birth, by definition. The average number of acquired nevi in the white adult is 15, although some studies have reported up to 40. In contrast, the average number in the black adult is two, and in the East Indian adult, six. These lesions are 3 cm in diameter Fixation to or location deep to fascia Onset in neonatal period Rapid or progressive growth Skin ulceration
nant viously
lesions noted
SUGGESTED
not suggested five
risk
by the prefactors.
PIR QUIZ
S
6. Superficial lesions of the head and neck that require biopsy for diagnosis are:
READING
Bingul 0, Graham JH, Helwig EB. Pilomatrixomas (calcifying epithelioma) children. Pediatrics. 1962;30:233-240 Hoss DM, Grant-Kels JM. Significant
A. B. C. D. E.
in
melanocytic lesions in infancy, childhood, and adolescence. Der,natol Clin. 1986;4:2944 Knight PJ, Hamoudi AF, Vassy LE. Midline neck masses in children. Surgery. 1983;93:603-61 1 Knight Pi, Mulne AF, Vassy LE. When is lymph node biopsy indicated in children with enlarged peripheral lymph nodes? Pediatrics. 1982;69:391-396 Knight Pi, Reiner CB. Superficial lumps in children: What, when, and why? Pediatrics. 1983;72: 147-153 Muhlbauer MD. Granuloma annulare. J Am Acad Dermatol. 1980;3:217-230 Pollard ZF, Robinson HD, Calhoun J. Dermoid cysts in children. Pediatrics. 1976;57:379-382 Rhodes AR. Pigmented birthmarks and precursor melanotic lesions of cutaneous melanoma identifiable in childhood. Pediatr Clin North Amer. 1983;30:435-463 Spraker MK. The vascular lesions of childhood. Dermatol Clin. 1986;4:79-87
Dermoid cysts. Exostoses. Histiocytosis X. Thyroglossal duct cysts. Congenital torticollis.
7. Common
benign
subcutaneous
lesions of the skin include of the following, except. A. Cavernous
each
hemangiomas.
B. Lipomas. C. Neurofibromatoses. D. Aggressive fibromatoses. E. Ganglion cysts. 8. On first inspection of a superficial skin lesion, it is essential to determine each of the following, except: A. Duration.
B. C. D. E. 9.
10.
Size. Pain. Determination of level. Age of patient.
Each of the following changes in acquired nevi indicate a need for biopsy, except: A. Sudden darkening. B. 1-lymphocyte invasion in the surrounding area. C. Change in size. D. Itching. E. Pain.
S
of warts may include each of the following, except: A. Liquid nitrogen.
Treatment
B. Electrofulguration. C. Laser. D. Excision. E. Radiography.
malignant superficial lesions in children involve: A. Thyroglossal ducts. B. Lymph nodes. C. Cavernous hemangioma.
11. Most
D. Neurofibromas. E. Nevi.
S 378
Pediatrics
in Review
VoL
13
No.
10
October
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
1992
Lumps and Bumps in Children Thomas C. Putnam Pediatrics in Review 1992;13;371 DOI: 10.1542/pir.13-10-371
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/13/10/371
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at University of Illinois at Chicago Library on October 28, 2014
