Lumps and Bumps

When lumps and bumps are discovered in children it is natural for parents to panic and suspect the worst – namely cancer. While cancers definitely do occur in children they are very rare, but should not be ignored. The Craniofacial Team of Texas, specialists in pediatric plastic surgery, are experts in children with lumps and bumps 

Lumps and Bumps – Mass and Lesion

As most parents know, humans have a lot of lumps and bumps.  Why is that?  Well, after an egg and a sperm fuse to form a single cell, zygote, a true miracle happens to form a little baby. That one cell not only multiplies to form billions of cells, but they also start to take on very unique and different shapes and functions to make everything from an eyeball to a toe nail.  The sheer diversity of function of the various portions of the human body is mind boggling, and so it is not too surprising that sometimes some cells can go a little awry.  These cells do not behave and/or form the right structure or perform the right function.  In the young child, this is often discovered as an area that looks a little different, acts a little different, causes a mass or something noticeable.  There are many, many such things that the doctors and physician assistants see in our patients.  If the tissue in question forms a very small “lump” or irregular area you may hear us call it a “lesion”.  If it forms a swelling or a “bump”, you may hear us call it a “mass”.  Most of the these things in children are very different from cancer, which is a clonal proliferation of cells that have lost their ability to control their replication, lost their original functional capabilities, and begin to spread outside the confines of their original anatomic boundaries.  While cancers definitely do occur in children, and we are involved in a great many of them, they are very, very rare.  For the most part, cancer is an older people’s phenomena.  That does not mean that lump and bumps, or lesions and masses, should be ignored.  They often expand with either cells or tissue fluids of one sort or another and cause harm by pressing on and destroying adjacent structures.  And sometimes they are just annoying and unsightly so we want to get rid of them. To clarify the terminology just a little more, the following paragraphs describe some of the terms we use in plastic and reconstructive surgery to describe human lumps and bumps.

What is a tumor?

The best way to think about tumors is that they are abnormal collections of abnormal cells that are either detectable visually, by feel (palpation), or radiographically (CT, MRI, or Xray).  Not all tumors are “cancer”; in fact, most are not cancer at all. 

Most often tumors are either:

1. An abnormal collection of malformed tissues which occurs during the early development of the child (eg., vascular malformation or teratoma)
2. A normal structure that is enlarged (eg., inflamed lymph node), most often from an inflammatory process
3. A collection of abnormally proliferating (multiplying) cells which occurs because of an error in cell cycle where the replication process just doesn’t turn off appropriately.  This collection of cells is called a neoplasm. Neoplasms can be benign or malignant (cancerous), distinguished by the fact that the cells of malignant tumors are so dysfunctional that they can now break away from the main collection of cells (primary tumor) and spread via the blood or lymph to other parts of the body.

Terminology of Lumps and Bumps

In general doctors are very casual and sloppy about their use of terms when it comes to communicating with patients about a detectable, abnormal volume of tissue. Below is a brief description of terms often used to describe and communicate findings:

Lesion: The word lesion is a very general term used in medicine to refer to a region in an organ or tissue that has suffered damage through injury or disease, such as a wound, ulcer, abscess, tumor, etc.  It is often the first term used to describe such area when a physician does not yet understand the cause for the disturbance.  Once a physician understands the nature of the disease process, usually the doctor starts calling it something more specific, like abscess, ulcer, inclusion cyst, etc.

Mass: You may often hear the term “mass” used before a diagnostic workup is initiated to refer to an abnormal volume of tissue.  The volume of tissue may be felt, visualized or seen radiographically.  “Mass” could be a tumor or it could be something like an infection with inflammation which causes the volume change.  It is the most general and nonspecific term used to describe an abnormal volume of tissue.  After a mass is determined to be a neoplasm (abnormal proliferation of a single type of cell), most doctors will often refer to it as a “tumor”.

Tumor:  The word “tumor” is a Latin term that simply means swelling.  So when you twist your ankle and it swells up, the ankle is “tumorous”.   Over time the word has almost become synonymous with “neoplasm” which is an abnormal proliferation (multiplying at an abnormally high rate) of cells forming a “mass” (detectable volume).  This is where the confusion takes place because a tumor can also be a collection of malformed cells or structures that occurs as an error of tissue development (embryogenesis).  The malformed cells have normal cell cycle processes so they are not growing like a neoplasm (see below), but likely at some point when the error occurred they did multiply too much, which is the reason that there is an abnormally large volume of this malformed tissue present. Nonetheless, these malformations do not maintain their proliferative capacity after birth. They are treated very differently than neoplasms. Examples would be vascular malformations and teratomas.  To make it more confusing, the “tumor” has, to some degree, become synonymous with a “benign neoplasm”.

Neoplasm: The term “neoplasm” specifically refers to a collection of cells derived from a single cell that lost its ability to regulate its capacity to multiply normally, and consequently multiplies at an abnormally high rate ultimately forming a “tumor” or “mass”, a detectable volume of this collection of cells.  Here is where it can get even trickier. Neoplasms can be benign or malignant.  A benign tumor is one where the cells that are proliferating at an abnormally high rate do not have the ability to break away from the original focus and spread to other parts of the body via the blood or lymph system.  The cells of a malignant tumor (cancer) do have the ability to break away from the main tumor and spread through the body.

Common Lumps and Bumps

Dermoids

The term dermoid is very confusing because the Pathologists and Gynecologists often refer to a type of ovarian tumor as a “dermoid”.  In reality, the ovarian tumor is a teratoma, but because some of the elements of the benign tumor for hair, nails and teeth (all derivatives of embryological ectodermal layer), the term dermoid has persisted.  The dermoid that we see in a child occurs in the periorbital region, or between the eyes close the bridge of the nose.  These represent true congenital malformations.  Cells that are forming skin elements are buried deep, usually around one of the joints between facial bones.

These joints are specialized in forming bone.  So when the cells of a dermoid start forming skin under the surface, there is no place for the sloughing skin cells to go, so they start forming a cyst.  The most common area is the lateral orbital region.  Usually there is no need to image these lesions, and it takes a fairly short procedure under anesthesia since we are working around the eye to remove it.  When the cyst is removed unruptured, the chance of recurrence is almost negligible.  Rupturing or Incision and Drainage is contraindicated and only makes things worse.  Because of their expertise in children and around the orbit, craniofacial surgeons should take these lesions out.  They never go away by themselves and cause erosion of adjacent tissues including the skull with penetration into the cranial cavity. The earlier they are removed the better, and we usually recommend that surgery should take place after 4 months of age, unless additional circumstances indicate earlier or later surgery.

Pilomatrixoma (also Pilomatricoma)

These lesions are benign tumors of skin derived from the hair matrix. They are neoplasms and typically occur on the scalp, face, and upper extremities. Clinically, these lesions present as a solitary subcutaneous nodule or cyst.  The skin overlying is often normal appearing or has some degree of flattening.  When you feel the lesion, it is intimately associated with the skin’s deep layer, the dermis.  Often there is calcifications within the lesion, especially notable in larger lesions which feel a lot like a rock or pebble under the surface. They do not tend to be painful even to touch.  Occasionally, they get big enough to rupture under the surface, causing  an acute inflammatory process that mirrors an abscess. This is usually associated with destruction of overlying skin and unsightly scarring, so we prefer to get these lesions early.  Surgical resection, often with a bit of skin from which it comes,  is the only solution for pilomatricomas.  The vast majority of times, these lesions are solitary and a patient will only experience one of them in their lifetime.  The few patients with multiple lesions need to be evaluated by a geneticist to rule out a mutation of the APC gene or the beta-catenin gene.  The APC gene is associated with cancer in early life, especially of the colon.

Epidermoid Cyst  (epidermal cyst, infundibular cyst, keratin cyst and  epidermoid inclusion cyst)

Epidermoid cysts most often derive from the neck of hair follicles which have become obstructed (with debris or skin cells), preventing the normal migrational egress of immature skin cells from the neck region of the gland to the surface skin.  The cells in the neck continue to divide and produce cells that slough into an ever-expanding  cystic space.  When the pressure in the cyst builds up, it becomes uncomfortable and even painful, and may occasionally express pus from the neck of the gland.  There is often a “punctum” associated with epidermoid cysts which represents the enlarged and distorted opening of the gland onto the surface of the skin.  Epidermoid cysts can also be caused by the traumatic entrapping of epithelium under the surface, with a similar result of the blockage of a hair follicle’s neck.  Some physicians will call this type of cyst an “epidermal inclusion cyst”, which is not a correct term but does explain its causation. This can be seen with piercings and other traumatic perforations of the skin.  Surgical excision is the only curative treatment for epidermoid cysts.  Excision of the punctum is key to making sure the cyst is completely excised and does not recur.

Benign Nevus (Mole)

The term nevus is a very general term which describes any visible mark on the skin.  It is often used today to describe a pigmented mark which represents a number of different conditions that lead to the change in pigmentation.  It is either 1. a proliferation of pigment producing cells, melanocytes (a common “mole”), 2.  a  clonal proliferation of melanocytes (neoplasia, like melanoma), 3.  an overproduction of melanin (skin pigment) by a normal number of melanocytes, or 4. an underproduction of melanin by a normal number of pigment cells.  There is a number of different types of nevi depending on the depth of origin, cell type, pigmentation characteristics, etc.  The different lesions bare several different names.

These lesions can be congenital (present at birth) or acquired (develop later).  Congenital moles are very common and some of them can get very large and cover critical areas of the body, like the face.  They often do not represent an increased risk of melanoma, but should be watched just like all other pigmented lesions.  The classic ABCDEs (asymmetry, border irregularity, color variegation, diameter > 6 mm, and evolution) of melanoma describe the features of moles that cause physicians to have concern that the lesion is changing into a melanoma, or acquiring some of the features of a melanoma (cellular atypia).  In children, the criteria are modified to include: amelanosis, bleeding or bumps, uniform color, small diameter or de novo, and evolution. Patients should always be looking for these types of changes in any moles that they have, congenital or acquired. The treatment of congenital nevi is very patient specific and the family and surgeon need to have very in-depth discussions to make sure the family understands risks, benefits, and has proper expectations for the outcome.

Treatment for nevi that do not have concern for atypical or melanoma-like features is very individualized and personal. Where one person sees a mole as a “beauty mark”, others see it as unsightly.  The only way to get rid of moles is to surgically excise them.  Superficial moles may be amenable to laser treatment to lighten them, but the laser does not get rid of the mole.  Downside to surgery is that the patient is replacing a scar for a mole.  If the scar is properly positioned and formed using plastic surgery techniques, this may be a good trade off.  Again, it is up to the patient.

Surgeons often send moles off the the dermatopathologist to determine if any cells that show features of melanoma or changes on the way to melanoma are present.  Unfortunately, pigmented lesions are not amenable to frozen section pathology, which can be done quickly at the time of surgery while the patient is still “on the table”.  They require permanent sectioning which takes time. The major drawback to this is that if worrisome cells are found, the surgeon may have to take the patient back to surgery to gain wider margins of resection so as to achieve “negative margins”.  If the surgeon is particularly concerned about this, he/she often will defer closure of reconstruction until the pathologist indicates that the margins are clear and adequate.  This leaves the patient with a wound for a short period of time, but avoids a surgeon performing a reconstruction and then later having to excise the reconstruction, only to have to now do a bigger reconstruction, “burning a bridge” so to speak.  Often a surgeon will just biopsy a lesion, taking just a small piece, if he or she is concerned about some of its features, so that a proper resection/reconstruction plan can be made.

Nevus Sebaceous

Nevus Sebaceous is a hairless, flat, waxy appearing lesion, sometimes in a linear arrangement and usually on the scalp and face.  These lesions are present at birth or appear in early childhood.  The lesion represents an overgrowth of sebaceous glands in the region of the nevus. There have been reports of malignancies originating in these lesions, but likely, much less commonly than historical reports.  Patients often want them removed because of their unsightly appearance, although clinical observation would not be a wrong choice.

If you would like more information about Lumps and Bumps – Masses and Lesions, please contact the Craniofacial Team of Texas by calling 512-377-1142 or toll free 877-612-7069 to schedule an appointment or complete an online appointment request.