Chapter 126

### Introduction

It will never get well if you pick it.

American Proverb

Lumps and bumps are very common presentations and the skin a very common site for neoplastic lesions. Most of these lesions only invade locally, with the notable exception of malignant melanoma. Pigmented skin tumours thus demand very careful consideration, although only a very few are neoplastic. The optimum time to deal with the problem and cure any skin cancer is at its first presentation. The family doctor thus has an important responsibility to screen these tumours and is faced with two basic decisions: the diagnosis and whether to treat or refer.

Most skin lumps are benign and can be left in situ, but the family doctor should be able to remove most of these lumps if appropriate and submit them for histological verification. The main treatment options available in family practice are: biopsy, cryotherapy, curette and cautery, excision or intralesional injections of corticosteroid.1 A list of common and important lumps is presented in Table 126.1.

Table 126.1

Important lumps and their tissue of origin3

### Skin cancer

The three main skin cancers are the non—melanocytic skin cancers—basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)—and melanoma. The approximate relative incidence is BCC 80%, SCC 15–20%, and melanoma less than 5%.2 The incidence of non-melanocytic skin cancer, which is increasing 2.5 times as fast as other cancers, is approximately 800 new cases per 100 000 population per year, and 25 per 100 000 for melanoma. About 80% of skin cancer deaths are due to melanoma and the rest mainly due to SCC.2

### A diagnostic approach to the lump

As with any examination, the routine of look, feel, move, measure, auscultate and transilluminate should be followed.

The lump or lumps can be described thus:

• number

• site

• shape—regular or irregular

• size (in metric units)

• position

• consistency (very soft, soft, firm, hard or stony hard)

• solid or cystic

• mobility

• surface or contour

• special features:

• attachments (superficial/deep)

• exact anatomical site

• relation to anatomical structures

• relation to overlying skin

• colour

• temperature (of skin over lump)

• tenderness

• pulsation (transmitted or direct)

• impulse

• reducibility

• percussion

• fluctuation (? contains ...

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