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Examination of a Swelling/Lump
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angle of the mouth and ear lobule (90%). As it is
common in area where tears roll down it is called as
tear cancer. It can occur occasionally in other parts
of skin (scalp, neck, arms, and hands) or mucocutaneous junction like in anal region, genitalia. It is only
locally malignant. It does not spread through blood
or lymph nodes. It can erode deeply into adjacent
deeper tissues even cartilages or bone and hence called
as rodent ulcer. But most BCC are superficial and
confined to skin. Erosion is common in lesions very
close to nose or eye. It can be nodular, cystic,
nodulocystic, ulcerative, multiple (associated with
syndromes), pigmented, geographical/field fire/forest
fire (wide area of involvement with central scabbing
and peripheral active proliferating edge) or basisquamous type (combination of BCC and SCC. It
behaves like SCC with regional nodal spread). BCC
never spreads into regional lymph nodes. Clinicopathologically it can be superficial; morpheic or
fibroepithelioma type of Pinkus. Histologically it
contains outer columnar cells arranged in palisading
manner with central polyhedral cells without prickle
cells or keratinisation. Clinically it is commonly
nodulocystic/noduloulcerative (90%), nontender,
slowly growing; nonmobile if fixed to deeper plane,
raised and beaded edge (not everted) with central area
of scabbing. Scab repeatedly falls off and reforms.
Itching over the scab can be present. Often it is
disfiguring. It gives a false impression of spontaneous
healing to the patient. Beads signify area of active
proliferative cells. Regional nodes are not involved
due to large sized cells. It should be differentiated
from squamous cell carcinoma; melanoma; keratoacanthoma or seborrhoeic keratosis. BCC near the eye/
nose/ear, BCC more than 2 cm size are called as high
risk BCC (Figs 3.105A and B to 3.107).
Squamous Cell Carcinoma (Epithelioma, SCC)
Squamous cell carcinoma of skin arises from squamous
layer (prickle cell layer) of the skin. It is the second
most common skin cancer. It is common in males.
It occurs usually in preexisting lesions like Bowen’s
disease, leukoplakia, chronic scars, chronic chemical
irritation, radiodermatitis, senile keratosis, Khangri
cancer in Kashmir, chimney scrotal cancer , and Kang
cancer of T ibetans. It can also occur as de novo. Grossly
lesion can be proliferative, ulcerative or red plaque
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A
B
Figs 3.105A and B: Common site of basal cell carcinoma
—above the line drawn between angle of mouth and ear lobule.
Also photo showing typical location of basal cell carcinoma.
like. It is common in face, cheek, lips, hands, legs
and sole. It can occur in penis, vulva, buccal cavity,
tongue, oesophagus, bronchus, gallbladder, anorectum, renal pelvis and urinary bladder.
Clinical features: Ulcerative or ulceroproliferative
lesion with raised and everted edge; indurated edge
and base; with hard, nodular, nontender enlarged
regional lymph nodes (Fig. 3.108). Blood spread is
not common in SCC. Marjolin’s ulcer is a well
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SRB’s Clinical Surgery
Fig. 3.106: Photo showing features of basal cell carcinoma
in the nape of neck. It is not a typical location of BCC.
Fig. 3.107: Patient with Xeroderma pigmentosa having
BCC nose. These patients are also prone for cutaneous
melanoma. Xeroderma pigmentosa is an autosomal
recessive (chromosome 9q) disease with skin erythema,
intolerance to UV rays, pigmentation and photophobia.
There is defect in DNA nucleotide repair mechanism. 60%
die at or before 20 years of age. Condition was first described
by Kaposi in 1874.
Fig. 3.108: Squamous cell carcinoma over eye
destructing eyelids. Note the everted edge.
nodal spread carrying good prognosis (Fig. 3.109).
Verrucous carcinoma of foot is called as carcinoma
cuniculatum. Histologically malignant squamous cells
with epithelial/keratin pearls are typical. More
than 75% keratin pearls are well differentiated;
50-75% is moderately differentiated; 25-50% poorly
differentiated; < 25% is undifferentiated.
Differential diagnoses: BCC; melanoma; keratoacanthoma; skin adnexal tumour. A rare variety of multiple
self healing SCC is observed usually in face as familial
autosomal dominant (chromosome 9q) disease in
western Scotland—Ferguson-Smith syndrome.
differentiated SCC occurring in unstable chronic scar
of long duration. It is common in scars of snake bite,
venous ulcer and burns. It is only locally malignant
without nodal spread. V errucous carcinoma is a variant
of well differentiated SCC occurring in mucous
membrane or mucocutaneous junction presenting as
dry, exophytic, warty, indurated growth without any
Fig. 3.109: Proliferative cauliflower-like lesion in the
foot—typical of squamous cell carcinoma.
Examination of a Swelling/Lump
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Naevi (Mole)
It is hamartomata of melanocytes due to excessive
stimulation. Few moles will be present during birth.
Number increases by age. Adult has got average of
60-100 moles in the body (in Caucasians). During
childhood and adolescence existing moles may get
more pigmented or may regress completely. Moles
are more common among Caucasians, Australians.
Moles are not seen in Albinos. Moles turning into
malignancy are less common in children and in
Negroes. Moles are more common in limbs, face and
mucocutaneous junction like mouth and anus. Mole
is usually light brown or black in colour which does
not fade by pressure. Moles are usually soft in
consistency. Usual size of a mole is 1-3 mm. Microscopic appearance does not reflect the macroscopic/
clinical look (Fig. 3.110).
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Blue naevus: It is uncommon smooth mole. It is seen
in children. It is located deep in the dermis (deep
intradermal) and so eventhough pigment is brown in
colour, due to overlying thick epidermis and part of
dermis fades it into blue colour. It is common in
buttocks (Mongolian spot), hands and feet.
Intradermal naevus: This is the mole which consists
of clusters of melanocytes in the dermis. It can be
flat/raised/hairy/nonhairy . It is common in arms, face
and trunk. It hardly becomes malignant.
Junctional naevus: It is centered in the junctional
layer/basal layer of the epidermis as clusters of
proliferating melanocytes. This type commonly turns
into malignancy . It is common in palms, digits, soles
and external genitalia (Fig. 3.111).
Fig. 3.110: Congenital naevus.
Types:
Hairy mole: It is most common type which is flat
or with slight raise with growing hairs on the surface.
It also contains sebaceous glands and so can get infected
to form a swelling which is difficult to differentiate
from malignant transformation (Fig. 3.112).
Non-hairy mole: It is also called as smooth mole as
it is not elevated but smooth, brown, pigmented lesion
without hairs on the surface.
Fig. 3.111: Junctional naevus.
Fig. 3.112: Hairy naevus.
Compound naevus: It is combination of intradermal
and junctional types. Intradermal part is inactive but
junctional part is potentially malignant.
Juvenile melanoma (Spitz naevus): It is a junctional
mole appearing before puberty. It is a misnomer. It
is seen in face.
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SRB’s Clinical Surgery
Hutchinson’s freckle: It is seen in elderly with lar ge
area of dark pigmentation. It is common in face, neck
and trunk. In the macular stage it is smooth and brown;
in the tumour stage it is dark and irregular. It can
turn into melanoma commonly . Malignant change is
often difficult to identify clinically . It is peculiar due
to its late age of onset and high chances of malignant
transformation.
Halo naevus: It is depigmentation halo around the
pigmented naevus. Malignant transformation in such
naevus needs to be ruled out.
Spindle cell naevus: It is dense, black pigmented
lesion containing spindle cells and atypical melanocytes at the junction. It is common in females with
high malignant potential.
Naevus spilus (speckled lentiginous naevus): It is
hyperpigmented speckles throughout. It has got low
malignant potential.
Naevus of Ota: It is a dermal melanocytic hamartoma
seen in the distribution of trigeminal nerve; commonly
ophthalmic/maxillary divisions. It is seen in Oriental
and African race adolescent females with a hormone
influence.
Naevus of Ito: It is similar lesion occurring in shoulder
region.
One should always remember that it is wrong to
assume all intradermal naevus remain benign and
all junctional naevus will turn into malignancy. Naevus
more than 1% of body surface area or more than 20
cm in size is called as giant naevus. Eventhough mole
and freckle are used synonymously, but by definition
mole is increased number of melanocytes and freckle
(ephelis) increased melanin pigment with normal
number of melanocytes.
Melanoma
It is a malignant tumour arising from melanocyte which
is the most aggressive cutaneous malignant tumour. It
is of neural crest (ectodermal) origin. It is 20 times more
commonly seen in whites than blacks. Incidence is
equal in both sexes. Incidence increases over years. It
is not known to occur before puberty. In females leg is
the commonest site (Fig. 3.113). In males trunk is the
commonest site. In Bantu tribe sole is the commonest
Fig. 3.113: Melanoma on the plantar aspect of the foot.
Patient often will not observe this lesion. Note the deep
pigmentation and ulceration over it.
site. It can occur in eyes, mucocutaneous junction,
mucosa, head and neck. It is common in Australia. It
is common in white skinned people. Exposure to
ultraviolet light predisposes to melanoma. Risk
factors—high society people; albinism; xeroderma
pigmentosa; junctional naevus; familial dysplastic
naevus syndrome; congenital naevi; family history of
melanoma; previously other skin cancer if occurred.
Clinical types
Superficial spreading (64%): It is the commonest type.
It has got more radial growth than vertical. It arises
from preexisting naevus. It carries better prognosis.
It has irregular variegated look.
Nodular melanoma (20%): It shows more vertical
growth with invasion; more aggressive; common in
mucosa and mucocutaneous junction; it appears as
de novo in skin. Nodal spread is common; it is uniform
and nodular; carries poor prognosis.
Lentigo maligna melanoma (10%): Less common;
least malignant; common in elderly females; common
in face, neck, hands. It is slow growing, in situ type.
Acral lentiginous melanoma (5%): Least common;
common in palms and soles; common in Japan, Africa
and Asia; nodular with vertical growth; attains large
size; has poor prognosis; less common in whites;
mimics fungal infection or pyogenic granuloma.
Amelanotic melanoma: It is worst type. Due to
undifferentiation tumour cells will not synthesize
melanin; rapidly progressive pinkish fleshy growth
is the presentation; mimics soft tissue sarcoma.
Desmoplastic melanoma: It has got high affinity for
perineural invasion; common in head and neck; carries
high recurrence rate.
Examination of a Swelling/Lump
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Subungual melanoma: It is involvement of nail fold
matrix; progressive widening pigmentation of nail fold
with nail dystrophy is typical—Hutchinson’s sign. It
was earlier thought of Acral lentiginous type but now
considered as superficial spreading type.
Classifications
Breslow’s grading: Depends on the depth/thickness
of skin involvement: I—0.75 mm; II—0.76-1.5 mm;
III—1.51-4 mm; IV—> 4 mm.
Clarks levels: Depends on extension into deeper plane:
1: epidermis only; 2: extension into papillary dermis;
3: entire papillary dermis is filled; 4: extension to
reticular dermis; 5: extension to subcutaneous tissue.
Melanoma can be cutaneous; extracutaneous (ocular
is common); occult (primary not known).
Clinical features: It can occur in a preexisting naevus
or de novo in normal skin. Pigmentation with irregular
surface, irregular margin; ulceration; bleeding; itching;
colour changes; depigmentation halo around the
pigmented area; recent increase in size.
ABCDE of melanoma: Asymmetry; Border irregu-
larity; Colour variation; Diameter > 6 mm; Elevation.
Induration is not seen in melanoma. Melanoma spreads
through lymphatics to regional nodes by permeation
or embolisation; through blood to liver (massive
pigmented liver); lungs (cough, haemoptysis, pleural
effusion, cannon ball secondaries); brain (convulsions,
localising features, raised intracranial pressure); bones
(bone pain, pathological fracture, neurological
deficits); skin; viscera (melanuria). Secondary skin
nodules within 2 cm of primary are called as satellite
nodules; nodules beyond 2 cm from primary up to
the regional nodes are called as ‘in-transit’ nodules
(Fig. 3.114). Melanoma in choroids carries better
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prognosis as there are no lymphatics. Late massive
liver secondaries even after 20 years is known to occur
when primary is specifically in choroid. Presentation
initially as secondaries is possible when occult primary
exists in anus, scalp, genitalia, eye, nailbed, external
auditory canal, adrenal medulla.
Differential diagnoses are other pigmented lesions
of the skin (Figs 3.115A and B to 3.118).
Pigmented lesions of the skin
• Seborrhoeic keratosis
• Dermatofibroma
• Pigmented BCC
• Naevus
• Cutaneous haemangioma
• Melanoma
• Skin adnexal tumours
• Solar keratosis
• Pyogenic granuloma
• Angiosarcoma of skin
• Café au lait patch
• Campbell de Morgan spot
• Venous dermatitis
A
Fig. 3.114: Melanoma in sole with satellite nodules. Satellite
nodules occur within 2 cm of the primary lesion.
B
Figs 3.115A and B: Melanoma face with
extensive destruction.
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Fig. 3.116: Melanoma thigh with secondaries in
inguinal lymph nodes.
A
Fig. 3.118: ‘In-transit’ nodules in melanoma. They are
secondary depositions in dermal lymphatics.
growing nonencapsulated fleshy malignant tumours.
It is 1% of adult malignancy . Commonest site is lower
limb (35%). Commonest soft tissue sarcoma is lipo-
sarcoma. Usually soft tissue sarcoma attains large size
more than 10 cm in 40% of cases. Spread is commonly
to lungs through blood. Lymphatic spr ead occurs only
in few soft tissue sarcomas like rhabdomyosarcoma,
synovial sarcoma, epithelioid sarcoma, angiosarcoma.
B
Figs 3.117A and B: Melanoma great toe. Note the
pigmentation near the base of the toe and extensive
involvement of the toe.
Sarcomas
Sarcomas arises from soft tissues (connective tissues,
mesenchymal) and bone. They are less common than
carcinomas but more aggressive. They are rapidly
Clinical features: Present as painless, smooth, hard,
vascular, progressive swelling of short duration which
causes compression and infiltration of adjacent
structures. Eventually it becomes painful and tender
due to nerve infiltration, infection, tumour necrosis.
Features of lung secondaries like cough, chest pain
and haemoptysis can be the presentations. Sarcoma
occurs in younger age group compared to carcinomas.
Skin over the swelling is stretched, glossy , with dilated
veins. V ery vascular sarcomas can be pulsatile. Incision
biopsy, X-ray, CT scans of part and chest, MRI are
the needed investigations. GTNM (Grade, Tumour
size, Nodal status, Metastasis) staging is used.
Examination of a Swelling/Lump
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Sarcomas are graded as low (liposarcoma, dermatofibrosarcoma), high (synovial sarcoma, rhabdomyosar-
coma, angiosarcoma) and undetermined (leiomyosarcoma). Soft tissue sarcoma may be superficial
means outside the superficial fascia; deep means deep
to superficial fascia; may be within one compartment
or involving many compartments.
Liposarcoma is the commonest soft tissue sarcoma
(20% of all soft tissue sarcomas). It can occur de novo
or in a preexisting lipoma. Thigh, back and retroperitoneum are the commonest sites. It can be well differentiated; myxoid; round cell; pleomorphic types.
Malignant fibrous histiocytoma (MFH) is soft
tissue sarcoma with fibrohistiocytic appearance. It is
common extremity sarcoma. It is seen in adults and
elderly.
Leiomyosarcoma arises from smooth muscles with
whorled appearance. It is common in retroperitoneum
and viscera. It can occur in piloerector muscle of skin.
Rhabdomyosarcoma arises from skeletal muscle.
It is common in head, neck, thigh, and arm. It is the
commonest sarcoma in children. It can be pleomorphic,
embryonal (seen viscera like urinary bladder),
botryoidal or alveolar. It is very aggressive tumour;
it can spread through lymph nodes.
Synovial sarcoma originates from synovial cells
of tendon sheath, joint capsule. It occurs in younger
age group; common in shoulder, thigh, and leg. It
spreads through blood. In 20% cases it can spread
to regional lymph nodes. It is high grade aggressive
sarcoma. In 10% of patients it shows calcification.
Fibrosarcoma is next common soft tissue sarcoma
after liposarcoma and malignant fibrous histiocytoma.
It arises from fibroblasts.
Kaposi’s sarcoma arises from vascular smooth
muscles or pericytes. It is common in skin, mucous
membrane, lymph nodes, or viscera. It is linked to
Human Herpes virus (HHV8). It presents as multiple
reddish blue nodules in the skin with ulceration over
the nodule with lymph nodal spread. European
Kaposi’s sarcoma is common in extremity; rare in
viscera; common in old age; African Kaposi’ s sarcoma
is common in children and young; involves skin and
lymph nodes. T ransplant associated Kaposi’ s sarcoma
mainly involves skin. AIDS associated Kaposi’s
sarcoma shows wide disseminated involvement with
spread; it is very aggressive (Figs 3.119 to 3.123) .
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Fig. 3.119: Kaposi’s sarcoma-reddish
blue nodules are typical.
Fig. 3.120: Aggressive vascular sarcoma of foot.
Fig. 3.121: Soft tissue tumour left thigh.
Hamartoma, Haemangioma and
Vascular Malformations
Hamartomata
Hamartano means—‘I miss’ (Greek) or ‘fault’ or
‘misfire’ or ‘error’. It is a benign lesion with aberrant
differentiation producing a mass of disorganised but
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Fig. 3.122: Malignant fibrous histiocytoma—a soft tissue
tumour. It is the second common type after liposarcoma.
SRB’s Clinical Surgery
Haemangioma
It is benign vascular endothelial tumour, common in
girls (3:1). It is commonly seen in skin and subcutaneous tissue but can occur anywhere in the body
like in liver, brain, lungs or other organs. It grows
rapidly in first year and 70% involutes in 7 years.
Early proliferative lesion is bright red, irregular; deep
lesion is bluish coloured. Involution causes colour
fading, softness, shrinkage leaving crepe paper like
area. Commonly it is central; common in head and
neck region (60%) (Fig. 3.124).
Classification
• Capillary
• Salmon patch (stork bite)
• Strawberry haemangioma
• Port wine stain (naevus flammeus)
• Cavernous
Fig. 3.123: Synovial sarcoma. It is very aggressive
sarcoma arising from tendon sheaths, joint capsule.
mature specialised cells or tissue indigenous to the
particular site. It is tumour like overgrowth of tissue
or tissues proper to that part. It may be single lesion
or multiple lesions. Haemangiomas, lymphangiomas,
A-V malformations, neural malformations are the
examples.
Problems with hamartomas: Pressure symptoms
locally; bleeding; infection; gigantism; cosmetic
problem. Hamartoma is older terminology; now word
is replaced by newer terms and definitions.
Fig. 3.124: Haemangioma in a child involving face
extensively. Haemangioma is usually compressible. On
applying continuous pressure swelling partially gets reduced
and on releasing swelling comes back to original size. Cystic
hygroma, aneurysms are compressible. Thrombosed
aneurysm is not compressible (By Prof. Ganesh Pai MCh).
Capillary Haemangioma
Salmon patch (stork bite): It presents at birth. It
commonly occurs in nape of the neck (50%), face,
Examination of a Swelling/Lump
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scalp and limbs. It usually involves wide area of skin.
It is caused by an area of persistent fetal dermal circulation. With age, it goes for spontaneous regression
and disappears completely (usually in one year). Hence
masterly inactivity is the treatment (Fig. 3.125).
Fig. 3.125: Salmon patch.
Strawberry haemangioma: It may start at birth or
child is normal at birth; between one to three weeks
it appears as red mark which rapidly increases in size
in 3 months to form strawberry/raspberry haemangioma (Fig. 3.126). It contains immature vaso-
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formative tissues. There will be eventually intravascular thrombosis, fibrosis and mast cell infiltration.
It is a true capillary haemangioma. It is 20 times more
common than port wine stain. It is common in white
girls (girl: boy :: 3:1). It is common in head and neck
region. It is clinically compressible, warm with bluish
surface. Bleeding can occur after minor trauma and
also ulceration. It involves skin, subcutaneous tissues
and often muscles also. After one year of age, it slowly
begins to disappear, and completely in 7-8 years (70%
in 7 years). It is the commonest haemangioma.
• Haemangioma in periorbital region obstructs the vision
in newborn with amblyopia and if persists for 7 days
causes permanent visual damage. Astigmatism also can
occur
• Haemangioma in nasal area in newborn may obstruct
nasal airway seriously (as newborn cannot breathe
through mouth—obligatory nasal breathing)
• Skin ulceration may cause haemorrhage
• Infection can occur which may lead into sepsis, necrosis
or rarely septicaemia
• Systemic steroids for 3 weeks induces involution
• Usually there is no role for surgery. Surgery is done
only for retained tissue after involution.
Port-wine stain (Naevus flammeus): It present at
birth and persists throughout life without any change.
Spontaneous regression will not occur. It presents as
smooth, flat, reddish blue/intensely purple area;
common in head, neck and face; often with maxillary
and mandibular dermatomes of 5th cranial nerve.
Eventually surface becomes nodular and keratotic. It
persists throughout life. It is actually a capillary
malformation even though considered under
haemangioma. It results from defect in maturation of
sympathetic innervation of skin causing localised
vasodilatation of intradermal capillaries. It is often
associated with Sturge-Weber syndrome, KlippelTrenaunay-Weber syndrome and Proteus syndrome.
It needs treatment—laser (pulsed dye/diode); excision
and grafting; cosmetic coverage. Often expected result
is not possible by treatment (Fig. 3.127).
Fig. 3.126: Strawberry haemangioma.
Cavernous Haemangioma
It is present at birth and consists of a multiple venous
channels. Its size increases gradually and may cause
problems. It often contains feeding vessels which is
of surgical importance. Sites: Head, neck, face, limbs,
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Fig. 3.127: Port wine stain (Naevus flammeus)
tongue, liver and other internal organs. Large or multiple cavernous haemangiomas can cause congestive
heart failure (hyperdynamic circulation) due to shunting of large quantity of blood. Cavernous haemangioma with dyschondroplasia is called as Maffucci
syndrome. Cavernous haemangioma is often mixed
with lymphatic component also (mixed vascular and
lymphatic).
Clinical features: It is smooth, soft, well localised,
warm, fluctuant, compressible, nonpulsatile swelling
with bluish surface occurring in skin and subcutaneous
tissue (often in mucosa like oral cavity) without any
transillumination (Figs 3.128A to C). Compressibility
and bluish surface is diagnostic. When swelling is
pressed it reduces partially/often completely but when
pressure is released it slowly attains its original size
and shape. V ascular and lymphatic malformations are
compressible. It is usually nontender unless it gets
infected or undergoes thrombosis or in case of
haemorrhage.
Differential diagnosis: L ymphangioma—It is brilliantly transilluminant unless it is infected or fibrosed.
Lipoma, cold abscess, lymph cyst—clinically it is
easier to differentiate.
Complications: Haemorrhage; DIC; thrombosis;
infection, ulceration and septicaemia; erosion into the
adjacent bone; high output cardiac failure.
Investigations: Ultrasound; Doppler; angiogram to
find out feeding vessel; platelet count; MRI/MR
angiogram to see feeding vessels and deeper extension
(Fig. 3.129).
A
B
C
Figs 3.128A to C: Cavernous haemangioma in the cheek
near angle of the mouth; in the tip of the tongue and one
involving large part of the tongue. Haemangioma tongue
is one of the causes of macroglossia.
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