As clinicians we have all encountered the situation where a patient asks “Doc, I have this bump here,” or, we review an X-ray with “something funny in the bone.” These are precarious situations because we do not want to miss a malignancy or cause a delay in diagnosis in today’s litiganous society. However, benign masses such as lipomas are common and we do not want to waste resources working up obviously benign masses. Therein lies the difficulty: when is a mass suspicious enough to warrant further work up?
Going back to medical school, the concept of “red flags” still holds true. These symptoms include night pain, unexpected weight loss, fever, chills and rapid growth all indicate a potentially aggressive mass. Any of these findings should alert the clinician that further study is required.
Soft tissue tumors are common with lipomas being the most prevalent. Any mass which is encountered should undergo documentation of the size and location of the tumor. Any scenario with red flags involved should undergo advanced imaging. MRI is the gold standard for evaluating soft tissue tumors. Important imaging findings include size of the lesion, location and signal characteristics. Lesions > 5 cm, mixed MRI signal and location below the fascia indicate potential malignancy.
Primary bone tumors are very rare. It has been estimated that an orthopedist in practice will encounter one primary bone malignancy in his practice lifetime. Thankfully, a large amount of information can be gleaned from a standard X-ray. Four questions need to be asked when evaluating a bony lesion:
- “What is the tumor doing to the bone?”
- “How is the bone reacting to the tumor?”
- “What is the age of the patient and the location of the tumor?”
- “Are there any unique findings on x-ray?”
Based on these questions a clinician can estimate the likelihood of a lesion being aggressive and malignant.
Treatment of any mass should be done by a clinician who is prepared to treat the tumor if it is malignant. Errors in biopsy often contaminate tissues and change the extent of resection oftentimes leading to a larger and more disfiguring procedure than what would have been needed initially.
To summarize, any patient who presents to a clinician with a soft tissue mass or bony lesion requires a history looking for red flags. Any lesion with the possibility of being aggressive requires imaging (MRI for soft tissues and x-rays for bone). Based on the imaging characteristics one can estimate the propensity of a mass being aggressive. If there is any possibility of a mass being malignant, the patient should be referred to the appropriate specialist.