Lumps & Bumps: Soft Tissue Masses and Lesions
With Dr. Danielle Walsh & Dr. Oliver Witt & Dr. Joy Collins · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 34:58 · stops at 35:43 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Retinoid medications for acne are significantly associated with development of pyogenic granulomas; removal of medication often resolves the lesion
Pyogenic granuloma surgical resection has approximately 3% recurrence rate with gross negative margins
Shave excision with curettage of pyogenic granuloma has 9.5% recurrence rate
Silver nitrate treatment for pyogenic granuloma has 15% recurrence rate, the highest among treatment options
In a large study, 80% of characteristic Spitz nevi involuted spontaneously
Half of pediatric dermatologists would observe classic Spitz nevi without excision, waiting for spontaneous resolution
In a series of 30 patients with incompletely removed Spitz nevi, 24 were observed and none recurred; 6 were re-excised and only 1 had residual disease
In a retrospective study with 1-3mm margins for Spitz nevi, 20% had positive margins on re-excision
Barnhill recommends 3-5mm margins for classic Spitz nevi, 1cm for atypical, and melanoma-protocol margins for severely atypical based on depth
About one-third of Spitz nevi cases had nodal micrometastases on sentinel lymph node biopsy in combined adult and pediatric series
In 8 series, 39% of Spitz nevi with sentinel lymph node biopsy were positive, but all patients remained disease-free at 3-year follow-up without further intervention
Pediatric melanoma ABCDE criteria capture only 40% of cases in children under 10 and 60% in children over 11
Melanoma margin recommendations: 5mm for in situ, 1cm for ≤1mm thick, 1-2cm for 1-2mm thick, 2cm for >2mm thick
Cochrane review suggests 2cm margins are adequate for thick melanomas; no benefit demonstrated for 4cm margins
Giant congenital nevi (>20cm) have 8% melanoma risk, higher if hairy; 60% of melanomas occur in first decade, reported as young as 3 years
Pediatric melanoma has higher metastatic rate to lymph nodes (about 25%) than adults, especially in children younger than 10 and with thicker lesions
If sentinel node is negative in melanoma, probability of subsequent recurrence is only about 5%
If sentinel node is negative in melanoma, probability of non-sentinel node being positive is low but not zero
Acute unilateral cervical lymphadenopathy is mostly bacterial (strep and staph); acute bilateral is usually viral
Chronic/subacute unilateral lymphadenopathy suggests atypical mycobacteria, Bartonella, tuberculosis, or toxoplasmosis
Chronic/subacute bilateral lymphadenopathy suggests EBV, CMV, or HIV
Lymphadenopathy may persist 6-8 weeks after antibiotic treatment
Biopsy indications for cervical lymphadenopathy include: >3cm, hard/fixed, supraclavicular or epitrochlear location, multiple nodal groups, systemic symptoms, hepatosplenomegaly, significantly abnormal labs, or abnormal imaging
FNA for lymph nodes has 90% sensitivity and specificity but 10% false rate, with higher false-negative rate in Hodgkin lymphoma
Malignancy rate in cervical lymph node biopsies varies 10-25% overall but ranges 12-80% depending on referral patterns and specialty
Atypical mycobacterial lymphadenitis is a local problem in immunocompetent children, usually age 1-5 years, enters through oropharynx, and is not considered contagious
In a randomized multicenter trial for atypical mycobacterial lymphadenitis, surgery had 96% cure rate versus 66% cure rate with antibiotics alone
In a series of 55 patients with confirmed atypical mycobacteria, 45 started on antibiotics and 30 (67%) resolved without surgery
Neonatal breast mastitis occurs mostly in term or near-term infants due to estrogen exposure; very uncommon in preemies because estrogen levels don't rise
Peak age for neonatal mastitis is 2-4 weeks; majority are staph but gram negatives reported
Parenteral antibiotics for 7-14 days may be needed for neonatal mastitis because infants have delayed absorption and delayed antibiotic efficacy
In two small series of neonatal mastitis with I&D, breast deformity occurred in 2 of 5 patients (40%) in one study and 2 of 7 patients (29%) in another
Fibroadenomas are the most common breast lesion in the under-20 age group, representing an exaggerated response to estrogen
About 10-15% of fibroadenomas are multiple and 10% are bilateral
Fibroadenomas typically increase in size over 6-12 months, then stabilize and can regress completely
Excisional biopsy for fibroadenoma is recommended if continuing to grow, changing, over 5cm, symptomatic, complex on ultrasound, unreliable follow-up, or severe family anxiety
Juvenile fibroadenomas are larger lesions with rapid growth, greater than 5cm, but only 10% reach that size
Juvenile fibroadenomas larger than 5cm are difficult to distinguish from cystosarcoma phyllodes, even on percutaneous biopsy
Simple fibroadenomas (isolated, well-demarcated, solid) have no increased cancer risk if no family history and no adjacent breast tissue abnormality
Complex fibroadenomas (with cysts, calcifications, or abnormal surrounding tissue) carry a slight increased risk of future breast cancer up to 20 years after diagnosis
Malignant breast disease in pediatric patients is rare and more commonly metastatic from other sites than primary breast tumors
Lymphoma patients treated with chest radiation at young ages have up to 25% higher incidence of malignant breast disease
American Society of Clinical Oncology discourages BRCA genetic testing before age 20 due to lack of timely medical benefit and psychosocial risks