Endgames Picture Quiz

A man with a mass in the thigh

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2483 (Published 10 April 2014) Cite this as: BMJ 2014;348:g2483
  1. Richard Bodington, fifth year medical student1,
  2. Paul R W Stanley, consultant plastic surgeon2
  1. 1Hull-York Medical School, Hull HU6 7RX, UK
  2. 2Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
  1. Correspondence to: R Bodington hy9rb{at}hyms.ac.uk

A 54 year old man presented to his general practitioner because of a fullness in his left lateral thigh that he first noticed while playing golf, although it was not related to an identifiable injury. He had a history of hypertension and fibromyalgia and was taking atenolol, ramipril, pregabalin, and tramadol but was otherwise well. The GP thought that the swelling was caused by a muscular injury, but the patient re-presented four months later because the mass had grown from a small bump to a swelling of 8 cm in diameter. It was also beginning to cause some knee stiffness but no pain. On examination he had a large firm swelling in his lateral thigh. On this occasion his GP referred him on a two week wait to the regional plastic surgery department. An ultrasound scan showed a 6 × 8 cm intramuscular mass with cystic changes and patchy neovascularity, but no inguinal or pelvic lymphadenopathy. Ultrasonography was followed by magnetic resonance imaging, with and without gadolinium contrast (fig 1).

Fig 1 Magnetic resonance imaging scan with gadolinium contrast

Questions

  • 1. What is the differential diagnosis?

  • 2. What features make this mass suspicious?

  • 3. What is the most appropriate action to take next?

  • 4. What are the options for managing this patient?

Answers

1. What is the differential diagnosis?

Short answer

Benign causes of a large lump in an extremity include haematoma, chronic muscle tear, an abscess, and lipoma. Malignant causes include sarcoma, lymphoma, and soft tissue metastasis from an occult tumour.

Long answer

This mass could be malignant or benign. Benign soft tissue lumps outnumber malignant ones in a ratio of at least 100:1.1 Benign causes of a large lump in the extremity include haematoma, chronic muscle tear, an abscess, and lipoma. In this case, the long slow growth pattern with no history of trauma make haematoma and a …

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