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Having lump in leg above knee. Should I take kenalog vaccination before going for biopsy?

Jul 2012
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Practicing since : 1993
Answered : 1196 Questions
Should I have a biopsy of the lump in my leg above the right knee on the right thigh and about 1/2 inch deep?

My dermatologist says it is a cyst, but she is not 100% sure and wants to inject it with KENALOG before doing the biopsy. Is that safe for a 69 year old white man with fair skin and blue eyes who was raised in Southern California; sun exposure all my life? I am told that is OK if you absolutely 100% know it is a cyst. If not, injecting a steroid into anything you are not 100% sure of the outcome before you inject it, is crazy and can have really bad results if it turns out to be cancer. In fact it may even cause the cancer to spread exponentially very fast or faster having the injection than if I did not get it. Who is right, or should I just forget about it and see what happens? Just so you know too; It has only grown about a 1/8" in diameter in a month or so and seems to be getting slowly bigger, so I am really concerned. I am torn between saying okay do the injection and roll the dice as she seems like a good person and confident we are dealing with a sebaceous cyst and I want to trust what she says to do. Or should I insist on a biopsy first? What would you do and why? PLEASE JUST DO NOT SAY WHAT TO DO, I NEED TO KNOW WHY, SO she thinks I am not stupid and at least did some research. If you just say not to let her do the injection OR do the biopsy I have to know why as that is the question. If you say get the biopsy, what could happen if she injects it like she wants to do and it turns out to be a bad cancer or something? I have a friend who has a really rare skin cancer called Merkel cell carcinoma and he says do not trust her. His cancer can move into the lymph system and did in a matter of a week or so when that same thing was done to his "cyst" that was cancer after all. What should I do? I have been to other doctors in the same clinic and they are kind of timid and say for me to do what she says to do if I want her as my doctor...

Thanks for your thoughtful answer.
Posted Fri, 31 Aug 2012 in Skin Hair and Nails
Answered by Dr. Praveen Rodrigues 7 hours later

Thanks for the query.

I empathise with your situation & quite understand your predicament. Allow me to be brief and to the point while answering your query / reasoning why. Sometimes the 'why' is not as important as it 'stresses' people out.

Having said that, in your case, an explanation seems in here goes.

In my humble opinion as a dermatologist for over 15 years, I would excise the cyst every single time (assuming you’re dealing with a sebaceous cyst here) as intralesional steroid injections are not the accepted line of treatment in a sebaceous cyst as the lesion & sac has to be removed in 'toto' to prevent recurrences. Also, if it is not a cyst & there is any doubt in your mind whatsoever, it is a simple matter to excise the cyst, biopsy it & give your mind that much required peace. Besides this, it will give you a 'definitive' diagnosis & do no harm except for the tiny surgical scar which again can be easily remedied with the 'lasers' et al we have nowadays (albeit purely for cosmetic reasons).

Even if it is a 'bursa' above your knee, I would still excise it. An orthopaedic opinion may be in order if there is any doubt it is linked to your knee joint.

Trust this answers your queries. Relax...while your friend does have a point, opinions are available dime a dozen; practicality is the order of the day & at the end of the day, YOU as a patient need to be clear & firm in your call irrespective on treading on said doctor's toes.

Let me know if you have still have concerns.

Cheers & Good luck!
Dr Praveen Rodrigues MD
Bangalore, India
Above answer was peer-reviewed by
Follow-up: Having lump in leg above knee. Should I take kenalog vaccination before going for biopsy? 15 hours later
Thank you so much for your kind and thoughtful opinion. It is very well written and completely understood. Thank you very much!

Now I have a follow-up question and a confession. The other friend with MCC MERKEL cell carcinoma is me. I wanted a complete unbiased opinion from someone who had nothing invested and could be objective as it relates to me and not something that already happened, like it did to me. I got that and I thank you very much.

I am the one with MCC. The exact same thing happened to me as I described to you in my question about what I should do. The only difference is she did it as compared to me not having that done to me yet. I wanted to know why she did it the way she did, at my VERY irst dermatologist appointment.

She actually did injected the "cyst" with a KENALOG injection before I knew what she was doing and I never even saw the needle and syringe as I was laying on a table...

I am only concerned as it seemed strange and very pertinent that after the injection and only within the next two days the sub dermal bump grew out of the top of my skin to about 1/2" high and widened to about 1/2" too. It was red, purple, and yellow and had rough ridges on the top of the “cyst".

I called the doctor and she had me come in and when she saw it you could see the scared and confused look in her eyes. She excised it but left quite a bit of what turned out to be the main site of the MCC tumor there and the pathology report even noted that after I read it too.

Of course it came back as Merkel Cell Carcinoma and then I was scheduled for a PET SCAN. The Scan revealed the tumor that was about the size of a large pea and 1/4" below the surface before the injection and great to the size I mentioned above and it had metastasized to the inguinal abdominal area and then the groin area too on the right side of my body or the same side of the original tumor.

I had surgery a week later because this disease moves incredibly fast and they were afraid not to do it immediately for fear of it moving even further. They took out 12 -20 nodes that had MCC in them. I finished radiation and had my 3 month PET scan follow-up without cancer detected.

FYI, the whole reason I asked this question is before she injected it, I asked if that was standard treatment or would a biopsy be best? She said it was standard for a sebaceous cyst and I even questioned that as I was a Navy Corpsman and had myself removed several of these, never used KENELOG and I had never seen one in that region before and none that I had treated ever, felt like the BUMP I had.

I asked her again afer it turned out to be a really bad and deadly cancer, if she thinks she still did the right thing and she again said yes. I don't think she should blatantly lie to me and in doing so risk my life either. I also feel strongly that she needs to rethink how she treats these for others.

Initially, I did not want to pursue any legal action and told her I would not if she simply would tell me if she felt if she had it to do over if she would have done the same thing. Her answer without thinking was a yes.

I am afraid that with this resession and having lost all I earned all my life to be dealt this cancer in this way is wrong and now I cannot work and will not be able to support my family the way I have alwasy done and I think it is her fault. Not that I have cancer certainly; but definately that it spread so fast and before I was able to catch it where it was when I saw her the first time and I would not be in so much danger of losing my life...

Now and only f you know or think you know if the exponential fast growth and change in physical characteristics is an indicator that the steroid caused the MCC to speed up the process to mastitis? I personally feel if she had not done that I would have been a stage 1 after the sentinel biopsy and have a long life to live.

Instead I am a stage3 A patient with a very good chance of recurrence, especially with this terrible carcinoma. If you are unfamiliar with it you can go to WWW.WWWW.WW and learn who to talk to there and other reference material too.

It is very rare, as only 1500 people a year get it so many doctor and even specialist of your field don't know much about it.

It is the worst skin cancer there is and is akin to small cell lung and pancreatic cancer and has the same, or in many cases, worse odds of survival once it travels out of the original site.

Can you please tell me if you feel the steroid had anything to do with the way it moved so quickly as it appeared to go "INTO HYPER DRIVE AFTER THE INJECTION is why I even know something appeared terribly wrong...

Thanks again for your great answer above and I look forward to hearing back on this follow-up question. In my last hypothetical question, in this one I switched to the victim instead of someone who may become one, as it seemed the best way to present that situation to you...


Answered by Dr. Praveen Rodrigues 7 hours later

I empathise with your particular situation and as a family man myself, feel for you. However, take a step back and take in the facts.

I stand by my 1st opinion that the steroid injection for a sebaceous cyst will never be my 1st line of treatment and have never 'injected' anyone over the last 15-20 years when I suspected a 'sebaceous cyst'. Having said that, if a 'bursitis' was suspected, then a steroid injection may have been a choice to decrease the infection.

However, there is no way of saying with any objectivity or certainity that the 'steroid injection' was solely or directly responsible for the 'rapid spread' of the tumor albeit, mechanical trauma has been implicated in documents to cause tumor dissemination.

You are right in stating that Merkel cell tumors are rare and one can easily 'overlook' them. But one does have to keep it in mind especially if it was a 'painful' tumor as I recall it is one of the rare 'painful tumors'. Again , these are semantics.

While I understand your ire and the desire to make sure this does not repeat itself with the said same doctor, my primary concern is that as a patient, you try and effect a full recovery; get better soon. The love and care of your family members & friends' should see you through.

I empathise with your initial desire for the sake of anonymity or 'double-blinding' my initial answer, but assure you regardless, I would have given you the same honest opinion as I did the first time around were you victim or someone who may have become one!

Do take care & Wish you a speedy complete recovery

Thanks once again. I will be happy to answer any other queries that you might have.
If you do not have further queries, please close this discussion.
Above answer was peer-reviewed by
Follow-up: Having lump in leg above knee. Should I take kenalog vaccination before going for biopsy? 15 hours later
You are so kind and it is very much appreciated. It is with that in mind that I will make some further requests for data about a couple of curious things you assumed and also to allow me to further explain the Merkel Cell Carcinoma tumor correctly.

After the below is fully answered to my satisfaction, as I do have a medical background and while I do understand some things about anatomy and physiology very well, I am certainly not a doctor. After I receive your answers to my questions below, I will finally close this discussion. Here they are:

Before the questions I need to clear up the status of this tumor as they are different somewhat than you stated, or assumed in your answers because I was not as clear as I needed to be.

First, this "Merkel cell carcinoma" tumor is not a painful tumor and if it were not an obvious growth, you would not know it is there. As such it does fell like a cyst so I give that to the dermatologist who did the injection instead of the biopsy as she should have done. By the way that is the proper protocol according to the American Dermatological Association or whatever that groups name is that determines standards of treatment for each specialty here in the US.

I noticed it while I was massaging my lower legs, due to my diabetic lower limb neuropthy pain. I felt a very small bump just above my right knee as my hands moved up past my knee to the tumor area where I first felt the bump, or I would have never noticed such a small "bump" there especially. I say there especially because it is in such an unusual place for a cyst in my experience in removing several myself while I was in the Navy and as a Navy Corpsman. As I stated, in my experience, it is truly an unusual place for a cyst and that is why I was concerned...

Here are the things that need your particular attention and/or comments back to me please.

1. My tumor started out, OR I first noticed it the first part of last November 2011 at or around the 1st of November 2011, as a small Q-Tip sized bump located where I explained it was in my first note to you.

2.Around the first part of December, or about a month after I first noticed it, I visited my family doctor to see if she thought it may be something to have looked at for further study. She said it was unusual, curious and in a place where you do not see a cyst normally, and as such we should have the dermatologist look at it. An appointment was made and scheduled for December 28, 2011.

3. I saw the dermatologist as planned on the date stated above. THIS PART IS IMPORTANT:

You are asked to keep in mind that the tumor had only grown to a pea sized from the Q-Tip sized tumor in well over a month AND in almost 2 months (Early November to Late December). But it had grown, so I too was more concerned.

4. When I saw the dermatologist, she examined it and remember too it was above my right knee to the right side of my lower thigh and no where near the knee to have any concerns with 'bursitis' as it was only the "cyst" that turned out to be a tumor we were concerned with. The key here is that the tumor, as we now know it now was, had ONLY GROWN about 1/10cm between November 1st and December 28th, again in almost TWO(2) months from first contact/sight.

5. Without notice and without my approval, the dermatologist took it entirety upon herself to inject the tumor with a steroid (KENELOG) and when I asked her why she did it, she said it was a sebaceous cyst and using KENELOG it would be gone in a 3 or 4 week period. I said are you sure it is a cyst and she said yes! I confirmed this by getting a copy of my medical record and it says this in my medical records too and just as I described it herein.

6. THE KEY HERE: Keep in mind the tumor, pre-injection and in almost two months only grew 1/10cm. But as soon, the next day, as the injection happened, the tumor started to grow noticeably. By the next week it grown to about 1-2/10cm and just a little out of the skin by the time two days had past.

7. After a week and a half, the tumor after injection, grew from about 1-2/10cm to now over 1cm and had changed colors to purple, yellow with a little reddish pink in it and it was rough on the top and it also grew to 1cm or more wide. THIS IS EXTREMELY UNUSUAL and to me can only be explained by the injection since no one ever seems to know what will happen if one brakes protocol and injects KENELOG into what turns out to be the fastest growing carcinoma known to man and medicine, or so it would appear ,especially if the circumstances are as I stated herein are as I have said they are and I think you would agree too...

My question is - as a doctor and a scientist, Dr. Rodrigues, what conclusion would you make under the above circumstances, after the injection was made to the tumor and if in fact it did grow and change complexities to the extent I say it did and as I explained above AND in such a short time line from where it started before seeing the dermatologist, on one day and then the next, almost have it explode to a size and color like this? What other conclusion could be made of this?

In your experience, or do you know of anyone, or have you ever studied about anyone getting anything similar done to them and then to have this conclusion? In your professional opinion and as a practicing dermatologist of over 15 years and with your military background too, have you any reason to believe that this result would have happened without a steroid injection, keeping in mind that it grew so slightly for over almost two, and then and ONLY AFTER the injection of a steroid to have it explode in the growth and change of colors so drastically like what it did? OR can you think of any reason that this could have happened at all like, or even close to like this, with your medical experience and background?

That is the total of my concern for what was done here. I understand the doctor could not have known I had cancer and especially the cancer it turned out to be.

But had she just done the biopsy on the first visit like she is supposed to do and what you yourself ALWAYS DO, ALWAYS, instead of injecting the "bump" with a steroid, does it not seem like she should know too, and as you do, that the biopsy and not the steroid was proper? I feel and almost know that I would probably just had the biopsy and then like the proper treatment plan calls for, had the sentinal biopsy once it was diagnosed as Merkel Cell Carcinoma as I say is the proper plan of treatment when it is first discovered as small as it was, I would be done with it and certainly not achieved the stage 3a status I have by her NOT following proper protocol?

It is my opinion that if it would NOT have grown to the exponential size it did after the injection and we would have been dealing with a much smaller sample as in "IF the whole bump" had it been excised as it should have been, by any dermatologists standards. It that not true or at least a logical assumption?

Thank you so kindly for your consideration of all the facts of my case and how the doctor did one thing that seems to have lead to the worst possible conclusion she could have done to me, or for me in this case.

You have been so kind and still forthcoming and I wish to thank you very much and ask that you forgive me once again for the "double blind" study of sorts I perpetrated to you.

I ALSO NOW KNOW TOO that you would have given me these same answers and I also know it is difficult to know the particulars of something such as I have been through, but that is why I wanted to ask a professional like you sir, who has nothing to gain OR lose by helping me understand more about my case here at all. That is also why I know you will now take into account these new revelations as I explained them herein to give me your conclusions. I will respect your answers and be done with this, if it makes any logical sense to me at all.

Thank you once again for your help.


Answered by Dr. Praveen Rodrigues 7 hours later

Thanks again,

I read with interest your observations that the tumor was not painful (here I was alluding to the fact that it may have been secondarily infected) but must concede that we learn new things in medicine each day & science is constantly evolving. Different doctors' have different ways of interpretating or going about things & some go purely by their experience. While injecting a 'sebaceous cyst' with kenalog may be documented in some texts, the definitive treatment still remains total excision.

In your case, Yes, it is very possible the injection may have preciptitated or 'hastened' the subsequent sequence of events.

One regrets the outcome of events but again, please look at the larger picture & don't stress yourself & 'dwell' in the past. Stress is another major accelerator of events untoward & is not going to help your cause.

Good luck once again & do hope your tumor defies all odds & enters total remission & all is well. I do hope this makes logical sense & thank you for respecting my views.

Cheers! Dr Praveen Rodrigues
MD Dermatologist, Cosmetologist, Venreologist,
Bangalore, India.
Above answer was peer-reviewed by
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