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Suggest treatment for lump on right bicep

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Posted on Wed, 23 Dec 2015
Question: I have a lump on my right bicep. I had an MRI of my shoulder and they went down on the view 6 inches below the humoral head or that is what they told me. The radiologist looked at the scans a couple times and he said he didnt see anything on MRI. No tumor, lipoma or enlarged lymph node.

Questions.

(1) there is clearly a lump beneath the skin. It is hard, the size of a pea, appears moveable and on top of the muscle. The lump itself doesnt seem to hurt but the area around it tender when pressed. If nothing showed on the MRI (T2 without contrast), what could this lump be?
(2). The MRI is the gold standard even without contrast so should I stop worrying?

I saw the dermatologist. He said it wasnt his area because it appeared to be deeper than the surface of the skin. He thought it was a lipoma, ganglion cyst or enlarged lymph node (note i confirmed the radiologist view after this appt because it didnt make sense). The MRI didnt see any of that.

What else can it be? Can I at least be confident that it isnt a sarcoma/cancer as it should have shown on MR, correct?

I am also happy to send images from MR if helpful. They said they went 6 inches from humoral head and the lump is about 5 inches down. I cant interpret the images to confirm that they did in fact go 6 inches down.

I am requesting advice from ortho as the derm said the lump was deeper and needed to see an ortho surgeon.
doctor
Answered by Dr. Grzegorz Stanko (2 hours later)
Brief Answer:
This is not a cancer for sure.

Detailed Answer:
Hello!

Thank you for the query.

Sometimes we try to diagnose something simple with very advanced tools. In my opinion this is what has happen to you. If you palpate a lump right under the skin, and its movable, clearly such lump is benign. No doubt in that. And as it is movable, has nothing to do with a bone.
First test which you should have is simple soft tissue ultrasound. The lump would be seen in this test for sure.
MRI is very good test. But it has some limitation like every other tool and lump right under the skin can be invisible in this test.

Answering your questions:
1. This lump still can be a cyst or lipoma.
2. MRI rules any malignant thing in the bones or muscles, so really you should not be worried. And for sure this is not any sarcoma.

How about seeing general surgeon instead of orthopedist? Instead of thinking what exactly the lump is (you can never be sure), it should be removed and tested. If its right under the skin, such procedure should be easy and painless.

Hope this will help. Feel free to ask further questions.
Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Grzegorz Stanko (20 hours later)
This is very insightful. Thank you. I had myortho appointment today but he wasnt very helpful. He also said that it appeared to move but wouldnt rule out cancer. I mentioned the MRI and he said without contrast it can be missed especially since the size of the lump is between size of a bb and a pea. He said it is a tumor but didnt know what kind. I asked if it felt hard or more rubbery and he couldnt say because he said with what may be surrounding,it was hard to say. I cant really tell either. He recommended an MRI with contrast to give me 90% confidence that it isn't cancer. I assume your recommendation is to go to general surgeon to take it out but wanted to get any additional thoughts based upon my discussion with ortho today.
doctor
Answered by Dr. Grzegorz Stanko (2 hours later)
Brief Answer:
I do not think this is any cancer.

Detailed Answer:
Actually contrast is used to see the blood circulation. In case of tumors, the blood circulation is always ample so malignant tumor is filled with contrast.
But as MRI is very accurate test, even without contrast, some tumor should be seen. And in case of any doubts, radiologist would write that there some tumor but he can not determine its nature and MRI with contrast should be done.
Here we have a situation where they dont see anything at all.

My recommendation for you is to have soft tissue ultrasound at first. And I do not thing this is a cancer. Cancer grows constantly, has rough surface, and after some time becomes not movable. It simply infiltrates all surrounding tissues.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Grzegorz Stanko (16 minutes later)
Is a soft tiasue ultrasound different from a regular ultrasound?

The radiologist saw nothing and said there was nothing to worry about. With your explanation on value of contrast that must be why even if the lump is small, and wouldnt be missed, correct?

Additionally your explanation that a tumor close to surface may not show up must explain it since there is clearly a lump. If i understand your initial response that doesnt mean cancer is missed but a benign lump/tumor may not show, correct.

I think the lump moves on top but does feel relatively fixed at bottom.
That said, 2 docs said it seemed movable.

Either way, it is small so that is positive. After our dialogue, i feel better but worse case it is likely early.
I forgot to note in my discussion with the ortho surgeon today. He told me to note if i start to see skin dimpling when looking for comcerning signs.

I dont know why i disnt mention it but i do notice dimpling on the skin above where the lump is located. I read that is a sign of a dermatofibroma thus good. Especially since they are usually small lumps like mone. After talking to him, I am now comcerned it may mean something bad. What are your thoughts?

Is the size of the lunp a good sign that, worse case, this is early stage?

doctor
Answered by Dr. Grzegorz Stanko (18 hours later)
Brief Answer:
Soft tissues ultrasound is different than regular one.

Detailed Answer:
Such ultrasound is different as the doctor is focused on the soft tissues. He also must use different probe (linear instead of convex). Such probe allows to see any lump right under the skin (and also deeper if that's necessary).
In case of MRI, we give contrast not to see something. We give it to distinguish one tissue from another tissues (we contrast blood). As cancer cells multiply really fast, they need a lot of blood (much more than any other regular tissue). This makes cancerous tissue to have a lot of blood vessels. When you give a contrast, such tissue glows.

Cancer is not missed. It simply does not appear so superficially (except skin cancer which is not dangerous). Cancer, even if starts from the superficial tissues, grows deeply affecting and infiltrating all tissues.
If it were a cancer, something would appear in the MRI.

Dimpling is not a significant sign. It would be important, if it were a breast cancer.
Size is also not an important sign as long as you describe it as small or medium.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Grzegorz Stanko (3 hours later)
I will close out this communication after this follow up but wanted to say you have been the best online doc i have worked with on my health through this service. You have been detailed in your explanation and provided valuable insight. I have also seen 3 docs face to face but your advice on the soft tissue ultrasound was what I needed to do and thus followed. I just had it done and am awaiting the radiologists final report but was told by the tech that it is a cyst that is not malignant. It is on top of rhe muscle but surrounded by tissue which explains what I was feeling. Hard, producing pain in he surrounding area and felt immobile to me.

Thank you again.
doctor
Answered by Dr. Grzegorz Stanko (47 minutes later)
Brief Answer:
You are welcome.

Detailed Answer:
You are welcome. I am glad that I was able to help you. And what is even more satisfactory, the lump is benign.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Grzegorz Stanko

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Suggest treatment for lump on right bicep

Brief Answer: This is not a cancer for sure. Detailed Answer: Hello! Thank you for the query. Sometimes we try to diagnose something simple with very advanced tools. In my opinion this is what has happen to you. If you palpate a lump right under the skin, and its movable, clearly such lump is benign. No doubt in that. And as it is movable, has nothing to do with a bone. First test which you should have is simple soft tissue ultrasound. The lump would be seen in this test for sure. MRI is very good test. But it has some limitation like every other tool and lump right under the skin can be invisible in this test. Answering your questions: 1. This lump still can be a cyst or lipoma. 2. MRI rules any malignant thing in the bones or muscles, so really you should not be worried. And for sure this is not any sarcoma. How about seeing general surgeon instead of orthopedist? Instead of thinking what exactly the lump is (you can never be sure), it should be removed and tested. If its right under the skin, such procedure should be easy and painless. Hope this will help. Feel free to ask further questions. Regards.