What is the diagnosis and management plan for a 53-year-old male patient with a neck mass resembling a lipoma (fatty tumor) in the posterior neck, considering the risks of infection with excision in a prison setting (Outpatient Clinic, OPC)?

From the Guidelines

I strongly advise against delaying the diagnostic workup and potential treatment of the neck mass for 7 months, as the risk of malignancy must be considered and ruled out promptly, according to the clinical practice guideline for evaluation of the neck mass in adults 1. The patient's neck mass, although resembling a lipoma, requires a thorough diagnostic evaluation to determine its nature, given that most persistent neck masses in adults are neoplasms, with a significant proportion being malignant 1.

Key Considerations

• The clinical practice guideline emphasizes the importance of considering a neck mass in an adult as potentially malignant until proven otherwise 1.
• The guideline recommends a prompt and efficient diagnostic workup to ensure timely diagnosis and intervention for potentially malignant diseases 1.
• Fine-needle aspiration (FNA) is recommended for patients with a neck mass deemed at increased risk for malignancy when the diagnosis remains uncertain, instead of open biopsy 2.

Diagnostic Approach

• Proceed with the ultrasound of the neck as planned to gather more information about the mass.
• Consider FNA if the ultrasound findings suggest a high risk of malignancy or if the diagnosis remains uncertain after imaging.
• Ensure the patient is closely monitored for any changes in the mass, such as rapid growth, pain, redness, or drainage, which would necessitate earlier intervention.

Treatment Considerations

• If the diagnosis confirms a benign lipoma, surgical excision can be planned, taking into account the patient's release from prison and the associated risks of infection in that environment.
• However, if malignancy is suspected or confirmed, prompt referral to a head and neck cancer specialist is crucial for timely and appropriate management.

From the Research

Lipoma Excision and Alternative Treatment Options

• Lipomas are benign tumors of mature fat cells that can be removed by liposuction or excision 3.
• A study on combined liposuction and excision of lipomas found that this technique is a safe alternative for lipoma removal, with low risk of malignancy and recurrence 3.
• Alternative treatment options, such as high-frequency ultrasound-guided injection of a Class III CE-marked device, have shown efficacy in removing lipomas, with a complete removal rate of 70.59% 4.

Safety Guidelines for In-Office Lipoma Excision

• In-office excision of lipomas can be performed safely, but guidelines should be followed to decrease the chance of major complications 5.
• These guidelines include obtaining a clear diagnosis prior to excision, ensuring familiarity with the anatomical location, deferring excision if the lipoma appears to be located in the subfascial plane, and aborting excision if the patient is at risk for local anesthetic toxicity or uncontrolled bleeding 5.

Surgical Management of Lipomas

• Surgical excision is the treatment of choice for lipomas, and the Z-incision design can be a useful alternative technique for the extirpation of lipomas, especially large lipomas 6.
• A surgical algorithm based on tumor size can be proposed, with the Z-incision design providing a larger surgical field area than linear incision 6.

Anesthesia for Lipoma Excision

• Ultrasound-guided regional blockade for lipoma excision can be a feasible and effective approach, reducing the number of needle passes required to complete the block and providing less procedure-related pain and longer pain relief 7.
• The ultrasound-guided lipoma plane (ULP) block can be used as an alternative to traditional block, with advantages including technically easier block placement and long-term analgesic effects 7.