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Referral
Ultrasound for Ganglia, Lipoma and Myxoid Cysts
Scope
Ganglia, lipoma and myxoid (mucous) cysts are common presentations. Observation and primary care assessment and management are appropriate for the majority of cases. Complications are rare and settle without the need for further intervention.
Diagnostic uncertainty with no suspicion of malignancy is not an indication for referral under these guidelines. A watchful waiting approach can often be helpful if there is uncertainty. In cases of diagnostic uncertainty where malignancy needs to be excluded, please refer according to BMUS (British Medical Ultrasound Society) criteria described in this guideline.
There is a Surgery for ganglion cyst commissioning policy that is described in the General Surgery section.
Please note pre-referral criteria are now applicable for ultrasound requests and referrals will be returned if this information is not contained within the referral letter.
Out of scope
Although they commonly occur as benign lesions in adults, ganglia are much less common in children therefore symptomatic soft tissue masses in children fall out of the scope of these guidelines.
Ganglia of the hand and wrist are common benign lesions. Ganglia less commonly present at the foot and ankle. They most frequently arise adjacent to joints and tendons, but may also be intratendinous or intraosseous.
Digital myxoid or mucoid cysts typically occur at the distal interphalangeal joints and can be associated with osteoarthritic joints. They can intermittently become inflamed but are rarely truly infected.
Signs and Symptoms
If aspiration of the lesion has not been possible (usually ganglia exude a thick clear gel when aspirated with a wide gauge needle under local anaesthetic) this should prompt the possibility of the lesion being a solid tumour.
The 2ww criteria for referral to the liposarcoma service include any of the following:
- Measurement exceeds 5cm
- Significant persistent pain that is not solely pressure related
- Rapid growth over a short period of time
- Deep fixity to muscle or fascia (the mass becomes less obvious on muscle contraction)
- Prior malignancy other than basal cell carcinoma
Differential Diagnosis
Referrers should be aware that certain pathology do not turn out to be ganglia but can present in a similar way. The following conditions fall into this category:
- Osteoarthritic changes in a joint
- Gouty tophi, rheumatoid nodules or synovitis
- Giant cell tumours
- Lipomas and other benign lesions
- Plantar fibromas
- Malignancy (rare): see Red Flag section for more information regarding 2ww criteria
The majority of these lesions do not require diagnostic ultrasound or onward referral and can be observed in primary care.
The majority of ganglia occur in the upper limbs. For lower limbs in particular, diagnostic uncertainty should prompt consideration of whether further imaging is of clinical value in line with BMUS guidance.
Soft tissue sarcomas are rare and account for approximately 1% of all malignant tumours. The age standardised incidence rate for soft tissue sarcoma for England is 44.9 cases per 1million population. This equates to 53 new cases per year in Devon.
Significant findings including all or any of the following:
- Mass that is fixed
- Tender
- Increasing in size
- Overlying skin changes etc.
These cases should either be scanned on an urgent basis or referred into a soft tissue sarcoma pathway.
Review of recently published British Medical Ultrasound Society (BMUS) good practice guidelines for justification of ultrasound requests shows very specific guidance for referral for ultrasound of soft tissues.
Most ganglia can be managed in primary care. Patients can be reassured that approximately 60% of ganglia resolve spontaneously therefore a simple watch and wait approach is often appropriate.
Options for primary care management include:
- Simple splint immobilisation for upper limb ganglia
- Analgaesia
- Aspiration or lancing with sterile wide gauge needle under local anaesthetic – may need repeated treatments.
- Steroid injections *
Ganglia frequently recur, but this is also true following surgical treatments.
*For ganglia of the wrist and hand, the cure rate following aspiration increases with 3 week splinting post procedure.
Referral Criteria
Ultrasound is not indicated in the following instances, and referrals will be returned:
- A lump that has not recently increased in size or changed in clinical features does not routinely require US for diagnosis
- Lipomata and ganglia that are typically less than 5cm, mobile, non-tender and show no significant growth over 3 months do not need US for diagnosis
Ultrasound is indicated in the following instances, please include this information in the referral:
- Soft tissue lump exceeding 5cm
- If findings are equivocal and diagnosis is essential to management e.g. "wrist mass? Ganglion? Radial artery aneurysm - excision planned?" – Then ultrasound is clearly warranted on a routine basis
Referral Instructions
e-Referral Service Selection:
- Specialty: Diagnostic Imaging
- Clinic Type: Ultrasound
- Service: DRSS-South Devon & Torbay-AQP-Non-Obstetric Ultrasound(NOUS) -Diagnostic Imaging-NHS Devon ICB - 15
Referral Forms
Evidence
References
- Ganglions Treatment & Management. Author: Valerie E Cothran, MD; Chief Editor: Harris Gellman et al.
- Cancer research UK. Soft tissue sarcoma
- National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE 2015
- Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically suspicious softtissue masses. Clin Radiol 2009;64:61521. doi:10.1016/j.crad.2009.01.01219414084.
- Soft tissue sarcoma. BMJ 2016;352:i436
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: June 2017
Review date: May 2019
