KAPITA SELEKTA

METABOLIC DISORDERS &

HEMATO-ONCOLOGY
DASAR ONKOLOGI
 Definitions

• Oncology: Greek :
• Oncos : Mass / Tumor
• Logos : Science

• Tumor: any swelling (currently used

almost exclusively to refer to a neoplastic
growth)
 Definitions

• Neoplasia: new growth

• Neoplasm: mass of cells that composes the
new growth
• Growth disturbances in which the regulatory
mechanisms of cell contact inhibition,
differentiation, and mitosis are defective
 Definitions

• Cancer: common term used for all malignant

neoplasms
• Benign neoplasm: a neoplasm that tends to grow
slowly, is well differentiated, does not metastasize,
and is usually non-life threatening
• Malignant neoplasm: a neoplasm that tends to grow
rapidly, is poorly differentiated, often metastasizes,
and frequently causes death of the host
 Definitions
• Metastasis: transfer of disease manifestations from
one organ to another. It is used mainly to refer to the
secondary growth of a malignant neoplasm in an
organ or site remote from the primary site
 Hematogenous
 Lymphogenous
Metastasis Process
How does Cancer Occur??

Normal tissue Cell growth ▲ Cells Death

Cancer Cell growth ▲ Cells Death

• Multiple genetic abnormalities ( in Oncogen / Tumor

Suppresor gen)
• Multi step
Initiation
Promotion
Progression
 Cells premalignant

INITIATION PROMOTION

Cells still Expansion of

have normal premalignant
phenotype clone
Multistage
INITIATION Progression to PROGRESSION
Malignancy
Cells
malignant

Protooncogen
Further genetic
changes Expansion of
malignant clone

METASTASES
 Causes of Cancer

External factors
 Chemicals
 Radiations
 Viral Infection
 Carcinogens PERSISTENT GEN ABNORMALITY
Abnormal cells growth

Internal factors
• Repair failure
 External factors

Chemicals Agents:
- Alkylating agent
- Polycyclic Hydrocarbon
- Aromatic Amin

Radiation:
- Ionization / X-ray Radiation
- UV Radiation

Viruses :
- Epstein Barr Virus (EBV)
- Human Papiloma virus (HPV)

Other Carcinogenic
- Alcohol
- Aflatoxin
- Tobacco
 Nomenclature
• Prefix, refers source of tissue
• - Skuamosa (squamous epithel),
• - Adeno-( gland tissue ),
• - Fibro- (Fibrous tissue),
• - Leiomyo-( smooth muscle),
• - Rabdomyo-(Skeletal muscle),
• - Lipo-(Fat),
• - Kondro (Cartilage), osteo-(Bone),
• - Hemangio-(Blood vessel),
• - Limfangio-(Lymphatic vessel )

• Suffix, refers to source of cells

- Carcinoma, Epithelial cell origin
• - Sarcoma, mesenchymal cell origin

• Suffix, refers to benign neoplasm

- oma
 Treatment of Neoplasia

Principal of treatment

1. Perform Diagnosis
2. Perform Staging
3. Performance States
4. Planning of Treatment
5. Implementation of treatment
6. Evaluation/ Follow up
1. Perform Diagnosis

- Anamnesis
- Physical examination
- Other Instrumentation :
Laboratory examination : Tumor marker
Imaging : x-photo
USG
CT Scan
MRI

Patologi : Fine needle aspiration biopsy (FNAB)

Incision biopsy
Core Biopsy
Frozen section
 2. Perform Staging
• Staging : T N M
• T(tumor) N(nodule) M(metastasis)

• T : Tumor Size
• N : Limphenode
• M : Metastases
 3. Performance States
Scor KARNOFFSKY Scor
ECOG

100% Normal, no complain, no evidence of desease 0 Fully active, able to carry on all predesease
performance without restriction
90% Able to carry on normal activity, minor signs or symptom of desease

80% Normal activity with effort, some sign or symtomps of desease 1 Restricted in phisically strenuous activity but
ambulatory and able to carry out work of a light
or sedentary nature, e.g., light house work, office
70% Cares for self, unable to carry on normal activity or to do active work
work

60% Requires occasional assistance, is mostly able to care for himself 2 Ambulatory and capable of all self –care but unable to
carry out any work activities, up and about more
than 50% of waking hours
50% Require considerable assistance and frequent medical care

40% Disabled, requires special care assistance 3 Capable of only limited self care and confined to bed
or chair more than 50% of waking hours
30% Severely disabled, hospitalization indicated, death not imminent

20% Very sick, hospitalization necessary, active supportive treatment 4 Completely disabled , cannot carry on any self-care,
necessary totally confined to bed or chair

10% Moribund, fatal processes progressing rapidly

0 Death 5 Death
4. Planning of Treatment

Therapy :
Curative : just for curable disease
Palliative: for non curable disease (ex: metastases disease)
Aim: Quality of Life

Modality of Treatment :
- Surgery/ Operation
- Radiotherapy
- Chemotherapy
- Hormonal therapy
- Immunology therapy
- Targeting cells therapy
- Gene therapy
5. Implementation of treatment
Application of planning therapy

6. Evaluation/ Follow up
- Evaluation of result treatment

- Evaluation of recurrency
 Early Detection of Cancer
7- Danger warning signalS : CAUTION

1.Change in bowel or bladdr4 habbits

2.A sore that dose not heal
3.Unusual bleeding or discharge
4.Thickening or lump in the breast or elsewhere
5.I ndigestion of Difficulty in swallowing
6.Obvious change in wart or mole
7.Nangging cough or hoarseness
7- WASPADA Bahaya Kanker
Waktu buang air besar/ kecil ada perubahan
A lat pencernaan terganggu/ kesukaran menelan
S uara / batuk yg tdk sembuh-sembuh
P ayudara / tempat lain terdapat benjolan
A ndeng-andeng yang berubah sifatnya
D arah dan lendir abnormal yg keluar dari tubuh
A danya luka yg tdk kunjung sembuh
 Screening for early detection
Example

Breast Cancer :
- Breast self examination (BSE)
- Clinical Breast Examination (CBE)
- Mammography

Colon cancer
- Benzidine test
BREAST DISEASE
 ANATOMY

Upper border:
Collar Bone

Lower borde:
6th or 7th rib

Inner border:
Edge ofsternum

Outer border:
Mid axillary Line
 Lymph Nodes of the Breast

Subclavian
nodes

Axillary
nodes Parasternal
nodes

Lateral
pectoral
nodes
 Breast Disease

Inflamation Process:

- Spesifik
Caused by TB
Specific sign, datia langhans cells

- Non Spesifik,
Caused by non specific bacterial(streptococcus,
staphylococcus, pseudomunas etc)
Symptom: Tumor
Rubor
Dolor
Kalor
 Mastitis

Breast abces

Left Brest Mastitis

Incision , drainage Breast abces

 Breast Disease

Neoplasm

Benign :
– Fibrocystic change
– Fibroadenoma mammae
– Phyllodes tumor benign type

Malignant:
– Breast carcinoma
– Paget's disease of the breast
– Phyllodes tumor malignant type
 Fibrocystic Change

1) 20%+ of premenopausal women

2) Discomfort, cysts
3) Treatment rarely required
4) More likely to detect a developing cancer
Sign & Symptom
- Mobile Cysts with well-defined margins
- Singular or Multiple
- May be Symetrical
- Upper outer quadrant or lower breast border
- Pain & Tenderness
 Treatment

• Imaging for questionable cysts

• Treatment based on symptom
• Atypical hyperplasia on pathology report indicates increased risk of
breast cancer
Fibroadenoma Mammae
• Most common benign breast tumor
• Late teens to early adulthood
• Rare after menophase

Sign & Symptom

• Firm, Rubbery, Round, Mobile mass
• Painless, non tender
• Solitary, 15-20% multiple
• Well Circumscibed
• 1 – 5 cm or larger
• most common in upper outer quadrant
Imaging:
• USG
• Mammography, for more than 35 years old women

Mammography
 Phyllodes tumor

• Giant Fibroadenoma with rapid growth

• Malignant Potential
 Gynecomastia

• Diffuse hypertrophy of breast

• 30-40 % of male population
• Adolescence and older man
• Caused by imbalanced estrogen / progesteron
• May be associated with genetic cancer families
 Breast carcinoma
Malignant neoplasm from epithelial duct or lobes of the breast

Risk Factors
Factors that Cannot be Lifestyle Risks
Prevented Oral Contraceptive Use
Gender Not Having Children
Aging Hormone Replacement
Genetic Risk Factors Therapy
(inherited) Not Breast Feeding
Family History Alcohol Use
Personal History Obesity
Race High Fat Diets
Menstrual Cycle Physical Inactivity
Estrogen Smoking
 Breast carcinoma

Types of Breast carcinoma

Ductal Carcinoma in situ (DCIS)

Ductal
cancer
cells
Invasive Ductal Carcinoma (IDC)

80% of breast cancer

Ductal cancer cells

breaking through
the wall
 Invasive Lobular Carcinoma (ILC)

Lobular cancer cells

breaking through
the wall
Illustration © Mary K. Bryson
 Diagnostic of Breast Carcinoma

• Triple Diagnostic:
- Clinic : - Anamnesis
- Physic Diagnostic

- Imaging :- USG
- Mammography

- Pathology
Clinical Stages of Breast Carcinoma

Clinical Staging is determined by :

Size of the original tumor (T),
Lymph nodes (L), and
Metastasis (M).

This is called the TNM Criteria.

 Paget's disease of the breast

Uncommon and distinctive skin cancer

characterized by eczema-like rash involving
the nipple with spread to surrounding areola
and skin
Clinical History of Paget’s Disease

• Itching and burning most common complaints

• Long history of eczematous changes of the nipple and

areola region of the breast Usually unilateral, can be
bilateral

• Symptoms and signs: pain, itching, burning sensation,

excoriation from itching, small vesicles that resolve and
recur, discharge, ulceration, nipple inversion

• Lesion is typically red, crusty, thickened, and irregular

sharply demarcated plaque
Mastalgia
Discomfort of Breast

Eliminate Methylxantine (coffee, chocolate)

Local heat/ cold
Support Bra
Low Sodium Diet

Medications for Mastalgia

NSAIDS
Spirinolactone
Monophasic oral contrseptive pills
seasonable?
THYROID GLAND
Thyroid Function:

• Hyperthyroid
• Euthyroid
• Hypothyroid
HYPERTHYROIDISM

Clinical Symptoms
Depends on
• Age of patient
• Magnitude of hormonal excess
• Presence of co-morbid condition

Screening Thyroid fungtion

• Basal Metabolisme Rate (BMR)
• Wayne Index
• New Castle’s Index
 Clinical symptoms
Skin :
- Warm
- May be erythematous (due to increased blood flow)
- Smooth- due to decrease in keratin
- Sweaty and heat intolerance
- Onycholysis
- Softening of nails and loosening of nail beds
- Hyperpigmentation
- Pruritis
- Thinning of hair
- Vitilago and alopecia areata
 Clinical symptoms

Eyes
• Exopthalmos
• Impaired eye muscle function (Diplopia)
• Periorbital and conjunctival edema
• Gritty feeling or pain in the eyes
• Corneal ulceration due to lid lag and proptosis
• Optic neuritis and even blindness
 Cardiovascular System

• Increased cardiac output (due to increased oxygen

demand and increased cardiac contractibility.
• Tachycardia
• Widened pulse pressure
• High output – heart failure
 Respiratory System

• Dyspnea on rest and with exertion

• Oxygen consumption and CO2 production increases.
• Hypoxemia and hypercapnea, which stimulates
ventilation
• Respiratory muscle weakness
• Decreased exercise capacity
• Tracheal obstruction
• May exacerbate asthma
• Increased pulmonary arterial pressure
 GI System

- Weight loss due to increased calorigenesis

- Hyperdefecation
- Malabsorption
- Steatorrhea
- Celiac Disease (in Grave’s Disease)
- Hyperphagia (weight gain in younger patient)
- Anorexia- weight loss in elderly
- Dysphagia
 Skeletal System

• Bone resorption
• Increased porosity of cortical bone
• Reduced volume of trabecular bone
• Serum alkaline phosphate is increased
• Increased osteoblasts
• Inhibit PTH secretions
• Decreased calcium absorption and increased
excretion
• Osteoporosis, Fractures
 Neuromuscular
System

• Tremors-outstretched hand and tongue

• Hyperactive tendon reflexes
 Psychiatric

• Hyperactivity
• Emotional lability
• Anxiety
• Decreased
concentration
• Insomnia
 Etiology
1 Grave’s disease
2 Toxic multi-nodular goiter
3 Toxic adenoma
4 Thyroiditis Subacute
5 Treatment Induced Hyperthyroidism Iodine Induced
 Treatment
Treatment depends upon
-Cause and severity of disease
-Patients age
-Goiter size
-Comorbid condition
-Treatment desired

Options
• Anti-thyroid (methimazole, PTU)
• Radioactive iodine
• Surgery
• Beta-blocker and iodides are adjuncts to above
treatment
 Hypothyroidism

• 1.8% of total population.

• Second only to DM as most common endocrine
disorder.
• Incidence increases with age.
• More common in females.
• 2-3% of older women.
 Etiology
• Hoshimoto’s thyroiditis-most common
• Idiopathic hypothyroidism-probably old
Hoshimoto’s
• Irradiation of thyroid
• Surgical removal
• Late stage invasive fibrous thyroiditis
• Iodine deficiency
• Infiltrative Diseases:
Sarcoidosis, Amyloidosis ,cleroderma,
Hemochromatosis
Common signs and symptoms
• Weakness
• Skin changes
• Slow speech
• Eyelid edema
• Cold sensation
• Decreased sweating
• Cold skin
• Thick tongue
• Facial edema
• Coarse hair
• Skin pallor
• Forgetfulness
• Constipation
 Thyroiditis

• Painless :
- Hashimotos Thyroiditis
- Subacute thyroiditis
- Riedels thyroiditis
- Chronic non specific thyroiditis
• Painfull
- Infection : - Acute
- Chronic : - Mycobacteria
- Fungal
 Hashimoto Thyroiditis

• Autoimun disease
• Age 45 -60 years
• Most common cause hypothyroidism
• Female > Male
• Gradual Thyroid Failure
 Etiology

• Genetic Component
• Concordance rate in monozygotic twin: 30-60%
• Association : Down Syndrome, Turner symdrome
 Subacute Thyroiditis/ De Quervian
Thyroiditis

Pathogenesis:

- Unclear but thought to result from viral or postviral

- Viral infection provides an Ag, viral or thyroid that is

released secondary to virus-induced host tissue damage

- This Ag stimulate cytotoxic T-cell which damage thyroid

follicular cells
 Clinically

• Unilateral or Bilateral gland Enlargment

• Transient (2-6 wk) Inflammation and
hyperthyroidism
• Pain, Fever, Fatigue, myalgia, anorexia,
malaise
• Followed by transient hypothyrodism (2-8 wk)
• Complete recovery
 Reidel Thyroiditis

• Rare disorder unknown etiology

• Characterized by extensive fibrosis involving thr
thyroid
• Gross : Hard, Fixed masses
• An Autoimmune etiology: presence of circulating
antithyroid antibody
 GOITER

Enlargement of the
Thyroid Gland

Diffuse Multinodular
Mortality/Morbidity:
• Most goiters are benign, causing
only cosmetic disfigurement.

• Morbidity or mortality may result from

compression of surrounding structures, thyroid
cancer, hyperthyroidism, or hypothyroidism.
 Sex and age:
• The female-to-male ratio is 4:1
• Thyroid nodules are less frequent in
men than in women, but when
found, they are more likely to be
malignant.
Classification:
Toxic goiter: A goiter that is associated with
hyperthyroidism is described as a toxic goiter. Examples
of toxic goiters include diffuse toxic goiter (Graves
disease), toxic multinodular goiter, and toxic adenoma

Nontoxic goiter: A goiter without hyperthyroidism

orhypothyroidism is described as a nontoxic goiter. It
may be diffuse or multinodular
Causes:
Worldwide, the most common cause for goiter
is iodine deficiency.

- Excess iodine or lithium ingestion, which

decrease release of thyroid hormone
- Goitrogens
- Exposure to radiation
- Thyroid hormone resistance
HYPERPARATHYROIDISM

Parathyroid Hormone
Secreted from the chief cells of the parathyroid gland as
an 84 amino acid protein.
Hyperparathyroid - Symptoms

• ~80% asymptomatic
• Stones (Kidneys)
- Calcium deposition and nephrolithiasis
- Urinary tract obstruction
• Bones
– Osteitis Firosa Cystica
• Increased osteoclasts
• Increased bone turnover
• Reduced cortical bone density
• Moans
– Fatigue, Depression, Confusion
Primary Hyperparathyroid
• Causes
– Solitary Adenoma
– Parathyroid Carcinoma (rare)
– Multiple endocrine neoplasia (rare)

• Hypersecretion of PTH
– Hypercalcemia,
– HypOphosphatemia
• Diagnosis
– Elevated serum PTH immunoassay (high
sens), high calcium, low or normal phos
(decr prox tubular reabsorption)

• Imaging
– 99m-technetium
– Ultrasound
• Treatment
– Surgical Indications
• Ca > 11.5, T-score < -2.5, renal stones
– Medical
• Replace volume
• Facilitate calciuresis (loop diuretics)
• Bisphosphonates – decrease bone
reabsorption.
• Calcitonin
• Hormonal Therapy – Raloxifene, other SERMs
 Secondary Hyperparathyroid
• Vit. D deficiency
• Primary decreased calcium absorption in elderly
• Increased phosphate in acute or chronic renal failure
• Renal Osteodystrophy
• Adynamic Bone Disease (low PTH)

Treatment
– Phos Binders
– Vitamin D analogs
• negative feedback on PTH gene transcription
• Limited use in setting of hypercalcemia
 Hypoparathyroidism

• Endocrine disorder where parathyroid glands

in the neck don’t produce enough
parathyroid hormone

• Lack of production of parathyroid hormone

makes calcium levels in the blood low
and phosphorus levels high
Signs and Symptoms
• Muscle Cramps (spasms)
• Dry Skin
• Seizures
• Pain in face, legs, feet

Treatment
– Calcium Carbonate tablets,
– Vitamin D Supplements
– Changing eating habits
NEOPLASMA KULIT
 Structure and Function
Skin—three layers
1. Epidermis
Epidermal appendages
– Stratum germinativum or
basal cell layer 1. Hair

– Stratum corneum or 2. Sebaceous glands

horny cell layer
3. Sweat glands
– Derivation of skin color
– Eccrine glands
2. Dermis
– Apocrine glands
– Connective tissue or
collagen 4. Nails

– Elastic tissue

3. Subcutaneous layer
Structure of Skin
 NEOPLASMA KULIT
Benign Pre malignan Lesion
• Benign epithelial tumors • Bowen's disease
• Seborrheic keratosis • Actinic keratosis
• Epithelial cyst • Keratoacanthoma
• Xanthoma • Marjolin’s Ulcer
• Hemangioma • Senile Keratosis
• Lymphangioma
• Mastocytosis Malignant :
• Squamous cell carcinoma
• Langerhans' cell histiocytosis • Basal cell carcinoma
• Lentigo • Malignant melanoma
• Nevus pigmentosus • Mycosis fungoides
• Angiosarcoma
Seborrheic keratosis

Benign skin growth that is very common

among people over 40 years of age.

Presentation:
• The growths resemble flattened or raised warts,
• from pink or yellow through brown and black.
• Only the top layers of the epidermis are involved,
• well demarcated

Causes
A mutation of a gene coding for a growth factor
receptor (FGFR3) has been associated with
seborrheic keratosis
 Epithelial Cyst

Epidermoid cyst
Dermoid cyst
Athemoma cyst
Pylonidal cyst

Epidermoid cysts
Cysts that are the result of the implantation of epidermal
elements

Slow growing and usually asymptomatic,

 Causes
- Sequestration of epidermal rests during embryonic life
- Traumatic or surgical implantation of epithelial elements

Physical
• Firm
• Round
• Mobile
• Flesh-colored to yellow or white
subcutaneous
• Nodules
• Variable size
Therapy : Excisi
 Dermoid Cyst:

• Congenital
• Mid Line
• Embrional skin fusion disorder
• Round shape, soft in touch
• No attach on skin

Therapy : Excisi
 Differential Diagnosis

• Branchial Cleft Cyst

• Calcinosis Cutis
• Dermoid Cyst
• Epidermoid Cyst
• Gardner Syndrome
• Lipomas
• Nevoid Basal Cell Carcinoma Syndrome
 Atherom/ Cebaceous Cyst

• Duct Obstruction
• Caracteristic : Puncta
Sebum
• Round shape, mobile,
• Infected sometimes
 Xanthoma

Xanthoma is a skin condition in which fat build up

Under the surface of the skin
Symptoms
• Xanthoma looks like a sore or bump under the skin
• Usually flat
• Soft to touch
• Yellow in colour
 Hemangioma

Histology
Cellular Hemangioma

Capillary Hemangioma

Cavernous Hemangioma
• Capillary or “strawberry”hemangiomas consist
of one or several bright-red, soft, lobulated
tumors that first appear between 3rd-5th week of life,
increase in size for several months and then
regressinvolution.

• Cavernous hemangiomas consists of large,

predominantly subcutaneous mass that may cause
deformity.
 Lymphangioma

Benign hamartomatous tumors of lymphatic vessels

Predilection to the head and neck with 50 – 75% occurring

Three types: capillary; cavernous and cystic lymphangiomas

Most (90%) are either evident at birth or become evident before age 2 years.
Cystic Hygroma (Cystic Lymphangiomas)

Most commonly occur in the neck

Cervical lymphangiomas are most common in the

posterior triangle and are soft, fluctuant masses

Occasionally could extend into the mediastinum or

upward into oral cavity ; could also extend into the
anterior triangle resulting in respiratory difficulties
 NEUROFIBROMAS.

• It may occur as solitary cutaneous lesions, in

which case one finds no café-au-lait spots
and no family history of the disease.
-Multiple cutaneous lesions w/ café-au-lait
spots, dominantly inherited, referred as
neurofibromatosis or von Recklinghausen´s
disease that starts to be manifested since
childhood
 Langerhans’ Cell Histiocytosis

• Abnormal clonal proliferation of a unique type of cell in

the monocyte-macrophage cell line known as the
Langerhans cell.

- Peak incidence in infants 1-2 yo

- Males X2 > females
- Focal or systemic
 Nevus Pigmentosus

• A benign pigmented melanocytic proliferation;

Raised or level with the skin,
Present at birth or arising early in life.
 ACTINIC KERATOSIS
-Provoked by an excessive and chronic exposure to sunlight
- Considered as “premalignant”
- It is typically seen as hyperkeratotic,
- Scaly plaques on the face, neck, limbs and trunk.
- Affects most commonly to old patients
- Micro; stratum corneum w/parakeratosis & atypic
keratinocytes that may evolve to Ca. in situ
invasive squamous cell carcinoma.
 BOWEN´S DISEASE
• It can be seen in non-sun exposed areas like oral mucosa,
vulva, etc. and is frequently associated to a visceral
malignancy.

• Clinically appears like an erythematous plaque with indolent

growth.
• Micro: a typical Ca. in situ
 Basal Cell Carcinoma

• Locally invasive carcinoma of the basal layer of the epidermis.

• It almost never metastasizes but it may kill by local invasion
• Commonest skin cancer
• Middle aged or elderly
• related to sunlight exposure, fair skinned people,
• Male : Female 2:1
• Lesions occur in exposed areas of the skin (75% occur in the head and
neck)
• Red nodule forms which expands to leave a characteristic rolled edge
with central ulceration ('rodent ulcer')
Clinical subtypes

1. Nodular BCC
2. Superficial BCC
3. Morphoeic BCC
4. Pigmented BCC
5. Basisquamous BCC
 Squamous Cell Carcinoma

Malignant tumour of the epidermis in which the

cells, if differentiated, show keratin formation

Associated with:
. Excessive sunlight exposure and pre-existing solar keratosis
. Exposure to chemical carcinogens such as coal tar products
. Chronic irritation/ inflammation (Marjolin's ulcer).
. Genetic predisposition e.g. Xeroderma Pigmentosum
. Pre-malignant conditions e.g. Bowen's disease, Leukoplakia
. Rare in patients under 60 years of age unless immunosuppressed
Clinical features

- Rapidly expanding painless,

- Ulcerated nodule rolled indurated
margin.
- May have a cauliflower-like appearance
with areas of bleeding,
- lceration or serous exudation.
- About 55% of lesions occur in the head
and neck region.
- About 25% of lesions occur on the
hands and arms.
- Metastasis may occur via local draining
lymph nodes and beyond.
 Malignant Melanoma
• Malignant tumour of epidermal melanocytes.

• Spread occurs via superficial lymphatics, to regional lymph nodes via

deep lymphatics, and

• via haematogenous spread to the lung, liver and brain.

• Range of colours and uniformity, often may bleed and ulcerate

Different types :
. Superficial spreading (48%)
. Nodular (23%)
. Lentigo maligna (15%)
. Acral lentiginous including periungual (6%)
. Amelanotic melanoma
• Asymmetry

• Border irregularity

• Color variegation

• Diameter >6mm

Nodular melanoma
Superficial spreading melanoma

Lentigo maligna melanoma

sun damaged skin of face, scalp and neck

Amelanotic Melanoma
Acral lentiginous melanoma
 MYCOSIS FUNGOIDES (T-cell lymphoma)
• In fact it represents a stage in the wide spec
trum of lymphoproliferative disorders that affects the
skin.

Plaque stage Tumor stage

Premycotic patch stage
poikiloderma
HEAD AND NECK
NEOPLASM
Head and Neck
Anatomy
Anterior Triangle – middle of the
neck, the sternocleidomastoid
muscle and lower border of the
mandible
-submental triangle
-submandibular triangle

Posterior Triangle-
sternocleidomastoid, the anterior
border of the trapezius, and the
middle third of the clavicle
Triangle Anatomy
Complex region

•300/ 800 nodes located in

HAN region
•Salivary glands
•Thyroid gland
•etc
 Lymph Node Identification
• Level 1 contains the submental and
submandibular nodes.

• Level 2 is the upper third of the jugular

nodes medial to the SCM, and the
inferior boundary is the plane of the
hyoid bone (clinical) or the bifurcation
of the carotid artery (surgical).

• Level 3 describes the middle jugular

nodes and is bounded inferiorly by the
plane of the cricoid cartilage (clinical) or
the omohyoid (surgical).

• Level 4 is defined superiorly by the

omohyoid muscle and inferiorly by the
clavicle.

• Level 5 contains the posterior cervical

triangle nodes.

• Level 6 includes the paratracheal and

pretracheal nodes.
 Neoplastic Masses

• Primary
• Secondary

Primary tumors
- Benign
- Malignant

Base on Lymph Node Level Identification

we can predict primary tumor that metastasis in the
neck Lymph Node
Neck Masses
Salivary gland
• Major :
Parotid gland
Submandibular gland
Sublingual gland

Minor:
Aerodigestive gland
 Congenital masses

Thyroglossal Cyst

• Most common congenital neck mass

• 50% present before age 20
• Midline (75%) or near midline (25%)
• Elevates on swallowing/protrusion of tongue
 Branchial Cyst

• Cystic mass anterior to SCM, below mandible

• May get infected
• Persistence of 2ndbranchialcleft
• May have small sinus tract into tonsillarfossa
• Contains cholesterol crystals
 Torticollis

• Torticollis is defined as abnormal twisting of the neck

which causes the head to be held in a rotated or tilted
position.

• May be congenital or acquired

• Occurs more frequently in children
than in adults
• The right side is affected in 75% of
patients
Causes of Torticollis

Traumatic

Infectious

Congenital vertebral anomalies (e.g. – congenital

scoliosis, cervical segmentation anomalies, Klippel-Feil
syndrome)
 Congenital Muscular Torticollis

• Fibromatosis colli that develops in SCM probably prior to birth,

• 75% of cases on right side
• Etiology is unclear: Arterial or venous obstruction? Intrauterine malposition?
 Cystic Hygroma
• A cystic hygroma is a congenital multiloculated lymphatic lesion
that can arise anywhere

• Classically found in the left posterior triangle of the neck.

• This is the most common form of lymphangioma.

• It contains large cyst like cavities containing watery fluid.

• Cystic hygromas are benign,

Causes
• Karyotypic abnormalities
• More common in persons with Turner syndrome, Down syndrome,
Klinefelter syndrome,

Physical
Cystic hygromas are typically soft, painless, compressible masses.
A Cystic hygroma typically transilluminates.

In children who present with Cystic hygroma of the neck, closely

evaluate for tracheal deviation or other evidence of impending airway
obstruction.

Closely inspect the tongue, oral cavity, hypopharynx, and larynx

because any involvement may lead to airway obstruction.

Referral to an expert
 Ranula

Cystic swelling floor of mouth

Mucous extravasation from sublingual salivary gland.
May extend through
 Leukoplakia
• Leukoplakia is a clinical term used to describe patches
of keratosis
• It is visible as adherent white patches on the mucous
membranes of the oral cavity, including the tongue
• It must be distinguished from diseases that may cause
similar white lesions, such as candidiasis or lichen
planus.

Sometimes described as precancerous

It is also associated with smoking

 Causes

Most result from chronic irritation of mucous membranes by carcinogen

• Primarily caused by the use of tobacco.

• possibly alcohol
• Candida albicans
• Other possible etiological agents implicated are HPV's,

• 5% to 25% of leukoplakias are premalignant lesions;

• Therefore, all leukoplakias should be treated as premalignant
lesions
 Oral Cancer

The most common sites of the oral cancer is the tongue and the floor of
the mouth.

The other common sites are

buccal vestibule,
buccal mucosa,
gingiva and rarely hard and soft palate.
 Diagnosis

Initially oral cancer may be asymptomatic

- Small ulcerative lesion.
- pain and discomfort
SOFT TISSUE NEOPLASM

Yan Wisnu P. Sp(B)KOnk

Soft Tissue Tumours

Definition: Mesenchymal proliferations that occur in the

extraskeletal, nonepithelial tissues of the body, excluding
the viscera, coverings of the brain, and lymphoreticular
system.
 Histologic type Benign Malignant
Adipose Tissue Lipoma Liposarcoma

Fibrous tissue Fibromatosis Fibrosarcoma

Nodular fasciitis
Fibrohistiocytic tumours Fibrous histiocytoma Malignant Fibrous
Dermatofibroma Histiocytoma

Skeletal Muscle Rhabdomyoma Rhabdomyosarcoma

Smooth Muscle Leiomyoma Leiomyosarcoma

Vascular Haemangioma Angiosarcoma

Lymphangioma
Peripheral nerve Neurofibroma Malignant peripheral
Schwannoma nerve sheath tumour

Uncertain histogenesis Granular cell tumour Synovial Sarcoma

Alveolar soft part
sarcoma
Epithelioid sarcoma
 FATTY TUMOURS

MORPHOLOGY.
Lipoma,
Well-encapsulated mass of mature adipocytes
• Varies considerably in size.
• It arises in the subcutis of the proximal extremities and
trunk, Most frequently during mid-adulthood.
• Circumscribed, soft, mobile, and painless
• Histologically, they consist of mature fat cells.

• Therapy: Extirpatie.
 Liposarcoma

Most common sarcomas of adulthood they are

uncommon in children.
They usually arise in the deep soft tissues of the
proximal extremities and retroperitoneum and are
notorious for developing into large tumors.

MORPHOLOGY.
Histologically, liposarcomas can be divided into
well-differentiated,
myxoid, round cell, and
pleomorphic variants.
The cells liposarcomas are readily recognized as lipoblasts
 Ganglion Cyst

• Ganglion cysts are sacs that contain the synovial fluid

found in joints and tendons.
• The cystic structures are attached to tendon sheaths
• It is most frequently located around the wrist
• The size of the ganglion cyst can vary over time.

The cyst contains clear fluid similar to normal synovial fluid

• About 65% occur on the upper surface of the wrist
• 20%–25% on the volar (palm) surface of the hand.
• The remaining 10%–15% of ganglion cysts occur on
the sheath of the flexor tendon.

• Therapy : Excision
• High recurrency
• With surgery and removed the valve joint
capsule, the recurrence rate is reduced to only
5 to 10%.
• Arthroscopy of the wrist is becoming available as
an alternative to open excision of ganglion cysts.
 Fibrous Tumours

Fibromatoses

SUPERFICIAL FIBROMATOSIS
They are characterized by
nodular or poorly defined fascicles of mature-appearing fibroblasts surrounded
by abundant dense collagen.

Immunohistochemical and ultrastructural studies indicate that many of these cells are
myofibroblasts

Examples: Dupuytren contracture, plantar fibromatosis

DEEP-SEATED FIBROMATOSIS (DESMOID TUMORS)

They present frequently as large,
Infiltrative masses that may recur after incomplete excision,
Do not metastasize.
 Fibrosarcoma

Fibrosarcomas are rare but may occur anywhere in the body

MORPHOLOGY.
• Typically, these neoplasms are unencapsulated,
• Infiltrative, soft
• Often having areas of hemorrhage and necrosis.
 TUMORS OF SKELETAL MUSCLE

- Almost all malignant.

- The benign variant, rhabdomyoma, is distinctly rare.

Rhabdomyosarcoma
• Most common soft tissue sarcomas of childhood and adolescence,
• Usually appear before age 20.
• Arise in any anatomic location
 TUMORS OF SMOOTH MUSCLE

Leiomyomas
Benign smooth muscle tumors
• Often arise in the uterus
• Usually not larger than 1 to 2 cm in greatest dimension

Leiomyosarcoma
- Account for 10% to 20% of soft tissue sarcomas.
- Most develop in the skin and deep soft tissues of the
extremities and retroperitoneum.
 SYNOVIAL SARCOMA

Synovial sarcomas account for approximately 10% of all soft tissue

sarcomas and rank as the fourth most common sarcoma.

MORPHOLOGY.
The histologic hallmark of synovial sarcoma is the biphasic morphology
of the tumor cells (i.e., epithelial-like and spindle cells).
 Benign Fibrous Histiocytoma

Clinics
• Solitary,
• Slow growing,
• Usually appearence during early or mid-adult life,
• slight predilection for females.
• It is mainly located on the extremities.
• The lesions are elevated or peduncolated, with
• diameter ranging from a few millimeters to a few
centimeters.
 Malignant fibrous histiocytoma
(MFH)
- Commonly occurring between age 50-70.
- Usually in a less aggressive form.
- Male : Female = 2:1.

Presentation
It can develop anywhere in the soft tissue
MFH occurs most commonly in the extremities
it presents as a painless enlarging soft tissue mass
Metastasis occurs most frequently in the lung (90%), bone
(8%) and liver

Diagnosis
Clinic, Imaging (MRI), biopsy for definitive diagnosis.
SKILL
 Mucous Membranes
Inspection
 Lymph nodes

Palaption

Anterior Cervical Lymph Nodes Palpation

Axillary lymph node Palpation Supra/ infraclavicula palpation

 Thyroid Gland

Palpation

Palpation of Thyroid from behind

 Breasts
• Inspection
Normal breast
Symmetry and balance

Abnormal signs
 Puckering
 Dimpling
 Retraction
 Nipple discharge
 Thickening of skin or lump or “knot”
 Retracted nipple
 Peau d’orange
 Inspection

Retracted nipple
Dimpling Mass

Ulcer
Peau d’orange
 Palpation

Palpation of the breast in supine position

Palpation all part of the breast

Do not use finger tip

Axillary palpation is a part of breast examination
 Skin Neoplasm

Inspection

Palpation
TERIMAKASIH