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
Cancer

Cell growth

Cell growth

Cells Death

Cells Death

Multiple genetic abnormalities ( in Oncogen / Tumor

Suppresor gen)
Multi step
Initiation
Promotion
Progression

Cells premalignant
INITIATION
Cells still
have normal
phenotype

PROMOTION

Multistage
Progression to
Malignancy

INITIATION

Expansion of
premalignant
clone
PROGRESSION

Cells
malignant

Protooncogen
Further genetic
changes

METASTASES

Expansion of
malignant clone

Causes of Cancer
External factors
Chemicals
Radiations
Viral Infection
Carcinogens

Internal factors
Repair failure

PERSISTENT GEN ABNORMALITY

Abnormal cells growth

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
N
M

: Tumor Size
: Limphenode
: Metastases

3. Performance
States
Scor

KARNOFFSKY

100%

Normal, no complain, no evidence of desease

90%

Able to carry on normal activity, minor signs or symptom of desease

80%

Normal activity with effort, some sign or symtomps of desease

70%

Cares for self, unable to carry on normal activity or to do active work

60%

Requires occasional assistance, is mostly able to care for himself

50%

Require considerable assistance and frequent medical care

40%

Disabled, requires special care assistance

30%

Severely disabled, hospitalization indicated, death not imminent

20%

Very sick, hospitalization necessary, active supportive treatment

necessary

10%

Moribund, fatal processes progressing rapidly

Death

ECOG

Scor

Fully active, able to carry on all predesease

performance without restriction

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
work

Ambulatory and capable of all self care but unable to

carry out any work activities, up and about more
than 50% of waking hours

Capable of only limited self care and confined to bed

or chair more than 50% of waking hours

Completely disabled , cannot carry on any self-care,

totally confined to bed or chair

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- WASPADA Bahaya Kanker
7.Nangging cough or hoarseness
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

Lateral
pectoral
nodes

Parasternal
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
Prevented
Gender
Aging
Genetic Risk Factors
(inherited)
Family History
Personal History
Race
Menstrual Cycle
Estrogen

Lifestyle Risks
Oral Contraceptive Use
Not Having Children
Hormone Replacement
Therapy
Not Breast Feeding
Alcohol Use
Obesity
High Fat Diets
Physical Inactivity
Smoking

Breast carcinoma
Types of Breast carcinoma

Ductal Carcinoma in situ (DCIS)

Ducta
l
cance
r cells

Invasive Ductal Carcinoma (IDC)

80% of breast cancer

Ductal cancer
cells breaking
through the
wall

Invasive Lobular Carcinoma (ILC)

Illustration Mary K. Bryson

Lobular cancer
cells breaking
through the
wall

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 Pagets 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 Castles 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 Graves 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 Graves 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

Hoshimotos thyroiditis-most common

Idiopathic hypothyroidism-probably old Hoshimotos
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 dont 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

Skinthree layers
1. Epidermis

Stratum
germinativum or
basal cell layer

1. Hair

Stratum corneum or
horny cell layer

3. Sweat glands

Derivation of skin
color

2. Dermis

Epidermal appendages

Connective tissue or
collagen
Elastic tissue

2. Sebaceous glands

Eccrine glands

Apocrine glands

4. Nails

Structure of Skin

NEOPLASMA KULIT
Benign

Benign epithelial tumors

Seborrheic keratosis
Epithelial cyst
Xanthoma
Hemangioma
Lymphangioma
Mastocytosis
Langerhans' cell histiocytosis
Lentigo
Nevus pigmentosus

Pre malignan
Lesion

Bowen's disease
Actinic keratosis
Keratoacanthoma
Marjolins Ulcer
Senile Keratosis

Squamous cell carcinoma

Basal cell carcinoma
Malignant melanoma
Mycosis fungoides
Angiosarcoma

Malignant :

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,

Causes
well demarcated
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 strawberryhemangiomas 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
regressinvolution.
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 caf-au-lait spots
and no family history of the disease.
-Multiple cutaneous lesions w/
caf-au-lait spots, dominantly inherited,
referred as neurofibromatosis or von
Recklinghausens 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.

BOWENS 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.

Premycotic patch stage

poikiloderma

Plaque stage

Tumor stage

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
Nodular fasciitis

Fibrosarcoma

Fibrohistiocytic tumours

Fibrous histiocytoma
Dermatofibroma

Malignant Fibrous
Histiocytoma

Skeletal Muscle

Rhabdomyoma

Rhabdomyosarcoma

Smooth Muscle

Leiomyoma

Leiomyosarcoma

Vascular

Haemangioma
Lymphangioma

Angiosarcoma

Peripheral nerve

Neurofibroma
Schwannoma

Malignant peripheral
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 sy

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 dorange

Inspection

Retracted

nipple

Mass

Dimpling

Peau dorange

Ulcer

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