Presentation for students

1. SURGICAL ONCOLOGY I
Principles & Practice
Hristo A. Rahman
Department of CardioVascular surgery
Medical University Plovdiv
University General Hospital Saint George-Plovdiv

2. Definition
• Tumor is independent and uncontrolled
growth of new cells that serve no useful
function.
• Tumors can be benign or malignant.

3. Difference between benign and malignant tumors
Benign Malignant
Slowly growing Rapidly growing
No definitive
capsule
Well-capsulated
Do not invade
adjoining structures
Invade adjoining
structures
Distant spread
through lymphatics
and blood stream
Poor prognosis
No distant spread
Good prognosis

4. Between benign and malignant tumors,
intermediate group of tumors exists.
The tumors in this group are:
- Locally invasive, but usually don’t spread by
lymphatics or vascular route:
1/ Pleomorphic adenoma of salivary glands;
2/ Basal cell carcinoma.

5. Pleomorphic adenoma of salivary gland

6. Basal cell carcinoma

7. Basal cell carcinoma

8. BENIGN TUMORS

9. ADENOMAArises from secretory glands: thyroid, parathyroid, breast.
If an adenoma contains large amount of fibrous tissue, it is
called fibroadenoma (commonly seen in breast).
If an adenoma has multiple cystic spaces, it is called as
cystadenoma (parotid, thyroid, pancreas, ovaries).
If an adenoma arises from secretory glands of mucous
membrane, it is likely to be pedunculated

10. Brest Fibroadenoma

11. Brest Fibroadenoma

12. Brest Fibroadenoma

13. Thyroid cystadenoma

14. Ovarian cystadenoma

15. Ovarian cystadenoma

16. Rectal polyp

17. FIBROMA
Arises from fibrous connective tissue.
Pure fibroma is rare and is mostly combined with
other mesodermal tissues:
Nerve sheath
Glandular tissue
Fat
Muscles
Neurofibroma
Fibroadenoma
Fibrolipoma
Fibromyoma

18. Neurofibroma

19. Fibroadenoma

20. Fibromyoma

21. Fibrolipoma

22. FIBROMA
Fibromas can be soft or hard depending upon
proportion of fibrous tissue with other cellular
tissue.

23. PapillomaBenign tumor arising from epithelial surface:
(skin or mucous membrane).
Consists of a central core of connective tissue
containing lymphatics and blood vessels that is
covered with epithelium.
The surface may be rough or made of finger
like projections.
Depending upon its location, the surface

24. Papilloma
• Squamous cell (skin, tongue, lip, cheek)
• Columnar cell (small and large intestine)
• Transitional cell (urinary bladder)

25. Squamous cell papilloma
palate

26. Papilloma
Papilloma of skin is of two types:
. 1/ Squamous Cell Papilloma;
2/ Basal Cell Papilloma

27. Squamous cell papilloma
skin

28. Basal cell papilloma
skin

29. Squamous Cell Papilloma. It has four types:
a. Congenital papilloma: present since birth
and is seen as brownish warty growth.
b. Soft papilloma: seen on eyelids, neck and
face of elderly people. It forms pedunculated,
soft, fleshy skin tags.

30. Soft papilloma
Skin tag

31. Squamous Cell Papilloma.
c. Keratin horn: seen in old people and is due
to excess keratin formation.
d. Infective papilloma: due to viral infection ( HPV ) caused
by Verruca vulgaris.
Common in children and young adults.
Usually seen at sites that are prone to trauma: beard area, hand,
feet and genitals.
Appears as small, pigmented nodules that unite to form frond-like
surface.
Most of the warts may disappear spontaneously.

32. Keratin horn

33. Keratin horn

34. Treeman syndrome

35. Basal Cell Papilloma
(Senile warts, Seborrheic keratosis)
Benign tumors due to overgrowth of basal layer
of epidermis.
They appear as raised, brownish warts over
face, neck and shoulders in elderly people.
Gradually increase in size but not in thickness.
They may fall off spontaneously.

36. Seborrheic keratosis

37. Papilloma
Treatment
Papillomas usually need surgical excision due to
cosmetic reasons.

38. Lipoma
Most common benign tumor arising from fat
cells of adult type.
It can occur anywhere in the body where fat is
present, hence named universal tumor.
The most common sites are nape of neck,
abdominal wall and thighs.

40. Lipoma
There are three types of lipoma:
1/ Encapsulated lipoma;
2/ Diffuse lipoma;
3/ Multiple lipomas

41. Encapsulated lipoma
Most common type present in subcutaneous tissue.
The patient presents with painless slow growing swelling of long duration.
On examination - soft smooth and lobulated swelling.
• Slipping sign: If edge of the swelling is pressed, it slips under the finger. It is
pathognomonic sign of lipoma and differentiates it from a cyst.
• Pseudo-fluctuation: A sense of fluctuation may be obtained since fat at body
temperature behaves like fluid.
• Pseudo-transillumination: The swelling may trans- illuminate due to presence of
clear fat.
• The swelling is free from overlying skin and freely mobile over underlying
structures.
• Sometimes the swelling may become pedunculated.

42. Lipoma

43. Diffuse lipoma
Rare type and does not have characteristic
features of lipoma hence called as pseudolipoma.
It is overgrowth of fat and does not have a capsule.
Usually presents as a diffuse swelling at nape of the
neck.

44. Multiple lipomas
. Sometimes subcutaneous lipomas are multiple
and painful due to presence of nerve tissue
(neurolipomas).
The condition is known as adiposis dolorosa or
Dercum’s disease.

45. Lipomas
ClassificationLipomas are also classified according to their anatomical plane:
1/ Subcutaneous: Commonest variety with charac- teristic features described above.
2/ Subfascial: It is difficult to diagnose because overlying fascia masks the lobulations
and negates the slipping sign. Long standing subfascial lipoma deep to epicranial
aponeurosis can erode the underlying bone.
3/ Intermuscular: Commonly seen in thigh and becomes fixed on muscle contraction.
4/ Submucous: Occurring under mucous membrane, e.g. in the tongue (causes
macroglossia), in the larynx (causes respiratory obstruction).

46. Lipomas
ClassificationLipomas are also classified according to their anatomical plane:
5/ Subserous: Occurring beneath pleura or in retroperitoneum. It may attain enormous size
without causing any symptoms due to presence of potential space.
6/ Extradural: It is a rare spinal tumor presenting with cord compression. Intracranial
lipomas do not occur due to absence of fat in the cranial cavity.
7/ Intraglandular: Lipoma occurring within the glands, e.g. breast, pancreas, beneath renal
capsule.
8/ Lipomas in relation to bones and joints:
 Subperiosteal;
 Subsynovial;

47. Lipomas
Complications
Long standing lipomas may undergo:
•Myxomatous degeneration;
• Saponification;
• Calcification.

48. Lipomas
Complications
Large sized lipoma in thigh or retroperitoneum may
undergo malignant transformation into liposarcoma.
The swelling starts growing rapidly in size and
becomes painful.
Overlying veins become dilated and surface
becomes warm due to increased vascularity.
If untreated, overlying skin may ulcerate and
fungate due to rapidly growing tumor.

49. Retroperitoneal liposarcoma

50. Liposarcoma

51. Ulceration due to rapid
growing

52. Lipoma
Treatment
Lipomas are treated by surgical excision.
Aim of surgery is to take care of cosmetic
disfigurement and to prevent complications.

53. Lipoma surgery

54. NeuromaBenign tumor of nerve tissue called neuroma. Based on site of
origin, they are of two types:
1/ True Neuromas
Very rare and arise from sympathetic nervous system.
They develop from neural crest.
2/ False Neuromas
Benign tumors arising from nerve sheath. This group includes:
2.1/ Neurilemmoma;
2.2/ Stump neuroma;
2.3/ Neurofibroma

55. False Neuromas
1/ Neurilemmoma (Schwannoma):
Benign tumor arising from Schwann cells.
Commonest site of involvement is acoustic nerve.
It produces a soft, whitish, lobulated mass that
displaces the nerve from which it arises.
It can be safely removed without damaging the
nerve of origin.

57. False Neuromas
2/ Stump neuroma:
After limb amputation, the end of a divided nerve forms a
fusiform swelling due to proliferation of nerve fibers.
Also called as ‘Amputation neuroma’.
Can cause numbness, tingling and severe neuralgic pain due
to pressure by prosthesis or nerve entrapment in the scar.
Treatment is excision of neuroma.
However, it can be prevented if nerve is divided at a higher

58. False Neuromas
3/ Neurofibroma:
Arises from the connective tissue of nerve sheath
(endoneurium).
Can appear at any age but usually presents in adult
life.
As nerve fibers pass through the tumor, so tumor
cannot be removed without damaging the nerve (c/f

59. False Neuromas
3/ Neurofibroma:
It has following types:
3.1/ Localised neurofibroma;
3.2/ Generalised neurofibromatosis;
( von Recklinghausen’s disease )
3.3/ Plexiform neurofibromatosis

60. NeurofibromaLocalised neurofibroma
Usually seen in subcutaneous tissue.
Mostly involves peripheral nerves (ulnar or median nerve)
or cranial nerves (acoustic neuroma).
Produces a fusiform swelling in direction of nerve.
Mostly asymptomatic, but patient may complain of paresthesia,
numbness and pain in distribution of the nerve.

61. NeurofibromaLocalised neurofibroma
• On examination, there is ‘tender subcutaneous nodule’ that is firm, smooth and circumscribed.
• The swelling typically moves at right angle to the
direction of nerve and fixed in the direction of nerve.
• The area of distribution of affected nerve should be
examined for sensory and motor weakness.
• Treatment: Asymptomatic neurofibroma should be left
as such since excision will always lead to the damage of involved nerve. Indications of excision
are:
 Cosmetic deformity.
 Symptomatic; causing severe pain and paresthesia.
 Rapidly growing (? Sarcomatous change).

62. Generalised neurofibromatosis
( von Recklinghausen’s disease )
Multiple neurofibromas are seen involving various parts of the body (face, neck, trunk and limbs)
It is an autosomal dominant disease and runs in families.
• It may involve peripheral, spinal and cranial nerves.
• There may be associated pigmentation of skin called Cafe-au-lait spots. It is so named because its appearance
resembles color of coffee diluted with milk
• One or more neurofibromas may undergo sarcomatous change.
• Treatment: ‘wait and watch’ policy since excision of so many swellings is not possible.
Sometimes, one or more swellings may need excision if there is:
 neurological deficit (e.g. pressure on spinal cord).
 Severe pain.
 Suspicion of malignant change.
• von Recklinghausen’s disease of bone is a separate entity

63. Cafe-au-lait spots

64. von Recklinghausen’s disease

65. Plexiform
neurofibromatosis• There is ‘myxofibromatous degeneration’ of
endoneurium so that affected nerve becomes enormously
thickened.
• Usually involves branches of 5th cranial nerve
(Trigeminal nerve) in area of face and scalp.
• The affected skin of face becomes thick, edematous,
pigmented and adherent causing severe cosmetic

66. Plexiform
neurofibromatosis•• As it grows in size, the involved skin starts hanging down in
pendulous folds (Pachydermatocele).
• The hanging skin folds can obstruct the vision.
• As a rule, the skin is covered with hair unless repeated friction
causes skin ulceration and scarring.
• Treatment is staged excision. However, it is difficult
and should be performed by a plastic surgeon.

67. Plexiform neurofibromatosis

69. Elephantiasis neuromatosa• It is advanced and severe form of plexiform neurofibromatosis.
• It usually affects lower limbs.
• The skin is coarse, dry and thickened. The subcutaneous tissue is also
greatly thickened and fat is replaced by fibrous tissue.
• The appearance resembles elephant’s hide and the patient finds walking
very difficult.
• Differential diagnosis: Filarial elephantiasis (involves
lymphatics).

70. Elephantiasis neuromatosa

71. Hemangioma

72. Lymphangioma

73. Hamartoma

75. Benign melanoma
(Pigmented nevus)• These are benign tumors arising from
melanocytes.
• Melanocytes are derived from neural crest and
are present in basal layer of epidermis.
• Proliferation of melanocytes produces
pigmented nevus. It has following types:

76. Benign melanoma
(Pigmented nevus). 1/ Lentigo: It is present only in basal layer of epidermis.
2/ Junctional nevus: It is localized aggregation of melanocytes projecting
into dermis. It appears as a brownish black, localized and slightly raised
lesion anywhere on the body. It can undergo malignant change.
3/ Dermal nevus: It is present entirely in the dermis. It is mostly seen on
face as ‘hairy mole’. It is a pigmented, dome shaped, soft, smooth lesion. It
never undergoes malignant change.
4/ Compound nevus: It is combination of both junctional and dermal
nevus. It is usually seen in adults as a pigmented, rounded and elevated
lesion. Its junctional component is prone to malignant change.

77. Lentigo

78. Benign melanoma
(Pigmented nevus)5/ Blue nevus: It is seen on face, dorm of hand and foot in babies.
It is darkly pigmented and due to presence of overlying thin normal epidermis, it looks
shiny and blue in color. Very rarely, it may undergo malignant change.
6/ Congenital nevus:
A. Hairy mole: Common variety and does not change to malignancy;
B. Giant lesion: It may cover 25% or more of body surface area as irregular pigmentation.
It can undergo malignant change.
7/ Hutchinson’s melanotic freckles: These are seen as dark pigmented, smooth and flat
lesions in elderly people on sun exposed areas (face and neck). These have high incidence of
malignant change .

79. Blue nevus

80. Giant congenital nevus

81. Hutchinson’s melanotic
freckles

82. Treatment
Pigmented nevus
Surgical excision. Indications are:
• Cosmetic reasons.
• Nevus exposed to repeated trauma, e.g. cuts during shaving, rubbing by
clothes (belts, brassier, etc.).
• Suspicion of malignant change.
The excision should involve 2 mm of healthy skin margin and the
specimen should always be sent for histopathological examination to rule
out malignancy.

83. Other benign tumors
Head & NeckTurban Tumor (Cylindroma)
• It arises from apocrine glands and is benign in nature.
• It forms a slow growing extensive swelling that covers
the scalp and looks like a turban.
• Surface ulceration is uncommon.
• Treatment is cryotherapy.

84. Cylindroma

85. Other benign tumors
Head & Neck
. Potato Nose (Rhinophyma)
The skin of distal nose becomes thickened and bluish
red in color.
The openings of sebaceous follicles become prominent.
Rarely, it may be associated with basal cell carcinoma.
Treatment is surgical excision of excess tissue.

86. Rhinophyma

87. Other benign tumors
Head & NeckKeratoacanthoma (Molluscum Sebaceum)
•It is a benign tumor arising from hair follicle.
•It is mostly seen on face and neck in young adults.
•It forms a small, solitary, hard tumor in subcutaneous
tissue, attached to overlying skin.
•Clinically, it resembles sebaceous cyst.
•There is central dark brown area that separates spontaneously in 2-4 weeks time
and it heals with scarring.

88. Keratoacanthoma
Molluscum sebaceum