TUMOR SOLID

Dr. ASRUL, SpB-KBD

BAHAN KULIAH FK UMSU

 Tumors
based on
* cell
of origin
* biologic behavior
 Benign  Malignant

Epithelial Mesenchymal Epithelial Mesenchymal

Differences between benign and malignant tumors
Feature Benign Malignant
Capsulation Usually present Usually absent

Mode of growth By expansion By infiltration

Differentiation Well differentiated Variable

Anaplasia Absent Present

Rate of growth Slow Rapid

Metastases Does not happen May occur

Recurrence Usually do not recur Common

Fate Cured by excision Usually fatal

( if not in vital area)
 Benign Malignant
Histology
Cells Uniform in size and Pleomorphic
shape

Nuclei Equal Hyperchramatic /

N/C ratio

Mitosis Few or absent Many ( abnormal)

( normal if present)

Blood Well formed Poorly formed

vascularisation
 Differentiation and Anaplasia

 Benign tumors
 Well differentiated
 Malignant tumors
 Range from well to poorly differentiated
 Hallmarks of anaplasia:
 Cells and nuclei show pleomorphism
 Cells contain abundant DNA, coarse, clumped chromatin
 Large NC ratio (1:1) rather than (1:4)
 Large nucleoli
 Large # of mitoses
 Dysplasia
 Precancerous condition in epithelial tissue
 Anaplastic cells in epithelium
 Dysplasia does not always progress to cancer
Rate of Growth

 Benign tumors
 Generally grow slowly over a period of years
 Malignant tumors
 Grow rapidly at an erratic pace
Local Invasion
 Benign tumors
 grow as cohesive, expanding masses that remain
 localized to site of origin
 Do not have capacity to metastasize to distant sites
 Frequently are surrounded by a fibrous cap

 Malignant tumors
 Grow with progressive infiltration, invasion and
destruction of host tissue
 Poorly demarcated from surrounding normal tissue
Benign

Malignant

Metastasis
 Metastasis

 Tumor implants that are discontinuous from the

primary tumors
 30% of newly diagnosed patients with solid
tumors present with metastases
 How do cancers spread?
 Direct seeding of body cavities or surfaces (Ov CA)
 Lymphatic spread (carcinomas)
 Hematogenous spread (sarcomas)
6 Capabilities of Cancers

 Self-sufficiency in growth signals

 Insensitivity to growth inhibitory signal
 Evasion of programmed cell death
 Limitless replicative potential
 Tissue invasion and metastasis
 Sustained angiogenesis
Benign tumors
 In general, benign tumors are designated by
attaching the suffix -oma to the cell of origin.
 Tumors of mesenchymal cells generally follow this
rule.
 fibroblastic cells  fibroma,
 cartilaginous tumor  chondroma,
 tumor of osteoblasts  osteoma
 Nomenclature of benign epithelial tumors is more
complex. They are variously classified, based on:
 their cells of origin
 microscopic architecture
 macroscopic patterns.
 Tumors
cell of origin
( basis of classification)

Surface Stromal
Parenchyma (papilloma)

I- Epithelial

II- More than one germ layer

Glandular
( ecto-endo- mesoderm-
endoderm) ( adenoma)
Benign epithelial tumors

I- Papilloma II Adenoma III Nevus

origin

surface glandular melanocytes

Papillomas

 Definition
 benign epithelial neoplasms producing
microscopically or macroscopically visible
finger-like or warty projections from epithelial
surfaces.
 Squamous cell papilloma
 it has a multiple finger-like projection with a
fibrovascular core
 composed of hyperplastic typical squamous
epithelium
Squamous papilloma: the most common
benign exophytic epithelial lesion of the oral cavity. 
Squamous cells papilloma
Polyp

 Definition
 benign or malignant neoplasm which
produces a macroscopically visible projection
above a mucosal surface and projects, for
example, into the gastric or colonic lumen
 The term polyp is preferably restricted to
benign tumors.
 Malignant polyps are better designated
polypoid cancers.
Colonic polyp. A, This benign glandular tumor (adenoma) is projecting
into the colonic lumen and is attached to the mucosa by a distinct
stalk. B, Gross appearance of several colonic polyps.
Adenomatous polyp (large
intestine)
 Villous adenoma

Tubular adenoma Poliposis

Malignisated adenoma
Ulcerated carcinoma

Ulcerated and infiltrative Ulcerated and infiltrative

carcinoma carcinoma
 Adenoma
 Definition
 benign epithelial neoplasm that forms glandular
pattern
 tumors derived from glands but not necessarily
reproducing glandular patterns.
 Types:
 Pure adenomas
 Mixed adenomas (epithelial and stromal component Eg.
fibroadenoma of breast)
 Functioning adenomas
 Cystadenomas - form large cystic masses with
secretions are trapped inside the adenomatous tissues
Eg. in the ovary,
 Papillary cystadenomas - papillary patterns that
protrude into cystic spaces
Ovarian papillary cystadenoma
Fibroadenoma
Functioning adenomas

 Tumors originating from epithelium of

endocrine glands
 They secrete hormones normally secreted by
their non-neoplastic counterparts
 Thyroid adenoma ….T3 & T4
 Pancreatic adenomas - Islet cell
adenoma….Insulin/ Glucagon
 Adrenal cortical adenoma….Steroids
Thyroid Adenoma
Well circumscribed; expansile.
adrenal adenoma
Lipoma
 Definition
 Benign soft tissue tumor composed of differentiated fat
cells.
 Clinical Features
 adult, fifth or sixth decade of life
 Any location containing fat, usually:
 upper half of body, particularly: trunk, neck

 subcutaneous

 Can occur in deep soft tissues: intramuscular or

intermuscular
 Single or multiple
 Diffuse lipomatosis
 Gross Pathology

 Can be large
 Usually encapsulated in superficial soft tissues
 Soft, mobile, and painless (except angiolipoma)
Bright yellow fat separated by fine fibrous trabeculae
 Except for the circumscription, the appearance is
indistinguishable from that of normal fat.
Histopathology
 Mature adipose tissue - no cellular atypia
 May present: fat necrosis, infarction, calcification
 Important not to confuse histiocytes associated with fat
necrosis with lipoblasts
 Rarely foci of mature metaplastic: cartilage,bone
 Ultrastructurally: univacuolar mature adipocytes
 Variants:
 Fibrolipoma
 Myxolipoma
 Chondroid lipoma
 Myolipoma
 Spindle cell lipoma
 Pleomorphic lipoma.
Lypoma Lyposarcoma
 Chondroid lipoma

Spindle cell lipoma

Pleomorphic lypoma
Leiomyomas
 Definition: benign stromal tumor mainly composed
of mature smooth muscle bundles
 Greek:
leios = smooth muV = (myo) mouse or muscle oma = tumor
 Were first described by Virchow in 1854
 Types:
 cutaneous leiomyomas: located in dermis,
characteristically superficial, small, multiple, and
grouped
 genital leiomyomas: solitary or multiple
 vascular leiomyomas (angioleiomyomas)
 deep-seated leiomyomas of nonvascular type:
extremities and also pelvic region of females
Gross Pathology

- yellowish pink or white-gray

- various size
- sharply circumscribed
- fairly firm
- large tumors may present area of
ischemic necrosis
Histopathology:

 Fascicles of spindle cells that tend to intersect

each other at right angles
 Cells
 fusiform in shape

 blunt-ended, elongated nuclei

 eosinophilic cytoplasm, limit not well distinct

 different range of cellularity

 minimal atypia and few mitotic figures

 occasionally, bizarre nuclear forms

 Could present ischemic necrosis

leimyoma
 Epithelioid leiomyoma
Vascular leiomyoma
Leiomyoma Leiomyosarcoma
Fibroma

 Definition: benign autonome proliferation of

fibroblast and myofibroblast associated with
excess of fibers
 They can grow in all organs, arising from
mesenchyme tissue
 It have to be differentiated from fibrosis which
is an excessive production of collagen fibers
Types:
 hard fibroma (fibroma durum) consists of many fibres and
few cells, e.g. in skin it is called dermatofibroma
 soft fibroma (fibroma molle) or fibroma with a shaft,
consist of many loosely connected cells and less fibroid
tissue e.g. fibroma pendulans
 angiofibroma - vasoactive tumor, with many dilated vessels
 cystic fibroma (fibroma cysticum) has central softening or
dilated lymhatic vessels
 myxofibroma
 Others: chondromyxoid fibroma, desmoplasmic
fibroma, nonossifying fibroma, ossifying fibroma,
perifollicular fibroma, pleomorphic fibroma
 Ovarian fibroma
 sex cord-sromal tumor
 most frequent during middle age
 gross pathological inspection:
 well circumscribed

 Solid, lobulated, firm

 Uniformly white
 billateral variants with edema are especially likely to be
associated with Meig‘s syndrome
microscopic examination

 Spindle stromal cells: closely packed, arranged in

‘feather-stitched’ or storiform pattern
 May be: hyaline bands or edema
 With or without thecomatous areas (fibrothecoma)
 Occasionally bizarre tumor cells unaccompanied
by mitoses
Ovarian fibroma showing hypocellular appearance,
bland nuclear features, and a suggestion of a storiform pattern of growth.
 Ovarian cellular fibroma. The
tumor is hypercellular,
but pleomorphism and
mitotic activity are minimal

Tendon sheath fibroma. The lesion

is hypocellular
and contains abundant collagen
fibroblasts with no atypia forming
a tumour
Chondroma
 Definition: benign cartilage producing tumor most
common in the small bones of the hands and feet.
 Significant risk of malignant transformation in Ollier's
disease and Maffucci's syndrome
 Enchondromas begin in spongiosa of diaphysis,
from which they expand and thin cortex
 Juxtacortical Chondroma
 less common than enchondroma
 Involve periosteal region of long bone or small bone of
hand or foot
 May recur if incomplete excision
Gross Pathology

 ≈30% multiple
 if predominantly unilateral designated Ollier's disease
 associated with ovarian sex cord–stromal tumors

 if also soft tissue hemangiomas (including spindle cell

hemangioendotheliomas) designated Maffucci's
syndrome
 Calcifying Enchondroma
 Variant presenting in metaphysis of long bones and
characterized by massive calcification
 Juxtacortical Chondroma
 Characteristically erode and induce sclerosis of
contiguous cortex
 head of humerus affected by multiple
chondromas in a patient with Ollier's disease

Arm of a patient affected by Maffucci's syndrome.

Innumerable chondromas are seen concentrated
in the distal aspect of the extremity
 Gross appearance of juxtacortical chondroma.
The tumor produces a semispherical
expansion of the involved bone.

Large asymptomatic enchondroma of femur in a 42-year-old woman.

The tumor is extensively calcified.
Histopathology
 Mature lobules of hyaline cartilage
 Commonly foci of:
 myxoid degeneration
 calcification
 endochondral ossification
 Juxtacortical chondroma:
 tends to be more cellular than medullary
counterpart
 may contain occasional plump or double
nuclei
 Soft Tissue Chondroma

Enchondroma of phalanx. The tumor has a typical lobulated appearance

Rhabdomyoma
 Definition: benign stromal tumors of the soft tissue
with skeletal muscle differentiation.
 Exceedingly rare
 Distinct subtypes with some overlap
 Adult Rhabdomyoma
 Almost exclusively oral cavity and vicinity in adults
 May be multifocal and recur locally
 Fetal Rhabdomyoma
 Almost exclusively:
 head and neck area (particularly retroauricular) in

children <3 years

 vulvovaginal region of middle-aged women - genital

rhabdomyoma
Histopathology
Adult Rhabdomyoma
 Cells: well differentiated
 large
 rounded or polygonal
 some have features of ‘spider cells'
 Cytoplasm:
 abundant, acidophilic
 contains variable amounts of lipid and glycogen
 frequently:
 cross striations

 intracytoplasmic rod-like (‘jack straw') inclusions

 May be intranuclear inclusions

 No mitotic activity or nuclear atypia
 Fetal Rhabdomyoma

 Very cellular
 Formed by:
 immature skeletal muscle fibers: some containing cross
striations
 primitive mesenchymal cells
 Development equivalent to fetal skeletal muscle of
7–12 weeks’ gestation
 No nuclear aberrations
 Mitoses rare
 Have been divided into:
 classic
 intermediate
Fetal rhabdomyoma
 Hemangioma
 Definition: group of entities which has a common
morphologic characteristic, form well-differentiated
blood vessels with endothelia and pericytes, and
have a limited proliferative capacity.

 Pathogenesis
 Gray zone between hamartomatous malformations and
true neoplasms
 Frequently designated as tumors because:
 usually localized

 mass effect

 Consistent lack of chromosomal alterations against true

neoplastic nature
Clinical Features

 Benign
 Can become very large
 Usually:
 child: many present at birth
 solitary
 when multiple (with or without associated lesions in
internal organs) or affecting a large segment of
body known as (multifocal) angiomatosis
 head and neck area: >50%, but also trunk
or extremities
 Classification According To Clinical
Appearance And Caliber Of Vessel
 Capillary hemangioma:
 small vessels of capillary caliber
 any organ

 Cavernous hemangioma:
 larger vessels with cystically dilated lumina
 thin walls
 Large-vessel hemangioma:
 may be composed of:
 vessels with structure of veins (venous hemangiomas) or

 combination of veins and arteries (racemose, cirsoid, or

arteriovenous hemangiomas)
 Skeletal muscle (intramuscular) hemangioma
 Spindle cell hemangioma:
 currently classified as benign endothelial neoplasm,
but variously described as:
 low-grade angiosarcoma
 non-neoplastic lesion related to a vascular
malformation
 Hobnail hemangioma
hemangiomul cavernos
 Lobular Capillary Hemangioma

skeletal hemangioma
 Sinusoidal hemangioma.
The vascular spaces are
widely dilated

Spindle Cell Hemangioma

Schwannoma
Synonyms: Neurilemoma, Neurinoma

 Definition: benign, encapsulated tumors of

differentiated Schwann's cells, usually localized in
peripheral nerves.
 Clinical Features
 Almost always solitary
 Location:
 most commonly:
 flexor surfaces of extremities
 neck
 mediastinum
 retroperitoneum
 posterior spinal roots
 cerebellopontine angle
 Gross Pathology
 Encapsulated
 Nerve of origin:
 often demonstrated in periphery flattened
along capsule but not penetrating substance
of tumor
 often contain cystic areas if large
Histopathology
 Usually two different patterns:
Antoni A areas:
 quite cellular, composed of spindle cells: often palisading or

organoid arrangement (Verocay bodies)

 Antoni B areas:
 tumor cells separated by abundant edematous fluid, which

may form cystic spaces

 occasionally isolated cells with bizarre hyperchromatic nuclei

 common in ‘ancient schwannomas’

 no particular significance
 Mitoses: usually absent or scanty
 Blood vessels: can be prominent and simulate vascular neoplasm
 Variants: - Cellular Schwannomas
- Psammomatous melanotic Schwannoma
Schwannoma of the cerebellopontine
angle - 8th nerve
dense areas called Antoni A (black arrow) and looser areas called Antoni B
(blue arrows).
The cells are elongated (spindle shaped) and the nuclei have a tendency to line up
Like normal Schwann cells, schwannoma cells are each surrounded
by a basement membrane.
 suggestion of nuclear palisading
and hyaline thickening of vessel walls.

Large hyperchromatic nuclei in schwannoma.

This is not necessarily an indication of malignant change
Cellular schwannoma.
The tumor has a homogeneous hypercellular
quality.
 Osteoid Osteoma
 Definition: is a benign painful (relieved by aspirin) bone
forming neoplasm usually less than 1 cm.
 Osteoblastoma is similar to osteoid osteoma with more
aggressive behavior.
 Clinical:
 Commonly 10–30 years of age
 Male:female ratio 2:1
 Most prominent symptom:
 intense pain:

 often sharply localized

 unaccompanied by clinical or laboratory evidence of infection
 characteristically more intense at night
 Vertebral lesions may be associated with scoliosis
 Gross Pathology

 Location: most frequently:

 Femur, tibia,humerus,fibula
 bones of hands and feet

 vertebrae

 Lesions of long bones:

 metaphyseal

 centered in the cortex (85%)

 may be: epiphyseal, juxta- or intra-articular, in

spongiosa (13%) or subperiosteal region (2%)
 Nidus surrounded by peripheral sclerotic reaction that
may extend several centimeters along both sides of
cortex
 Histopathology

 Sharply delineated central nidus:

 composed of more or less calcified osteoid:
 lined by plump osteoblasts

 growing within highly vascularized connective

tissue without evidence of inflammation

 surrounded by variably thick layer of dense bone
 wedge-shaped nidus protruding slightly
above the surface and
surrounded by sclerotic bone
The small, reddish central nidus is
Surrounded by a thick layer of sclerotic bone
Exuberant new osteoid and bone formation by plump osteoblasts.
The stroma is cellular and well vascularized
 Myxoma
 Definition: benign mesenchymal tumor with a hypocellular,
hypovascular, bland appearance, composed of fibroblasts
embedded in an abundant myxoid matrix, commonly located
in the intramuscular compartment.
 Clinical Features
 Rare, usually adult, should be seriously questioned if a child
 More common in females
 Arise within:
 skeletal muscle, especially in thigh:

 if multiple usually associated with fibrous dysplasia of bones of

same extremity
 juxta-articular region, particularly in the knee:
 skin, breast, and other locations:
 if multiple consider Carney's syndrome, which also includes: spotty
cutaneous pigmentation, nodular pigmented adrenal disease other
endocrine abnormalities
Pathology
 Gross: mucoid, slimy appearance
 Histopathology
 Typically bland and hypocellular throughout
 Mitotic activity practically absent
 Blood vessels extremely scanty
 May be focal aggregates of foamy histiocytes:
 contain neutral fat with oil red O stain
 should not be confused with lipoblasts of myxoid liposarcoma8
 Ultrastructurally:
 principal cell of intramuscular myxoma resembles fibroblast
with:
 prominent granular endoplasmic reticulum
 well-developed Golgi apparatus
 cytoplasmic filaments9
 intramuscular myxoma

Note the hypocellular quality, lack of

encapsulation, lack of atypia and
paucity of vessels
Melanocytic nevus
 Strictly speaking, the term nevus denotes any
congenital lesion of the skin (e.g., birthmark).
 Melanocytic nevus, however, refers to any congenital
or acquired neoplasm of melanocytes,
 melanocytes have been transformed from highly
dendritic single cells normally interspersed among
basal keratinocytes to round cells
 Common acquired melanocytic nevi - clinical
appearance:
 tan to brown
 uniformly pigmented
 small (usually <6 mm across), solid regions of
relatively flat (macules) to elevated skin (papules) with
well-defined, rounded borders
 Morphology
 formed by melanocytes that grow in aggregates, or "nests,“
 Nuclei of nevus cells:
 uniform and rounded in contour
 contain inconspicuous nucleoli
 show little or no mitotic activity
 Types
 junctional nevi
 the cell are growing along the dermoepidermal junction

 are believed to represent an early developmental stage in

melanocytic nevi
 compound nevi
 eventually, most junctional nevi grow into the underlying

dermis as nests or cords of cells

 intradermal nevi
 in older lesions, the epidermal nests may be lost entirely to

form pure.
 maturation= nevus cells from the dermo-epidermal
junction progressive growth into the underlying dermis
 more superficial nevus cells
 less mature, larger,
 tend to produce melanin,
 grow in nests,
 deeper nevus cells
 more mature,
 are smaller, fusiform contours
 produce little or no pigment
 grow in cords, fascicles resembling neural tissue.

 This sequence of maturation of individual nevus

cells is of diagnostic importance in distinguishing
some benign nevi from melanomas, which usually
show little or no maturation
Nevus
Nevocellular nevus, junctional type. junctional nevus: rounded nests of nevus
lesions are small, relatively flat, cells originating at the tips of rete ridges
symmetric, and uniform. along the dermoepidermal junction.
 Nevocellular nevus, compound type.
dome shaped, the symmetry and uniform
pigment distribution suggest a
benign process.

combine the features of junctional

nevi (intraepidermal nevus cell
nests) with nests and cords of
nevus cells in the underlying dermis.
Dysplastic nevus - often has a compound nevus component and an asymmetric
"shoulder" composed of a junctional nevus component
Presence of cytologic atypia (irregularly shaped, dark-staining nuclei) at high
magnification.The dermis underlying the atypical cells characteristically shows
linear, or lamellar, fibrosis