Preskas Bedah Ing.doc

Scalp TUMOR

Arranged by : Andriana Wijaya

PRECEPTOR: Dr. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCS

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT FACULTY OF MEDICINE YARSI UNIVERSITY ARJAWINANGUN DISTRIC GENERAL HOSPITAL APRIL 9th – JUNE 30th 2018 0

I. name:

Tn.M

Age:

48 years.

Gender:

Man.

Religion:

Islam

Education:

SMP

Work:

trader

Address:

gintung lor

Sign RSMS:

21 April 2018

II.ANAMNESA 1. Main complaints: A lump on the head. 2. Additional complaints: Headaches. 3. Disease History Now: Surgery Clinic patients

come to hospitals with complaints

Arjawinangun there is a bump on the head. Felt a lump growing since ± 3 months SMRs. Palpable lumps soft and difficult to move. Patients also complain of headaches. Complaints of pain in lumps, pale, rapid weight loss and decreased appetite denied. 4. Past medical history: History of diabetes mellitus denied. History of hypertension is unknown. A history of lung disease is undeniable. Previous trauma history is undeniable. 1. Family Disease History: There are no family members with the same complaint as patients.

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III.PHYSICAL EXAMINATION

A. Status Generalists 1.

General Situation: Looked ill being.

1.

Public Awareness: Compos mentis.

3. Vital Sign: T: 120/80 mmHg. N: 88 x / minute. R: 24 x / minute. S: 36.6 ºC. 4. Form: normocephale 5. eye: Conjunctival pallor (- / -), sclera jaundice (- / -), pupil isokor (+/ +), light reflex (+ / +). 6. Nose: septal deviation (-), discharge (-), epistaxis (-). 7. Ear: No abnormalities. 8. Mouth: Dry (-), anemic (-). 9. Neck: Lymphadenopathy (-). 10. Thoraks: LUNGS Inspection: Symmetrical, motion lag (-), intercostal retractions(-). Palpation: Focal fremitus right = left. Percussion: Sonor on both lung fields. Auscultation: Sounds right-left vesicular basis, ronkhi (- / -) Wheezing (- / -). HEART Inspection: Ictus cordis was not visible. Palpation: No thriil, ictus cordis palpable. Percussion: Maximum heart within normal limits. Auscultation: BJ I-II regular, Murmur (-), Gallop (-). 11. abdomen

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Inspection: Flat, hematoma (-), venektasi (-). palpation: Supple, tenderness (-). Percussion: Timpani in all abdominal region. Auscultation: bowel sounds (+) normal. 12. extremity Superior: Akral warm, edema (- / -), cyanosis (- / -). Inferior: Akral warm, edema (- / -), cyanosis (- / -). IV. SUPPORTING INVESTIGATION Hb: 15.7 g / dl. Leukocytes : 7300 / ml. hematocrit: 47.3%. platelets: 235,000 / ml. monocytes: 0.7 granulocytes: 3.6 MCV: 85,7 MCH: 285 MCHC: 33.2 V.DIAGNOSIS WORK Scalp tumor VI.DIAGNOSIS APPEAL Melanoma malignancy. VII. MANAGEMENT medical: -

ceftazidime 3 × 1. Ketorolac 3 × 1 amp. Ranitidine 3 × 1 amp.

operative: -

Excision.

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IX.

PROGNOSIS Quo ad vitam: Dubia ad bonam. Quo ad functionam: Dubia ad bonam.

DISCUSSION Scalp TUMOR 4

Anatomy Based on the ATLS (2004), the anatomy of the head, among others: 1. Scalp (Scalp) The scalp is composed of five layers called Scalp namely: a. Skin or skin. b. connective Tissue or connective tissue. c.

Or galea aponeurosis aponeurotika or connective tissue in direct contact with the skull

d. Loose areolar tissue or loose support network. e. pericranial, Loose supporting tissue separates the galea aponeurotika of pericranial and is the accumulation of blood (hematoma subgaleal). The scalp has many blood vessels so that if there is bleeding due to scalp laceration will cause a lot of blood loss, especially in infants and children.

The cranium layer

2. Skull

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The cranium consists of a dome (calvaria) and the base of the skull. Kalvaria particularly in the temporal was thin, but here is covered by the temporal muscle. Uneven-shaped base of the skull so that the brain can hurt the bottom while moving due to the process of acceleration and deceleration. Basic cranial cavity is divided into three fossa: anterior fossa, fossa media, and posterior fossa. Anterior fossa is a frontal lobes, medium fossa is a temporal lobe and posterior fossa is the space the bottom brainstem and cerebellum.

3. meninges Meninges membranes covering the entire surface of the brain and consists of three layers namely: the dura mater, the arachnoid and piamater. Dura mater is the tough membrane, composed of fibrous connective tissue that is firmly attached to the inner surface of the cranium. Because it is not attached to the arachnoid membrane underneath, there is a potential space (subdural space) located between the dura and arachnoid, which is often found subdural hemorrhage. In brain injury, artery-vein that runs on the surface of the brain to the superior sagittal sinus in the midline or called Bridging Veins, may experience tearing and causing a subdural hemorrhage. Superior sagittal sinus venous blood flow into the transverse sinus and sinus sigmoideus. Lacerations of the sinuses can result in severe bleeding. Meningeal arteries situated between the dura and the inner surface of the cranium (epidural space). A fracture of the skull can cause lacerations of the

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arteries and can lead to bleeding epidural. The most frequently injured was the middle meningeal artery, located in the temporal fossa (fossa media). Below there is a second layer of the dura mater of the meninges, the thin and transparent layer called the arachnoid. Piamater third layer is firmly attached to the surface of the cerebral cortex. Cerebrospinal fluid circulates in the subarachnoid space. 4. Brain The human brain consists of the cerebrum, cerebellum, and brainstem. The cerebrum consists of the right and left hemispheres separated by falks dural folds of the cerebral namely the inferior side of the superior sagittal sinus. On the left cerebral hemisphere there are centers of human speech. Hemispheres of the brain containing the speech center is often referred to as the dominant hemisphere. The frontal lobes are related to emotional functioning, fiungsi motor, and the dominant side containing the center of speech expression. Parietal lobe associated with sensory function and spatial orientation. Regulate the temporal lobe memory function. The occipital lobe is responsible for the vision process. The brain stem consists of mesensefalon (mid brain), pons, and medulla oblongata. Mesensefalon and punch the upper part contains the reticular activating system that functions in awareness and vigilance. At the center of the medulla oblongata are kardiorespiratorik, which stretches to the spinal cord below. A small lesions in the brain stem can already cause severe neurological deficits. The cerebellum is responsible for co-ordination and balance functions, located in the posterior fossa, associated with the spinal cord, brain stem, and also both cerebral hemispheres.

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5. Cerebrospinal fluid Cerebrospinal fluid (CSS) generated by khoroideus plexus with a production speed of 20 ml / hr. CSS flow from the lateral ventricle through the foramen monro towards the third ventricle and then through aquaductus sylvii into the ventricle IV. Furthermore, CSS out of the system into the ventricle and the subarachnoid space located throughout the surface of the brain and spinal cord. CSS will be reabsorbed into the venous circulation through the arachnoid villi. Intra-cranial pressure increases because of cerebrospinal fluid production exceeds the amount absorbed. This occurs when there is an excessive production of cerebrospinal fluid, an increase in the flow resistance or pressure on the venous sinuses. Compensatory mechanisms that occur are transventricular absorption, dural absorption, nerve root absorption and unrepaired meningocoeles sleeves. The first ventricular dilation usually occurs in the frontal and temporal horns, often asymmetrical, this situation led to the elevation of the corpus callosum, the tension or perforation of the septum pellucidum, thinning of the cerebral mantle and ventricular dilation III downwardly until the pituitary fossa (causing pituitary disfunction).

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6. tentorial Tentorial serebelli divides the cranial cavity into a supra-territorial space (consisting of the anterior cranial fossa cranial fossa media) and infratentorial space (containing the posterior cranial fossa). Mesensefalon (midbrain) connects the cerebral hemispheres and the brainstem (pons and medulla oblongata) runs through a gap called the cerebellar tentorium notch tentorial. Oculomotor nerve (N.VII) runs along the tentorium, when pressured by time or brain edema will cause herniation. The parasympathetic fibers to contraction of the pupils are on the surface of the oculomotor nerve. Paralysis is caused suppression fibers resulting in dilation of the pupil. When the emphasis continues causing a lateral deviation of the eyeball and down. Dilated pupils accompanied ipsilateral contralateral hemiplegi known classic syndrome tentorium herniation. Intracranial bleeding is generally found on the same side with the pupil dilated though not always. SOFT TISSUE TUMOR preliminary Tumors are abnormal lump or swelling in the body, but in a certain sense the tumor is a lump caused by neoplasms. Clinically, tumors differentiated into classes neoplasms and cysts nonneoplasma example, due to inflammation or hypertrophy. Neoplasms may be malignant or benign. Malignant neoplasms or cancers occur due to arise and breeding of cells in an uncontrolled manner so that these cells grow continuously deforming the growth and organ function. Cancer, carcinoma, or sarcoma grew infiltrate (infiltrating) into the surrounding tissue while destroying it (destructive), it can spread to other parts of the body and is generally fatal if left unchecked. Benign neoplasms grow with firm boundaries and does not infiltrate, not undermine, but enlarges and presses the surrounding tissue (expansive), and generally do not metastasize, such as lipoma.

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Pathologic tumor classification was made based on the results of the microscopic examination of tissue and tumor cells. These microscopic examination appears overview of malignancy were very varied, ranging from the relatively benign to the most vicious. At one organ may present one or more neoplasms that are different. Tumor cells are body cells transformed and autonomic grow out of control normal cell growth so that these cells differ from normal cells in shape and structure. The distinguishing characteristics of tumor cells depends on the magnitude of the deviation in the growth, and the ability to hold danmenyebabkan infiltration metastasis. Definition Soft Tissue Tumors (STT) is an abnormal lump or swelling caused by the growth of new cells. Etiology Etiology of Soft Tissue Tumors, among others: 1. genetic condition There is certain evidence of the formation of mutagens is a predisposing factor for some soft tissue tumors, the report lists the abnormal gene, that gene has an important role in the diagnosis. 2. RadiasiMekanisme that patogenic is the emergence of radiation-induced gene mutations

that

drive

neoplastic

transformation.

3. environmental carcinogens An association between exposure to various carcinogens and after it reported rising incidence of soft tissue tumors. 4. InfeksiInfeksi Epstein-Barr virus in a weak immune person will also increase the

likelihood

of

soft

tissue

tumor

development.

5. TraumaHubungan between trauma and Soft Tissue Tumors apparently accidental. Trauma may draw medical attention to pre-existing injuries.

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Signs and symptoms TYour soft tissue tumors and symptoms are not specific, depending on the location where the tumor is located, generally symptoms of the presence of a lump under the skin that does not hurt. Only a few people who complain of pain, which usually occurs as a result of hemorrhage or necrosis in the tumor, and could also be because of the emphasis on nerves edge. Dnatural early stages, soft tissue tumors usually do not cause symptoms because of the soft tissue is relatively elastic, tumors can grow bigger, pushing aside normal tissue, before they are felt or cause any problems. Sometimes the first symptom is usually pain or swelling clumps. And can cause other symptoms, such as pain or soreness, as close to nerve compression and muscle. If in the abdomen can cause abdominal pain, generally cause constipation. Soft Tissue Tumor and Cancer When the skin over the lump is still good and there were no injuries in the form of ulcers, the possibility of a bump comes from the bottom of the skin of the soft tissue that is under the skin, or it could be from the ribs, but the most likely is of the soft tissue when magnifying relatively quickly in time short. The soft tissues are part of the body that lies between the skin and bones and internal organs. Belonging to the soft tissues include muscles, tendons, connective tissue, fat and synovial tissues (tissues around joints).Muscles are networks that have a special ability that is contracted to move. Muscles consist of cylindrical fibers that have the same properties as other networks, all tied into bundles of small fibers by a type of connective tissue that contain contractile elements. Tendons are fastener muscle on the bone, tendon fibers in the form of loops which are white, shiny, and elastic. Connective tissue complete the framework of the body, and consists of a network of areolar and elastic fibers. Soft tissue tumors can occur in all parts of the body from head to toe. Soft tissue tumors, there are benign and some malignant. Malignant tumors or cancers known as soft tissue or soft tissue sarcoma Soft Tissue Sarcoma (STS), which derived from tissues mesenchym extraskeletal,

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locatedbetween the epidermis and parenchym tissue organs. Tumors derived from lymphoid system and organ-specific tissues excluding Soft Tissue Tumors. STS consists of various types of tumor groups.

Soft tissue cancer, including cancers that are rare, the incidence is only about 1% of all malignancies in adults and 7-15% of all malignancies in children. Can be found in all age groups. In children, most often at about 4 years of age and in adults most at the age of 45-50 years. The most common location is in the lower limbs that is equal to 46% where 75% of it is above the knee, especially in the thigh area.In the upper limbs ranging from the upper arm, forearm palm up about 13%. 30% in body parts on the outside and the inside, such as the abdominal wall, and also on the soft tissue in the abdomen and near the kidneys or the so-called retroperitoneal area. In the head and neck area of about 9% and 1% in other places, among others in the chest. 12

The spread or metastasis of cancer is most commonly through blood vessels to the lungs (most often), to the liver, bones. Rarely spreads through the lymph nodes. Symptoms and signs are nonspecific soft tissue cancer, depending on the location where the tumor is located, generally symptoms of the presence of a lump under the skin that does not hurt. Only a few people who complain of pain, which usually occurs as a result of hemorrhage or necrosis in the tumor, and could also be because of the emphasis on nerves edge. Soft tissue benign tumors usually grow slowly, not rapidly enlarged, feels soft when touched and when the tumor is moved relatively easily moved from the surrounding

tissue

and

never

spread

to

distant

places.

Soft tissue cancer in general is growing relatively fast to grow, evolve into a hard lump, when you move a bit difficult to move and can spread to distant places to the

lungs,

liver

and

bones.

If the size of the cancer is so large, it can cause ulcers and bleeding in the overlying skin. The most common diagnostic methods in addition to clinical examination, is the examination of biopsy, could be able to fine needle aspiration biopsy (FNAB) or biopsy of the tumor tissue directly in the form of an incisional biopsy is a biopsy by taking a portion of the tumor tissue, for example when the size of the

tumor

is

large.

When the size of a small tumor, the biopsy can be done with the removal of the entire tumor. Tissue biopsies examined by a doctor of anatomic pathology, and it can be seen whether a soft tissue tumor is benign or malignant. When malignant, can also be seen and determined the tumor histologic subtype, which is very useful to determine the next course of action. If the diagnosis is confirmed, the treatment depends on the type of soft tissue tumor itself. If benign, then quite simply benjolannnya being named and no other additional measures. If the result is a malignant soft tissue tumors or cancer, the treatment is not only the tumors are removed, but also the surrounding tissue until the tumor-free according to predetermined rules, depending on where the location of this cancer. Measures such treatment is wide excision surgery.

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The use of radiotherapy and chemotherapy only as a supplement, but the response is not so good, except for the type of soft tissue cancer that comes from muscle called embryonal rhabdomyosarcoma. For the large size of cancer, after surgery combined with radiotherapy. In soft tissue cancer that is advanced, with a large size, the risk of recurrence after surgery can still occur. Therefore, after the operation the patient typically must often control to monitor the presence or absence of recurrence or relapse operating area in the countryside where the form metastases in the lungs, liver or bones. Here is one example of soft tissue tumors (Soft Tissue Tumors): lipoma 1, Definition Lipoma is a benign mesenchymal tumor (benign mesenchymal tumors) originating from fat tissue (adipocytes). 2. variant Lipoma a. Adenolipoma, variations in breast lipoma. Often have a marked fibrotic component. Usually considered a hamartoma. b. Angiolipoma contains many tiny blood vessels. c. Lipoma heart (cardiac lipomas) can whitewash follow fat necrosis.

2. pathophysiology In general, tumors of soft tissues (soft tissue tumors [STI's]) is masenkimal proliferation that occurs in extraskeletal nonepitelial tissue of the body, excluding the viscera, meninges, and limforetikuler system. Can arise in place anywhere, even though approximately 40% occurred in ekstermitas down, especially the thigh area, 20% in ekstermitas above, 10% of head and neck, and 30% in weight and retroperitoneum. The parameters necessary to determine the clinical management are: a. The greater the size of the tumor mass, the worse the outcome. b. Histology and staging classification (grading) accurate (mainly is based on the degree of differentiation), and the estimated rate of growth based on the expansion of mitosis and necrosis. 14

c. Staging. d. The location of the tumor. The more superficial, the better the prognosis. 3. Clinical manifestations Lipomas are often no symptoms (asymptomatic). Symptoms appear depending on the location, for example: a. Patients with lipoma of the esophagus (esophageal lipoma) may be accompanied by obstruction, pain when swallowing (dysphagia), regurgitation, vomiting (vomiting), and reflux. Esophageal lipomas may be associated

with

aspiration

and

respiratory

infections

successive

(consecutive respiratory infections). b. Lipoma in the main airway (major airways) can cause respiratory failure (respiratory distress) associated with bronchial disorders (bronchial obstruction). Patients present with parenchymal lesions (parenchymal lesions) or endobronchial. c. Lipoma is also common in the breast, but not as much as expected given the extent of fatty tissue. d. Lipoma in the gut (intestines), for example: the duodenum, jejunum, colon can cause abdominal pain (abdominal pain) of the obstruction or intussusception, or may become apparent through bleeding (hemorrhage). e. Lipoma heart (cardiac lipomas) are mainly located in subendocardial, intramural rare, and normally is not encapsulated (unencapsulated). Seen as a yellow mass in the rooms / chambers of the heart (cardiac chamber). f. Lipomas may also appear in the subcutaneous tissue of the vulva. Usually pedunculated and dependent. Indication

4.

Lipoma removed for the following reasons: a. b. c. d. 5.

Cosmetics (type of subcutaneous lipomas). For the evaluation of tissue (histology). When accompanied by symptoms. As we grow, enlarged, more than 5 cm. Medical therapy

Medical therapy including endoscopic excision of the tumor in the upper gastrointestinal tract (eg, esophagus, stomach (stomach), and duodenum) or colon. 6.

Therapy Surgery (Surgical Therapy)

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Surgery (complete surgical excision) with the capsule is essential to prevent local recurrence (local recurrence). Treatment depends on the location of the tumor. In an unusual location, the removal of lipoma adjust its place. a. The local displacement indicated in lipoma near the main airway (major airways). Lipoma require resection of lung parenchyma of the lung or respiratory tract is involved (the Involved airway). b. The local removal (Local removal) is indicated in the intestinal lipoma (intestinal lipomas) that causes obstruction. c. If lipomas esophagus by endoscopy can not be moved, it would require surgery (surgical excision). d. Lipoma of the breast (breast lipomas) basically eliminated if in doubt. e. Lipoma intestine, particularly the duodenum, should be eliminated either endoscopically or surgically because they can cause obstruction, jaundice, or bleeding (hemorrhage). f. Lipoma of the vulva can be eliminated on the spot (locally excised). 7. record a. Lipomas occur in 1% of the population. b. Lipoma is a tumor of the soft tissue (soft tissue tumor) is the most common. c. Liposuction can be done on a small lipoma in the face (facial small lipomas) for aesthetic reasons. d. Liposuction is indicated for the treatment of lipoma medium or medium (eg, 4-10 cm) and large (large) (eg,> 10 cm). In lipomas are small, there is no profit being reported for the tumor to be extracted (extracted) through a small incision (small incisions).

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BIBLIOGRAPHY

1. Anonymous. Soft Tissue Sarcoma. Makassar: Subdivision Tumor Surgery, Department of Surgery, Faculty of Medicine, University of Hasanuddin. 2007, p. 2. Rasjad C. Introduction of Orthopedic Surgery. Jakarta: Yarsif Watampone. 2007, p. 301-303. 3. S. Reksoprodjo set Lecture Surgery. Jakarta: Binarupa Script. 1995, p. 331340. 4. Sjamsuhidajat R, Wim de Jong. Textbook of Surgery, edition 2. Jakarta: EGC. 2005, p. 933-934. 17

5. http://emedicine.medscape.com 6. http://en.wikipedia.org/wiki/Soft_tissue_tumor 7. http://repository.usu.ac.id/bitstream/123456789/21501/4/Chapter%20II.pdf 8. http://www.dinkes.kalbar.go.id/ 9. http://www.iditangerang.or.id/artikel/detail_artikel.php?recordid=39

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