SUG402 — General Surgery II: Lecture Note

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This is the complete lecture note for SUG402 General Surgery II. You can read it online below, open it in the full viewer, or download the PDF for offline study. It pairs with the course's video lectures, so you can read and watch together.

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: SUG 402 Course title: General Surgery II Course credit load: 5 Units Series 1: Solid Tumours and Neoplasms • Part 1.1: Biology and Classification of Tumours o Sub Part 1.1.1: Benign versus malignant tumours o Sub Part 1.1.2: Tumour classification and nomenclature o Sub Part 1.1.3: Staging and grading • Part 1.2: Clinical Approach to the Patient with a Tumour o Sub Part 1.2.1: History taking in oncology o Sub Part 1.2.2: Physical examination of a tumour o Sub Part 1.2.3: Investigations • Part 1.3: Skin and Soft Tissue Tumours o Sub Part 1.3.1: Benign skin tumours o Sub Part 1.3.2: Malignant skin tumours o Sub Part 1.3.3: Soft tissue sarcomas • Part 1.4: Bone and Vascular Tumours o Sub Part 1.4.1: Primary bone tumours o Sub Part 1.4.2: Secondary (metastatic) bone disease o Sub Part 1.4.3: Vascular tumours and anomalies • Part 1.5: Lymphoma and Lymph Node Disease o Sub Part 1.5.1: Hodgkin's lymphoma o Sub Part 1.5.2: Non-Hodgkin's lymphoma o Sub Part 1.5.3: Reactive and metastatic lymphadenopathy • Part 1.6: Principles of Surgical Oncology o Sub Part 1.6.1: Curative surgical principles o Sub Part 1.6.2: Palliative surgery and supportive care

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS o Sub Part 1.6.3: Multimodal cancer treatment Introduction Neoplasia, the abnormal and uncontrolled proliferation of cells, is one of the most important areas of surgical practice. Solid tumours account for the majority of cancer-related deaths worldwide, and the surgeon plays a central role in their diagnosis, staging, and treatment. Understanding the biological differences between benign and malignant tumours, the principles of tumour classification and staging, and the surgical principles that govern oncological resection is fundamental to the practice of General Surgery II. This Series introduces the core concepts of surgical oncology. We begin with the biology and classification of tumours, then examine the clinical approach to a patient presenting with a tumour. We then survey specific categories of solid tumours: skin and soft tissue, bone and vascular, and lymph node disease. We close with the overarching principles of surgical oncology including curative and palliative surgery and multimodal treatment. Series Learning Outcomes Upon completing this Series, you should be able to: • SLO 1.1: distinguish benign from malignant tumours on biological, clinical, and histological grounds, and describe the classification and staging of tumours, • SLO 1.2: describe a structured approach to the history, examination, and investigation of a patient presenting with a tumour, • SLO 1.3: describe the clinical features and management of common skin tumours, melanoma, and soft tissue sarcomas, • SLO 1.4: describe the clinical features, investigation, and management of primary bone tumours, metastatic bone disease, and vascular tumours, • SLO 1.5: describe the clinical features and management of Hodgkin's lymphoma, non-Hodgkin's lymphoma, and lymphadenopathy, and • SLO 1.6: describe the principles of curative and palliative surgery and multimodal cancer treatment. 1.1 Biology and Classification of Tumours

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 1.1.1 Benign versus malignant tumours A benign tumour is a neoplasm that grows slowly, is well-circumscribed, is enclosed in a fibrous capsule, does not invade adjacent tissues, and does not metastasise. Microscopically, the cells resemble the parent tissue (well-differentiated), show minimal mitotic activity, and have no nuclear atypia. Examples include lipoma, fibroma, adenoma, and papilloma. Despite being non-cancerous, benign tumours can cause harm by compression of adjacent structures (for example, a meningioma compressing the brain) or by hormonal secretion (for example, an adrenal adenoma causing Cushing's syndrome). A malignant tumour (cancer) grows rapidly, invades adjacent tissues, lacks a true capsule, and has the capacity to metastasise (spread to distant sites via lymphatics or blood). Microscopically, malignant cells show pleomorphism (variation in cell size and shape), nuclear atypia, increased and abnormal mitotic figures, loss of normal architecture (dedifferentiation), and prominent nucleoli. The biological hallmarks of cancer include sustained proliferative signalling, evasion of growth suppressors, resistance to apoptosis, replicative immortality, angiogenesis, and invasion and metastasis. Fill in the blank: A benign tumour is ________ (enclosed in a fibrous capsule) and does not ________. Malignant cells show ________ (variation in cell size and shape) and abnormal mitotic figures on histology. 1.1.2 Tumour classification and nomenclature Tumours are classified by their tissue of origin. Tumours arising from epithelial tissue are called carcinomas (the most common type of cancer): adenocarcinoma (from glandular epithelium), squamous cell carcinoma (from squamous epithelium), transitional cell carcinoma (from urothelium), and undifferentiated carcinoma. Tumours arising from mesenchymal (connective) tissue are called sarcomas: osteosarcoma (bone), liposarcoma (fat), leiomyosarcoma (smooth muscle), rhabdomyosarcoma (skeletal muscle), and fibrosarcoma (fibrous tissue). Tumours of haematopoietic origin include lymphomas (lymphoid tissue) and leukaemias (bone marrow). The suffix -oma generally denotes a benign tumour (lipoma, fibroma, adenoma); however, there are important exceptions: melanoma, hepatoma, and lymphoma are all malignant despite the -oma suffix. The suffix -carcinoma and -sarcoma always denote malignancy. Mixed tumours contain more than one cell type (for example, the pleomorphic adenoma of the parotid gland contains both epithelial and mesenchymal elements). Teratomas arise from totipotent germ cells and contain elements of all three germ layers. Fill in the blank: Tumours arising from epithelial tissue are called ________, while those from mesenchymal tissue are called ________. The suffix -oma generally denotes a ________ tumour, though melanoma and lymphoma are important exceptions. 1.1.3 Staging and grading

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Tumour grading describes the degree of differentiation of the tumour cells (how closely they resemble the parent tissue). Grade 1 (well-differentiated: cells closely resemble normal tissue: low-grade: generally better prognosis), Grade 2 (moderately differentiated), and Grade 3 (poorly differentiated: cells bear little resemblance to normal tissue: high-grade: generally worse prognosis). Grade 4 (undifferentiated or anaplastic) is sometimes used. Grading is determined by the pathologist from the histological appearance. Tumour staging describes the anatomical extent of the disease (how far the cancer has spread). The TNM system is the international standard: T (primary tumour: T1 to T4 by size and local invasion), N (regional lymph node involvement: N0 to N3), and M (distant metastasis: M0 or M1). TNM categories combine to assign an overall stage (I to IV). Staging is the most important prognostic factor and determines treatment: Stage I and II are generally localised and potentially curable by surgery; Stage III has regional spread; Stage IV has distant metastasis and is generally incurable by surgery alone. Fill in the blank: Tumour ________ describes the degree of differentiation, while tumour ________ describes the anatomical extent of spread. In the TNM system, M1 indicates the presence of distant ________, and the overall stage is ________ (the highest). Figure 1.1: Benign versus malignant tumour features, tumour classification and nomenclature, and TNM staging Pilot questions 1.1

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 11. Distinguish benign from malignant tumours using six features. (Linked to SLO 1.1) 12. Classify tumours by tissue of origin and give an example of each class. (Linked to SLO 1.1) 13. Explain the suffix rule for tumour nomenclature and give three exceptions. (Linked to SLO 1.1) 14. Describe tumour grading and explain its prognostic significance. (Linked to SLO 1.1) 15. Describe the TNM staging system and state what Stage IV indicates. (Linked to SLO 1.1) 1.2 Clinical Approach to the Patient with a Tumour 1.2.1 History taking in oncology The oncological history begins with the presenting complaint: the site and duration of the lump or symptom, whether it has changed in size (rapid growth suggests malignancy), and whether it is painful (most malignant lumps are painless until advanced; pain in a bone tumour suggests periosteal invasion or pathological fracture). Key associated symptoms: unexplained weight loss (a cardinal feature of malignancy: above 10 percent body weight in 6 months is significant), night sweats and fever (the B symptoms of lymphoma), haemoptysis (lung cancer), haematuria (renal or bladder cancer), and change in bowel habit (colorectal cancer). The history must also cover: the patient's age and sex (certain tumours have age and sex predilections: osteosarcoma in adolescents; breast cancer predominantly in women), family history (BRCA1/2 mutations in breast and ovarian cancer; familial adenomatous polyposis in colorectal cancer; Li-Fraumeni syndrome in sarcomas), occupational and environmental exposure (asbestos: mesothelioma; ultraviolet radiation: skin cancer; cigarette smoking: lung, bladder, and oesophageal cancer), and previous cancer treatment (radiation-induced sarcoma is a late complication of radiotherapy). Fill in the blank: Unexplained weight loss of more than ________ percent of body weight in 6 months is a cardinal feature of malignancy. The B symptoms of lymphoma are unexplained weight loss, night ________, and fever. Asbestos exposure is associated with ________. 1.2.2 Physical examination of a tumour The structured examination of a lump follows the sequence established in General Surgery I: site and size, shape, surface, edge (well-defined or ill-defined: ill-defined edges suggest infiltration and malignancy), consistency (stony-hard suggests malignancy or calcification), fluctuance, transillumination, pulsatility, reducibility,

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