Professional Documents
Culture Documents
Table of Contents
Interface of Pathology and Clinical Medicine .............................................................................................................1
Cellular Pathology I .....................................................................................................................................................2
Cellular Pathology II ....................................................................................................................................................4
Inflammation I – Acute Inflammation ........................................................................................................................6
Inflammation II – Chronic Inflammation ....................................................................................................................9
Biology of Human Neoplasia: Introduction and Overview ...................................................................................... 12
Pathology of Human Neoplasia (The Practical Issues) ............................................................................................ 15
Molecular genetics of cancer .................................................................................................................................. 18
Identical clinical presentations can be caused by dramatically different pathologies; different pathologies will
require different treatments.
Famous people with pathology include Hubert Humphrey, Sergi Grinchov, the anonymous roofer, Elvis, and JFK.
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Cellular Pathology I
Disturbance of homeostasis:
Stress or increased demand can be met by adaptation; injurious stimuli may lead to cell injury / death.
Failure to adapt can lead to injury/death as well: e.g. adaptations to long-standing hypertension can
predispose to sudden MI.
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Reperfusion injury: previously ischemic area reperfused; inflammatory cells all enter at once; big influx of ROS
and calcium (pumps damaged) – may cause irreversible changes in cells.
Necrosis: morphological changes in nucleus & cytoplasm occurring after cell death in a living tissue. (two key
points: cell now dead but host was alive when it happened). Features:
Eosinophilia (loss of RNA/ribosomes; proteins denatured). Looks more pink.
Nuclear features: pyknosis (dark, shrunken), karyorrhexis (broken down), karyolysis (totally dissolved)
Interstitial features: inflammation (need to be alive for this to happen
Subtypes of necrosis:
Coagulative: after infarction (ischemic cell death) in solid tissues except brain. Most common.
o Tissue architecture looks same, “tombstones” of hyper-eosinophilic cells (more pink)
o Usually resolves as scar after neutrophils, macrophages scavange
Liquefactive: after infarction in brain.
o Tissue architecture lost, complete hydrolysis / digestion of dead cells
o Resolves by cyst/cavity formation
o Abscess: Liquefactive necrosis as result of localized bacterial infections (fungal, parasitic)
Accumulation of neutrophils within abscess cavity (making hydrolytic enzymes)
o Pus: dead neutrophils / cell debris
Requires surgical drainage
Caseous: “cheese-like”; after TB/fungal infections in immunocompetent individual
Granuloma: Necrotic center surrounded by rim of inflammatory cells
Fat necrosis: post-release of pancreatic lipase
o Membrane lipids broken down to FFAs, add calcium = saponification (calcium/fat deposits)
Amount of tissue damaged permanently can depend on quickness of reperfusion (e.g. post-MI or stroke).
Functional consequences can vary for same etiology, pathology, etc.
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Cellular Pathology II
Hyperplasia: increase in the number of cells in tissue/organ. May or may not include hypertrophy.
Physiologic: e.g. compensatory hyperplasia (e.g. liver), lactating breast.
Pathologic
o endometrial hyperplasia (pituitary-gonadal axis abnormalities, menorrhagia = heavy bleeding),
o benign prostatic hyperplasia (includes secondary hypertrophy of bladder muscle)
Hypertrophy: increase in individual cell mass, leading to increase in organ mass. Reversible, response to stimulus
Physiologic: muscle hypertrophy after working out
Pathologic: hypertrophic myocardium (↑cytoplasm, ↑nucleus size = “boxcar nucleus”). Could be from
chronic hypertension, aortic valve disease, or some other chronic hemodynamic overload.
Etiology:
o hormone-induced (uterus & breast in pregnancy),
o increased workload (pumping iron or pathologic / cardiac muscle)
o genetic causes (myostatin mutation)
Metaplasia: reversible replacement of one differentiated cell type by another differentiated cell type.
Adaptive substitution (new cells can better withstand environment)
Smoking-associated squamous metaplasia – better able to withstand tobacco insult
o Reserve cell metaplasia (change in reserve cell population, which are reprogrammed over time
to develop into squamous cells rather than columnar epithelium)
o May undergo neoplastic progression (normal metaplasia dysplasia cancer) especially if
insult continues.
o Example: Barrett esophagus (squamous columnar to withstand acid at gastroesophageal
junction).
Dysplasia: epithelium starts to exhibit abnormal changes; pre-cancerous but mutations starting to occur
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o Does have clinical implications – can be irreversible if hepatocytes die fibrosis cirrhosis
Apoptosis: programmed cell death.
Physiologic: embryogenesis, hormone-dependent (menstruation), mature tissue homeostasis
Pathologic:
o Response to DNA damage from radiation, free radicals, etc. (via p53)
o Viral infections (viral hepatitis)
o Cytotoxic T-cell mediated injury (transplant rejection or autoimmune conditions)
Mediators (KNOW THIS)
o Caspases: cysteine proteases that play essential role in execution phase of apoptosis. Require
activation from inactive form via activation cascade
o Bcl-2: anti-apoptotic protein (but bcl-2 family contains both pro- and anti-apoptotic proteins)
o p53: stops cell division in response to DNA damage to facilitate recovery; if recovery fails
apoptosis.
Morphology of apoptosis:
Characteristic Apoptosis Necrosis
Specific cells affected Stimulus Usually physiologic Pathologic
(necrosis = sheet of cells)
Involvement Single cells Groups of cells
Organized process;
Chromatin Uniformly dense masses No pattern
systematic breakdown of
DNA fragmentation Inter-nucleosomal Random
DNA (necrosis = smear)
Cell morphology Apoptotic bodies Swelling, degen.
Inflammation Absent Present
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Inflammation I – Acute Inflammation
Inflammation: a complex response of vascularized tissues to various stimuli, leading to the accumulation of
fluids and leukocytes in the extravascular tissues.
Triggers include trauma, ischemia, neoplasm, infection, foreign matter, immune rxns, etc.
Edema: excess of fluid in interstitial spaces or serous cavities (e.g. pleuroa, pericardium, peritoneum)
Transudate: edema with low protein content due to ↑ hydrostatic pressure
Exudate: edema with high protein content, often containing blood cells, due to ↑hydrostatic pressure
and ↑ vascular permeability
o Serous: exudate with few inflammatory cells (pale yellow)
o Serosanginous: exudate with erythrocytes (red tinged)
o Fibrinous: contains large amounts of fibrin (after coagulation of clotting factors)
o Purulent: high inflammatory cell content (often with bacterial infections)
o Supperative: purulent exudate with significant pus (liquefactive necrosis)
What is inflammation trying to do? Deliver effector cells and molecules, provide physical barrier via
microvascular coagulation to prevent spread, promote repair of offending tissue.
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3. Leukocytes extravasate & phagocytose
Want to kill microbes, ingest offending agents, degrade necrotic tissue
Lots of blood cells extravasate, not just leukocytes (RBC, platelets, etc)
Glucocorticoids help reduce inflammation by decreasing extravasation
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ii. Superoxide converted hydrogen peroxide by spontaneous dismutation
iii. H2O2 is killing molecule (and other ROS/RNS)
b. Microbial response: catalase degrades H2O2 to H2O and O2
i. Pts with Chronic Granulomatous Disease lack NADPH oxidase system genes, susceptible
to infections by catalase positive microganisms
Complement puts holes in the target, kinin is involved in vasodilation and smooth mm relaxation, clotting
involves fibrin depositing, cyclooxygenase is involved in prostaglandin formation (COX), cytokines & others get
in play too.
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Inflammation II – Chronic Inflammation
Example of organization: pleura following pneumonia, fibrin exudate, forms pleural adhesion
Phlegmon = cellulitis = opposite of an abcess (acute, overwhelming infection spreading along skin – S.
aureus & group A streptococci)
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Chronic Inflammation:
a prolonged process where acute inflammation and destruction
proceed at the same time as healing / immune response (balance)
Causes: anything that causes acute inflammation (if it persists), infections, autoimmunity (most common in US),
alloimmunity (transplants), foreign materials (insoluble, inanimate)
Clinical classification:
Primary: de novo cause (no clinically evident acute inflammation)
Secondary to acute inflammation
Histological classification:
Macrophagic (diffuse or granulomatous), e.g. TB
Lymphocytic (diffuse or focal / follicle formation), e.g. autoimmunity
Supperative (lots of neutrophils, abcess formation) e.g. osteomyelitis
Macrophagic infiltration:
1. Granulomatous: macrophages arranged into compact masses (follicles); epitheloid appearance like a
fence or barracade.
a. Granuloma = focal area of granulomatous inflammation.
i. Small cluster of epitheloid cells surrounded by lymphocytes
ii. Caseation in middle, then epitheloid layer & macrophagic giant cells; ring of
lymphocytes then fibrous tissue walling off on outside.
iii. E.g. tuberculosis
b. Epitheloid cells: pale, pink, granular cytoplasm & indistinct cell boundaries; hypodense
elongated nucleous
c. Giant cells: fusion of 6-8 macrophages (epitheloid); can contain 20+ small nuclei
i. Langhans giant cell (peripheral/horse-shoe nuclei arrangement): chronic immune
granulomata like TB or sarcoidosis
ii. Foreign body giant cell (scattered nuclei throughout cytoplasm) – e.g. asbestosis
d. Foreign body granuloma: particulate mater in middle (too large for phagocytosis by one Mφ)
e. Immune granuloma: inducing cell-mediated immmunity, Mφ present to T-cells, T-cells produce
cytokines to transform Mφ to epitheloid & giant cells
i. E.g. TB: granuloma (“tubercle”) caused by M. tuberculosis (acid-fast), usually caseating
f. GRANULOMA ≠ GRANULATION TISSUE
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Lymphocytic infiltration: hallmark of autoimmune diseases
Collection of lymphocytes in an organ that doesn’t usually have them
Diffuse or focal lymphocytic infiltrations
o Focal infiltrations: “ectopic follicles” – look just like lymph node follicles but elsewhere in body
B-cells in center, T-cells in cortex
Hashimoto’s thyroiditis: autoimmune reaction against thyroid (focal)
MS: collection of lymphocytes like follicle in brain
INFLAMMATION SUMMARY
ACUTE CHRONIC
DURATION Short (days) Long (months-years)
ONSET Acute Insidious
INFLAMMATORY CELLS Neutrophils, macrophages Macrophages, Lymphocytes, Fibroblasts
VASCULAR CHANGES Vasodilation, leakage Angiogenesis (granulation tissue)
EDEMA Yes Usually no
CARDINAL CLINICAL SIGNS Yes Usually no
TISSUE NECROSIS No Yes (ongoing)
FIBROSIS No Yes (ongoing)
SYSTEMIC EFFECTS High fever Low-grade fever, weight loss, anemia
BLOOD CHANGES Neutrophilia, lymphocytosis Variable. Polyclonal
hypergammaglobulinemia
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Biology of Human Neoplasia: Introduction and Overview
Neoplasia: clonal proliferation of cells with somatic genetic alterations and aberrant regulation of growth
Benign: don’t threaten life of neoplasm
Malignant (cancer): ability to invade into normal tissues and metastasize into distant tissues
Neoplasms generally form masses (tumors) but some (e.g. pre-invasive or in situ neoplasms) don’t form visible
masses.
Many cancers do have increased growth (↑mitotic figures & growth fraction = proportion of cycling cells).
Others replicate at normal rate & suppress apoptosis (p53, bcl-2, BAX). So if tx only focuses on proliferating cells,
may miss these that are suppressing apoptosis.
Some of these pathways do both (regulate replication & apoptosis) – so these oncogenes can be very important;
blocking their functions can even lead to regression of cancer via ↑apoptosis (“oncogene addiction”)
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a. Determined in part by routes of vascular & lymphatic drainage
(GI to mesenteric LN / liver, others to regional lymph nodes & lungs)
b. Not entirely dictated by drainage (breast, prostate, lung bone; breast/lung CNS)
3. Paget (1889) – “dependence of seed on the soil” (cancer cell on organ)
a. current research: chemokines from cancers & chemokine receptors in receptor organ tissue
Genomic instability
Many somatic genetic mutations Multiple phenotypic alterations
Most cancer cells aneuploid (abnormal # & structure of chromosomes)
Continuous rearrangement as cancer cells divide
o Shortening of telomeres – “anaphase bridging” where ends stick together in anaphase
o Inadequate mitotic spindle checkpoint (imperfect alignment & segregation)
o Problems maintaining structure: from defective DNA repair mechanisms (p53, BRCA1&2)
Leads to non-homologous recombination of broken chromosomes & translocatiosn
o Defective mismatch repair: ↑mutations at sequence level
Increased microsatellite instability (MSI)
Genomic instability important in carcinogenesis (need many mutations to make cancer) & development of
resistance to chemotherapy.
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Morphology: abnormal, with hyperchromatism (increased chromosomal material) & abnormal, irregular
shape. Structurally abnormal mitosis.
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Pathology of Human Neoplasia (The Practical Issues)
Ways to characterize:
1. Patterns of differentiation (Epithelial, Mesenchymal, Hematopoetic, Melanocytic, Glial)
2. Sub-types: e.g. for epithelial neoplasm: squamous, glandular (adeno), basal/basaloid, transitional
(urothelial), undifferentiated. Each pattern of differentiation has its own sub-types
3. Morphology: papillary, cystic, polypoid, mucinous, etc.
4. Benign (have very minimal risk of progressing to malignancy) and malignant tumors
Borderline or low malignant potential tumors: don’t fall into these categories well
E.g. carcinoid tumor – neuroendocrine differentiation; respiratory / digestive systems; big range of
malignancy.
Multiple patterns of differentiation:
epithelial + mesenchymal = fibroadenoma (benign) or carcinosarcoma (malignant).
Tetroma: more than one germ cell layer from pleuripotential cells
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Characteristics of benign cells Characteristics of malignant cells
Relatively low nuclear: cytoplasmic ratio Increased nuclear size (high N:C ratio)
Round nucleus, even distribution of chromatin, small or Irregular nuclear shape, irregular distribution of
inconspicuous nucleoli chromatin, prominent nucleoli
Maintenance of cellular polarity and differentiation Loss of cellular polarity and variable loss of
differentiation
Mitoses are uncommon, are located in usual location Mitoses are common, located above basal cell layer,
(e.g., basal layer), and have typical appearance and have atypical appearance.
These are descriptive characteristics, not rules (consideration of all features in context is important)
Cytopathology: characterizing malignancy, etc. based on these features (e.g. Pap smear for aspirated cervical tissue)
Ancillary techniques
Immunohistochemistry
No single marker but some are useful (e.g. p63 for normal basal cell layer in prostate; if missing =
cancerous; AMACR overexpressed in most prostate cancers)
Mostly not helpful for benign vs malignant but can be used to phenotype tumor (e.g. heomatopoetic
neoplasms – use on suspended cells post-flow-cytometry.
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o PSA: mortality has declined post-PSA introduction
o Associated with over-Dx and over-Tx of disease
o Some mixed studies on benefits in terms of mortality
Research: better early detection, monitoring disease (mass spec, DNA from cancer cells).
Still need tissue diagnosis before Tx currently (limits of sensitivity & specificity)
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Molecular genetics of cancer
Theory of genetic basis: need social controls on cells; have a high mutational load of a complex organism.
Average human gene mutated 1010 times in lifetime (almost all somatic)
We handle our mutational load well:
Protect the germline cells (separation from somatic cells early in embryological development)
Innate resistance to tumorigenesis (single mutation inadequate)
Clonal selection theory: tumorigenesis occurs as serial expansion of successive clones of cells,
punctuated by acquisition of certain mutations which give a cell and progeny a selective growth
advantage over neighboring cells
o Why are so many mutations needed? Downregulation mechanisms protect cells (need multiple
mutations to inactivate downregulatory syndromes & accumulate small effects to cause
selective advantage)
o Clonal changes (present in all cells of a neoplasm) indicate important events
o Genetic / epigenetic heterogeneity arises (even though genetic instability not universal in
neoplasms) – genetic instability just accelerates
o Clone is population that derives from single cell; offspring (subclones) compete to see who can
dominate neoplasm (with selection). Otherwise you’d just end up with heterogenous group &
benign neoplasm. Have to select each time one by one or else tumor mass would be huge
o Subsets with worse prognosis = those with more mutations
o Neoplasms arise from chance events so genetic profile varies from pt to pt (individualize
therapy)
Pediatric tumors may be exception (arise in window of opportunity & don’t resemble
adults: maybe need fewer mutations & not as many steps)
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o Chromatin structure
3. DNA-maintenance genes: genes inactivated by mutations, often before tumorigenesis (need second hit
for selective advantage)
o DNA repair genes (e.g. xeroderma pigmentosum genes)
o Chromosome stability genes (BRCA2, etc.)
4. Passenger mutations: have no special meaning in the neoplasm
Types of mutations:
Amplification: overproduction of proteins
Rearrangement / translocation: fusion of two genes from different proteins or oncogene placed behind
strong promoter
Small mutation: e.g. point mutation, can activate or inactivate gene
Large deletion: often a second hit – cause inactivation of suppressor gene, or loss of heterozygosity
(LOH), exposing first hit’s mutation
Viral insertion: can allow viral oncogenes to continue to be expressed
Telomere shortening: can cause genetic instability, deletions, translocations. Re-activation in
malignancy helps prevent extreme of this process (cell death) in malignant tumor cells
Rational therapy:
Old model: screen all kinds of toxins for ability to kill cancer cells in culture
New model: look for specific biochemical properties
New ideas: augment deficient function(p53 – hard); replace function (hard without gene therapy working);
inactivate a function (Gleevec – very successful); take advantage of neoplastic defect; re-express genes;
augment immune responses
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Acquired drug resistance via mutations: from mutations in drug-binding pocket; mutations causing
compensatory increase in activity, or mutations eliminating cell’s toxic response
Carcinogens
Dietary / environmental:
o can use Ames assay (expose to potential mutagen; count colonies on plate that have mutated,
subtract background rate), others (cheaper in bacteria, really expensive in animal models).
o End up only screening things that are pretty certain to be carcinogenic
o Some are suspected carcinogens
o Example: Aflatoxin causes p53 mutations in hepatocellular carcinomas in Africa & China
Infectious causes:
o Indirect mechanism: mitogenesis & inflammation (e.g. HBV & hepatocellular carcinoma, H.
pylori & gastric cancer)
o Direct mechanism: viral proteins that inactivate tumor-suppressor genes (e.g. HPV & cervical
cancer)
Non-mutated genes can also play a role (may be over- or under-expressed in neoplasms & provide good
background for neoplastic development
What is a neoplasm
“A clone of cells distinguished from other tissues by autonomous growth and somatic mutations”
Mutations in growth-controlling genes
Supporting, reactive tissues accompany tumor growth
Grow in conditions that would otherwise be limiting
Caveats:
All neoplasms have been found to have somatic mutations
Inciting stimulus usually not shown for neoplasms
Neoplasms often do control their own proliferation, but control is altered & cell # increases (evidence:
most neoplasms are benign)
Other masses & proliferations
o Keloids, developmental abnormalities, granulation tissue, synovitis, etc.
o As long as it’s not clonal, it’s not a neoplasm
Neoplasms are not always masses (e.g. leukemias, etc.)
Neoplasms are not just a proliferative abnormality (this would just be hyperplasia) but rather a large
increase in stem cell # (clonal)
Mutations in growth controlling genes can be inherited rather than acquired (insufficient to cause
neoplasms on their own). ADDITIONAL SOMATIC MUTATIONS ALWAYS REQUIRED.
FAP VS HNPCC (Familial Adenomatous Polyposis vs. hereditary nonpolyposis colorectal cancer)
FAP: first change occurs quickly (lots of early adenomas) but it takes around 20 years to accumulate more hits
HNPCC: first change occurs slowly, but fast progression afterwards (2 years) – harder to treat
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