NEOPLASIA

(2012-2013)
Dr.H.M.Zahawi,FRC.Path

What is a NEOPLASM ? What is benign/malignant ? What is CANCER ? What are the different types of cancer ? How & why does is it occur ? How do cancers spread ? How do cancers affect the body ? How is cancer diagnosed ? How can it be prevented ?

Definitions :

Neoplasm = New growth of cells producing a

mass Benign neoplasm = Limited new growth without invasion or spread Malignant neoplasm = invasive growth locally, which also spreads to distant sites.

Carcinoma : Malignant tumor of epithelial cells Sarcoma : Malignant tumor of connective tissue cells Lymphoma: Malignant tumor of lymphoid ts.

Cancer is a general term for all malignant growths of whatever type Tumor may be used instead of neoplasm but the term is not accurate Oncology : study of cancer in all its aspects

NEOPLASM :

Abnormal mass of tissue, the growth of which EXCEEDS and is UNCOORDINATED with that of of the normal tissues, and PERSISTS in the same way even AFTER REMOVAL of the stimulus which produced the change . Neoplasms grow from transformed cells !

Features of transformed cells :

ANY CELL IN THE BODY CAN TRANSFORM & ACQUIRE NEW FEATURES

Uncontrolled growth Useless Persistent

This transformed cell may arise from : A- One germ layer :

Endoderm Mesoderm Ectoderm

e.g: epithelial cell, connective tissue, endothelial cell, blood , BM, lymph node, others B- More than one germ layer C- Mixed

Classification of neoplasms :
What is the purpose of classification?

To provide help in diagnosis To allow correct treatment

How are tumors Classified ? Cell of origin Behavior of tumor Degree of differentiation

Structure of neoplasms :

Parenchymal cell & Stromal (supporting) cell Degree & type of stromal cells may contribute to the appearance of tumors
If there is stromal proliferation hardness of the tumor Scirrhous tumor Desmoplasia If there is lack of many stromal cells, the tumor may be soft or cystic

Serous cystadenoma of ovary

Scirrhous Carcinoma of breast

Benign Epithelial tumors :

Adenoma - glandular epithelial tumor often producing a secretion e.g. (mucin) which may be intraepithelial or intraluminal Papilloma / Polyp epithelial tumor forming finger like projections from an epithelial surface with a connective tissue center, often projecting from the mucosal surface of a hollow organ

Structure of Polyp( Adenoma)

Squamous Papilloma

Malignant epithelial tumor : Carcinoma

Squamous cell carcinoma e.g. skin,mouth, cervix, bronchus.etc Adenocarcinoma from glandular origin, e.g.G.I.T.,endometrium,breast, kidney, thyroid..etc

Connective tissue cell origin :

Benign : Named by tissue of origin with attached suffix oma e.g. fibroma, lipoma, chondromaetc

Malignant connective tissue tumors:

SARCOMA : Prefix (origin)+ suffix (sarcoma) e.g. Osteosarcoma, liposarcoma , angiosarcoma, leiomyosarcoma , rhabdomyosarcoma

Nomenclature: Cell of origin + Suffix

Suffix - oma Carcinoma / Sarcoma Fibroma Fibrosarcoma Osteoma Osteosarcoma Adenoma Adencarcinoma Papilloma Squamous cell carcinoma Chondroma Chondrosarcoma Exceptions: Leukemia, Lymphoma, Glioma

Some tumors are MIXED !!!

Mixed Tumors :

Tumors derived from a single germ cell layer that differentiates into more than one cell type..e.g. mixed tumor of salivary gland, Fibroadenoma of breast
OR :

Teratomas made of a variety of parenchymal cell types that derive from more than one germ cell layer formed by totipotent cells that are able to form ectoderm, endoderm & mesoderm

TERATOMA :

May be benign or malignant depending on structure, site, age, sex . Contain skin ,sebaceous & mucus glands,hair,cartilage, bone, respiratory epithelium, glial tissue..etc.
Usual location is ovary or testes

Tumors of primitive fetal origin :

Blastoma : from immature tissue

May arise in kidney, liver, retinaetc e.g. Retinoblastoma

The great majority of these tumors are malignant & occur in infants & children

Some tumors have names that do not conform with general rules :
Melanomas arise from nevus cells Seminomas arise from testicular germ cells Lymphomas arise from lymph nodes Some tumors are named eponymously e.g. Hodgkins disease, Wilms tumor.etc Note : See table on page 164

Some tumors are NOT true neoplasms

Hamartoma :
Tumor like malformation in which there is abnormal mixing of normal components of the organ ,either in the form of change in quantity or arrangement of tissue elements. e.g. Lung Hamartoma.

Choristoma :

Different types of tissue, ectopic to the region. e.g. Diverticulum in small intestine , (Meckles D.) containing gastric tissue Both hamartoma & choristoma are present at birth & do not become malignant .

How do benign & malignant tumors differ?

Differentiation & anaplasia Rate of growth Presence of capsule Local invasion Distant metastases

Benign versus malignant tumors

1- Differentiation:
-

This indicates the degree of resemblance of the tumor cell to its cell of origin, functionally & morphologically. e.g
Cells of a lipoma may look exactly like normal fat cells.

LIPOMA

LIPOSARCOMA

Features of differentiation include :

Epithelial cells : - formation of glands - formation of keratin - formation of secretionetc Connective tissue cells : - formation of osteoid - presence of lipoblasts - Striations in tumors of skeletal muscle.etc

NORMAL

When a tumor cell loses its differentiation it gradually gains features of DYSPLASIA

Dysplasia is an abnormal growth in which there is a process of gradual loss of differentiation. It is may precede malignancy Complete loss of differentiation ANAPLASIA

Severe Dysplasia/ Anaplasia

Cytological Features of Dysplasia Increased nuclear size , N/C ratio Variation in nuclear & cell size : PLEOMORPHISM Loss of differentiating features Increased nuclear DNA content HYPERCHROMATISM

Features of dysplasia (continued) :-

Nucleoli :Prominent, sometimes multiple Mitotic figures : Increased

Abnormal mitoses: may be present

Loss of normal stratified arrangement in an epithelial surface

Intraepithelial Neoplasia
Dysplasia involving an epithelial surface Low grade & High grade High grade dysplasia ,limited by epithelial basement membrane CARCINOMA IN SITU

Intraepithelial Neoplasia

Carcinoma in Situ

B.M.

Invasive squamous cell carcinoma

NOTE :

Not all dysplasia progress to higher grade or carcinoma in situ. Not all carcinoma in situ progress to invasive CA

2- Rate of growth

Rate of growth usually correlates with level of differentiation May be rapid in some benign tumors EXAMPLES ??? Some tumors may shrink in size HOW ??? Some malignant tumors may outgrow their blood supply

Some tumor growths are semicontroled : HORMONE DEPENDENCE :

This is through presence of receptors on surface - Breast CA - Thyroid CA - Prostatic CA IMPORTANT FACT !! WHY ???

3- Local invasion & Encapsulation

Benign tumors frequently have a capsule Malignant tumors progressively invade & destroy surrounding tissue e.g.Breast cancer infiltrating skin Basal cell carcinoma face infiltrating nerve *Second most important feature distinguishing malignant tumors

4- Metastasis :

Spread of malignant tumors to distant sites not contigious with the main tumor Most important in diagnosing malignancy All tumors can potentially metastasize except BASAL CELL CARCINOMA Metastasis is often proportionate to the size and differentiation of the primary tumor

Routes of metastases :

Lymphatics Blood vessels Seeding within body cavities/ Transcoelomic Spread

1- Lymphatic Spread :

More characteristic in Carcinoma Spread follows the anatomical route of drainage e.g. Breast cancer in left upper upper quadrant Left axillary L.N. In medial quadrant internal mammary chain supraclavicular & infraclavicular Lung Ca:Peribronchial tracheobronchial LNs hilar LNs

IMPORTANT IN SURGICAL RESECTION :

Sentinal Lymph Node : First lymph node in the pathway of a primary tumor. Usually outlined by dye Not all enlarged L.N.s indicate metastases e.g. Reactive hyperplasia Histiocytic infiltrate in sinuses

2- Hematogenous spread :

Usually venous first following anatomical drainage : Lung & Liver More characteristic of Sarcoma ,but may in occur in later stages of carcinoma Certain carcinomas invade veins early RENAL Carcinoma renal vein IVC Hepatocellular Carcinoma Portal &Hepatic v.

3- Transcoelomic spread:

Within peritoneal or pleural cavity e.g.: CA of upper lobe of lung to lower lobe CA of stomach to ovary CA of ovary tends to spread widely through peritoneal surface CA of colon across peritoneum to S.I.& colon

Summary : Differences between benign & malignant neoplasms

BENIGN

vs

MALIGNANT
Anaplastic High mitotic index Rapid growth Infiltrative growth without capsule Invasion Metastases

Well-differentiated Low mitotic index Slow Growth With capsule No invasion No metastases

EPIDEMIOLOGY of CANCER

CANCERS in USA
Males Females

Prostate Lung & bronchus Colon & Rectum ----------------------------Cancer Deaths Lung & Bronchus Colon & rectum Prostate

Breast Lung & Bronchus Colon & Rectum ----------------------------Cancer Deaths Lung & Bronchus Breast Colon & rectum

CANCERS common in JORDAN 2008 :

M A L E S F E M A L E S Colorectal Lung Urinary Bladder Prostate Leukemia

Breast

Colo-rectal Corpus Uteri Thyroid Non- Hodgkins Lymphoma

WHAT FACTORS may influence the incidence of cancer ?

Incidence may be related to

Genetic polymorphism : Individual predisposition to disease Individual response to environmental agents Individual response to drugs e.g. P450 Ethnic Factors

1&2- Geographic & environment & other factors (Multifactorial)

Prostatic CA ---- High in USA Colorectal CA ----High in USA Breast CA ---- High in USA Gastric CA -- High in Japan Skin CA------ High in New Zealand Hepatocellular CA ---High in Africa ,China Nasopharyngeal CA--- Far East Burkitt Lymphoma ----- Africa

Environment :

Diet Occupation Sunlight Personal habits Overweight

3- Age :

In general , cancer incidence AGE However , certain cancers occur more in children Acute Leukemia Some Lymphoma Some CNS Tumors Bone &soft tissue Sarcomas Blastomas

4- Heredity :

5-10% of tumors

A- Inherited Cancer Syndromes : Presence of defined genetic abnormality, usually AD, often specific phenotype e.g.

APC gene : Familial Adenomatous Polyposis Coli MEN1 & RET genes : MEN syndromes NF1 & NF2 genes : Neurofibromatosis skin pigmentation RB gene : Retinoblastoma

B - AR syndromes of DNA Repair :

Chromosomal & DNA instability Best example :

XERODERMA PIGMENTOSUM

C- Familial cancers : No specific phenotype & multifactorial

Family members have higher incidence to common cancers

- CA of COLON - CA of BREAST - CA of OVARY

Younger age groups, multiple or bilateral, two or more family members are affected. Some linked to inheritance of mutant genes e.g. BRCA-1 & BRCA-2

5- Acquired Preneoplastic Syndromes

These are associated with increased risk for CA and most are related to rapid or abnormal cell proliferation .
1- Endometrial Hyperplasia & carcinoma 2- Cervical Leukoplakia (Dysplasia) & Cervical Squamous cell CA. Also oral leukoplakia. 3- Bronchial epithelial dysplasia & lung & Squamous cell CA

Acquired preneoplastic syndromes (continued)

4- Liver Cirrhosis & Hepatocellular CA 5- Ulcerative Colitis & Colorectal CA 6- Villous Adenoma & Colorectal CA 7- Others

MOLECULAR BASIS OF CANCER

Neoplasms arise from a single clone of cells :

Group of cells produced from a single ancestral cell by repeated cellular replication. Thus they can be said to form a single "clone". MONOCLONAL

Steps in Neoplastic Transformation :

1-Non lethal damage TRANSFORMATION
2-Cell Proliferation : initially Polyclonal MONOCLONAL CELLS 3-Genetic instability of malignant phenotype cells with diverse features progression of tumor INVASION & METASTASES

Principles :

Tumors arise from clonal growth of transformed cells that have developed mutations in four classes of genes :

Growth promoting proto-oncogenes Growth inhibiting tumor suppressor genes Genes regulating apoptosis Genes involved in DNA repair

More than one mutations in above result in abnormal growth of cells

Genes in Neoplastic Transformation:

Carcinogenesis is a MULTISTEP PROCESS !

Transformed Cell

TRANSFORMATION & PROGRESSION Self-sufficiency in growth signals Insensitivity to growth-inhibiting signals Evasion of apoptosis & repair Angiogenesis Limitless replicative potential: Telomerase Invasive ability Metastatic ability

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Tumor Progression : This is the stepwise accumulation of mutations resulting in increasing features of malignancy.

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Gene Lesions in Tumors

- Non detectable - Detectable

Different Gene Lesions :

1- Point mutation : Change in a single base in a nucleotide sequence may activate an oncogen, or inactivate a tumor suppressor e.g. RAS oncogen (codon 12, 13 ) in Pancreatic carcinoma

2- Translocation :
Balanced t. mainly in lymphoid and hematopoietic tumors :

Burkitt Lymphoma : 8;14 Follicular B cell Lymphoma : 14;18 Chronic myeloid leukemia : 9;22

( PHILADELPHIA Chromosome )

Fusion Gene is produced: BCR- ABL

(tyrosine kinase activity)

Other fusions identified in some prostate & lung CA.

Balanced translocation seen in some solid tumors : Ewing Sarcoma t.(11;22)(q24;12)

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3- Gene amplification :
- Double minutes : small fragments of extrachromosomal DNA - Homogenous staining regions produced by chromosomal segments with various lengths and uniform staining intensity Examples : - Neuroblastoma : N-MYC - Breast carcinoma : HER2/Neu

Gene Amplification :

4-

Chromosomal deletions: More in nonhematopoietic & solid tumors e.g. Retinoblastoma 13q band14 also several in colorectal CA

5- Chromosomes loss or gain : Change from the normal multiples of 23 ( Aneuploidy)

Result : Change in structure or quantity of gene product

Other Methods influencing Transformation

Micro RNAs : Single stranded RNA of about 22 nucleotides act as regulators of genes Overexpression of miRNAs can contribute to carcinogenesis by the expression of tumor suppressors. Deletion or loss of expression of miRNAs can lead to overexpression of proto-oncogenes. Epigenetic changes : approximately stepwise process by which tumor suppressor genes and DNA repair genes can be silenced . This is modified by environmental influences, & occurs by methylation.

GENES IN NEOPLASTIC TRANSFORMATION

1-Genes coding for growth : Classified by site of action Proto-oncogenes are dominant genes. Mutant proto-oncogenes Oncogenes oncoprproteins They include :
Growth factors Cell surface receptors Signal transduction proteins Nuclear transcription factors Cell cycle proteins Inhibitors of apoptosis

1-Oncogenes coding Growth Factors

Cell growth is stimulated by its own GF or from other cells :

Platelet derived growth factor (PDGF) seen in glioblastomas Fibroblast growth factor(FGF)-stomach CA & melanomaetc Transforming Growth Factor (TGF-)in sarcomas

Products of other oncogens (e.g.RAS) may cause over expression of GF

2-Oncogenes coding Growth Factor Receptors

GF integrate with membrane receptors tyrosine kinase activity nucleus Mutant receptor continuous signals even in the absence of GF..OR Normal but overexpressed hypersensitive to GF Epidermal GF receptor family: ERBB1 in 80% of sq.CA lung ERBB2 ( HER 2 NEU) in 25-30% of breast & ovarian CA --Increase = POOR PROGNOSIS

3- Oncogenes in Signal Transduction:

RAS & non receptor ABL RAS action:

Active RAS
GDP GTP proliferation

GTPase activity by (GAP)

Mutations in GAPs(NF1):Neurofibromatosis Commonest oncogen mutation Point mutations in codon 12, 13 are present in 30% of cancers, specially CA pancreas &Colon

Action of ABL : Non receptor associated tyrosine kinase signal transmission

Normal ABL is located in nucleus where it promotes apoptosis Chronic myeloid leukemia : Mutation 9:22 translocation BCR- ABL gene This new gene protein is retained in cytoplasm where it has tyrosine kinase activity cell proliferation New action is Proliferation +No Apoptosis

4-Nuclear Transcription Factors : DNA transcription regulated by genes e.g. MYC*, JUN, FOS.etc. In normal :MYC protein + DNA Activation of Cyclin Dependant Kinases ( CDKs) initiation of cell cycle MYC MYC mutation sustained activation Examples :

Dysregulation of MYC present in Burkitts lymphoma due to translocation (t8:14) Breast ,colon, lung CA & neuroblastoma

5- Cyclins & Cyclin Dependant Kinases regulate Cell Cycle phases

Family of proteins that control entry of the cells at specific stages of cell cycle ( D, E, A, B.etc.) Level of a specific cyclin increases at a specific stage, then decreases rapidly after the cell departs that stage Function by phosphorylating certain proteins ( e.g.RB protein) Cyclins bind to CDKs, activating them

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Two important groups :

- Cyclin D family CDK4 & CDK6 at G1 S phase checkpoint - Cyclin B-CDK1 activate G2 M transition

Activity of CDK/ Cyclin regulated by CDK inhibitors Selective or nonselective inhibition Examples : p21, p27inhibit all CDKs while p15, p16inhibit CDK4 &CDK6 Expression of p21 is controlled by the tumor suppressor protein p53 G1 phase arrest in response to a variety of stress stimuli.

Mutations that disregulate activity of cyclins & CDKs cell proliferation Examples : Cyclin D is overexpressed in breast, liver, & esophageal cancers Amplification of CDK4 gene present in melanoma, sarcomas, glioblastoma

2- Cancer Suppressor Genes:

Growth inhibitory pathway by:

* Regulate cell cycle : Rb gene

* Regulate cycle & apoptosis: P 53 * Block GF signals: TGF- * APC regulates -catenin

Cancer suppressor genes are recessive genes which may be lost in familial or sporadic cases.

In cases with familial predisposition for development of tumors, affected persons inherit one defective (nonfunctional) copy of a tumor suppressor gene and lose the second one through somatic mutation. In sporadic cases, both copies are lost through somatic mutations.

1- RB gene : First studied in Retinoblastoma: Called RB gene Both copies of gene must be lost for neoplastic transformation to occur This is called loss of heterozygosity

Retinoblastoma :

Autosomal dominant hereditary disease (40%) May be sporadic (60%) In familial, patients carry one mutation in their genome, followed by second mutation in retinal cells
No tumor develops unless two alleles in 13q14 become mutant (two hit theory) incidence of bilateral Retinoblastoma and osteosarcoma in hereditary forms

Inheritance of Retinoblastoma

Mode of action of RB gene:

RB exists in active nonphosphorylated & inactive phosphorylated forms. Active RB binds to transcription factors (E2F) NO TRANSCRIPTION CyclinD/CDK4, and cyclinE/CDK2 phosphorylate RB. Inactive RB releases transcription factor E2F TRANSCRIPTION (G1 S phase ) Many oncogenic DNA viruses (HPV)may act similarly by inactivating RB

2- p 53

p53 is a negative regulator of cell cycle 70% of tumors show homozygous loss of p53 (commonest suppressor) Guardian of the Genome OR (Policeman) preventing genetically damaged cells from progressing through new cycle.

p53 is inactivated by its negative regulator,MDM2.

Upon DNA damage or other stresses, various pathways will lead to the dissociation of the p53 and MDM2 complex.

Mode of activation & action :

P53 senses DNA damage through various sensors e.g. ATM protein ** P53 is also activated by anoxia Activated p53

Transcription of CDKI(p21) cell cycle arrest at G1 Transcription of GADD45 ( repair gene) p53 is a regulator of apoptosis

Result :

More time for repair Normal Failed repair Apoptosis or Senescence (permanent cell cycle arrest)

Fixed mutation NEOPLASIA

Significance of p53 mutation :

Acquired mutation in many cancers e.g. colon, breast, lung , leukemiaetc Inherited mutation in one allele Li - Fraumeni S. 25 fold malignancy: sarcoma, leukemia, breast carcinom and gliomas .. etc May be blocked by some DNA viruses (EBV) producing viral induced cancers

3- TGF-

Antiproliferative activity: - regulation of RB pathway at G1 by action on some cyclins & CDKs - blocks GF signals Mutational inactivation of TGF- components seen in 100% of pancreatic carcinoma & the majority of colonic CA

4- Contact Inhibition :

Contact inhibition is maintained by interactions between transmembrane proteins (E- cadherins )

1- NF2 gene product ( merlin ) 2- APC gene E- cadherins are reduced in many cancers.

Action of APC gene :

Gene product is a cytoplasmic protein , acts in adhesion by regulating the destruction of -catenin in cytoplasm : APC + -catenin + E-Cadherin Adhesion Destruction Complex
Mutant APC release of -catenin nucleus Result stimulates proliferation

Individuals with inherited one mutant allele of APC develop 100s to 1000s of adenomatous polyps in their 2nd.3rd.decade of life Additional mutations colonic carcinoma 100% risk in familial polyposis coli
70-80% of sporadic colonic carcinoma show mutant APC

3- Evasion of Apoptosis :

Extrinsic pathway through binding of CD95 to receptor ultimately activating EXECUTIONER CASPASES Apoptosis. Some tumors have levels of CD95 Apoptosis Intrinsic pathway :Mutations in genes of BCL-2 family involved in programmed cell death which regulate mitochondrial permeability through CASPASES promoting or suppressing apoptosis.

BCL-2 Family :
BAX, BAK promote permeability BCL-2 , BCL-XL inhibit permeability BH3-only protein regulates the balance BCL-2 prevents apoptosis, prolonging life. Activated by translocation (18:14) (q32;q21) Follicular B cell Lymphoma

Autophagy :

Normal process in cells Cancer cells may accumulate mutations avoiding autophagy, OR alter the process making it inefficient.

Result : Prolonged cell life !

4-Limitless replication potential(Telomeres)

These are specialized structures at the end of chromosomes which are shortened after each division and may play a role in determining the life of individual cells. Shortening is prevented by TELOMERASE Active in stem cells, not in somatic cells In many cancers, telomerase is reactivated. Majority of cancers telomerase

5- Genomic instability due to defective DNA Repair Genes

Repair mutations in other genes Persons with inherited mutations in these genes are at risk for cancer
These include :

1- Nucleotide excision repair genes

Damage by U-V light . Defective in

Xeroderma Pigmentosum

Damage by ionizing radiation & drugs e.g. nitrogen mustard (Blooms S)& (ATM)

Repair genes (continued) 2-Mismatch repair genes : These repair errors in pairing of nucleotides during cell division (Spell Checkers) Microsatellite Instability (MSI)

e.g. G+T instead of A+T

( HNPCC). (Hereditary Nonpolyposis Colonic Ca.) Several types found in familial and sporadic cancers ( 15%)

Repair genes ( continued) : 3- BRCA -1 & BRCA-2 ? Mode of function 80% familial breast cancer & ovarian CA BRCA 2 in breast CA in both sexes, e.g: prostate,ovary, pancreas, stomach CA

Rarely inactivated in sporadic cases.

6- Development of Sustained Angiogenesis :

Tumors remain small or in situ ( <1-2mm.diameter) without angiogenesis Angiogenesis Antiangiogenesis Angiogenic Switch

Angiogenic Factors :
Controlled by HYPOXIA which induces angiogenic factors by tumor cells
1. Hypoxia-Inducible Factor (HIF-1)VEGF 2. RAS mutation VEGF 3. Proteases from tumor or stroma VEGF

Anti- Angiogenesis :
1. Thrombospondin1(TSP-1)induced by P53

Inactivation of P53 Angiogenesis

2. VHL protein destroys HIF-1 No VEGF

Both P53 &VHL are tumor suppressors

Germ line mutation of VHL von Hippel-Lidau Syndrome hereditary renal CA hemangiomas in CNSetc

3. Angiogenesis inhibitors from stromal cells in ECM : Angiostatin, Endostatin, Vasculostatin

vascular density = Poor prognosis

7- Ability to invade & metastasize

Tumors may generate clones with different phenotypic features, accumulate mutations, leading to a more aggressive nature e.g.

Non antigenic growth , Increase rate of growth, Invasion, Metastases etc

Rate of generation of these clones differs in individual tumors e.g.

Osteosarcoma versus Basal Cell Carcinoma

Metastatic Pathway:

Metastases occurs in two phases :

1- Invasion :

Loosening of intercellular junctions Attachment Degradation of ECM Migration 2- Vascular dissemination

1- Mechanism of invasion of ECM :

1- Detachment of tumor cells

Inactivation of E-Cadherin OR activation of catenin detachment of cells - Loss of function E-Cadherin in many CAs 2- Degradation of ECM by proteases :e.g. Matrix Metalloproteinase (MMPs) Cathepsin D, Type IV collagenase Result of digestion of ECM Cleavage products of matrix have chemotactic activity for more tumor cells

3- Attachment of tumor cells to matrix components by laminin & integrin receptors to ( basement membrane ) & ECM 4- Migration of tumor cells : Tumor derived cytokines e.g. Autocrine motility factor

2- Vascular dissemination :

1- Invasion of the circulation : Adhesion to endothelium retraction of endothelium vessel 2- Attack by NK cells, some escape by formation of a thrombus 3- Escape from circulation : Adhesion to endothelium retraction of endothelium escape to tissue

WHAT INFLUENCES SITE OF METASTASES ?

Anatomical Location Complimentary adhesion molecule between tumor cells & target organs Chemoatractants liberated by target organs Protease inhibitors present in certain tissues

Examples of Tropism ( Homing )

Lung Carcinoma Adrenals & Brain Neuroblastoma Liver & Bone

Less common sites of metastases include skin,muscle , thyroid, breast ,heart .etc.

Spleen , Cartilage , are almost never involved by metastatic tumours.

CARCINOGENIC

AGENTS

1- CHEMICAL Carcinogens 2- PHYSICAL Carcinogens 3- MICROBIAL Carcinogens, mainly VIRAL

- CHEMICAL CARCINOGENS :

Chemical carcinogens are electrophilic and enter nucleus, damage DNA mutation Initiated Cell . Therefore :
Initiator - Chemical inducing irreversible DNA damage Promoter-Augment effect of initiator by promoting cell growth

PROMOTORS in chemical carcinogenesis Promoters sometimes promote growth in the Initiated cells so that they proliferate FASTER than normal cells. They have to be used AFTER the initiator.

HORMONES PHORBOL ESTERS (TPA), activate kinase C PHENOLS DRUGS

Carcinogens are divided into : Direct Carcinogens Directly produce damage without prior metabolic conversion Indirect Carcinogens(Procarcinogen) Need metabolic conversion in liver by cytochrome P-450 dependent monooxygenases ultimate carcinogen

Major types of Chemical Carcinogens :

1- Alkylating Agents : Direct, used in chemotherapy of cancer may induce Leukemia 2- Polycyclic Hydrocarbons : Indirect & very strong , include benzidine , smoke...etc. e.g.cigarette smoke CA Lung 3- Aromatic Amines & Azo dyes : Rubber & Food Industry e.g. naphthylamine Bladder CA

Chemical carcinogens ( Continued) 4- Nitrosamines : Endogenous or food preservatives e.g.Gastric & Colon CAetc.

5- Aflatoxin B1 : Naturally occurring carcinogen present in fungus. Aspergillus flavus Hepatocellular CA

Mode of action in chemical Carcinogens Chemical carcinogens contain highly reactive electrophil groups that combine to DNA, RNA, or proteins producing mutations
Genes commonly affected are RAS & P53 May be very specific Signature Mutation Some strong chemicals act as Initiator & Promoter e.g. polycyclic hydrocarbon

2- PHYSICAL CARCINOGENS :

U-V light : - Effect depends on intensity of exposure & quantity of melanin - Production of pyrimidine dimers in DNA MUTATION in RAS , P 53 - Failed repair Skin CA - Skin cancer includes :
Squamous Cell CA Basal Cell CA

Ionizing Radiation:

- Explosions Leukemia after 7 yrs. Latent period Breast,colon, thyroid, lung CA - Therapeutic exposure Thyroid CA, Leukemia - Mechanism:Free radical injury Mutations in RAS, RB. P53 Asbestos fiber inhalation : Mesothelioma & Lung CA

3- Microbial CARCINOGENESIS :
1- HPV-Human Papilloma Virus Benign squamous papilloma (wart) groups 1,2,4 & 7 * Low risk groups (6, 11) Genital Squamous Cell Papilloma * High risk group ( 16, 18 ) Squamous Cell CA in cervix, vulva, perianal & oropharyngeal regions

Mode of Action :

HPV have transforming early genes (E6,E7) inactivate suppressor genes E6 acts on p53no apoptosis E7 binds to E2F blocks Rb action & activates cyclins, & inhibit CDKI High risk groups have a stronger affinity of early genes to E2F Result Cell proliferation

2- EBV : Ebstein Barr Virus

BURKITTS LYMPHOMA **

----------------------------------------

B CELL LYMPHOMA HODGKINS LYMPHOMA subset NASOPHARYNGEAL CA

Post transplant lymphoma CNS Lymphoma in AIDS patients

Mode of action in Burkitts Lymphoma :

EBV has LMP1 gene- receptor for B cells

Induce B cell proliferation Prevents apoptosis by activating BCL2

Controlled POLYCLONAL B proliferation Dysregulation of c- myc by translocation : BURKITTS Lymphoma (t 8:14)

Malaria & Malnutrition may play a role in immunity ( Lost T cell control ). In endemic cases EBV is identified in tumor cells

In Nasopharyngeal Carcinoma : LMP 1 is expressed on epithelial cells activating cell proliferation ======================== LMP 1 also activates pro- angiogenic factors Both in Burkitt Lymphoma & Nasopharyngeal Carcinoma other environmental factors play a role

3-Hepatitis B & Hepatitis C Viruses

Multifactorial oncogenic effect but mainly Immunologically mediated chronic liver disease Cirrhosis Hepatocellular CA in 70 -85% .

In both types there is inflammations mediators cell death cell proliferation & progressive mutations !

In addition : The HBV encodes Hbxprot. Has dual action : Acts as growth promoting gene Hbx binds to p 53 Inactivates suppressor function

The HCV has HCV core Protein which may act through activating signal transduction Proliferation

4- Oncogenic RNA Viruses :

HTLV-1 induces Leukemia /Lymphoma Transmitted sexually,blood or milk Mode of action : Virus TAX gene attaches to T cells: Produce cytokines +receptor autocrine stimulation proliferation Suppresses action of TP53 &CDKI

POLYCLONAL MONOCLONAL LEUKEMIA

5- Helicobacter pylori :

First described as a cause for peptic ulcer Multifactorial etiology in gastric CA & gastric lymphoma ( MALT lymphoma ) Immune mediated gastric damage with FR Occurs in only 3% after a long latent period In adenocarcinoma,H.pylori contains Cytotoxic Associated A gene (Cag A) GF Cell proliferation Other strains cytokines & TNF MALTOMA

Mode of action :
LYMPHOMA : Chronic gastritis mucosal lymphoid follicles reactive polyclonal B cells monoclonal B cells Malt lymphoma CARCINOMA : Chronic gastritis atrophy intestinal metaplasia dysplasia Gastric Carcinoma

CANCERS --ASSOCIATED CARCINOGEN

CA LUNG Smoking CA CERVIX Sexual transmission of HPV CA BLADDER Rubber Industry CA LIVER Aflatoxin, HBV & HCV CA THYROID Radiation ANGIOSARCOMA of Liver Plastic (PVC) MESOTHELIOMA Asbestos

TUMOR IMMUNOLOGY

Numerous mutations occur in individual cells during life.

Why arent there MORE tumors ????

IMMUNE SURVEILLANCE !!!

What is Immune Surveillance ?

Normal immunity present to protect against development of tumors Tumors have ANTIGENS counteracted by ANTIBODIES in the body Evidence ?

When there is no immunity More Cancers Patients with congenital immune deficiency have 200 times risk of cancer & immunosuppressed patients have increased rates of cancers (Lymphoma)

HOST DEFENSES

CD8+ T-Cells*** NK cells MACROPHAGES ANTIBODIES

CYTOTOXIC CD8+ T-CELLS are the main eliminators of tumor cells

Types of Tumor Antigens :

Tumors share MHC with normal cells

Tumor specific & Tumor Associated AGs may be helpful in diagnosis & follow up of some tumors

Specific & Associated Tumor AG:

1- Products of mutant oncogenes & tumor suppressor genes e.g. RAS protein 2- Mutant proteins induced by chemical and radiation induced tumors 3- Overexpressed normal cellular proteins or aberrantly expressed e.g. :

Tyrosinase in melanoma Cancer Testes Genes : MAGE-1(melanoma..) HER-2 in CA breast

4- Tumor AG produced by oncogenic viruses in HPV & EBV infection

5- Oncofetal AG: Carcinoembryonic AG (CEA) in colon and fetoprotein in liver CA 6- Several mucins: MUC-1 in breast CA and CA-125, CA-19-9 in ovarian CA 7- Cell Type- specific differentiation AG in B lymphomas (CD10&CD20)

MANY OF THESE CAN BE USED AS

TUMOR MARKERS !

How do tumor cells escape immune surveillance?

Mutation, like microbes MHC molecules on tumor cell surface Immunosuppressive agents Antigen masking Apoptosis of cytotoxic T-Cells (CD8), i.e., the tumor cell KILLS the T-cell! Others

Clinical Aspects of Neoplasia

Effects of TUMOR on the HOST

Location extension & anatomic pressure HORMONE production Various Syndromes ACUTE symptoms rupture, infarction, intestinal obstruction, bleeding ....etc
Any of above may happen in both BENIGN & MALIGNANT tumors

METASTASES

Cancer Cachexia :

Wasting syndrome characterized by loss of body fat & weight, with MUSCLE LOSS marked weakness , anorexia ,anemia & fever. Reduced food intake but high metabolic rate Possibly due to release of cytokines by tumor cells & macrophages

Paraneoplastic Syndrome :

Systemic symptoms that cant be explained by effects of local or distant spread of tumor or hormones appropriate to tumor tissue. Due to ectopic production of hormones or other factors May precede the tumor (occult cancer) or mimic metastases Occur in 10%-15% of malignant tumors.

Types of Paraneoplastic Syndromes :

Endocrinopathies Osseous & Articular changes Vascular & hematological changes Nephrotic syndrome ( Protein losing S.) MANY OTHERS !

Examples of Paraneoplastic Syndromes :

Small Cell Carcinoma of Lung : Cushings Syndrome** ( ectopic ACTH ) ADH secretion Hypertrophic osteoarthropathy & finger clubbing Venous thrombosis** ** Also in Pancreatic CA

Finger Clubbing

Pulmonary Osteoarthropathy

examples (continued)

Squamous Cell CA lung Breast CA Renal Carcinoma

Parathormone related hormone Hypercalcemia

Note : Hypercalcemia is more commonly produced by lytic bone metastases

examples (continued)

Hepatic & Renal CA Polycythemia ( Erythropoietin) Advanced Cancers Nonbacterial thrombotic endocarditis. Fibrosarcoma & Hepatoma Hypoglycemia ( Insulin like hormone) Many other examples

Grading & Staging of Tumors

Must be documented for all malignant tumors : To quantify the aggressiveness of tumor To outline mode of therapy To compare different modes of therapy To give an approximate prognosis

Prognosis :

This indicates the final outcome of the disease in terms of 5year or 10 year survival. This is influenced by : Tumor Type e.g. Lung CA versus Lip CA Tumor Grade & Stage Host reactions

Grade of tumor: Based on level of differention :

This indicates the degree of resemblance of tumor cells to cell of origin and is always based on microscopic criteria. Grade I : Well differentiated tumor Grade II :Moderately differentiated tumor Grade III : Poorly differentiated tumor Grade IV : Anaplastic tumor

NORMAL GRADING for Squamous Cell Carcinoma

STAGE of Tumor :

This indicates the extent of spread of tumor. Clinical ,investigative procedures and pathological appearance of tumor have to be used to assess it. It depends on : * Size of tumor
* Regional lymph node involvement * Metastases to distant organs

TNM Staging System :

T : Size and extent of primary tumor(1-4) N : Presence and extent of lymph node involvement ( 0-3) M : Presence or absence of distant metastasis ( X0-1) e.g.T1,N1, M0 ----------------------------------Staging is more important than grading because it affects treatment

CANCER DIAGNOSIS

General Outline :

History & clinical examination Symptoms: What the health care worker learns from talking to the patient . Signs : Physical examination of patient e.g. A mass may be palpable or visible, feveretc

Radiographic techniques X ray CT scan MRI Ultrasound Laboratory tests :

General such as blood picture, stool for occult blood , blood sugar.etc Special techniques

1-Morphological Methods :

1- Cytological methods : Study of cells : - Smear - FNA, Brush, Fluid tappingetc Papanicolaou stain (PAP) often used. False(+), False (-) - A negative report does not exclude malignancy, repeat - Advise biopsy, even if (+ )

Normal PAP smear of Cervix

Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 18 December 2006 10:36 AM) 2005 Elsevier

Dysplastic Epithelial Cells in smear

Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 18 December 2006 10:36 AM) 2005 Elsevier

2- Histological methods :

Biopsy of tissue: Needle & core biopsy , Endoscopic Biopsy, or open surgical biopsy Frozen Section (Rapid technique) Paraffin Section ( 36-48 hrs. or longer ) H&E, Special histochemical stains e.g. ( PAS, CONGO RED, PERLs stains) or by IMMUNOHISTOCHEMICAL Methods

3- Immunohistochemistry Staining by use of monoclonal AB directed against various components in cell may help in diagnosis of undifferentiated cancers or help in identifying source of a metastatic tumor.

Cytokeratin Carcinoma Different groups of cytokeratins indicate origin of the carcinoma e.g. CK 7, CK20.etc Common leukocyte antigenLymphoma S 100 Neural tissue, melanocytic lesions Desmin, Vimentin Sarcoma

Undifferentiated Tumor

Cytokeratin for epithelial cells indicating Carcinoma

Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 18 December 2006 10:36 AM) 2005 Elsevier

Undifferentiated Malignant tumor

Desmin Positive for connective tissue indicating Sarcoma

4-Electron microscopy :

For recognition of intracellular structures e.g. desmosomes , or neurosecretory granules.etc.

Not considered a practical tool for diagnosis

2- Tumor Markers :

Used to identify tumor associated enzymes, hormones , antigens etc Their uses are to :
I - Confirm diagnosis. II -Determine the response to treatment III- Detect early relapse.

Present in serum or urine. Present in normal & tumor tissue, so are not specific but their level is important.

Types of Tumor Markers

1- Hormones :

Human Chorionic Gonadotrophic Hormone ( HCG) Elevated levels are seen in Pregnancy & Gestational Trophoblastic Disease (Choriocarcinoma) Some tumors of testes. Ectopic hormones in paraneoplastic Synd. not used as tumor markers.

2- Oncofetal Antigens :

Carcinoembryonic Antigen ( CEA ) : in fetal tissue & some malignancies Colorectal CA & Pancreatic CA
Alpha Fetoprotein (AFP) : Cirrhosis : Elevated Hepatocellular carcinoma : Extremely high Also in some testicular tumors

3- Isoenzymes : Prostatic Acid Phosphatase ( PAP )

levels seen in Metastatic prostatic CA Useful in : * Staging prostatic CA * Assessment of prognosis * Response to therapy.

4- Specific Proteins :

Immunoglobulins secreted in Multiple Myeloma Prostate -specific antigen ( PSA ) : Present in epithelium of prostatic ducts. * Prostatic hyperplasia & * in Prostatic CA * Level correlates with Stage of CA

5- Several mucins

MUC-1 in breast CA CA-125 & CA-19-9 in ovarian CA Also useful in pancreatic & hepatobiliary CA

3- Molecular Diagnosis :

Methods used include :

PCR (Polymerase Chain Reaction) FISH (Fluorescent In Situ Hybridization)

Used for diagnosis to detect gene rearrangement, translocations, amplificationsetc

BCR-ABL Chronic Myeloid Leukemia Monoclonal proliferation of B or T cells 13q 14 deletion in Retinoblastoma.

For prognosis : gene amplification

HER- 2 NEU in breast carcinoma N-MYC in neuroblastoma

Detection of residual disease in chronic myeloid leukemia (BCR-ABL) Detection of genes of hereditary cancer e.g BRCA-1 in breast cancer Useful in TARGETED THERAPY

4- Flow Cytometry :

Technique for identifying cells &their components (as DNA) by staining with a fluorescent AB & detecting the fluorescence Correlates with rate of growth & prognosis

Useful in the diagnosis & classification of Lymphoma & Leukemia

Molecular Profiling of Tumors

THOUSANDS of genes identified from tumors give the cells their own identity and FINGERPRINT and may give important prognostic information as well as guidelines for therapy. Some say this may replace standard histopathologic identifications of tumors.

What do you think?

FIGHT CANCER !!!

EARLY DIAGNOSIS !

EARLY DIAGNOSIS of CANCER :

This is very important as many cancers are curable if they are diagnosed early. Specific symptoms should be followed up e.g. Abnormal bleeding Change of voice Change in a nevus Abnormal lump in breast An ulcer that does not healetc.

Specific procedures : Self examination of the breast Mammography Serial PAP smears for the cervix Serial sputum cytology in smokers Serial urine cytology in some cases, e.g. bilharziasis, workers in rubber Screening for genetic mutations in familial cancers. -

FIGHT CANCER BY AWARENESS & EARLY DETECTION .

THANK YOU !