American J o u rnal o f P at h o l o g y , V o l . 1 4 6 , N o .

1 , J anu ary 1 995

C o p y rig h t
) American S o ciet y f o r I nv es t ig at iv e P at h o l o g y
R ev iew
Ap o p t o s is , O nco s is , and N ecro s is
An O v erv iew o f C el l D eat h
G u id o M aj no and I s ab el l e J o ris
Fro m t h e D ep art ment o f P at h o l o g y , U niv ers it y o f
M as s ach u s et t s M ed ical S ch o o l , W o rces t er, M as s ach u s et t s
Th e h is t o rical d ev el o p ment o f t h e ceU d eat h co n-
cep t is rev iew ed , w it h s p ecial at t ent io n t o t h e o ri-
g in o f t h e t erms necro s is , co ag u l at io n necro s is ,
au t o l y s is , p h y s io l o g ical ceU d eat h , p ro g rammed
ceU d eat h , ch ro mat o l y s is ( t h e f irs t name o f ap -
o p t o s is in 1 91 4 ) , k ary o rh ex is , k ary o l y s is , and
ceU s u icid e, o f w h ich t h ere are t h ree f o rms : b y
l y s o s o mes , b y f ree rad ical s , and b y a g enet ic
mech anis m ( ap o p t o s is ) . S o me o f t h e t y p ical f ea-
t u res o f ap o p t o s is are d is cu s s ed , s u ch as b u d -
d ing ( as o p p o s ed t o b l eb b ing and z eio s is ) and t h e
inf Z ammat o ry res p o ns e. Fo r ceU d eat h no t b y ap -
o p t o s is t h e mo s t s at is f act o ry t erm is accid ent al
ceU d eat h . N ecro s is is co mmo nl y u s ed b u t it is no t
ap p ro p riat e, b ecau s e it d o es no t ind icat e af o rm
o f ceU d eat h b u t ref ers t o ch ang es s eco nd ary t o
ceU d eat h b y any mech anis m, incl u d ing ap o p t o -
s is . Ab u nd ant d at a are av ail ab l e o n o ne f o rm o f
accid ent al ceU l d eat h , namel y is ch emic ceU d eat h ,
w h ich can b e co ns id ered an ent it y o f it s o w n,
cau s ed b y f ail u re o f t h e io nic p u mp s o f t h e
p l as ma memb rane. Becau s e is ch emic ceU d eat h
( in k no w n mo d el s ) is acco mp anied b y s w eU ing ,
t h e name o nco s is is p ro p o s ed f o r t h is co nd it io n.
Th e t erm o nco s is ( d eriv ed f ro m 6 nk o s , meaning
s w el l ing ) w as p ro p o s ed in 1 91 0 b y v o n R eck l ing -
h au s en p recis el y t o mean ceU d eat h w it h s w eU ing .
O nco s is l ead s t o necro s is w it h k ary o l y s is
and s t and s in co nt ras t t o ap o p t o s is , w h ich l ead s
t o necro s is w it h k ary o rh ex is and ceU s h rink -
ag e. ( Am J P at h o l 1 995, 1 4 6 : 3 - 1 5)
K no w l ed g e in t h e f iel d o f cel l d eat h h as g reat l y in-
creas ed d u ring t h e p as t 2 0 y ears o r s o . I n t h e co u rs e
o f t h is rap id ad v ance, new co ncep t s , s u ch as ap o p -
t o s is , ap p eared o n t h e s cene, and ancient t erms s u ch
as necro s is came t o b e u s ed in a new co nt ex t . I n-
ev it ab l y , s o me co ncep t u al and s emant ic s t rains d e-
v el o p ed ; a recent rev iew er s aw f it t o co ncl u d e t h at
" t h ere is no f iel d o f b as ic cel l b io l o g y and cel l p a-
t h o l o g y t h at is mo re co nf u s ing and mo re u nint el l ig ib l e
t h an is t h e area o f ap o p t o s is v ers u s necro s is . " 1 Th e
p u rp o s e o f t h is p ap er is t o o f f er a crit ical and , w e
h o p e, co ns t ru ct iv e o v erv iew o f t h e t erms and co n-
cep t s rel at ed t o cel l d eat h .
I t w il l b e u s ef u l t o b eg in b y t racing t h e main s t ep s
t h at l ed u s t o w h ere w e no w s t and .
D ev el o p ment o f t h e C el l D eat h C o ncep t
Th e f act t h at cel l s can p eris h is d is cu s s ed in L ect u re
XV o f V irch o w ' s C el l u l ar P at h o l o g y amo ng " p as s iv e
p ro ces s es and d eg enerat io ns . " 2 U nd ers t and ab l y , no
micro s co p ic d es crip t io n o f cel l d eat h is incl u d ed , as
h is t o l o g ical s t ains w ere no t u s ed in 1 8 58 . Th u s , t o p ics
rel at ed t o cel l d eat h are t reat ed in t h is l ect u re at a
g ro s s l ev el , u nd er names s u ch as d eg enerat io n, s o f t -
ening , necro s is , and mo rt if icat io n, w h ich w as s y no ny -
mo u s w it h g ang rene. Fo r o u r p res ent p u rp o s es it is
rel ev ant t o no t e t h at V irch o w u s es necro s is t o mean
an ad v anced s t ag e o f t is s u e b reak d o w n, s imil ar t o
w h at w e w o u l d no w cal l g ang rene: " I n necro s is w e
S u p p o rt ed in p art b y N at io nal I ns t it u t es o f H eal t h G rant D K 3 2 52 0
( I J ) .
Accep t ed f o r p u b l icat io n Au g u s t 1 0, 1 994 .
Ad d res s rep rint req u es t s t o D r. G u id o M aj no , D ep art ment o f P a-
t h o l o g y , U niv ers it y o f M as s ach u s et t s M ed ical C ent er, 55 L ak e Av -
enu e N o rt h , W o rces t er, M A 01 6 55- 01 2 5.
W e d ed icat e t h is p ap er t o t h e memo ry o f D r. M arcel Bes s is , p io -
neer in t h e s t u d y o f cel l d eat h , eminent cl inician, and f o u nd er o f
t h e f irs t I ns t it u t e o f C el l u l ar P at h o l o g y , w h o p as s ed aw ay in P aris
o n M arch 2 8 , 1 994 .
3
4 M aj no and J o ris
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
co nceiv e t h e mo rt if ied [ g ang reno u s ] p art t o b e p re-
s erv ed mo re o r l es s in it s ex t ernal f o rm" ( p . 3 58 ) . Th is
h ad b een t h e t rad it io nal u s ag e o f t h e t erm necro s is ,
no t o nl y in t h e t ex t b o o k o f V irch o w ' s t each er R o k it an-
s k y 3 b u t al s o , as necro s is , in ancient G reek t ex t s at
l eas t s ince G al en. 4
V irch o w ' s L ect u re XV al s o creat es a s p ecial cat -
eg o ry o f reg res s iv e p ro ces s es u nd er t h e name necro -
b io s is , a t erm h e b o rro w ed f ro m a co nt emp o rary au -
t h o r, K . H . S ch u l t z . I ncl u d ed amo ng t h e necro b io t ic
p ro ces s es , f o r ex amp l e, w ere t h e " s o f t ening s . "
N ecro b io s is is t h u s d ef ined , p erh ap s , t o f it t h e mo d el
o f b rain s o f t ening : " Th e p art v anis h es , s o t h at w e can
no l o ng er p erceiv e it in it s p rev io u s f o rm. W e h av e no
necro s ed f rag ment at t h e end o f t h e p ro ces s . " A f o o t -
no t e ex t end s t h e d ef init io n ( emp h as is o rig inal ) :
" N ecro b io s is is d eat h b ro u g h t o n b y ( al t ered ) l if e - a
s p o nt aneo u s w earing o u t o f l iv ing p art s - t h e d es t ru c-
t io n and annih il at io n co ns eq u ent u p o n l if e - nat u ral as
o p p o s ed t o v io l ent d eat h ( mo rt if icat io n) . " Th e u s e o f
necro b io s is t h ro u g h o u t V irch o w ' s b o o k and l at er in-
d icat es t h at t h is t erm w as s o met imes meant t o imp l y
al s o " s l o w d eat h " o r " d eat h o f t is s u es w it h in t h e l iv ing
b o d y . " N eed l es s t o s ay , necro b io s is w as a v ag u e and
amb ig u o u s t erm. Af t er a l o ng career it is f inal l y d is -
ap p earing . Ano t h er t erm f ro m V irch o w ' s L ect u re XV
t h at need s ret h ink ing is d eg enerat io n. V irch o w ' s " f at t y
d eg enerat io n" s t il l cl ing s o n5; it s h o u l d b e b anis h ed ,
b ecau s e cel l s can d ie b u t cert ainl y canno t d eg ener-
at e int o s o met h ing el s e. I n o u r o p inio n, t h ere are f ew
d ef ens ib l e u s es o f t h is t erm in g eneral p at h o l o g y ; w e
can t h ink o f t w o : f o r t h e b reak d o w n o f ax o ns , as in
W al l erian d eg enerat io n, and f o r t h e b reak d o w n o f car-
t il ag e mat rix in d eg enerat iv e o s t eo art h rit is .
Th e nex t s t ep , aro u nd 1 8 7 7 , w as t h e id ent if icat io n
o f co ag u l at io n necro s is b y C arl W eig ert and J u l iu s
C o h nh eim. To d ay t h is t erm ev o k es a rat h er o b v io u s
and no nco nt ro v ers ial l es io n, mainl y t h e w h it e inf arct ,
b u t t h is w as no t t ru e in t h e b eg inning , w h en it ap p l ied
t o a co nd it io n t h at in o u r v iew h as v irt u al l y no t h ing t o
d o w it h co ag u l at io n necro s is .
W h en C arl W eig ert ( 1 8 4 5- 1 904 ) w as t raining u nd er
V irch o w , d ip h t h eria w as a co mmo n cau s e o f d eat h , as
t h e v accine w as no t av ail ab l e b ef o re 1 8 8 0. D ip h t h eria
cau s es necro s is o f t h e t rach eo b ro nch ial ep it h el iu m,
w h ich b eco mes imp reg nat ed w it h f ib rin and l eu k o -
cy t es and t end s t o s l o u g h o f f as a l eat h ery , w h it is h
p s eu d o memb rane ( d ip h t h 6 ra is G reek f o r t anned
h id e) . W eig ert , w h o w as es p ecial l y int eres t ed in f ib rin
( w it nes s t h e f ib rin s t ain o f h is name) , b ecame im-
p res s ed b y t h is co mb inat io n o f ep it h el ial necro s is and
f ib rin. 6 - 9 H e h el d t h e cu rrent v iew t h at d ead l eu k o -
cy t es cau s e f ib rino g en t o co ag u l at e and p ro p o s ed
t h at t h e s ame mech anis m t h at p ro d u ced t h e d ip h -
t h erit ic p s eu d o memb rane w as at w o rk al s o in p ro -
d u cing w h at w e no w cal l w h it e inf arct s . H e ev en re-
f erred t o t h e t y p ical w ed g e- s h ap ed w h it e inf arct s as
f ib rin w ed g es ( Fib rink eil e) . 9 J u l iu s C o h nh eim, ano t h er
d is cip l e o f V irch o w , accep t ed t h is v iew and int ro -
d u ced , in t h e 1 8 7 7 ed it io n o f h is t ex t b o o k , t h e t erm
co ag u l at io n necro s is . 1 0 S o o n t h e f ib rin co mp o nent
w as f o u nd t o b e u nrel at ed t o t h e co ag u l at io n o f t h e
t is s u e1 1 ; t o d ay W eig ert ' s co ncep t s u rv iv es o nl y in
w h at w e cal l f ib rino u s necro s is . H o w ev er, an imp o r-
t ant b y p ro d u ct o f W eig ert ' s s t u d ies w as t h e o b s erv a-
t io n t h at necro t ic cel l s l o s e t h eir nu cl ei. b
Th e ro l e o f p ro t ein d enat u rat io n in t h e g enes is o f
co ag u l at io n necro s is w as v ag u el y h int ed in
C o h nh eim' s t ex t b o o k 1 0; it co u l d no t es cap e t h e p a-
t h o l o g is t s ' at t ent io n t h at necro t ic t is s u e l o o k ed l ik e
" co ag u l at ed al b u men. " 1 2 I nt eres t ing l y , t h e no t io n t h at
p ro t ein d enat u rat io n may p art icip at e in cel l d eat h w as
f irs t p ro p o s ed in 1 8 8 6 b y a b o t anis t , G . Bert h o l d . 1 3 , 1 4
Th is is j u s t o ne o f t h e many co nt rib u t io ns mad e b y
p l ant p at h o l o g y t o animal p at h o l o g y , t h e l at es t o ne
b eing t h e t et raz o l iu m met h o d f o r d et ect ing d ead t is -
s u e o n g ro s s s p ecimens , o rig inal l y u s ed b y b o t anis t s
f o r id ent if y ing no nv iab l e s eed s ( rev iew ed in ref erence
1 5) .
W eig ert ' s no t io n o f co ag u l at io n necro s is h ad t h e
v irt u e o f t rig g ering , af t er 1 8 8 0, many ex p eriment al
s t u d ies o n cel l d eat h , 1 6 p ro d u ced b y l ig at ing t h e renal
art ery , b y maint aining t is s u e f rag ment s s ep t ical l y o r
as ep t ical l y in v it ro , 1 1 o r b y int ro d u cing t h em int o t h e
p erit o neal cav it y o f ex p eriment al animal s . 1 7 M u ch o f
t h e p res ent t ermino l o g y o f cel l d eat h , b es id es co ag u -
l at io n necro s is , s t ems f ro m t h at era. Au t o l y s is w as
p ro p o s ed in 1 900, al t h o u g h t h e co ncep t w as k no w n
earl ier. 1 3 ' 1 6 ' 1 8 P y k no s is w as in u s e aro u nd 1 8 90. 1 9
K ary o l y s is and k ary o rh ex is w ere p ro p o s ed in 1 8 7 92 0
b y E d w in K l eb s o f K l eb s iel l a f ame ( h e s p el l ed h is
K ary o rh ex is rig h t , b u t t h e erro neo u s K ary o rrh ex is ap -
p eared in t h e t it l e o f an 8 0- p ag e p ap er in 1 8 901 9 and
h as l as t ed ev er s ince) . C h ro mat in marg inat io n ( R and -
s t el l u ng ) w as d es crib ed in 1 8 90. 1 7 S o me t erms b o rn
in t h o s e d ay s ch ang ed meaning , s u ch as ch ro ma-
t o l y s is ( 1 8 8 5) , 2 1 and o t h ers d is ap p eared , s u ch as
p l as marh ex is , 2 0, ch ro mat o p y k no s is , and d eco ns t it u -
t io n. 2 2
S p o nt aneo u s cel l d eat h as a p h y s io l o g ical ev ent
w as d is cu s s ed al mo s t as s o o n as s t ains b ecame
av ail ab l e. I t w as b o rn w it h a b ang in 1 8 8 5 in a p ap er2 1
b y t h e s ame W al t h er Fl emming w h o creat ed t h e t erms
ch ro mat in and mit o s is . 2 3 Fl emming s t u d ied o v arian
f o l l icl es in mammal s and no t iced t h at t h e ep it h el ial
l ining o f reg res s ing f o l l icl es w as l it t ered w it h cel l s t h e
nu cl ei o f w h ich w ere b reak ing u p ( Fig u re 1 ) . 2 1 H is
caref u l camera l u cid a d raw ing s il l u s t rat e t h e h al f -
Ap o p t o s is , O nco s is , and N ecro s is 5
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
Fig u re 1 . A4 0p t o s is as o b s erv ed in 1 8 8 5 b y
Fl emming , 2 1 w h o cal l ed it ch ro mat o l y s is . To p
l ef t : N o rmal rab b it o v arian f o l l icl e near mat u -
nit y , 1 mm in d iamet er. N u mero u s ep it h el ial
mit o s es . To p rig h t : E arl y s t ag e o f inv o l u t io n in a
nearb y f o l l icl e. M any ep it h el ial cel l s are in v an-
o u s s t ag es o f
d eat h b y ch ro mat o l y s is ; s o me are
s h ed int o t h e l u men. Bo t t o m: d et ail o f t h e s ame
inv o l u t ing f o l l icl e. M o s t ep it h el ial cel l s in co n-
t act w it h t h e o v u m are no rmal ( o ne is in mit o -
s is ) ; t h o s e f art h er remo v ed are u nd erg o ing
ch ro mat o l y s is . N o t e t h e h al f - mo o ns o f ch ro ma-
t in t y p ical o f ap o p t o s is . ( O s miu m f ix at io n; s a-
f ranin and g ent ian v io l et s t aining . C amera l u -
cid a d raw ing s . )
mo o ns o f p y k no t ic ch ro mat in t y p ical o f ap o p t o s is
( Fig u re 1 ) as w el l as ap o p t o t ic b o d ies l o o s e in t h e
cav it y o f t h e f o l l icl e. Fl emming g av e a name t o t h e
p ro ces s , ch ro mat o l y s is , ref erring t o t h e f act t h at t h e
b ro k en u p nu cl eu s u l t imat el y d is ap p ears . A f ew
mo nt h s l at er t h e s ame o b s erv at io ns w ere p u b l is h ed
b y a G erman med ical s t u d ent , Franz N is s en, 2 4 w h o
o b s erv ed ch ro mat o l y s is al s o in l act at ing mammary
g l and s ( Fig u re 2 ) .
C h ro mat o l y s is and nu cl ear p at h o l o g y b ecame a
f as h io nab l e t o p ic2 5 1 9; b eau t if u l ex amp l es o f w h at w e
w o u l d l ab el ap o p t o s is w ere s een in b reas t cancers b y
S t ro b e, 2 6 and b y 1 91 4 eno u g h d at a w ere av ail ab l e f o r
a G erman anat o mis t , L u d w ig G rap er, t o p u b l is h a p a-
p er ent it l ed ( in t rans l at io n) " A new p o int o f v iew re-
g ard ing t h e el iminat io n o f cel l s . " 2 7 G rap er' s p remis e
is t h at s o me mech anis m mu s t ex is t t o co u nt erb al ance
mit o s is , es p ecial l y in ep it h el ia, and co ncl u d es t h at
Fl emming ' s ch ro mat o l y s is is t h e ans w er: " C h ro ma-
t o l y s is mu s t ex is t in al l o rg ans in w h ich cel l s mu s t b e
el iminat ed " ( p . 3 7 7 ) . Th e d eb ris , h e w rit es , are t ak en
u p b y neig h b o ring ep it h el ial cel l s , b u t s o met imes t h ey
are s o ab u nd ant t h at t h ey are el iminat ed int o an o r-
g an' s l u men, as is t h e cas e f o r " u t erine mil k " ( b o t h
f eat u res are t y p ical o f w h at w e no w cal l ap o p t o s is ) .
G rap er al s o ex p eriment s o n t h e y o l k s ac, w h ich , h e
arg u es , mu s t s h rink p ro g res s iv el y : it s cel l s d o no t
s h rink , s o t h e s ac as a w h o l e co u l d o nl y b eco me
s mal l er b y o ne o f t w o mech anis ms : 1 ) b y d ev el o p ing
f o l d s o r 2 ) b y el iminat ing cel l s , w h ich G rap er reco g -
niz es as t h e rig h t ans w er ( Fig u re 3 ) . G rap er co n-
cl u d es t h at t h e " p h y s io l o g is ch e Z el l el iminat io n" o c-
cu rs b y ch ro mat o l y s is d u ring t h e s h rink ag e o f o rg ans ,
as w el l as no rmal l y in cert ain g l and s . I n es s ence, " a
s is t er cel l [ S ch w es t erz el l e] eng u l f s a neig h b o ring cel l
t h at b reak s d o w n" ( p . 3 91 ) . An int eres t ing s id e is s u e
co mes u p as G rap er p o int s o u t t h at t h e p ers is t ent
d es crip t io ns o f s o - cal l ed amit o s is ( nu cl ear d iv is io n
6 M aj no and J o ris
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
Fig u re 2 . Ap o p t o s is as s een in 1 8 8 6 b y a G erman med ical s t u d ent ,
Franz N is s en, in t h e l act at ing mammary g l and . 2 4 N is s en b ecame
aw are o f Fl emming ' s s t u d y , 2 ' af t er h av ing co mp l et ed h is o w n, and
co ncl u d ed t h at t h e name cb ro mat o l y s is w as v ery s u it ab l e al s o t o h is
o w n f ind ing s .
Fig u re 3 . Ap o p t o s is il l u s t rat ed in 1 91 4 b y L . G rap er as ch ro mat o l y -
s is . 2 7 W al l o f t h e y o l k s ac in t h e co u rs e o f inv o l u t io n, in a 2 0- cm em-
b ry o o f Acant h ias , a creat u re t h at w e h av e b een u nab l e t o id ent if y .
An ep it h el ial cel l h as t ak en u p t h ef rag ment ed nu cl eu s o f a neig h b o r-
ing cel l t h at d ied d u ring t h e inv o l u t io n p ro ces s .
w it h o u t mit o s is ) w ere d u e t o t h e erro neo u s int erp re-
t at io n o f cel l s t h at h ad t ak en u p nu cl ear mat erial f ro m
a nearb y cel l t h at d ied b y ch ro mat o l y s is .
Th is mil es t o ne p ap er mad e no s ig nif icant imp act .
P erh ap s it w as o v erl o o k ed b ecau s e it ap p eared at t h e
o u t s et o f W o rl d W ar in a G erman j o u rnal o n cel l u l ar
inv es t ig at io n t h at many p at h o l o g is t s mig h t h av e
mis s ed . Th e t erm ch ro mat o l y s is w as ad o p t ed b y
neu -
ro p at h o l o g is t s t o mean s o met h ing ent irel y d if f erent ,
namel y t h e ap p arent b reak d o w n o f N is s l s u b s t ance
af t er t rans ect io n o f t h e ax o n. H o w ev er, t h e o rig inal
co ncep t o f ch ro mat o l y s is d id s u rv iv e amo ng emb ry -
o l o g is t s , w h o u nd ers t o o d it s imp o rt ance as a mo r-
p h o g enet ic mech anis m. Th is l ine o f s t u d ies w as s u m-
mariz ed in a mas t erl y p ap er b y G l u ck s mann
in
1 950. 2 8 H ere is h is d es crip t io n o f p h y s io l o g ical cel l
d eat h in t h e emb ry o .
" Th e init ial s t ag e, ch ro mat o p y cno s is , co ns is t s . . . in
t h e ap p earance o f a s ing l e ch ro mat ic mas s s it t ing as
a cap o n t h e v acu o l e f o rmed b y t h e no n- ch ro mat ic
mat erial . . . . Bo t h t h e nu cl eu s and t h e cy t o p l as m . . . .
s h rink b y t h e l o s s o f f l u id . . . . Th e g ranu l e l o s es it s af -
f init y f o r nu cl ear s t ains , b eco mes Feu l g en- neg at iv e,
b reak s u p and d is ap p ears : t h is is ch ro mat o l y s is . . . .
Th e d eg enerat ing cel l may b e p h ag o cy t o s ed b y a
neig h b o u r. " I t is f u rt h er s p ecif ied t h at " t h e nu cl eu s
may b reak u p int o s ev eral p y cno t ic g ranu l es , " and
t h at " mit o ch o nd ria rarel y s h o w ch ang es " s u ch as are
f o u nd in cel l s ex p o s ed t o inj u rio u s ag ent s .
Al l t h is is , o f co u rs e, ano t h er f ine d es crip t io n o f ap -
o p t o s is . G l u ck s mann real iz ed t h at h e w as d es crib ing
a s p ecial f o rm o f cel l d eat h , b u t h is s t u d ies w ere l im-
it ed t o cel l d eat h in emb ry o nic t is s u es . Th u s it w as
nat u ral f o r h im t o as s u me t h at t h is p art icu l ar f o rm o f
cel l d eat h w as ch aract eris t ic o f v ert eb rat e o nt o g en-
es is and t h eref o re d if f erent f ro m, rat h er t h an ap p l i-
cab l e t o , cel l d eat h in ad u l t t is s u es . G rap er h ad g o ne
f art h er.
O d d l y eno u g h , t h e ro l e o f p ro t ein d enat u rat io n in
cel l d eat h w as no t co nf irmed u nt il 1 96 0, b y s t u d ies o f
o p t ical d ens it y , l ig h t d if f ract io n, and au t o f l u o res cence
o f d y ing and d ead t is s u es . 2 9 Th es e s t u d ies w ere car-
ried o u t b y t h e o l d met h o d o f imp l ant ing f rag ment s o f
rat l iv er int o t h e p erit o neu m o f o t h er rat s . Th e f o l l o w ing
ap p ear t o b e t h e b as ic ru l es o f is ch emic cel l d eat h f o r
t h e l iv er; v ariat io ns s h o u l d b e ex p ect ed f o r o t h er cel l
t y p es :
1 ) C el l d eat h and necro s is are v ery d if f erent ent i-
t ies . I s ch emic cel l d eat h , d ef ined f u nct io nal l y b y t h e
p o int o f no ret u rn, o ccu rs l o ng b ef o re necro s is and is
no t d et ect ab l e h is t o l o g ical l y ( f o r rat l iv er t h e p o int o f
no ret u rn is k no w n t o o ccu r at ap p ro x imat el y t o 2 t o
2 . 5 h o u rs ) ; ind eed , it is u s ef u l t o p o int o u t t h at t h e
d if f erence b et w een cel l d eat h and necro s is , b io l o g i-
cal l y a k ey is s u e, h as b een co mp l et el y o v erl o o k ed in
recent l it erat u re. 2
2 ) I s ch emic l iv er cel l s s w el l f o r 6 t o 7 h o u rs , t h en
l o s e w at er and s h rink ( Fig u re 4 ) . E arl y in t h e s w el l ing
p ro ces s t h ey d ie. W e can no w ad d t h at t h e s w el l ing
p ro ces s is u nd ers t o o d as a res u l t o f io n p u mp f ail u re
Ap o p t o s is , O nco s is , and N ecro s is 7
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
P o int o f , r
4
1 3 0-
s
1 1 0-
C 1 00-
_
90-
0
( L S
7 0-
w 0 ret u rn
I
J /
A 1 03 in O A 03
H o u rs D ay s
Fig u re 4 . C u rv e o b t ained b y w eig h ing f rag ment s o f rat l iv er af t er
t h ey h ad b een l ef t in t h e p erit o neal cav it y o f o t h er rat s f o r 0 t o 7 2
h o u rs . I t s h o w s t h at is ch emic l iv er cel l s s w el l b ef o re t h ey d ie, co nt inu e
t o s u el l t h ereaf t er, t h en s h rink . Th e ap p ro x imat e t ime o f cel l d eat h is
ind icat ed as t h e p o int o f no ret u rn. D at a f ro m
M aj no
et al . 2 9
b y l ack o f ATP and t h at t h e s w el l ing is acco mp anied
b y int ens e b l eb b ing ( t o b e d is cu s s ed f u rt h er) .
3 ) Th e d y ing and d ead cel l ' s p ro t eins f ace t w o p o s -
s ib l e f at es : h y d ro l y s is and /o r d enat u rat io n.
4 ) P ro t ein d enat u rat io n b eg ins w h il e t h e cel l is s t il l
al iv e, b eing d et ect ab l e at 3 0 minu t es . To d ay w e can
int erp ret t h is f ind ing b y as s u ming t h at t h e u b iq u it in
s y s t em, w h ich t arg et s d enat u red cel l s f o r h y d ro l y s is
b y an energ y - req u iring s y s t em, 3 0 3 1 is o v erw h el med
and can no l o ng er f u nct io n f o r l ack o f ATP . Th e d e-
nat u rat io n p ro ces s is s t il l g o ing o n af t er 1 2 d ay s .
5) D u ring is ch emic cel l d eat h and t h e s u b s eq u ent
co ag u l at io n necro s is , l arg e amo u nt s o f cal ciu m are
t ak en u p b y t h e af f ect ed cel l s . 3 2
Th e co ncep t o f cel l s u icid e s u rf aced f o r t h e f irs t
t ime af t er t h e l y s o s o mes w ere d is co v ered in t h e l at e
1 950s . D e D u v e p ro p o s ed t h at cel l s mig h t b e k il l ed
f ro m w it h in, b y an ex p l o s io n o f t h eir l y s o s o mes act ing
as " s u icid e b ag s " ( s u mmariz ed in ref erence 1 5) . Th e
id ea w as s o o n d is cred it ed , b u t w e no w k no w t h at it is
p ro b ab l y t ru e in s p ecial circu ms t ances , namel y in t h e
cry s t al d is eas es , in w h ich l eu k o cy t es p h ag o cy t iz e
cry s t al s t h at b reak o p en t h e l y s o s o mes ( s u mmariz ed
in ref erence 1 5) .
Free rad ical p at h o l o g y ap p eared in t h e 1 96 0s , and
it l ed t o t h e id ent if icat io n o f ano t h er mech anis m o f cel l
s u icid e, es p ecial l y in l iv er cel l s as a res u l t o f cert ain
int o x icat io ns , 3 3 namel y , t h e int racel l u l ar rel eas e o f
f ree rad ical s , w h ich can d amag e cel l u l ar o rg anel l es
( s u mmariz ed in ref erence 1 5) . Th is l ine o f res earch
h el p ed l ead t o t h e p ro p o s al o f a f inal co mmo n p at h -
w ay f o r cel l d eat h f ro m d if f erent cau s es , ie, a ris e in
int racel l u l ar cal ciu m. 3 4 ' 3 5
Th en came ap o p t o s is , t h e t h ird and p erh ap s t h e
u l t imat e f o rm o f cel l s u icid e, p u rp o s ef u l s u icid e, and
o ne o f t h e mo s t ex cit ing d ev el o p ment s in mo d ern b i-
o l o g y . Th e crit ical ex p eriment ( p u b l is h ed in 1 97 1 ) w as
ex t rao rd inaril y s imp l e; K err3 6 ind u ced l iv er at ro p h y in
t h e rat b y t y ing o f f a l arg e b ranch o f t h e p o rt al v ein.
H e no t iced a d is cret e d ro p - o f f o f cel l s b y a s eq u ence
o f ch ang es t h at h e cal l ed at f irs t s h rink ag e necro s is
and a y ear l at er ap o p t o s is . 3 7 Th e nex t crit ical s t ep
came ind ep end ent l y f ro m t h e s t u d y o f irrad iat ed l y m-
p h o id t is s u es . I t w as k no w n f ro m h is t o l o g ical s t u d ies
t h at t h e nu cl ei o f irrad iat ed l y mp h o cy t es b reak
d o w n. 3 8 I n 1 97 6 3 9and 1 98 1 4 0. 4 1 t h ree g ro u p s ex am-
ined el ect ro p h o ret ical l y t h e ch ro mat in o f irrad iat ed
t is s u es and f o u nd t h at it b ro k e d o w n int o f rag ment s
t h at p ro d u ced a t y p ical , l ad d er- l ik e p at t ern, s u g g es t -
ing t h at t h e f rag ment s w ere mu l t ip l es o f nu cl eo -
s o mes . 4 1 Th en W y l l ie et a1 4 2 in 1 98 4 l ink ed t h e l ad d er
p at t ern w it h t h e p h eno meno n o f ap o p t o s is and
t h ereb y ad d ed a s p ecif ic b io ch emical mark er t o t h e
d is t inct iv e mo rp h o l o g ical ch ang es o f ap o p t o t ic cel l s .
Th is d is co v ery l ed t o an eno rmo u s increas e in p ap ers
o n ap o p t o s is , w it h t h e l at es t d ev el o p ment s in t h is f iel d
co ncerning t h e g enes inv o l v ed in cel l s u icid e and t h e
p o s s ib il it y o f u s ing ap o p t o s is as an ap p ro ach t o t u mo r
d iag no s is and t h erap y . 4 3 - 4 7
I n ret ro s p ect , it is mind - b o g g l ing t h at earl ier p a-
t h o l o g is t s ( o u rs el v es incl u d ed ) p aid s o l it t l e at t ent io n
t o t h e mech anis m o f o rg an s h rink ag e d u ring at ro p h y ,
ev en af t er it h ad b een caref u l l y d es crib ed . P erh ap s it
ap p eared t o o s imp l e and s el f - ev id ent , o r as d u l l as
au t o l y s is in v iv o . 4 8 I t is a f air g u es s t h at t o d ay t h e
mech anis m o f at ro p h y w o u l d h av e a l o w p rio rit y in
co mp et ing f o r g rant s u p p o rt .
W e w il l no w ex amine mo re cl o s el y t h e t w o b es t
k no w n mo d al it ies o f cel l d emis e: cel l d eat h b y s u icid e
( ap o p t o s is ) and cel l d eat h b y mu rd er ( accid ent al cel l
d eat h ) .
C el l D eat h b y S u icid e: Ap o p t o s is
As ment io ned earl ier, cel l s can co mmit s u icid e b y at
l eas t t h ree mech anis ms , b u t ap o p t o s is s t and s o u t as
a f o rm o f int ent io nal s u icid e b as ed o n a g enet ic
mech anis m. Fo r o u r p u rp o s es it w il l s u f f ice t o l is t t h e
k ey f eat u res o f ap o p t o s is , as many co mp reh ens iv e
rev iew s are av ail ab l e. 4 9- 52
1 ) Ap o p t o s is is a f o rm o f cel l d eat h ch aract eriz ed
b y mo rp h o l o g ical as w el l as b io ch emical crit eria and
can b e co ns id ered as a co u nt erp art o f mit o s is , as
G rap er h ad p ro p o s ed .
2 ) M o rp h o l o g ical l y t h e cel l s h rink s and b eco mes
d ens er, as imp l ied in t h e o rig inal name s h rink ag e ne-
cro s is . 3 6 Th e ch ro mat in b eco mes p y k no t ic and
p ack ed int o s mo o t h mas s es ap p l ied ag ains t t h e
nu cl ear memb rane ( marg inat io n o f ch ro mat in; Fig u re
*u
;
4 I I I
I
i
I I
i
I I
I I
I
I
d 1 4
u 0 iz l a Z 4 z 3
8 M aj no and J o ris
A/P J anu ary 1 995, V o l . 1 4 6 , N o . 1
5) , creat ing cu rv ed p ro f il es t h at h av e ins p ired d e-
s crip t iv e t erms f o r o v er a cent u ry , s u ch as h al f - mo o n- ,
h o rs e- s h o e- , s ick l e- , 1 9 l ancet - , and s h ip - l ik e ( nav icu -
l ar3 0) . Th e nu cl eu s may al s o b reak u p ( k ary o rh ex is ) ,
and t h e cel l emit s p ro ces s es ( t h e b u d d ing p h eno m-
eno n) t h at o f t en co nt ain p y k no t ic nu cl ear f rag ment s .
Th es e p ro ces s es t end t o b reak o f f and b eco me ap -
o p t o t ic b o d ies , w h ich may b e p h ag o cy t iz ed b y mac-
ro p h ag es o r neig h b o ring cel l s o r remain f ree; h o w -
ev er, t h e cel l may al s o s h rink int o a d ens e, ro u nd ed
mas s , as a s ing l e ap o p t o t ic b o d y .
3 ) Th ere is l it t l e o r no s w el l ing o f mit o ch o nd ria o r
o t h er o rg anel l es .
4 ) Bio ch emical l y , t h e D N A is b ro k en d o w n int o s eg -
ment s t h at are mu l t ip l es o f ap p ro x imat el y 1 8 5 b p , d u e
t o s p ecif ic cl eav ag e b et w een nu cl eo s o mes .
5) Th e p ro ces s is u nd er g enet ic co nt ro l 4 6 ' 4 7 and
can b e init iat ed b y an int ernal cl o ck , o r b y ex t racel -
l u l ar ag ent s s u ch as h o rmo nes , cy t o k ines , k il l er cel l s ,
and a v ariet y o f ch emical , p h y s ical , and v iral ag ent s .
6 ) Ap o p t o s is can ru n it s co u rs e v ery f as t , ev en in
minu t es ( 3 4 minu t es f ro m t h e o ns et o f b u d d ing t o
co mp l et e b reak u p in t h e mo v ie b y Bes s is t o b e d is -
cu s s ed b el o w ) . Fo r t h is reas o n ap o p t o s is is remark -
ab l y u no b t ru s iv e in t is s u e s ect io ns . 53 I n ro u t ine s ec-
t io ns t h e b es t cy t o l o g ical mark er o f ap o p t o s is is
k ary o rh ex is , es p ecial l y in an is o l at ed cel l . Fo rt u nat el y ,
Fig u re 5. Th e t w o main reg u l at o rs o f cel l p o p u l at io ns , mit o s is ( b o t -
t o m l ef t ) and ap o p t o s is ( t o p rig h t ) . I n t h e ap o p t o t ic cel l , t h e nu cl eu s is
f rag ment ed ( k ary o rh ex is ) and t h e ch ro mat in is p y k no t ic. O ne o f t h e
nu cl earf rag ment s co nt ains a ch aract eris t ic h al f - mo o n o f co nd ens ed
ch ro mat in. ( E l ect ro n micro g rap h f ro m a rat p ro s t at e 2 d ay s af t er
cas t rat io n. Bar = 2
Y ) .
a recent t ech nical ad v ance mak es t h e id ent if icat io n o f
ap o p t o s is a mat t er o f s imp l e h is t o ch emis t ry , a met h o d
t h at t ak es ad v ant ag e o f t h e f act t h at t h e D N A b reak ing
p o int s ( nick s ) ex p o s e mo l ecu l ar end ing s t h at are
ch emical l y s p ecif ic. 54
7 ) Th e rap id l y d ev el o p ing t al e o f ap o p t o s is w arns
u s t h at g eneral iz at io ns are d ang ero u s b ecau s e, f irs t ,
cel l s u icid e d o es no t al w ay s t ak e t h e f o rm o f ap o p -
t o s is ; s eco nd , cel l mu rd er b y cy t o t o x ic l y mp h o cy t es
l ead s t o ap o p t o s is ; t h ird , t h ere s eem t o b e s ev eral
v ariet ies o f ap o p t o s is 55 and f o u rt h , d if f erent cel l t y p es
may f o l l o w d if f erent ru l es . 2
Th e o nl y f l aw t h at w e f ind in t h e name o f ap o p t o s is
is t h at it incl u d es b o t h cel l d eat h ( p res u mab l y rep re-
s ent ed b y cel l s h rink ag e and p y k no s is ) and necro s is
( t h e s eco nd ary b reak u p int o a cl u s t er o f ap o p t o t ic
b o d ies ) . Th is h as creat ed s o me co nf u s io n: h o w can
ap o p t o s is b e o p p o s ed t o necro s is , as many au t h o rs
d o , if ap o p t o s is p ro d u ces cl as s ic imag es o f necro s is ?
Th e remed y may b e s imp l e eno u g h : t h e s eco nd
p h as e o f ap o p t o s is s h o u l d b e cal l ed ap o p t o t ic ne-
cro s is , as o p p o s ed t o is ch emic, t o x ic, o r mas s iv e ne-
cro s is ( s ee b el o w ) . E x amp l es o f ap o p t o t ic necro s is
are t h e s u nb u rn cel l s o f t h e ep id ermis and t h e C o u n-
cil man b o d ies o f t h e l iv er. 53
W e mig h t ad d t h at t h e G reek name ap o p t o s is is
mo s t f el icit o u s , s u g g es t ing as it d o es t h e d is cret e im-
ag e o f l eav es d ro p p ing o f f h ere and t h ere f ro m a t ree
( ap 6 , meaning f ro m and p t 6 s is , meaning a f al l ) as
o p p o s ed t o t h e mas s iv e cel l d eat h o f an inf arct . W e
w il l o nl y no t e t h at t h e p ro nu nciat io n ap o t o s is ( s k ip -
p ing t h e s eco nd p ) 3 7 is no t co nf irmed b y t h e G reek
s ch o l ars w h o m w e h av e co ns u l t ed . A recent l et t er t o
N at u re56 mak es t h e s ame p o int : no b o d y s ay s
h el ico ' t ers .
Th e S h rink ag e and C o nd ens at io n o f
Ap o p t o t ic C el l s
I t is int eres t ing t o co mp are t h es e t w o f eat u res o f ap -
o p t o s is w it h t h e s h rink ag e and co nd ens at io n t h at o c-
cu r af t er is ch emic cel l d eat h as a res u l t o f p ro t ein
d enat u rat io n2 3 ( Fig u re 4 ) . To t h is d ay , t h e s h rink ag e
and co nd ens at io n o f t h e ap o p t o t ic cel l are no t ex -
p l ained . 4 6 C o u l d t h ey b e ro o t ed in t h e s ame mech a-
nis ms t h at o p erat e in is ch emic cel l d eat h ? Th e in-
creas ed d ens it y , v is ib l e o n l ig h t and el ect ro n
micro g rap h s , co u l d ref l ect t h e accu mu l at io n o f d e-
nat u red p ro t eins , p erh ap s b y f ail u re o f t h e u b iq u it in
s y s t em. P ro t ein d enat u rat io n h as b een l ink ed t o in-
creas ed int racel l u l ar cal ciu m, 3 4 ' 3 5 and in s o me f o rms
Ap o p t o s is , O nco s is , and N ecro s is 9
AJ P J anu ar
1 995,
V o l . 1 4 6 , N o . 1
o f ap o p t o s is cal ciu m d o es increas e. 4 6 ' 56 Becau s e
d enat u red p ro t eins are au t o f l u o res cent , t h eir p res -
ence in ap o p t o t ic cel l s s h o u l d b e f airl y eas y t o t es t ,
and w e are p res ent l y at t emp t ing t o d o s o .
Th e Bu d d ing P h eno meno n
I n t h eir ag o ny , cel l s d y ing b y ap o p t o s is emit a nu mb er
o f p s eu d o p o d ia, a p ro ces s t h at K err h as ap t l y d e-
s crib ed as b u d d ing . 50 Th e emis s io n o f cel l u l ar p ro -
ces s es , o b v io u s o n el ect ro n micro g rap h s o f ap o p -
t o t ic cel l s , 50 b eco mes d ramat ic w h en w it nes s ed b y
t ime- l ap s e cinemat o g rap h y o f is o l at ed cel l s . W e can
s ay t h is b ecau s e ap o p t o s is w as f il med accid ent al l y in
t h e 1 950s , d u ring a s t u d y o f cel l d eat h , 58 4 0 w el l b e-
f o re ap o p t o s is w as reco g niz ed as a s p ecial ent it y . A
French h emat o l o g is t , t h e l at e M arcel Bes s is , ex am-
ined b y t ime- l ap s e cinemat o g rap h y t h e mo d es o f cel l
d eat h o f h u man l eu k o cy t es maint ained b et w een s l id e
and co v ers l ip ( Fig u re 6 ) . O ne o f t h e s eq u ences s h o w s
a l eu k o cy t e emit t ing p s eu d o p o d ia ( b u d d ing ) and f i-
nal l y b reak ing u p w it h al mo s t ex p l o s iv e s u d d ennes s .
Bes s is d es crib ed t h is cel l u l ar b eh av io r as " cel l d eat h
b y f rag ment at io n. " 6 0 A s t u d y f rame b y f rame ev en
s h o w s t w o h al f - mo o ns o f ch ro mat in in an ap o p t o t ic
b o d y ( Fig u re 6 ) . Th e s eq u ence w as s een b y D r. K err
w h o ag reed t h at it ap p ears t o rep res ent ap o p t o s is
( J FR K err, p ers o nal co mmu nicat io n, 1 994 ) .
Th e p at h o g enes is o f t h e b u d d ing p h eno meno n is
no t u nd ers t o o d ; p erh ap s it is rel at ed t o t h e f inal
b reak u p o f t h e cel l . I t is mil d er in t h e s t if f k erat ino -
cy t es , 53 p erh ap s ex p l aining w h y ap o p t o s is o f k era-
t ino cy t es can p ro d u ce t h e rel at iv el y l arg e, ro u nd ed
int raep it h el ial b o d ies cal l ed s u nb u rn cel l s . 53 Th e
b u d s may co nt ain any t y p e o f o rg anel l es , incl u d ing
nu cl ear f rag ment s , and d o no t s w el l ; t h ey s h o u l d no t
b e co nf u s ed w it h b l eb s . Bl eb s are t y p ical o f is ch emic
cel l d eat h . Th ey are b l is t er- l ik e, f l u id - f il l ed s t ru ct u res ,
t y n iq l l v y r iv I I L OI 1
I J I L I
u
Fig u renir o f nr6 n. Te1 rt k t h w t nrin t g f rnm t h re n o t n
L Y Y I U C : t l ~ ~ ~ ~ ~ ~ ~
I C V I U l L I l L U D : I I I L I I U t f I
Fig u re 6 . Th e f irs t k no w n cinemat o g rap b ic reco rd ing o f ap o p t o s is .
memb rane and are ap t t o s w el l and b u rs t , and s o me Tw o f rames f ro m a 1 955 t ime- l ap s e mo v ie
b y
M arcel Bes s is , s h o w ing
may p inch o f f and f l o at aw ay . S o me b l eb s are rev ers -
a l eu k o cy t e in v it ro s aid t o b e d y ing b y f rag ment at io n. ' 57 - 59 To p : A
l eu k o cy t e ( p ro b ab l y a mo no cy t e, Al ) j u s t b ef o re it s d emis e. Bo t t o m:
ib l e. Th e mech anis m o f b l eb b ing ap p ears t o d ep end Th e s ame l eu k o cy t e 3 3 minu t es l at er, af t er an ep is o d e o f
b u d d inig
o n a d is co nnect io n b et w een t h e cel l memb rane and
( no t s h o w n) . I t h as s u d d enl y b ro k en u p int o ap o p t o t ic b o d ies , t w o o f
u o b ich co nt ain cl u mp s o f d ens e ch ro mat in ( arro u ' ) , mno s t l ik el y t h e
t h e u nd erl y ing cy t o s k el et o n ( rev iew ed in ref erence t y p ical h al f mo o ns o f ap o p t o s is .
( R ep ro d u ict io n ait h o riz ed f o r D r. M .
1 5) .
Bes s is
b y
D r. J . L .
Biniet . )
S t u d ent s o f ap o p t o s is s o met imes ref er t o t h e d y -
ing cel l as p erf o rming z eio s is . 52 53 Th e t erm z eio s is
( f ro m t h e G reek z 6 io , meaning b o il ) w as creat ed b y h av e rep res ent ed b l eb b ing . To o u r k no w l ed g e, b l eb -
C o s t ero and P o merat in 1 951 6 1 t o d es crib e a b u b - b ing h as nev er b een s een in el ect ro n micro g rap h s o f
b l ing p ro ces s o b s erv ed in l iv ing cu l t u red f rag ment s ap o p t o t ic cel l s . Th eref o re, in t h e co nt ex t o f ap o p t o -
o f nerv o u s t is s u e. Th e b u b b l ing o ccu rred al o ng d en- s is , it is b es t t o u s e t h e t erm b u d d ing ins t ead o f
d rit es and w as no t s t u d ied in d et ail , b u t it s eems t o z eio s is .
1 0 M aj no and J o ris
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
Ap o p t o s is and K ary o rh ex is
K ary o rh ex is , w h ich u s ed t o b e a d es crip t iv e t erm o f
l it t l e rel ev ance, h as g ained new s t at u s s ince it t u rned
o u t t o b e a f eat u re o f ap o p t o s is . I t is t ru e t h at k ary o -
rh ex is , w h en o b s erv ed in is o l at ed cel l s , s u g g es t s ap -
o p t o s is . H o w ev er, it is cert ainl y no t p at h o g no mo nic o f
ap o p t o s is . I t s o rig inat o r, K l eb s , s aw it in a v ariet y o f
d y ing ( and inf ect ed ) t is s u es . 2 0 N eu ro ns can s h o w
k ary o rh ex is as a res u l t o f is ch emia6 2 and h y p ero x ia. 6 3
K ary o rh ex is o ccu rring in t u mo rs mig h t b e t ak en as a
manif es t at io n o f p ro g rammed cel l d eat h and , t h ere-
f o re, as a g o o d p ro g no s t ic s ig n, in o p p o s it io n t o t h e
nu mb er o f mit o s es ( and t o t h e ex t ent o f mas s iv e ne-
cro s is ) . 6 4 H o w ev er, t h e l it erat u re in t h is reg ard is
s o mew h at co nf u s ing . S o me au t h o rs int erp ret k ary o -
rh ex is in mal ig nant t u mo rs in t h e s ame w ay as mas -
s iv e necro s is , t h at is , as a b ad s ig n. Becau s e many
mit o s es are al s o an ind icat io n o f p o o r p ro g no s is ,
k ary o rh ex is and mit o s is h av e b een l u mp ed t o g et h er
as a mit o s is - k ary o rh ex is ind ex , u s ed t o mean " nu m-
b er o f nu cl ei s h o w ing eit h er mit o s is o r k ary o rh ex is p er
h ig h p o w er f iel d . ' 6 5 W h en t h is is d o ne, f req u ent
k ary o rh ex is co rrel at es w it h p o o r p ro g no s is , at l eas t
f o r neu ro b l as t o ma. I s t h is a mis u nd ers t and ing , o r are
w e d eal ing w it h a f o rm o f k ary o rh ex is t h at d o es no t
rep res ent ap o p t o s is ? Th is p u z z l ing is s u e s h o u l d b e
eas il y s et t l ed b y u s ing t h e s p ecif ic h is t o ch emical
s t ain, 54 rat h er t h an k ary o rh ex is , f o r d iag no s ing ap -
o p t o s is .
Ap o p t o s is and I nf l ammat io n
I t is u s u al l y s t at ed t h at ap o p t o s is d o es no t ind u ce an
inf l ammat o ry res p o ns e, w h ereas is ch emic cel l d eat h
d o es . Th is need s t o b e q u al if ied . O nce t h e macro p h -
ag es h av e mad e co nt act w it h t h eir ap o p t o t ic t arg et ,
t h ey s t ick t o it b y means o f v it ro nect in recep t o rs , 6 6 b u t
h o w d o t h ey f ind t h eir t arg et in t h e f irs t p l ace? Th ey
mu s t h av e b een s o meh o w at t ract ed t o it , al b eit o v er
a s h o rt d is t ance, and t h is s eq u ence is cert ainl y t y p i-
cal o f inf l ammat io n.
I t is t ru e t h at ap o p t o t ic cel l s d o no t s eem t o at t ract
neu t ro p h il s o r l y mp h o cy t es . Th is co u l d ref l ect a q u al i-
t at iv e d if f erence o f ap o p t o t ic cel l d eat h , b u t it co u l d
al s o mean t h at cel l s d y ing s ing l y ( as ap o p t o t ic cel l s
u s u al l y d o ) rel eas e s u ch s mal l q u ant it ies o f ch emo at -
t ract ant s t h at no t al l t h e mo l ecu l ar s p ecies reach t h e
v as cu l ar end o t h el iu m in ef f ect iv e co ncent rat io ns ( t h e
end o t h el ial cel l s are res p o ns ib l e f o r init iat ing t h e s e-
q u ence o f l eu k o cy t e emig rat io n; rev iew ed in ref er-
ence 1 5) .
W h en ap o p t o s is o ccu rs o n a l arg e s cal e, as in cer-
t ain p h as es o f emb ry o nic d ev el o p ment , h o rd es o f
p h ag o cy t es ap p ear
o n t h e s cene. S au nd ers and co l -
l ab o rat o rs 6 7 h av e b eau t if u l l y il l u s t rat ed t h is
p h eno m-
eno n in s it u at io ns t h at
t h ey ref er t o as
cat acl y s mic
necro s is , s u ch as t h e d eat h o f cel l s in t h e
int erd ig it al
z o nes 6 7 - 6 9 ( Fig u re 7 ) .
I n t h es e s it u at io ns t h e ent ire
mas s o f d ead ap o p t o t ic cel l s is rep l aced b y a cro w d
o f mo no nu cl ear
p h ag o cy t es ; as mat t er o f f act , t h e
b es t met h o d f o r d emo ns t rat ing t h is cat acl y s mic ev ent
is t o s t ain t h e t is s u e in v iv o w it h N il e red , a
l y s o s o -
mo t ro p ic d y e ( rev iew ed in R ef erence 1 5) . Th e
d y e
rev eal s no t t h e d ead cel l s b u t t h e l y s o s o mes o f
p h ag o cy t es in w h ich t h eir d eb ris are p ack ed . Th e
p h ag o cy t es are s o nu mero u s t h at , o nce s t ained , t h e
cl u s t ers can b e s een w it h t h e nak ed ey e ( Fig u re 7 ) .
M icro s co p ical l y t h e
imag e is u nd o u b t ed l y s u g g es t iv e
o f inf l ammat io n, b u t t h e nat u re o f t h e p h ag o cy t ic cel l s
is no t cert ain.
Th ey are p ro b ab l y no t d eriv ed f ro m t h e
b l o o d b ecau s e circu l at ing mo no cy t es are no t
p res ent 7 0 at t h e s t ag es u nd er co ns id erat io n. Th ey are
eit h er t is s u e macro p h ag es o r p arench y mal cel l s
( " S ch w es t erz el l en" 2 7 ) t h at b ecame p h ag o cy t ic. Th is
rais es t h e int eres t ing p o s s ib il it y t h at p h ag o cy t o s is b y
no np ro f es s io nal p h ag o cy t ic cel l s w o u l d b e a u s ef u l
ad ap t at io n t o p ro g rammed cel l d eat h in t h e
emb ry o ,
w h en a cl ean- u p o p erat io n is req u ired b u t a f u l l - b l o w n
inf l ammat o ry res p o ns e is no t y et av ail ab l e.
O ne inf l ammat o ry f eat u re o f ap o p t o s is d o es s eem
u nu s u al , namel y , t h e f act t h at t h e cel l d eb ris ( ap o p -
t o t ic b o d ies ) are o f t en p h ag o cy t iz ed b y neig h b o ring
cel l s s u ch as ep it h el ial cel l s , w h ich are no t p ro f es -
s io nal p h ag o cy t es . Th is d o es ap p ear t o b e cel l u l ar
cannib al is m, b u t is it s p ecif ic t o ap o p t o s is , o r d o es it
rep res ent a g eneral t end ency o f cel l s t o d ev o u r t h eir
Fig u re 7 . L ef t : A cl as s ic p ict u re o f p ro g rammed cel l d eat h in t h e l eg
b u d o f a ch ick emb ry o , s t ained in v iv o w it h N il e red ( w h ich b eco mes
co ncent rat ed in p h ag o s o mes ) . Th e d ark int erd ig it al z o nes rep res ent
my riad s o f red - s t ained macro p h ag es s cav eng ing t h e d eb ris o f cel l s
t h at d ied o n s ch ed u l e. R ig h t : A s q u as h p rep arat io n o f a 4 - d ay ch ick
emb ry o , s t ained w it h N il e red , s h o w ing p h ag o cy t es l o ad ed w it h d eb ris
o f d ead cel l s . Bar = 1 0, . ( Fro m S au nd ers and Fal l o n6 6 w it h p ermis -
s io n) .
Ap o p t o s is , O nco s is , and N ecro s is 1 1
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
d is ab l ed neig h b o rs , h o w ev er t h ey may h av e d ied ?
M o re d at a are need ed .
Ap o p t o s is and P ro g rammed C el l D eat h
A mis u nd ers t and ing h as aris en h ere, d u e t o t h e f act
t h at t w o d if f erent p ro g rams are inv o l v ed in ap o p t o s is :
1 ) a p ro g ram t o carry o u t s u icid e and 2 ) ano t h er p ro -
g ram t o t rig g er t h e s u icid al p ro g ram.
Th e p h eno meno n p ro p erl y cal l ed p ro g rammed cel l
d eat h receiv ed it s name b ef o re ap o p t o s is 6 7 , 7 1 ; it re-
f erred t o s it u at io ns in w h ich cel l s are p ro g rammed t o
d ie at a f ix ed t ime. S u ch is t h e d eat h o n s ch ed u l e o f
cert ain cl u s t ers o f cel l s in t h e emb ry o . 3 1 Fo r ex amp l e,
in t h e ch ick emb ry o nic p l at e, a g ro u p o f cel l s h as t o
d ie at a p recis e t ime t o h el p creat e t h e o u t l ine o f a
w ing , mu ch as a s cu l p t o r h ammers o f f ch ip s o f marb l e
t o p ro d u ce a s t at u e. Th es e d o o med cel l s d ie o n
s ch ed u l e ev en if t h ey are t rans p l ant ed el s ew h ere in
t h e emb ry o . 6 7 Th is f o rm o f cel l d eat h is p ro g rammed
in t h e s ens e t h at a g enet ic cl o ck s el ect s a g iv en t ime
f o r t h e d eat h o f cert ain cel l s . W h en t h e t ime h as co me,
a d if f erent p ro g ram mu s t d ict at e t o t h es e cel l s h o w t o
eng ineer s u icid e ( eg , ap o p t o s is ) . I n mo s t cas es t h e
mo rp h o l o g y o f t h is d eat h o n s ch ed u l e t u rns o u t t o b e
ap o p t o s is , b u t in o t h er cas es it is no t , mo s t no t ab l y in
s p ermat o cy t es and s p ermat id s in t h e co u rs e o f no r-
mal s p ermat o g enes is , 7 2 in t h e mas s iv e p ro g rammed
cel l d eat h t h at o ccu rs d u ring t h e d ev el o p ment o f t h e
nerv o u s s y s t em, 7 3 o r in t h e mas s iv e d eat h o f w h o l e
o rg ans d u ring t h e met amo rp h o s is o f cert ain in-
s ect s . 4 4 I n o t h er w o rd s , t h ere are many s it u at io ns in
w h ich p ro g rammed cel l d eat h o ccu rs b y a mo rp h o -
l o g ical and b io ch emical mech anis m t h at is no t ap -
o p t o s is . Th ere is ro o m h ere f o r ad d it io nal d is co v eries .
I n recent y ears t h ere h as b een an u nf o rt u nat e t en-
d ency t o u s e p ro g rammed cel l d eat h and ap o p t o s is
int erch ang eab l y , b ecau s e in b o t h cas es g enet ic p ro -
g rams are inv o l v ed . Th is is co nf u s ing . 7 4 , 7 5 Th e g e-
net ic p ro g ram o f p ro g rammed cel l d eat h is a cl o ck
s p ecif y ing t h e t ime f o r s u icid e, w h ereas t h e g enet ic
p ro g ram o f ap o p t o s is s p ecif ies t h e w eap o ns ( t h e
means ) t o p ro d u ce ins t ant s u icid e.
W e t h eref o re reco mmend t h at t h e name p ro -
g rammed cel l d eat h co nt inu e t o b e u s ed , as o rig inal l y
p ro p o s ed , f o r d eat h o n s ch ed u l e and no t as a s y n-
o ny m o f ap o p t o s is .
C el l D eat h N o t b y Ap o p t o s is : Accid ent al
C el l D eat h
Th e d is co v ery , and naming , o f ap o p t o s is o b l ig e u s t o
f ind s u it ab l e names f o r t h e t y p es o f cel l d eat h t h at
o ccu r b y o t h er mo d al it ies . Th is b ring s o u t t h e p ro b l em
t h at t h e maj o r s o re s p o t in t h e no mencl at u re o f cel l
d eat h is p recis el y t h e l ack o f a s u it ab l e name f o r cel l
d eat h t h at o ccu rs no t b y ap o p t o s is
b u t b y s o me ex -
t ernal ag ent . I nt u it iv el y , t h e co ncep t s eems s imp l e,
as
w e are ref erring t o cel l d eat h b y accid ent al cau s es ,
s u ch as h eat , w h ich w o u l d p ro d u ce t h e cel l u l ar
eq u iv al ent o f mu rd er. I nd eed d eat h b y mu rd er h as
b een s u g g es t ed , h al f in j es t , 7 6 b u t it is q u it e
mis l ead -
ing , as cel l mu rd er b y k il l er cel l s , as w e h av e s een,
p ro d u ces ap o p t o s is . 52 Accid ent al cel l d eat h w as p ro -
p o s ed b y Bes s is , 59 and it is cert ainl y t h e b es t av ail -
ab l e t erm, al t h o u g h it is no t p erf ect b ecau s e acci-
d ent al cau s es , s u ch as mil d h eat o r t o x ic ag ent s , can
al s o ind u ce ap o p t o s is . N ecro s is is t h e t erm cu rrent l y
u s ed f o r no nap o p t o t ic, accid ent al cel l d eat h . 7 7 W e
f ind it u t t erl y co nf u s ing , b ecau s e necro s is s h o u l d no t
b e u s ed t o d ef ine a mo d e o f d eat h , as w e w il l no w
ex p l ain.
W h at is N ecro s is ?
Th e s t art ing p o int f o r ans w ering t h is q u es t io n s h o u l d
b e t h at , o nce ag ain, cel l d eat h and necro s is are t w o
v ery d if f erent t h ing s . C el l d eat h is a p ro ces s t h at l ead s
t o t h e p o int o f no ret u rn, w h ich , f o r l iv er cel l s s u b mit t ed
t o t o t al is ch emia, l ies , as s t at ed ab o v e, at ap p ro x i-
mat el y 1 50 minu t es , 1 5' 3 2 at w h ich t ime s carcel y any
ch ang es can b e s een in h is t o l o g ical s ect io ns . N e-
cro s is is f u l l - b l o w n o nl y af t er 1 2 t o 2 4 h o u rs . I n o t h er
w o rd s , cel l s d ie l o ng b ef o re any necro t ic ch ang es
can b e s een b y l ig h t micro s co p y . To s ay cel l d eat h b y
necro s is imp l ies t h at t h e cel l d ies w h en it b eco mes
necro t ic, w h ich is p at ent l y u nt ru e. I t is rat h er l ik e s ay -
ing t h at cl inical d eat h o ccu rs b y p o s t mo rt em au t o l y -
s is . Fu rt h ermo re, necro s is h as b een u s ed f o r a v ery
l o ng t ime ( ap p ro x imat el y 2 000 y ears ) t o mean d ras t ic
t is s u e ch ang es v is ib l e t o t h e nak ed ey e and t h eref o re
o ccu rring w el l af t er cel l d eat h . I t is imp o rt ant , b o t h
co ncep t u al l y and d id act ical l y , t o p res erv e t h is u s ag e.
N ecro s is is s ig nal ed b y irrev ers ib l e ch ang es in t h e
nu cl eu s ( k ary o l y s is , p y k no s is , and k ary o rh ex is ) and
in t h e cy t o p l as m ( co nd ens at io n and int ens e eo s ino -
p h il ia, l o s s o f s t ru ct u re, and f rag ment at io n) . W e can
s af el y as s u me t h at t h es e are t h e f eat u res o f a cel l ' s
cad av er, w h at ev er t h e mech anis m o f t h e cel l ' s d eat h ,
b e it is ch emia, h eat , t o x ins , mech anical t rau ma, o r
ev en ap o p t o s is . Th e mo s t co mmo n micro s co p ic s et -
t ing s o f necro s is are 1 ) , cel l s t h at d ied s ing l y d is p l ay -
ing t h e mo rp h o l o g ical ch ang es o f ap o p t o s is , f o r
w h ich w e h av e s u g g es t ed t h e t erm ap o p t o t ic necro -
s is , and 2 ) , g ro u p s o f cel l s t h at d ied o f is ch emia,
w h ich w e can cal l is ch emic necro s is o r mas s iv e ne-
cro s is w h en t h e mech anis m is no t k no w n.
1 2 M aj no and J o ris
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
Bu t w h at w as t h ere b ef o re is ch emic necro s is ? O b -
v io u s l y , is ch emic cel l d eat h . Th is is t h e o nl y v ariet y o f
cel l d eat h ( o t h er t h an ap o p t o s is ) t h at h as b een s t u d -
ied in d et ail . Th e d at a at h and are eno u g h t o o f f er a
co h erent p ict u re o f cel l d eat h b y is ch emia, o u t l ining
an ent it y t h at can b e s et u p as a co u nt erp art t o ap -
o p t o s is . Becau s e ent it ies need a name, w e p ro p o s e
o nco s is .
Ap o p t o s is v ers u s o nco s is
I s ch emic cel l d eat h is ch aract eriz ed b y s w el l ing ; t h u s
it s h o u l d b e d ef ined b y a name t h at ref ers t o s w el l ing .
Th ere is s u ch a name in t h e l it erat u re, namel y , o nco s is
( f ro m 6 nk o s , meaning s w el l ing ) . Th is t erm w as co ined
b y v o n R eck l ing h au s en7 8 al mo s t 1 00 y ears ag o , p re-
cis el y w it h t h e meaning o f cel l d eat h w it h s w el l ing . I n
a mo no g rap h o n rick et s and o s t eo mal acia, p u b l is h ed
p o s t h u mo u s l y in 1 91 0, v o n R eck l ing h au s en d e-
s crib ed d eat h w it h s w el l ing p rimaril y in b o ne cel l s . I t
is an o b v io u s b u t l it t l e k no w n f act t h at o s t eo cy t es o f -
t en d ie w it h enl arg ement o f t h eir l acu nae and s o me-
t imes al s o o f t h eir canal icu l i. P at h o l o g is t s w it h ex p er-
t is e in b o ne d is eas es are f amil iar w it h s u ch imag es ,
es p ecial l y in b o ne t is s u e t h at d ies b y s l o w is ch emia,
eg , in t h e s t u mp s o f a f ract u re ( ev en V irch o w il l u s -
t rat es t h is p h eno meno n, w it h o u t g iv ing it a name, in
Fig u re 1 2 9 o f h is C el l u l ar P at h o l o g y 2 ) . V o n R eck l ing -
h au s en' s co l o r il l u s t rat io ns o f o nco t ic o s t eo cy t es are
s t rik ing ( Fig u re 8 ) . I t is cert ainl y a t o u r d e f o rce f o r t h e
s w el l ing o s t eo cy t e t o enl arg e it s s t o ny l acu na. V o n
R eck l ing h au s en w as p ro b ab l y co rrect in as s u ming
t h at t h is p ro ces s req u ired an enz y mat ic ef f ect , w h ich
h e cal l ed t ry p s is . ( N o t e t h at V o n R eck l ing h au s en in-
cl u d ed in o nco s is al s o t h e mo d e o f d eat h o f t h e s o -
cal l ed h y p ert ro p h ic cel l s o f t h e g ro w t h cart il ag e.
Th ere is no d o u b t t h at t h es e cel l s s w el l and b eco me
h y d ro p ic b ef o re t h ey d ie. H o w ev er, t h eir mo d e o f
d eat h , in o u r v iew , is s t il l a my s t ery . Th eir s w el l ing is
p ro b ab l y q u it e u nrel at ed t o h y p ert ro p h y , as b o t h V ir-
ch o w 2 and v o n R eck l ing h au s en7 8 o b s erv ed . Th eir
mo d e o f d eat h is cert ainl y p ro g rammed , w h ich f it s
w it h ap o p t o s is , b u t t h e s w el l ing d o es no t . P erh ap s w e
are d eal ing h ere w it h y et ano t h er f o rm o f cel l d eat h . )
Af t er v o n R eck l ing h au s en t h e t erm o nco s is co n-
t inu ed t o b e u s ed b y E u ro p ean p at h o l o g is t s w o rk ing
o n b o ne t is s u e. W e p ro p o s e t h at it b e g iv en a mo re
g eneral mis s io n, as a co u nt erp art , t o ap o p t o s is . I t is
co ncis e and d es crip t iv e. By it s ref erence t o s w el l ing
it is p art icu l arl y w el l s u it ed t o co nt ras t w it h s h rink ag e
necro s is , and it al l o w s necro s is t o co v er, as it al w ay s
d id , t h o s e ch ang es t h at o ccu r af t er cel l d eat h . I n t o -
d ay ' s med ical j arg o n, t h e ro o t o nco - is no t l imit ed t o
t h e s w el l ing o f t u mo rs ( f o r ex amp l e, o nco t ic p res -
s u re) . O u r p ro p o s al is s u mmariz ed in Fig u re 9. I t w il l
b e no t iced in t h is f ig u re t h at necro s is can o ccu r af t er
O N C O S I S
2 A
2 B
2 C
. . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
oi
O k . . . :
o t is ek
o &e,
, : 4 : S t M l it rw
C R O S I S
+
I C
. . . , ` . E - . : . . . " a . T
Fig u re 8 . O nco s is in o s t eo cy t es as il l u s t rat ed b y v o n R eck l ing h au s en
in 1 91 0. ( ref erence 7 8 Tal . XXI ) . Fro m t h e t ib ia o f a 3 0- mo nt h - o l d
g irl u ' it h o s t eo p o ro t ic o s t eo mal acia ( rick et s ) .
p ro f , b o ne l amel l ae w it h
no rmal o s t eo cy t es ; O nk . K p . and O nk . K nk p . , s u w o l l en, d y ing , o r d ead
o s t eo cl y t es in enl arg ed l acu nae; t ru S t . , cro s s s ect io ns o f d il at ed b o ne
canz al icu l i. ( S ect io ns o f t nd ecal cif ied b o ne s t ained w it h t h io nine; d i-
l at ed canal icu l i and s o me l acu nae ap p ear b l ack b ecau s e t h ey are
f il l ed w it h air inj ect ed int o t h e b o ne ( ref erence 7 8 p 1 3 5) , a met h o d
no t k no w n in o u r d ay . O rig inal d raw ing w at erco l o red . )
P H AG O C Y TO S I S ,
I N FL AM M ATI O N
a
P H AG O C Y TO S I S
BY M AC R O P H AG E S
O R N E AR BY C E L L S
Fig u re 9. Tu J o p at h u ay s o f cel l d eat h l ead ing t o necro s is . At t h e t o p is
s h o w n a nio rmal cel l . 1 A S u w el l ing . 1 B: V acu o l iz at io n, b l eb b ing , and
increas ed p ermeab il it y . 1 C : N ecro t ic ch ang es . ie, co ag u l at io nl ,
s h rink ag e, and k ary o l y s is . 2 A: S h rink ag e and p y k no s is . 2 B: Bu d d ing
and k arv o rh ex is . 2 C : N ecro t ic ch ang es , ie, b reak u p int o a cl u s t er o f
ap o p t o t ic b o d ies ( 2 C ad ap t ed f ro m W eed o n et al 53 ) .
k . AA4 ;-
1 9
. : : ii : :
- ,
Ap o p t o s is , O nco s is , and N ecro s is 1 3
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
b o t h f o rms o f cel l d eat h . A f ine ex amp l e o f p o s t -
ap o p t o t ic necro s is is t h e cat acl y s mic necro s is in em-
b ry o t is s u es d es crib ed b y S au nd ers and Fal l o n. 6 6
K err and H armo n50 h av e al s o p o int ed o u t t h at ap o p -
t o t ic cel l b o d ies can incu r ex t racel l u l ar b reak d o w n
and ref erred t o t h is p o s t - ap o p t o t ic ch ang e as s ec-
o nd ary necro s is , t h ereb y co ncu rring w it h o u r v iew
t h at necro s is can o ccu r al s o af t er ap o p t o s is .
I n s u mmary , w e can d ef ine o nco s is as f o l l o w s : 1 ) ,
o nco s is is a f o rm o f cel l d eat h acco mp anied b y cel -
l u l ar s w el l ing , o rg anel l e s w el l ing , b l eb b ing , and in-
creas ed memb rane p ermeab il it y ; 2 ) , it s mech anis m is
b as ed o n f ail u re o f t h e io nic p u mp s o f t h e p l as ma
memb rane; 3 ) , it is cau s ed , t y p ical l y , b y is ch emia and
p o s s ib l y b y t o x ic ag ent s t h at int erf ere w it h ATP g en-
erat io n o r increas e t h e p ermeab il it y o f t h e p l as ma
memb rane; 4 ) , it ev o l v es w it h in 2 4 h o u rs t o t y p ical
necro s is ; 5) , it is u s u al l y acco mp anied b y k ary o l y s is ;
6 ) , it can b e d iag no s ed b y t es t s o f p ermeab il it y o n
w h o l e cel l s , eit h er in s u s p ens io n ( b y d y e ex cl u s io n
t es t s ) o r b y el ect ro n micro s co p y ( u s ing a co l l o id al
mark er) 7 9; 7 ) , t h e D N A b reak s d o w n in a no ns p ecif ic
f as h io n4 2 ; and 8 ) , t h e cel l u l ar ch ang es ( increas ed
p ermeab il it y o f t h e p l as ma memb rane, cel l s w el l ing ,
o rg anel l e s w el l ing and v acu o l iz at io n, and s imu l t a-
neo u s p ro t ein d enat u rat io n and h y d ro l y s is ) can o nl y
b e h int ed at b y o rd inary h is t o l o g ical t ech niq u es .
M any ex p eriment s h av e s h o w n t h at b l eb b ing , d e-
s crib ed ab o v e, b eg ins d u ring t h e earl y s t ag es o f is -
ch emic d amag e and is init ial l y rev ers ib l e. L arg e
b l eb s may b u rs t , and it h as b een s u g g es t ed t h at t h is
may b e t h e f inal b l o w t o a d y ing cel l ( rev iew ed in ref -
erence 1 5) .
W h y k ary o l y s is s h o u l d f o l l o w o nco s is is no t k no w n.
As reg ard s t h e mech anis m o f k ary o l y s is , a h u g e l it -
erat u re ap p eared earl y in t h e 1 900s , w h en au t o l y s is
w as a f as h io nab l e res earch t o p ic ( rev iew ed in ref er-
ences 1 3 , 1 6 , and 4 8 ) . Th e b as ic p ro b l em w as al -
read y id ent if ied b y W eig ert : h as t h e ch ro mat in l eak ed
o u t , o r h as it l o s t it s s t ainab il it y ? Fro m t h e s t u d ies o f
Tru mp et a1 8 0 it ap p ears t h at b o t h mech anis ms can
o p erat e.
I n cl o s ing , w e w o u l d l ik e t o p o int o u t t w o f act s . Firs t ,
o nco s is and ap o p t o s is are merel y t w o f o rms o f cel l
d eat h , amo ng many o t h ers t h at remain t o b e d e-
s crib ed . C o ns id er, f o r ex amp l e, t h at f o rm o f cel l d eat h
t h at mak es h is t o p at h o l o g y p o s s ib l e, namel y d eat h b y
f ix at io n. H is t o l o g ical f ix at iv es are d es ig ned t o p ro -
d u ce t h e p erf ect crime, d eat h w it h o u t v is ib l e t races .
W h at s h al l w e cal l it ? S eco nd , in t h es e d ay s o f mo -
l ecu l ar p at h o l o g y , it is w el l t o rememb er t h at t h e mar-
v el o u s s t o ry o f ap o p t o s is w as init iat ed b y a v ery
s imp l e, al mo s t el ement ary mo rp h o l o g ical o b s erv a-
t io n, acces s ib l e t o t h e micro s co p es o f o u r g reat -
g rand f at h ers .
Ack no w l ed g ment s
W e are ind eb t ed t o P au l a A. D ad ian f o r s ecret arial
and b ib l io g rap h ic h el p , t o C h ris t ine L . D u ns h ee f o r
p h o t o g rap h ic h el p , incl u d ing p rint s f ro m t h e Bes s is
mo v ie, t o J ean M . U nd erw o o d f o r el ect ro n micro -
s co p ic p rep arat io ns , t o M rs . Anne B. G reene f o r Fig -
u re 9, t o Bet h H . M ay nard M el l o r f o r Fig u re 4 , and t o
R ich ard W o l f e, C u rat o r o f R are Bo o k s at t h e C o u nt w ay
L ib rary o f H arv ard M ed ical S ch o o l , f o r h el p in o b t ain-
ing and p h o t o g rap h ing p recio u s o l d b o o k s .
R ef erences
1 . Farb er E : I d eas in p at h o l o g y : p ro g rammed cel l d eat h :
necro s is v ers u s ap o p t o s is . M o d P at h o l 1 994 , 7 : 6 05-
6 09
2 . V irch o w R : C el l u l ar P at h o l o g y as Bas ed u p o n P h y s i-
o l o g ical and P at h o l o g ical H is t o l o g y , ed 2 . Trans l at ed
f ro m G erman b y B C h ance, 1 8 59. R ep ro d u ced b y D o -
v er P u b l icat io ns , N ew Y o rk , 1 97 1 , p p 3 56 - 3 8 2
3 . R o k it ans k y C : H and b u ch d er al l g emeinen p at h o l o g i-
s ch en Anat o mie. V ienna, Brau mO l l er &S eid el , 1 8 4 6
4 . L id d el l H G , S co t t R : A G reek - E ng l is h L ex ico n. O x f o rd ,
Th e C l arend o n P res s , 1 96 8
5. S aib ara T, H imeno H , U ed a H , O nis h i S , Y amamo t o Y ,
E nz an H , H ara H , Tak eh ara Y , U t s u mi K : Acu t e h ep at ic
f ail u re w it h s w o l l en mit o ch o nd ria and micro v es icu l ar
f at t y d eg enerat io n o f h ep at o cy t es t rig g ered b y f ree
rad ical init iat o r. L ab I nv es t 1 994 , 7 0: 51 7 - 52 4
6 . W eig ert C : U b er C ro u p u nd D ip h t h erit is . E in ex p eri-
ment el l er u nd anat o mis ch er Beit rag z u r P at h o l o g ie d er
s p ecif is ch en E nt z O nd u ng s f o rmen. V irch o w s Arch
P at h o l Anat 1 8 7 7 - 1 8 7 8 , 7 2 : 4 6 1 - 501
7 . W eig ert C : U b er C ro u p u nd D ip h t h erit is . I I . Th eil .
Beo b ach t u ng en b eim M ens ch en. V irch o w s Arch
P at h o l Anat 1 8 7 8 , 7 2 : 2 1 8 - 2 57
8 . W eig ert C : K rit is ch e u nd erg anz end e Bemerk u ng en
z u r L eh re v o n d er C o ag u l at io ns nek ro s e mit b es o n-
d erer Beru ck s ich t ig u ng d er H y al inb il d u ng u nd d er
U mp rag u ng g ero nnener M as s en. D M ed W o ch en-
s ch rif t ( Xl ) 1 8 8 5, 4 5: 7 8 0- 7 8 2
9. W eig ert C : U b er d ie p at h o l o g is ch en G erinnu ng s -
v o rg ang e. V irch o w s Arch P at h o l Anat 1 8 8 0, 7 9: 8 7 - 1 2 3
1 0. C o h nh eim J : L ect u res o n G eneral P at h o l o g y : Th e P a-
t h o l o g y o f N u t rit io n, s ect 1 1 , ed 2 . Trans l at ed f ro m G er-
man b y AB M cK ee. R ep ro d u ced b y Th e N ew S y d en-
h am S o ciet y , L o nd o n 1 8 8 9
1 1 . K rau s F: U b er d ie in ab g es t o rb enen G ew eb en s p o n-
t an eint ret end en V erand eru ng en. Arch E x p P at h o l
P h armak o l 1 8 8 7 , 2 2 : 1 7 4 - 2 00
1 2 . S ch mau s H , Al b rech t E : Z u r Frag e d er C o ag u l at io n-
s nek ro s e. D M ed W o ch ens ch rif t 1 8 99, 6 : 8 9- 1 1 4
1 4 M aj no and J o ris
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
1 3 . C amero n G R : P at h o l o g y o f t h e C el l .
S p ring f iel d ,
C h arl es C . Th o mas , 1 951
1 4 . Bert h o l d G : S t u d ien O b er P ro t o p l as mamech anik .
L eip z ig , V erl ag Art h u r Fel ix , 1 8 8 6
1 5. M aj no G , J o ris I : C el l s , Tis s u es and D is eas e: P rin-
cip l es o f G eneral P at h o l o g y . Bo s t o n, Bl ack w el l S ci-
ence, I nc. , ( in p res s )
1 6 . W el l s G H : C h emical P at h o l o g y : Being a D is cu s s io n o f
G eneral P at h o l o g y f ro m t h e S t and p o int o f t h e C h emical
P ro ces s es I nv o l v ed . P h il ad el p h ia, W B S au nd ers C o
1 92 5
1 7 . Arnh eim G : C o ag u l at io ns nek ro s e u nd K erns ch w u nd .
V irch o w s Arch P at h o l Anat 1 8 90, 1 2 0: 3 6 7 - 3 8 3
1 8 . J aco b y M : U b er d ie f erment at iv e E iw eis s s p al t u ng u nd
Ammo niak b il d u ng in d er L eb er. H o p p e- S ey l er' s Z
P h y s io l C h em 1 900, 3 0: 1 4 9- 1 59
1 9. S ch mau s H , Al b rech t E : U b er K ary o rrh ex is . V irch o w s
Arch P at h o l Anat 1 8 94 , 1 3 8 : 1 - 8 0
2 0. K l eb s E : D ie Al l g emeine P at h o l o g ie. Z w eit er Th eil .
S t o ru ng en d es Bau es u nd d er
Z u s ammens et z u ng .
J ena, V erl ag G u s t av Fis ch er, 1 8 8 9
2 1 . Fl emming W : U b er d ie Bil d u ng v o n R ich t u ng s f ig u ren
in S au g et h iereiern b eim U nt erg ang G raaf ' s ch er Fo l -
l ik el . Arch Anat E nt w G es ch 1 8 8 5, 2 2 1 - 2 4 4
2 2 . P f it z ner W : Z u r p at h o l o g is ch en Anat o mie d es Z el l -
k erns . V irch o w s Arch P at h o l Anat 1 8 8 6 , 1 03 : 2 7 5- 3 00
2 3 . W al d ey er W : U b er K ary o k ines e. Arch P h y s io l 1 8 8 7 ,
1 - 2 8
2 4 . N is s en F: U b er d as V erh al t en d er K erne in d en M il ch -
d ru s enz el l en b ei d er Ab s o nd eru ng . Arch M ik ro s k o p
Anat 1 8 8 6 , 2 6 : 3 3 7 - 3 4 2
2 5. R u g e G : V o rg ang e am E if o l l ik el d er W irb el t h iere. M o r-
p h o l J ah rb u ch 1 8 8 9, 1 5: 4 91 - 554
2 6 . S t ro b e H : Z u r K ennt nis v ers ch ied ener cel l u l arer
V o rg ang e u nd E rs ch einu ng en in G es ch w u l s t en. Beit r
P at h o l Anat 1 8 92 , 1 1 : 1 - 3 8
2 7 . G rap er L : E ine neu e Ans ch au u ng O b er p h y s io l o g is ch e
Z el l au s s ch al t u ng . Arch Z el l f o rs ch 1 91 4 , 1 2 : 3 7 3 - 3 94
2 8 . G l u ck s mann A: C el l d eat h s in no rmal v ert eb rat e o n-
t o g eny . Bio l R ev C amb P h il o s S o c 1 951 , 2 6 : 59- 8 6
2 9. M aj no G , L a G at t u t a M , Th o mp s o n TE : C el l u l ar d eat h
and necro s is : ch emical , p h y s ical and mo rp h o l o g ic
ch ang es in rat l iv er. V irch o w s Arch P at h o l Anat 1 96 0,
3 3 3 : 4 2 1 - 4 6 5
3 0. R ech s t einer M : U b iq u it in. N ew Y o rk , P l enu m P u b l is h -
ing , 1 98 8
3 1 . C iech ano v er A, S ch w art z AL : Th e u b iq u it in- med iat ed
p ro t eo l y t ic p at h w ay : mech anis ms o f t h e reco g nit io n o f
t h e p ro t eo l y t ic s u b s t rat e and inv o l v ement in t h e d eg -
rad at io n o f nat iv e cel l u l ar p ro t eins . FAS E B 1 994 ,
8 : 1 8 2 - 1 91
3 2 . M aj no G : D eat h o f l iv er t is s u e: a rev iew o f cel l d eat h ,
necro s is , and au t o l y s is . Th e L iv er, v o l . 2 . E d it ed b y C H
R o u il l er. N ew Y o rk , Acad emic P res s , 1 96 4 , p p 2 6 7 - 3 1 3
3 3 . Farb er E , Fis h er M M : To x ic I nj u ry o f t h e L iv er, p art A.
N ew Y o rk , M arcel D ek k er, 1 97 9
3 4 . Farb er J L : Bio l o g y o f d is eas e: memb rane inj u ry and
cal ciu m h o meo s t as is in t h e p at h o g enes is o f co ag u l a-
t iv e necro s is . L ab I nv es t 1 98 2 , 4 7 : 1 1 4 - 1 2 3
3 5. Farb er J L : C al ciu m and t h e mech anis ms o f l iv er ne-
cro s is . P ro g res s in L iv er D is eas es . E d it ed b y H .
P o p p e, and F. S ch af f ner. N ew Y o rk , G ru ne &S t rat t o n,
1 98 2 , p p 3 4 7 - 3 6 0
3 6 . K err J FR : S h rink ag e necro s is : a d is t inct mo d e o f cel l u -
l ar d eat h . J P at h o l 1 97 1 , 1 05: 1 3 - 2 0
3 7 . K err J FR , W y l l ie AH , C u rrie AR : Ap o p t o s is : a b as ic
b io l o g ical p h eno meno n w it h w id e- rang ing imp l icat io ns
in t is s u e k inet ics . Br J C ancer 1 97 2 , 2 6 : 2 3 9- 2 57
3 8 . S p ear FG , G l u ck s mann A: Th e ef f ect o f g amma rad ia-
t io n o n cel l s in v iv o : s ing l e ex p o s u res o f t h e no rmal t ad -
p o l e at ro o m t emp erat u re. Br J R ad io l 1 93 8 , 1 1 : 53 3 - 553
3 9. S k al k a M , M at y 6 o v a J , C ej k o v a M : D N A in ch ro mat in
o f irrad iat ed l y mp h o id t is s u es d eg rad es in v iv o int o
reg u l ar f rag ment s . FE BS L et t 1 97 6 , 7 2 : 2 7 1 - 2 7 4
4 0. Y amad a T, O h y ama H , K inj o Y , W at anab e M : E v id ence
f o r t h e int ernu cl eo s o mal b reak ag e o f ch ro mat in in rat
t h y mo cy t es irrad iat ed in v it ro . R ad iat R es 1 98 1 , 8 5:
54 4 - 553
4 1 . Z h iv o t o v s k y BD , Z v o narev a N B, H ans o n K P : C h arac-
t eris t ics o f rat t h y mu s ch ro mat in d eg rad at io n p ro d u ct s
af t er w h o l e- b o d y X- irrad iat io n. I nt J R ad iat Bio l 1 98 1 ,
3 9: 4 3 7 - 4 4 0
4 2 . W y l l ie AH , M o rris R G , S mit h AL , D u nl o p D : C h ro mat in
cl eav ag e in ap o p t o s is : as s o ciat io n w it h co nd ens ed
ch ro mat in mo rp h o l o g y and d ep end ence o n macro mo -
l ecu l ar s y nt h es is . J P at h o l 1 98 4 , 1 4 2 : 6 7 - 7 7
4 3 . Th o mp s o n H J , S t rang e R , S ch ed in P J : Ap o p t o s is in
t h e g enes is and p rev ent io n o f cancer. C ancer E p id e-
mio l Bio mark ers P rev 1 992 , 1 : 597 - 6 02
4 4 . S ch w art z L M , O s b o rne BA: P ro g rammed cel l d eat h ,
ap o p t o s is and k il l er g enes . I mmu no l To d ay 1 993 , 1 4 :
58 3 - 590
4 5. R af f M C : C el l d eat h g enes : D ro s o p h il a ent ers t h e f iel d .
S cience 1 994 , 2 6 4 : 6 6 8 - 6 8 3
4 6 . K err J FR , W int erf o rd C M , H armo n BV : Ap o p t o s is : it s
s ig nif icance in cancer and cancer t h erap y . C ancer
1 994 , 7 3 : 2 01 3 - 2 02 6
4 7 . W y l l ie AH : D eat h g et s a b rak e. N at u re 1 994 , 3 6 9: 2 7 2 -
2 7 3
4 8 . Brad l ey H C : Au t o l y s is and at ro p h y . P h y s io l R ev 1 92 2 ,
2 : 4 1 5- 4 3 9
4 9. Bo w en I D , Bo w en S M : P ro g rammed C el l D eat h in Tu -
mo rs and Tis s u es . L o nd o n, C h ap man and H al l , 1 990
50. K err J FR , H armo n BV : D ef init io n and incid ence o f ap -
o p t o s is : an h is t o rical p ers p ect iv e. Ap o p t o s is : Th e M o -
l ecu l ar Bas is o f C el l D eat h . E d it ed b y L D To mei and
FO C o p e. N ew Y o rk , C o l d S p ring H arb o r L ab o rat o ry
P res s , 1 991 , p p 5- 2 9
51 . To mei L D , C o p e FO ( E d s ) : Ap o p t o s is : Th e M o l ecu l ar
Bas is o f C el l D eat h , v o l 2 . N ew Y o rk , C o l d S p ring H ar-
b o r L ab o rat o ry P res s , 1 994
52 . R az v i E S , W el s h R M : Ap o p t o s is in v iral inf ect io ns . Ad v
V iru s R es 1 995, 4 9: 1 - 6 0
53 . W eed o n D , S earl e J , K err J FR : Ap o p t o s is : it s nat u re
and imp l icat io ns f o r d ermat o p at h o l o g y . Am J D er-
mat o p at h o l 1 97 9, 1 : 1 3 3 - 1 4 4
Ap o p t o s is , O nco s is , and N ecro s is 1 5
AJ P J anu ary 1 995, V o l . 1 4 6 , N o . 1
54 . G av riel i Y , S h erman Y , Ben- S as s o n S A: I d ent if icat io n
o f p ro g rammed cel l d eat h in s it u v ia s p ecif ic l ab el ing
o f nu cl ear D N A f rag ment at io n. J C el l Bio l 1 992 , 1 1 9:
4 93 - 501
55. M art in S J : Ap o p t o s is : s u icid e, ex ecu t io n o r mu rd er?
Trend s C el l Bio l 1 993 , 3 : 1 4 1 - 1 4 4
56 . Fu nd er J : Ap o p t o s is : Tw o p o r no t t w o p ? N at u re 1 994 ,
3 7 1 : 98 ( L et t er)
57 . D u k e R C , W it t er R Z , N as h P B, D ing - E Y o u ng J , O j ciu s
D M : C y t o l y s is med iat ed b y io no p h o res and p o re-
f o rming ag ent s : ro l e o f int racel l u l ar cal ciu m in ap o p t o -
s is . FAS E B J 1 994 , 8 : 2 3 7 - 2 4 6
58 Bes s is M C : M o rt d ' u ne cel l u l e: anal y s e d ' u n f il m en co n-
t ras t e d e p h as e. S emaine H 6 p it au x 1 955, 6 0: 2 1 - 3 2
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v ers el y rel at ed t o necro s is and d et ermines net g ro w t h in
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