Chapter 6

NEOPLASIA
Sr. No. TOPIC Page No.
1 Neoplasia 2

2 Characteristics of benign and malignant tumors 2

3 Carcinogenesis: molecular basis of cancer 6

4 Carcinogenic agents: 9

Chemical carcinogens 9
Radiation carcinogenesis 11
Microbial carcinogenesis 13

5 Paraneoplastic syndrome 16

6 Laboratory diagnosis of cancer 17

7 Important questions 23
 NEOPLASIA

Definition

(Given by Sir Rupert Willis) Neoplasm = new growth.

A neoplasm is an abnormal mass of tissue, the growth of which exceeds and persists in the same
excessive manner after cessation of the stimuli, which evoked the change. The abnormal mass is
purposeless, partly autonomous and preys on host for nutrition, vascular supply and endocrinal
support.

Mixed tumor

Tumor cells are usually monoclonal in origin, arising from single germ layer. However, some
tumor arising from a single clone undergo divergent differentiation along two cell lineages.
These are called ‘mixed tumors’. E.g. Pleomorphic adenoma of salivary gland, malignant mixed
tumor of salivary gland, Wilm’s tumor (kidney)

Teratoma
They arise from totipotential cells normally present in ovary and testis and sometimes
abnormally present in midline embryonic rests. Such cells have the capacity to differentiate into
any of the three germ layers. Teratoma are classified into:
• Benign (mature) teratoma: when all components of teratoma are differentiated
• Immature (malignant) teratoma: cells resemble embryonal/immature fetal tissue
• Monodermal teratoma

Choriostoma
Choriostoma is an ectopic (heterotopic) rest of normal tissue. E.g. pancreatic rest in mucosa of
small intestine.

Hamartoma
Is a mass of disorganized but mature tissue indigenous to particular site.

CHARACTERISTICS OF BENIGN AND MALIGNANT TUMORS

Four characteristic features that differentiate benign tumors from malignant:

1. Differentiation & anaplasia
2. Rate of growth
3. Local invasion
4. Metastasis

Differentiation & anaplasia

Differentiation: is the extent to which parenchymal cells resemble comparable normal cells,
both morphologically & functionally. Benign tumors and low-grade malignant tumors are well
differentiated.

Anaplasia: means ‘to form backward’ or lack of differentiation or reversion of differentiation to

a more primitive level. Anaplasia is the hallmark for malignancy. Features of anaplasia include:
1. Pleomorphism: variation in cell size and shape.
2. Abnormal nuclear morphology:
a. Nuclear enlargement leading to increased nuclear cytoplasmic ratio (normal- 1:4 -
1:6). In cancer it may reach up to 1:1.
b. Nuclear pleomorphism and hyperchromasia
c. Coarsely clumped chromatin distributed along nuclear membrane
d. Irregular nuclear membrane
e. Presence of large nucleoli
3. Mitosis: large numbers of mitoses, reflecting the high proliferative rate. This however
does not reflect malignancy because many normal cells with high proliferative rate too
have high mitosis, e.g. bone marrow. More important feature of malignancy is presence
of atypical and bizarre mitotic figures having tripolar, quadripolar, or multipolar spindles

4. Loss of polarity: Tumor cells are loosely attached to each other, thus detach and
rearrange in a disorganized fashion; called loss of polarity.
5. Tumor giant cells

Functional capabilities: Better-differentiated cells retain the functional capabilities of their

normal counterparts. E.g. well-differentiated squamous cell carcinoma elaborate keratin, while
poorly differentiated squamous cell carcinoma is negative for keratin. Some carcinomas of non-
endocrine origin, produce hormones, called ectopic hormone production; e.g. bronchogenic
carcinoma produce ACTH.

Rate of growth

The rate of growth of a tumor is determined by 3 factors:

1. doubling time of tumor cells
2. fraction of tumor cells that are in the replicative pool called growth fraction. The growth
fractions of the most rapidly growing tumors like leukemia, lymphoma and small cell
carcinoma of lung, do not have growth fraction of more than 20%.

Anticancer drugs act on cells, which are in replicative pool. Thus rapidly growing tumors
respond well to chemotherapy, while slow growing tumors do not. A combined modality
treatment is used for the latter. The tumor is de-bulked with surgery or radiation. The
surviving tumor cells shift from G0 to cell cycle and thus become susceptible to drug
therapy.
3. rate at which cells are shed or die. Rate of proliferation exceeds cell death in rapidly
growing tumors.

In general benign tumors grow slowly and malignant tumors grow rapidly. There are exceptions
to this general rule.
Moreover, the rate of growth of tumors may not be constant over time. Factors such as hormonal
stimulation, adequacy of blood supply, and unknown influences may affect their growth. For
example:
1. size of uterine leiomyoma increases during pregnancy, while the tumor atrophies after
menopause
2. Some malignant tumors grow slowly for years and then suddenly increase in size. It may
happen when the tumor develops an aggressive subclone of transformed cells.

Cancer stem cells: Cancers are immortal suggesting that they have “stem cells”. Cancer stem
cells may arise from:
1. normal tissue stem cells; e.g. CML originates from normal hematopoietic stem cell, or
2. differentiated cells that acquire the property of self-renewal; e.g. AML are derived from
differentiated myeloid precursors that acquire capacity for self-renewal

Similarly, tumor- initiating cells (T-ICs) are identified in solid tumors like breast carcinoma,
glioblastoma multiforme and colon cancer. T-ICs constitute only 0.1% to 2% of the total cells in
these tumors. Some tumors have T-ICs constituting 25% of the total cells.

Like normal stem cells, cancer stem cells have a high intrinsic resistance to conventional
therapies, because of their low rate of cell division and the expression of factors, such as multiple
drug resistance-1 (MDR1), that counteract the effects of chemotherapeutic drugs.

An emerging theme is that the genes and pathways that maintain cancer stem cells are the same
as those that regulate normal tissue stem cell homeostasis. E.g.
1. BMI1, in both normal hematopoietic and leukemic stem cells
2. WNT pathway, in normal colonic crypt stem cells and colonic adenocarcinoma “stem
cells”

Local invasion
Tumor is termed ‘invasive’ when the cells breach through the underlying basement membrane.
Local invasion is pathognomic of malignant tumors. Next to metastasis, invasion is the most
reliable feature to differentiate malignant from benign.

Benign tumor Malignant tumor

Grow as cohesive mass, that does not invade Invade the surrounding tissue in a crablike
fashion
Usually develop a capsule around them May develop pseudocapsule
Have well-defined cleavage plane A well-defined cleavage plane is lacking
Discrete, readily palpable, mobile and can be Cannot be enucleated
surgically enucleated
Exception- hemangioma is a benign tumor
which is often unencapsulated

Metastasis
Definition: Meta = transformation; stasis = residence. Metastasis is tumor implants
discontinuous with the primary tumor. Metastasis greatly reduces survival.
Significance: Benign tumors do not metastatize while malignant tumors do.

Some malignant tumors rarely metastatize or metastatize very late in course. They are locally
aggressive. These include:
• Basal cell carcinoma of skin
• Glioma of CNS

Routes of spread:
1. Lymphatic
2. Hematogenous
3. Others:
a. Transcoelomic spread (seeding of body cavities)
b. Along epithelium
c. Via CSF
d. Implantation

Lymphatic route for metastasis: Most common pathway of spread by carcinomas. Sarcomas
can also spread by this route. However this discrimination is misleading since there are
numerous interconnections between lymphatic and vascular channels.

Patterns of spread:
1. Lymphatic permeation: Cancer cells grow along the wall of lymphatic channels
2. Tumor emboli: Tumor embolus travels through the lumen of lymphatic channel to reach
the draining lymph node. The embolus enters lymph node at its convex surface through
its afferent vessel and lodges in subcapsular sinus initially.

Course taken: Lymph node metastasis may follow:

1. Natural route of drainage: e.g. Breast carcinoma in upper outer quadrant disseminates to
axillary nodes, while cancers in the inner quadrant disseminate to internal mammary
nodes. Infraclavicular and supraclavicular nodes get involved later.
2. Skip metastasis: A local lymph node in the group is bypassed, due to obliteration of
regional lymph node by inflammation or irradiation or venous-lymphatic anastomosis
3. Retrograde metastasis: tumor embolus flowing in the direction against that of lymph
flow. E.g. metastasis of carcinoma of prostate to supraclavicular lymph nodes.

Sentinel lymph node: is “the first node in a regional lymphatic basin that receives lymph flow
from the primary tumor.” To avoid the considerable surgical morbidity associated with a full
axillary lymph node dissection in breast cancer patients, sentinel node is assessed for presence or
absence of metastasis. Sentinel node mapping can be done by injection of radiolabeled tracers
and blue dyes. Sentinel nodes are studied under frozen section. Sentinel node study is done for
other tumors as well.

Lymph node, a barrier: Lymph nodes also serve as effective barriers to further dissemination, at
least for a while by:
1. Destroying tumor cells by tumor- specific immune response or
2. By undergoing reactive hyperplasia in response to tumor debris and antigens

Thus, enlargement of nodes in the vicinity of tumor may be caused by:

1. tumor metastasis or
 2. reactive hyperplasia

Hematogenous route of spread:

Typically used by sarcomas. Carcinomas also use it.

Sources used for spread: Veins, venules and capillaries are preferred due to thin wall. Arteries
are less preferred because of thick wall and elastic component.

Some tumors like renal cell carcinoma and hepatocellular carcinoma have propensity to invade
and grow along renal/IVC and portal/hepatic veins respectively. This necessarily does not cause
metastasis.

Favorable sites for dissemination:

1. Liver (portal area)
2. Lung (caval area)
3. Vertebra (cancers arising in close proximity to vertebral column; e.g. thyroid and
prostate)

Unfavorable sites:
1. Spleen
2. Muscle

Other routes of spread:

1. Transcoelomic spread: Cancer crosses the serosa of an organ to enter body cavity
(coelom). Cells are carried in coelomic fluid to get implanted on serosal surface of same
or any other organ without penetrating the substance of organ. Peritoneal cavity is the
common route of transcoelomic spread; pleural and pericardial cavities are less involved.
E.g.
a. Pseudomyxoma peritonei: mucus secreting tumors of stomach, appendix or ovary,
producing gelatinous neoplastic masses in peritoneal cavity
b. Krukenberg tumor: adenocarcinoma of stomach and colon metastatizing to both
ovaries

2. Spread along epithelium lined surfaces: Intact mucosa is resistant to tumor implants.
Breached mucosa favor implantation. E.g.:
a. Spread of endometrial carcinoma to ovary via fallopian tube
b. Spread of renal cell carcinoma to urinary bladder through ureter

3. Implantation: Iatrogenic spread by scalpel, needles, sutures, FNAC

CARCINOGENESIS: MOLECULAR BASIS OF CANCER

Seven key features of carcinogenesis
1. Self-sufficiency in growth signals (oncogenes)
2. Insensitivity to growth-inhibitory signals, tumor suppressor genes
3. Evasion of apoptosis
4. Limitless replicative potential
 5. Sustained angiogenesis
6. Ability to invade and metastasize
7. Defects in DNA repair

Pre-malignant lesions like dysplasia/hyperplasia can progress to cancer. Alterations in oncogenes

and tumor suppressor genes accumulate during tumor progression and correlate with the clinical
aggressiveness of cancer.

Self-sufficiency in growth signals (oncogenes)

Genes that promote autonomous cell growth in cancer cells are called oncogenes, and their
unmutated cellular counterparts are called proto-oncogenes. Oncogenes act through their
product, oncoproteins.

Normally, cell proliferation undergoes following steps:

1. Growth factors (GF): release of GF
2. GF receptors: binding of growth factor to its receptor
3. Signal transduction proteins: activation of signal-transducing proteins on the inner
leaflet of the plasma membrane and transmission of signal across the cytosol to the
nucleus
4. Transcriptional proteins: activation of the proteins leading to initiation of DNA
transcription
5. Cell cycle regulators: activation of the regulators so that the cell enters into cell cycle

Following are the strategies used by cancer cells to acquire self-sufficiency in growth signals:
Category Mode of activation Associated tumor
GROWTH FACTORS
PDGF-β Overexpression Astrocytoma
Osteosarcoma
Fibroblast growth factors Overexpression Stomach cancer
Amplification Breast cancer
TGF-α Overexpression Astrocytomas
HCC
GROWTH FACTOR RECEPTORS
PDGF receptor Overexpression, Gliomas
translocation Leukemias
EGF-receptor family Overexpression SCC lung
Gliomas
SIGNAL TRANSDUCTION PROTEINS
GTP-binding Point mutation Ca colon
Ca lung
Nonreceptor tyrosine kinase Translocation CML
ALL
RAS signal transduction Point mutation Melanomas
TRANSCRIPTIONAL PROTEINS
C-MYC Translocation Burkitt lymphoma
N-MYC Amplification Neuroblastoma
Small-cell carcinoma of
lung
L-MYC Amplification Small-cell carcinoma of
lung
CELL CYCLE REGULATORS
Cyclin D Amplification Ca breast
Ca esophagus

Insensitivity to growth inhibition and escape from senescence: tumor suppressor

genes

Oncogenes drive proliferation of cells while tumor suppressor genes apply brakes to cell
proliferation. Failure of growth inhibition by latter is one of the cause of cancer development.

To explain the inherited and sporadic occurrence of tumor, Knudson proposed “two-hit”
hypothesis:

In familial cases, children inherit one defective copy of gene in the germ line (one hit); the other
copy is normal. Tumor develops when the normal allele is mutated as a result of spontaneous
somatic mutation (second hit).

In sporadic cases both normal alleles must undergo somatic mutation (two hits) to develop
cancer.

Table: Tumor suppressor genes

Location of gene in cell Name of gene Tumors associated
with their mutation
Cell surface TGF-β Carcinoma of colon
E-cadherin Carcinoma of stomach
Inner aspect of plasma membrane NF1 Neurofibromatosis
Cytoskeleton NF2
Cytosol APC Familial adenomatous polyposis
Nucleus RB1 Retinoblastomas, osteosarcoma
p53 Most human cancers
WT1 Wilms' tumor
BRCA1 & Carcinoma of breast & ovary
BRCA2

p53:
• A little over 50% of human tumors contain mutations in this gene.
• p53 is located on chromosome 17p13.1
• p53 acts as a “molecular policeman” or “guardian of genome” or “gatekeeper” against the
formation of cancer
• In non-stressed, healthy cells, p53 has a short half-life of 20 minutes, which increases in
stressed cells
• p53 is a transcription factor that sense cellular stress, such as DNA damage, shortened
telomeres and hypoxia. p53 prevents neoplastic transformation by three interlocking
mechanisms:
1. activation of temporary cell cycle arrest (quiescence)
 2. induction of permanent cell cycle arrest (senescence)
3. triggering programmed cell death (apoptosis)

Evasion of apoptosis
Cell death by apoptosis is a physiologic response to several pathologic conditions that might
contribute to malignancy if the cells remained viable. Some of the mechanisms of evasion of
apoptosis by tumor cells:

1. Reduced levels of CD95/Fas render tumor cells less susceptible to apoptosis by

CD95L/FasL.
2. Some tumors have high levels of FLIP, which prevent activation of caspase 8.
3. BCL2 gene protects tumor cells from apoptosis.

Limitless replicative potential: telomerase

most normal human cells have a capacity of 60 to 70 doublings. After this, the cells lose their
ability to divide and become senescent. This phenomenon has been ascribed to progressive
shortening of telomeres at the ends of chromosomes.

Angiogenesis
Solid tumors cannot enlarge beyond 1 to 2 mm in diameter unless they are vascularized. 1- to 2-
mm zone represents the maximal distance across which oxygen, nutrients, and waste can diffuse
from blood vessels.

Cancer cells can stimulate

1. neo-angiogenesis- new vessels sprout from previously existing capillaries, or
2. vasculogenesis- endothelial cells are recruited from BM

Effect of angiogenesis on tumor growth:

1. supplies needed nutrients and oxygen, and
2. newly formed endothelial cells stimulate the growth of adjacent tumor cells by secreting
growth factors, such as insulin-like growth factors (IGFs), PDGF, and granulocyte-
macrophage colony-stimulating factor.
3. They provide access for metastasis.

CARCINOGENIC AGENTS

Chemical carcinogens
History
Sir Percivol Pott noticed increased incidence of scrotal skin cancer in chimney sweepers due to
chronic exposure to soot. He suggested that chemical agents could evoke cancer.

Mechanism of chemical carcinogenesis

Steps involved in chemical carcinogenesis:

Initiation Promotion
Mechanism: initiator causes permanent DNA Mechanism: promoter has no effect on DNA;
damage induces proliferation of initiated cell indirectly
Change is irreversible Change is reversible
Dose independent Dose dependent; sub-threshold levels are
without effect
Damage has memory Does not have memory, hence multiple doses
should not be widely spaced

Initiation-promotion sequence that can cause tumor:

Initiation should be followed by promotion
There can be time gap between initiation and promotion. Former has memory.
Promotion should be in multiple applications, since it is dose dependent
Multiple promoters should be applied within short duration. Latter does not have memory.

Initiation-promotion sequence that cannot cause tumor:

Only initiator, no promoter
Only promoter, no initiator
Promoter preceding initiator
The multiple does of promoters applied at wider duration.

Complete carcinogen:
Some chemicals possess the capacity of both initiation and promotion. They are called complete
carcinogens.

Mechanism of initiation:
Body possesses many oxidative enzymes e.g. cytochrome P-450 dependent mono-oxygenases,
which are known to inactivate carcinogenic agents

Initiators destroy these oxidative enzymes

Initiators are electron-deficient atoms that readily react with electron-rich sites in cell; e.g. DNA,
RNA, proteins, causing mutation

This mutated cell must undergo at least one cycle of proliferation so that the change in DNA
becomes ‘fixed’ or permanent

Mechanism of promotion:
• Promoters reduce GF requirement of initiated cell
• Promoters make initiated cells less responsive to growth inhibitory signals.
• Promoters are powerful activators of substrates required for signal transduction, e.g.
protein kinase C.

Initiators
They are of two types:
1. direct acting compounds- require no metabolic conversion to become carcinogenic. They
are a group of weak chemical carcinogens.
2. indirect acting compounds or procarcinogens- require activation to become carcinogenic

Table: Initiators
Direct acting chemical carcinogens
Alkylating agents ü Dimethyl sulfate
ü anti-cancer drugs (cyclophosphamide, chlorambucil): should be
used judiciously or can cause secondary cancer usually acute
myeloid leukemia
Acylating agents Acetyl imidazole
Procarcinogens
Polycyclic and ü Comprise the largest group of carcinogens
heterocyclic aromatic ü Most potent are present in fossil fuels
hydrocarbons ü E.g.: Benz(a)anthracene, dibenz(a,h)anthracene,
7,12-dimethylbenz(a)anthracene
ü Benzo(a)pyrene present in cigarette smoke causes lung cancer
ü They are present in smoked meats and fish
ü Kangri (earthern pot containing embers) kept under the clothes, close
to abdominal wall by natives of Kashmir in winters, cause abdominal
wall cancer
Aromatic amines, ü Dimethyl-amino-azo-benzene (butter yellow) cause liver cancer
amides, azo dyes ü Benzidine and β-naphthylamine (found in aniline dyes & rubber)
causes liver and bladder cancer
Natural plant and Approximately 30 known chemical carcinogens are produced by plants
microbial products and micro-organisms. E.g.:
ü Aflatoxin B1 derived from fungus, Aspergillus flavus that grows in
stored grains and plants; induces hepatocellular carcinoma
ü Safrole
ü Betel nut
Others ü Vinyl chloride derived from PVC (polyvinyl chloride) causes
hemangiosarcoma of liver
ü Asbestos causes bronchogenic carcinoma and mesothelioma
ü Metals like nickel, lead, cobalt cause lung cancer

Promoters
1. High levels of dietary fat, leads to increased secretion of bile acids for digestion. Bile
acids act as promoters for development of colon cancer.
2. Hormones e.g. prolonged use of diethylstilbestrol causes endometrial carcinoma
3. Artificial sweetners: saccharin, cyclamates

Radiation carcinogenesis
Radiation carcinogenesis is caused by ultraviolet rays and ionizing radiation.
Ultraviolet rays

Source: Sunlight and UV lamp

Table: Sunlight
Group Wavelength Effect
UVA 320-400 Reaches us; its oncogenic effect is under study
UVB 280-320 Reaches partially and induces cancer
UVC 200-280 Carcinogenic but filtered by ozone layer. Atomic bombing
and industrial pollution will break the ozone layer and expose
us to the most harmful UVC

Degree of risk of developing cancer on exposure to UV rays:

1. Intensity of exposure to UVB
2. Quantity of melanin in skin (melanin absorbs UV light). Thus fair individuals are more
prone to UV light injury.

Mechanism of carcinogenesis by UV light:

• Form pyrimidine dimers in DNA, which cause transcriptional errors
• Also cause mutation of other oncogenes and tumor suppressor genes

Cancers caused by UV light (on the exposed part of body):

1. Squamous cell carcinoma
2. Basal cell carcinoma
3. Melanoma

Ionizing radiation
Classification:
Electromagnetic rays Particulate radiation
α-ray Protons
β-rays Neutrons
γ-rays
X-ray

Higher incidence of cancer is seen:

1. X-ray workers
2. Radiotherapists
3. Miners in radioactive elements
4. Survivors of Hiroshima and Nagasaki bombing

Mechanism of carcinogenesis by ionizing radiation:

• Direct action: mutation
• Indirect action: dislodge ion from water in body forming highly reactive free radicals

Tumors caused by ionizing radiation:

1. Leukemia except CLL: atomic bomb survivors of Hiroshima and Nagasaki, developed
AML and CML, after about a latent period of 7 years
 2. Solid tumors of breast, colon, thyroid and lung were seen in the survivors of Hiroshima
and Nagasaki bombings after a much longer latent period.
3. Infants and young and children exposed to head and neck therapeutic irradiation develop
thyroid cancers

Organs resistant to ionizing radiation induced neoplasia:

1. Skin
2. Bone
3. GIT

Radiation injury in syndromes associated with DNA repair defect

Table: Autosomal recessive disorders characterized by defect in DNA repair

Xeroderma ü Characterized by extreme photosensitivity

pigmentosum ü Defect: inability to repair UV-light induced DNA damage
ü Hence increased incidence of cancers of sun-exposed areas
Ataxia-telangiectasia ü Characterized by cerebellar ataxia and oculocutaneous telangiectasia
ü Defect: inability to repair damage by ionizing radiation
ü Hence prone to developing lymphoid malignancies
Fanconi’s anemia ü Characterized by congenital malformation, progressive aplastic
anemia and predisposition to leukemia.
ü Defect: sensitive to DNA cross-linking agents
Bloom’s syndrome

Microbial carcinogenesis
Cancer causing microbial agents

DNA viruses RNA viruses Bacteria

1. Human papilloma virus 1. Hepatitis C virus (HCV) 1. Helicobacter pylori
(HPV) 2. Human T-cell leukemia
2. Epstein Barr virus (EBV) virus (HTLV), type-1
3. Hepatitis B virus (HBV)
4. Kaposi’s sarcoma herpes
virus (KSHV)

DNA oncogenic viruses

Human papilloma virus (HPV):
Types:
70 types are known:
• ‘Low risk’ type: HPV type 1, 2, 4, 6, 11 are associated with benign squamous papilloma
(warts)
• ‘High risk’ type: HPV type 16, 18, 31, 33, 35, 51 are associated with malignant tumors;
squamous cell carcinoma of cervix, anogenital region, oral cavity, larynx
Pathogenesis:
• Viral DNA attaches to host gene at E1/E2 region. This causes over-expression of E6 &
E7 proteins:
o E6 degrades p53
o E7 binds to tumor suppressor protein pRb
• Carcinogenic potential of HPV type depends on the affinity of E6 & E7 proteins to bind
to p53 & pRb respectively. ‘Low risk types’ have low affinity while ‘high risk’ types
have high affinity.
• p53 exists in two forms- ‘arginine’ & ‘proline’. Women with ‘arginine’ form are at seven
fold more risk of developing cervical cancer.

Epstein Barr virus (EBV): is a member of herpes family.

Pathogenesis:
EBV infects epithelial cells of oropharynx and circulating B-cells via CD21 molecule

Induces B-cell growth Immortalizes B-cells

by activating by upregulating bcl-2 gene,
growth promoting pathways thus preventing apoptosis

EBV causes 4 human cancers:

1. Burkitt’s lymphoma
2. Nasopharyngeal carcinoma
3. B-cell lymphoma, particularly in immuno-compromised patients (AIDS, organ
transplant)
4. Hodgkin’s disease

EBV associated Burkitt’s lymphoma:

• History: Burkitt’s lymphoma was first noticed by ‘Burkitt’ in African children in 1958. It
is predominantly a tumor of jaw bone.
• Tumor progression: EBV infected individuals with good immune system are either
asymptomatic or develop self-limiting infectious mononucleosis. Environmental factors,
like chronic malaria, favor carcinogenesis and individual develops Burkitt’s lymphoma, a
tumor of B-cells.
• Classification:

African Non-African
Most common childhood tumor Uncommon
Endemic; cofactor like chronic malaria Sporadic cases seen
90% carry EBV genome 15-20% carry EBV genome

• Pathogenesis: EBV causes B-cell proliferation. Actively dividing B-cells are at an

increased risk of developing t(8;14) mutation.

EBV associated Nasopharyngeal carcinoma: Contrast to Burkitt’s lymphoma, 100% of

nasopharyngeal carcinoma is associated with EBV infection.

Hepatitis B virus (HBV):

Carcinogenic potential of HBV:

Pathogenesis: Effect of HBV as a carcinogen is indirect:

HBV causes liver injury

Leads to regenerative hyperplasia

These mitotically active liver cells are prone to mutations, either spontaneously or in presence of
environmental agents like aflatoxin

HBx protein produced by HBV has 2 effects:

1. causes transcriptional activation
2. binds to p53 & inhibits growth suppression

RNA oncogenic viruses

Hepatitis C virus (HCV):
Carcinogenic potential of HCV:

Acute infection

Resolution (15%) Chronic (85%) Fulminant (Rare)

hepatitis hepatitis
 Stable disease (68%) Cirrhosis (17%)

HCC &/ death (8.5%) Stable cirrhosis (8.5%)

Pathogenesis: Like HBV, effect of HCV as a carcinogen is also indirect.

Human T-cell leukemia virus (HTLV), type-1:

Is a retrovirus
Contains gag, pol, env & long terminal repeat (LTR) region; like other retroviruses
In addition, it has ‘tax’ gene

Pathogenesis:
Virus has affinity for CD4+ T cells, which are transformed into neoplastic cells by ‘tax’ gene,
which causes transcriptional activation of c-fos, c-sis genes

Carcinogenic bacteria
Helicobacter pylori:
Lesions caused:
1. Chronic gastritis
2. Gastric lymphoma
3. Gastric carcinoma (rarely)

Pathogenesis of gastric lymphoma:

H. pylori causes chronic infection

Recruits T-cells

Reactive T-cells activate polyclonal B-cells, normally present in gastric mucosa in ‘mucosa
associated lymphoid tissue (MALT)’

B-cells proliferate

Cause B-cell lymphoma or MALToma

PARANEOPLASTIC SYNDROME

Definition

Non-endocrine tumors may produce hormones or hormone-like products, called ectopic hormone
production. Symptom complexes in cancer bearing patients that cannot be readily explained by
elaboration of hormones indigenous to the tissue from which the tumor arose and neither by it’s
local or distant spread, are called ‘paraneoplastic syndromes’. These occur in about 10% of
patients with advanced malignant disease.

Importance:
• They may represent the earliest manifestation of an occult neoplasm.
• They may cause significant clinical problems and can be lethal.
• They may mimic metastatic disease.

Clinical syndrome Underlying cancer Causal mechanism

ENDOCRINOPATHIES
Cushing syndrome Small cell Ca of lung ACTH or ACTH-like hormone
Pancreatic Ca
Hypercalcemia SCC of lung Parathyroid hormone related
Breast Ca protein
RCC
Hypoglycemia Ovarian carcinoma Insulin or insulin-like product
Fibrosarcoma and other
sarcomas
Carcinoid syndrome HCC Serotonin, bradykinin
Bronchial adenoma
Pancreatic Ca
Polycythemia Gastric carcinoma Erythropoietin
Renal carcinoma
HCC
NERVE AND MUSCLE SYNDROME
Myasthenia gravis Bronchogenic Ca Immunological
DERMATOLOGICAL DISORDERS
Acanthosis nigricans Gastric Ca Immunological, Epidermal GF
Lung Ca
Uterine Ca
OSSEOUS, ARTICULAR AND SOFT TISSUE CHANGES
Hypertrophic Bronchogenic Ca Unknown
osteoarthropathy &
clubbing of fingers

VASCULAR & HEMATOLOGIC CHANGES

Venous thrombosis Pancreatic carcinoma Tumor products (mucin) that
(trousseau’s syn.) Bronchogenic carcinoma activate clotting
Nonbacterial thrombotic Advanced cancer Hypercoagulability
endocarditis
OTHERS
Nephrotic syndrome Various cancers Tumor antigens, immune
complexes

LABORATORY DIAGNOSIS OF CANCER


Laboratory diagnosis of cancer is getting more complex and specialized. The role of clinical data
and radiological findings in cancer diagnosis cannot be undermined. Moreover, the tissue
submitted for diagnosis should be adequate, representative and well preserved.

Table: Preservation of tissue for various procedures

Mode of tissue diagnosis Mode of preservation
Routine histopathology study & IHC 10% formalin
Frozen section examination Normal saline
Electron microscopy Gluteraldehyde
Hormone, receptor, or other types of molecular analysis Prompt refrigeration

Cytology
Definition

Cytological diagnosis rests on study of individual cells or a group of cells, which have exfoliated
spontaneously or are removed by clinical procedures. Cytology smears can be obtained from fine
needle aspiration (FNA) and exfoliated cells.

Applications
FNA cytology: FNAC is commonly used for readily palpable lesions at sites like breast, thyroid
and lymph nodes. Modern imaging techniques allow FNA of lesions in deep-seated sites, such as
thorax, abdomen and retroperitoneum.

Exfoliative cytology: Applications of exfoliative cytology include Pap smear examination for
detection of cervical cancer, sputum/bronchial lavage, pleural/pericardial/peritoneal effusions,
urine, gastric secretions and CSF examination

Advantages

1. OPD procedure, does not require hospitalization

2. Does not require anesthesia
3. Less painful
4. The procedure can be repeated without inconvenience
5. Report can be given in few hours
6. Cost effective

Limitations

1. A small population of cells are sampled

2. Sample may not be representative of the lesion
3. Architectural details cannot be studied


 Histopathology
Haematoxylin and Eosin (H&E) stained tissue sections remain the mainstay of tissue diagnosis.


Frozen section
Frozen section is requested when a quick on-table diagnosis is required.

Applications
1. To differentiate between- malignant/ benign/ reactive lesion
2. To assess margins of surgical resection for absence of tumor

Advantages
1. Operation theatre side procedure
2. Rapid procedure, takes less than an hour
3. Helps the operating surgeon on table, to decide further line of management
4. Decreases the anxiety of patient and relatives waiting for histopathological report

Limitations
1. Failure to take tissue from representative area
2. Certain tissues are not suitable- friable/ haemorrhagic
3. Sections are cut at 8-10 µm thickness, hence morphological clarity is less
4. There is no dehydration, so cells appear larger
5. Any difficult diagnosis is unsuited
6. Time is too short to do extensive study

Histochemical and cytochemical stains
They are additional diagnostic tools, which help pathologists to identify the chemical
composition of cells. Some of the commonly used special stains are:

Substance Stain
BM collagen Periodic Acid Schiff (PAS), Reticulin, Van Gieson,
Masson’s trichrome
Glycogen PAS
Acid mucin of mesenchymal origin Alcian blue
Calcium Von Kossa
Argyrophilic/ argentaffin granules Silver stains
Cross-striations Phosphotungstic acid-haemotoxylin (PTAH) stain

Immunohistochemistry
Immunohistochemistry is a widely used complement to routine histopathology. It makes use of
antibodies to identify antigens on cells. Enzymes are used to catalyze a color-coded reaction,
which helps in recognizing this antigen-antibody complex.

Applications
1. Support histopathological diagnosis in difficult cases, e.g. poorly differentiated tumors
2. Categorization of undifferentiated malignant tumors, e.g. in some cases anaplastic
carcinoma, melanoma, lymphoma and sarcoma may look alike. They need to be
accurately differentiated because their treatment and prognosis are different.
3. Diagnosing metastatic cancers with unknown primary
4. Therapeutic and Prognostic value: e.g. ERPR and Her2/neu study are done on breast
cancers. ERPR positive tumors respond to anti-oestrogen therapy; while Her2/neu
positive tumors are associated with poor prognosis.

Selection of antibodies to be used

A differential diagnosis should be developed based on clinical data and H&E examination.
Based on this specific IHC markers could be chosen or else pan-markers can be used.

Table: Some commonly used IHC markers

Tumor Immunostain
Epithelial tumors (carcinoma) Pankeratin (HMW-K, LMW-K),
epithelial membrane antigen
(EMA), carcinoembryonic antigen
(CEA)
Mesenchymal tumors (sarcoma)
1. In general Vimentin
2. Myogenic
a. General Desmin, actin
b. Skeletal muscle Myoglobin
3. Fibrohistiocytic tumor α-1-anti-chymotrypsin
4. Vascular tumor Factor VIII, CD34
Other tumors:
1. Melanoma HMB-45
2. Lymphoma LCA/CD45
a. Pan B-cell marker CD20
b. Pan T-cell marker CD3
c. Reed-Sternberg cells (Hodgkin’s lymphoma) CD15, CD30
3. Neural tumors Neurofilaments
4. Glial tumors of brain GFAP
5. Neuroendocrine tumors Chromogranin

Electron microscopy
It has limited use in tumor diagnosis. It can be helpful in confirming diagnosis arrived on light
microscopic examination.
 Tumor EM feature
Squamous cell carcinoma Desmosome
Adenocarcinoma Microvilli or intracytoplasmic mucin
Melanoma Melanosomes
Neuroendocrine tumor Dense core granules
Endothelial tumor Weibel-Palade bodies

Flow cytometry
Principle
Single cell from a suspension of cells is made to flow through a beam of light between detectors.
The light scattered is registered & converted into electronic signals. Cellular features such as cell
size, cytoplasmic granules, DNA content etc. are studied. It is of particular use in hematological
malignancies.

Applications
1. Study DNA ploidy
2. Proliferative fraction of tumor
3. Cell surface antigen for classification of leukemia and lymphoma

Molecular diagnosis
Molecular diagnosis is used in selected cases for predicting behavior of tumors.

Procedures

1. Karyotyping
2. Hybridization
3. Polymerase chain reaction (PCR)

Applications
1. Diagnosis of malignant tumors:
a. Helps in distinguishing between reactive lymph node (giving polyclonal
expression) and lymphoma (giving monoclonal expression)
b. Round blue cell tumors in children cannot be differentiated morphologically. In
such cases, molecular diagnosis is helpful. E.g. One of the d/d for small round
blue cell tumor is Ewing sarcoma, which shows t(11;22)(q24;q12) translocation
2. Prognosis of malignant tumors: e.g. N-MYC gene amplification in neuroblastoma is an
indicator of poor prognosis
3. Detection of minimal residual disease: e.g. detection of BCR-ABL transcripts by PCR
gives a measure of the residual leukemia cells in treated patients with CML.
4. Diagnosis of hereditary predisposition to cancer: e.g. germ-line mutation in BRCA1, and
BRCA2 is associated with high risk of developing breast/ovarian cancer.
 Molecular Profiles of Tumors
Until recently only individual gene expressed by tumor could be studied. DNA microarray
technology (PCR/gene chips) allows large-scale analysis of gene expression, thus making it
possible to study the entire molecular profile of tumor and control sample. A short-list of genes,
which are differentially expressed by the two groups are generated. This “signature” is used to
predict behavior of tumors. E.g.:
1. phenotypically identical large B-cell lymphomas from different individuals may
markedly vary in their survival rates, due to difference in their molecular profile
2. a 70-gene prognosis “signature” has been established for breast cancer. It is a powerful
predictor of prognosis in young patients and predicting metastasis during the first 5 years
after diagnosis.

A smaller panel of 21 genes is also available, which is a predictor of likely benefit of

chemotherapy in breast cancer patients.

“Proteomics” a technique used to obtain profiles of proteins have been developed recently.
Proteins might closely related to the level of mRNA post-transcriptionally.

Tumor markers
Definition
Tumor markers are biochemical indicators of the presence of a tumor detected in plasma or other
body fluids. These markers could be surface antigens, cytoplasmic proteins, enzymes and
hormones.

Tumor markers may however have low sensitivity and low specificity. For e.g. PSA may be
elevated in benign prostatic hyperplasia (BPH) and low PSA does not rule out prostatic cancer.

Applications
1. Support diagnosis
2. Determine response to therapy
3. Indicate relapse

Tumor markers

Tumor markers Associated tumors

Hormones:
Human chorionic gonadotropin (hCG) Trophoblastic tumors,
non-seminomatous testicular tumors
Calcitonin Medullary Ca of thyroid
Onco-fetal antigens:
Alpha-fetoprotein (AFP) Hepatocellular carcinoma (HCC),
 non-seminomatous testicular tumors
Carcinoembryonic antigen (CEA) Ca colon, Ca pancreas, Breast cancer, Ca
lung, Ca stomach
Isoenzymes:
Prostatic associated antigen (PAA) Prostatic adenocarcinoma
Neuron-specific enolase Small cell carcinoma of lung, neuroblastoma
Specific proteins:
Prostatic specific antigen (PSA) Prostatic cancer
Immunoglobulins Multiple myeloma
Mucin:
• CA-125 Ovarian cancer
• CA-19-9 Colonic cancer, pancreatic cancer
• CA-15-3 Breast cancer
New molecular markers:
p53, APC & RAS mutants in serum and stool Colon cancer
p53 & RAS mutants in serum and stool Pancreatic cancer
p53 & RAS mutants in serum and sputum Lung cancer
p53 mutant in urine Bladder cancer

IMPORTANT QUESTIONS

SHORT NOTES

1. Laboratory diagnosis of cancer

2. Metastasis
3. Paraneoplastic syndrome
4. Tumor markers
5. Viral carcinogenesis
6. Chemical carcinogenesis
7. Oncogeneic DNA viruses
8. Tumor progression
9. Routes of spread of tumor

SHORT ANSWERS
. Question & Answers
1. List microscopic features of anaplasia.
Ans. 1. Pleomorphism of cell
2. Abnormal nuclear morphology (nuclear enlargement, nuclear pleomorphism and
hyperchromasia, coarsely clumped chromatin, irregular nuclear membrane, large
nucleoli)
3. Mitosis (increased and/or atypical and bizarre mitotic figures)
4. Loss of polarity
5. Tumor giant cells
2. Two viruses which cause human cancers
Ans. DNA oncogenic viruses:
1. Human papilloma virus (HPV) causes SCC of uterine cervix
 2. Epstein Barr virus (EBV): Burkitt’s lymphoma, nasopharyngeal Ca
3. Hepatitis B virus (HBV): hepatocellular carcinoma (HCC)
4. Kaposi’s sarcoma herpes virus (KSHV): Kaposi’s sarcoma
RNA oncogenic viruses:
1. Hepatitis C virus: HCC
2. Human T-cell leukemia virus (HTLV), type-1: leukemia
3. Define complete carcinogen.
Ans. Some chemicals possess the capacity of both initiation and promotion. They are called
complete carcinogens.
4. Name two hormone dependent carcinomas.
Ans. Breast carcinoma, prostatic adenocarcinoma
5. Name two tumor markers for epithelial malignancy.
Ans. Carcinoembryonic antigen (CEA), prostatic specific antigen (PSA)
6. Name two IHC markers for epithelial tumors.
Ans. Pankeratin (HMW-K, LMW-K), epithelial membrane antigen (EMA),
carcinoembryonic antigen (CEA)
7. Name two ectopic hormones produced by lung tumors.
Ans. ACTH/ACTH-like substance produced by small cell carcinoma of lung
Parathyroid hormone-related protein by squamous cell carcinoma of lung

The End