Pathology: Introduction & Neoplasia

Table of Contents
Interface of Pathology and Clinical Medicine .............................................................................................................1
Cellular Pathology I .....................................................................................................................................................2
Cellular Pathology II ....................................................................................................................................................4
Inflammation I – Acute Inflammation ........................................................................................................................6
Inflammation II – Chronic Inflammation ....................................................................................................................9
Biology of Human Neoplasia: Introduction and Overview ...................................................................................... 12
Pathology of Human Neoplasia (The Practical Issues) ............................................................................................ 15
Molecular genetics of cancer .................................................................................................................................. 18

Interface of Pathology and Clinical Medicine

Pathology: pathos = suffering; logos = the study of

Identical clinical presentations can be caused by dramatically different pathologies; different pathologies will
require different treatments.

Famous people with pathology include Hubert Humphrey, Sergi Grinchov, the anonymous roofer, Elvis, and JFK.

Osler is responsible for 95% of all medical aphorisms.

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 Cellular Pathology I

Four pillars of pathology:

 Etiology: what initiates a process?
 Pathogenesis: what is its mechanism?
 Morphology: how is it recognized?
 Functional consequences: how does it produce disease?

Disturbance of homeostasis:
 Stress or increased demand can be met by adaptation; injurious stimuli may lead to cell injury / death.
 Failure to adapt can lead to injury/death as well: e.g. adaptations to long-standing hypertension can
predispose to sudden MI.

 Hypoxia: reduction or absence of a normal oxygen supply to an organ

(may result from ischemia = ischemic hypoxia)
 Ischemia: reduction / absence of blood supply to an organ or tissue
 Infarction: death of portion of tissue as result of ischemia (infarction = process, infarct = result)
 White infarct: organs where there’s one blood supply (liver, kidneys, spleen) – wedge shaped infart
downstream of blockage
 Red infarct: main blood supply cut off, reperfused by secondary blood supply (e.g. lung)

Mechanisms of cell injury (inter-dependent & synergistic):

 Decrease in ATP
o Example toxin: cyanide
 Increased (or dec.) intracellular Ca+2
o Increase because Ca/Mg pumps shut down (↓ATP)
o Leads to overactive enzymes (phospholipase, endonuclease, ATPase, protease) – damage
membrane, DNA, etc.
o Example toxin: glutamate excitotoxicity in neurons
 Reactive oxygen species – unpaired e- in outer orbit; leads to oxidative damage
o Superoxide, H2O2, OH- or reactive nitrogen species too
o Endogenous sources (metabolism, enzymes, ox-phos, inflammatory cells)
o Exogenous sources (O2 toxicity, chemicals, radiation, reperfusion injury)
o Usually in balance, but oxidative stress may occur if endogenous anti-oxidants overwhelmed
 Aging, diabetes, alzheimer’s, smoking, cancer, atherosclerosis, etc.
o Example toxin: acetaminophen in liver
 Membrane damage  if irreversible damange, considered the “point of no return”
o Example toxin: complement from immune system

Reversible injury: shut down ox-phos, ↓ATP. Morphological features:

 Swelling of organelles – ER, mito – and membrane blebbing (Na/K pumps shut down). Organelle
changes a.k.a. hydropic/vacuolar degeneration
 Clumping of chromatin (↑anaerobic glycolisis (lactic acid),↓pH, chromatin begins to clump)
 Lipid deposition (↓ protein synthesis; lipids can’t be attached to proteins & build up in cell). A.k.a. fatty
change (steatosis), seen in liver & myocardium
Irreversible when membrane damage starts to occur; time to “point of no return” depends on tissue.

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Reperfusion injury: previously ischemic area reperfused; inflammatory cells all enter at once; big influx of ROS
and calcium (pumps damaged) – may cause irreversible changes in cells.

Necrosis: morphological changes in nucleus & cytoplasm occurring after cell death in a living tissue. (two key
points: cell now dead but host was alive when it happened). Features:
 Eosinophilia (loss of RNA/ribosomes; proteins denatured). Looks more pink.
 Nuclear features: pyknosis (dark, shrunken), karyorrhexis (broken down), karyolysis (totally dissolved)
 Interstitial features: inflammation (need to be alive for this to happen

Subtypes of necrosis:
 Coagulative: after infarction (ischemic cell death) in solid tissues except brain. Most common.
o Tissue architecture looks same, “tombstones” of hyper-eosinophilic cells (more pink)
o Usually resolves as scar after neutrophils, macrophages scavange
 Liquefactive: after infarction in brain.
o Tissue architecture lost, complete hydrolysis / digestion of dead cells
o Resolves by cyst/cavity formation
o Abscess: Liquefactive necrosis as result of localized bacterial infections (fungal, parasitic)
 Accumulation of neutrophils within abscess cavity (making hydrolytic enzymes)
o Pus: dead neutrophils / cell debris
 Requires surgical drainage
 Caseous: “cheese-like”; after TB/fungal infections in immunocompetent individual
 Granuloma: Necrotic center surrounded by rim of inflammatory cells
 Fat necrosis: post-release of pancreatic lipase
o Membrane lipids broken down to FFAs, add calcium = saponification (calcium/fat deposits)

Amount of tissue damaged permanently can depend on quickness of reperfusion (e.g. post-MI or stroke).
Functional consequences can vary for same etiology, pathology, etc.

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 Cellular Pathology II

Hyperplasia: increase in the number of cells in tissue/organ. May or may not include hypertrophy.
 Physiologic: e.g. compensatory hyperplasia (e.g. liver), lactating breast.
 Pathologic
o endometrial hyperplasia (pituitary-gonadal axis abnormalities, menorrhagia = heavy bleeding),
o benign prostatic hyperplasia (includes secondary hypertrophy of bladder muscle)

Hypertrophy: increase in individual cell mass, leading to increase in organ mass. Reversible, response to stimulus
 Physiologic: muscle hypertrophy after working out
 Pathologic: hypertrophic myocardium (↑cytoplasm, ↑nucleus size = “boxcar nucleus”). Could be from
chronic hypertension, aortic valve disease, or some other chronic hemodynamic overload.
 Etiology:
o hormone-induced (uterus & breast in pregnancy),
o increased workload (pumping iron or pathologic / cardiac muscle)
o genetic causes (myostatin mutation)

Atrophy: cellular shrinkage due to loss of substance.

 Denervation (e.g. poliovirus infecting neurons innervating skeletal mm)
 Disuse (e.g. hand with a cast on)
 Hormonal: menopause (↓estrogen, endometrium from proliferative to cystic atrophy, can lead to
irritation & atrophic vaginitis)
 Senile atrophy (brain decreases in size with age)
 Nutritional atrophy
o Marasmus: protein-calorie malnutrition, swollen stomach b/c of lowered oncotic pressure
o Cachexia: severe muscle wasting (AIDS, cancer, other chronic inflammation)
Cellular atrophy may include progressive cell loss so tissue / organ can shrink as well (gross scale atrophy too)

Metaplasia: reversible replacement of one differentiated cell type by another differentiated cell type.
Adaptive substitution (new cells can better withstand environment)
 Smoking-associated squamous metaplasia – better able to withstand tobacco insult
o Reserve cell metaplasia (change in reserve cell population, which are reprogrammed over time
to develop into squamous cells rather than columnar epithelium)
o May undergo neoplastic progression (normal  metaplasia  dysplasia  cancer) especially if
insult continues.
o Example: Barrett esophagus (squamous  columnar to withstand acid at gastroesophageal
junction).

Dysplasia: epithelium starts to exhibit abnormal changes; pre-cancerous but mutations starting to occur

Intracellular accumulations: cells can accumulate exogenous or endogenous substances

 Anthracosis: universal finding in people who have lived in city. Black streaks = macrophages that
phagocytosed carbon. No clinical importance
 Lipofuscin: golden brown “wear-and-tear” pigment; tombstone of lipid peroxidation
 Fatty change: absolute increase in intracellular lipids. Potentially reversible. Most common in liver
o Causes: Morbid obesity (diffuse), alcohol abuse (may have central lobule sparing)

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 o Does have clinical implications – can be irreversible if hepatocytes die  fibrosis  cirrhosis
Apoptosis: programmed cell death.
 Physiologic: embryogenesis, hormone-dependent (menstruation), mature tissue homeostasis
 Pathologic:
o Response to DNA damage from radiation, free radicals, etc. (via p53)
o Viral infections (viral hepatitis)
o Cytotoxic T-cell mediated injury (transplant rejection or autoimmune conditions)
 Mediators (KNOW THIS)
o Caspases: cysteine proteases that play essential role in execution phase of apoptosis. Require
activation from inactive form via activation cascade
o Bcl-2: anti-apoptotic protein (but bcl-2 family contains both pro- and anti-apoptotic proteins)
o p53: stops cell division in response to DNA damage to facilitate recovery; if recovery fails 
apoptosis.
Morphology of apoptosis:
Characteristic Apoptosis Necrosis
 Specific cells affected Stimulus Usually physiologic Pathologic
(necrosis = sheet of cells)
Involvement Single cells Groups of cells
 Organized process;
Chromatin Uniformly dense masses No pattern
systematic breakdown of
DNA fragmentation Inter-nucleosomal Random
DNA (necrosis = smear)
Cell morphology Apoptotic bodies Swelling, degen.
Inflammation Absent Present

Inhibit apoptosis = facilitate tumorigenesis

 HPV: carcinogen (squamous cell carcinoma of cervix) – HPV abrogates function of p53, p21
 Follicular lymphoma – constitutive activation of Bcl-2

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 Inflammation I – Acute Inflammation

Inflammation: a complex response of vascularized tissues to various stimuli, leading to the accumulation of
fluids and leukocytes in the extravascular tissues.

Triggers include trauma, ischemia, neoplasm, infection, foreign matter, immune rxns, etc.

Edema: excess of fluid in interstitial spaces or serous cavities (e.g. pleuroa, pericardium, peritoneum)
 Transudate: edema with low protein content due to ↑ hydrostatic pressure
 Exudate: edema with high protein content, often containing blood cells, due to ↑hydrostatic pressure
and ↑ vascular permeability
o Serous: exudate with few inflammatory cells (pale yellow)
o Serosanginous: exudate with erythrocytes (red tinged)
o Fibrinous: contains large amounts of fibrin (after coagulation of clotting factors)
o Purulent: high inflammatory cell content (often with bacterial infections)
o Supperative: purulent exudate with significant pus (liquefactive necrosis)

What is inflammation trying to do? Deliver effector cells and molecules, provide physical barrier via
microvascular coagulation to prevent spread, promote repair of offending tissue.

Acute inflammation: early & immediate response (minutes to days).

 Characteristics:
o Edema (exudate of fluids & plasma proteins)
o Emigration of leukocytes (esp. neutrophils)
 Triple response of Lewis (histidine mediated):
1. Transient vasoconstriction
2. Wheal (fluid leakage)
3. Flare (vasodilation)
 Steps:
1. Changes in vascular caliber and flow
 Continuity equation: velocity = flow rate / cross sec. area (wider = slower velocity)
 Poiseuille’s law: flow rate increases with r4 (wider = more flow through)
 Bernoulli’s principle: velocity & pressure related inversely
 In acute inflammation: transient vasoconstriction of arterioles followed by vasodilation
of arterioles & capillary beds
 Blood flow increases (Poiseuille’s): heat & redness
 Blood velocity decreases (continuity): blood stasis
 Hydrostatic pressure increases (Bernouilli): extravasation & exudate
2. Increased vascular permeability (leakage)
 Plasma proteins lost so intravascular oncotic pressure drops (higher now in interstitum).
Flow of water out (oncotic & hydrostatic pressure too) when normal balance disrupted
 Results in tumor = swelling (edema)
 Mechanisms
 Contraction of endothelial cells in venules (most common: separation of
junctions; chemically mediated by histidine, reversible & short-lived – 15-30m)
 Reorganization of cytoskeleton in endothelial cells, transcytosis, direct
endothelial injury can play a role too

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 3. Leukocytes extravasate & phagocytose
 Want to kill microbes, ingest offending agents, degrade necrotic tissue
 Lots of blood cells extravasate, not just leukocytes (RBC, platelets, etc)
 Glucocorticoids help reduce inflammation by decreasing extravasation

Role of leukocytes (extravasation & phagocytosis)

Granulocytes are key in acute inflammation
 Neutrophils especially (eosinophils for allergies / parasitic infections, basophils & mast cells release
histadine for allergic hypersensitivity, monocytes in chronic inflammation)
 Time course:
1. Neutrophils (6-24h)
2. Monocytes / macrophages (24-48 hrs)
3. Lymphocytes (end, except viral infections where they can be first)
Sequence:
1. Extravasation
a. Margination: larger cells pushed to edge of vessel (RBC in central column) – pushed out even
farther during inflammation
b. Rolling: tumbling & transient halting.
i. Selectins: bone-marrow-derived & endothelial cell expression only
1. Slow down leukocyte under flow & signalling properties (rolling)
2. Ca dependent, carbohydrate binding proteins
3. Example: l-selectin on leukocyte, binds to GlyCam1 addressin (lymph node HEV)
ii. Addressins: expressed on endothelial cells on different sites, bind to homing receptors
on lymphocytes
c. Adhesion: firm attachement to endothelial surfaces. Mediated by complementary molecules.
i. Integrins: α/ß subunit heterodimers from IgG family with lots of types.
1. Classical examples are VLA4 (leukocyte) – VCAM1 (endothelial cell) and LFA1
(leukocyte) – ICAM1 (endothelial cell).
2. LFA1-ICAM1 binding is Mg dependent (↑affinity) and Ca dependent (↑avidity)
d. Diapedesis: passage across endothelium through intercellular junctions
i. Happens in venules (no smooth mm in wall)
ii. Endothelium to basement membrane, where they secrete collagenase to break down
e. Chemotaxis: direction to site of injury under influence of chemotactic agents; move using
pseudopod
i. Exogenous: bacterial products
ii. Endogenous: complement (c5a), lipoxygenase pathway products, chemokines (specific
for cell types, lots known)
2. Phagocytosis
a. What to eat?
i. Opsonic phagocytosis: target covered by something (Fc receptors for Ab Fc segment,
complement receptors for C3b)
ii. Non-opsonic phagocytosis: pathogen associated molecular patterns (PAMPs) (Mannose,
formyl-peptide, toll-like receptors for LPS, etc)
b. Target identified, internalized via Ca-dependent process, phagosome fuses with lysosomes &
secretory vessels to destroy & excrete waste.
3. Microbial killing
a. Neutrophils make microbicidal free radicals
i. NADPH oxidase reduces O2 to superoxide anion

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 ii. Superoxide converted hydrogen peroxide by spontaneous dismutation
iii. H2O2 is killing molecule (and other ROS/RNS)
b. Microbial response: catalase degrades H2O2 to H2O and O2
i. Pts with Chronic Granulomatous Disease lack NADPH oxidase system genes, susceptible
to infections by catalase positive microganisms

Chemical mediators of inflammation: vasoactive amines (histamine, serotonin), plasma proteases

(complement, kinins, clotting), arachadonic acid metabolites (prostaglandins, leukotrienes), cytokines – most
involved in vascular permeability regulation too (no surprise)

Complement puts holes in the target, kinin is involved in vasodilation and smooth mm relaxation, clotting
involves fibrin depositing, cyclooxygenase is involved in prostaglandin formation (COX), cytokines & others get
in play too.

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 Inflammation II – Chronic Inflammation

Outcomes of acute inflammation:

1. Complete resolution
2. Healing by connective tissue replacment (granulation tissue / organization; fibrosis)
3. Abcess formation
4. Chronic inflammation

Granulation tissue / organization

 After big tissue damage / fibrin exudation
 Buds of endothelial cells  grow and canalize / anastamose
 Macrophages migrate in
 Myofibroblasts & fibroblasts appear, proliferate, form collagen fibers
o Fibrosis: excessive deposition of collagen fibers
 Appearance: packed with cells, juicy, capillaries, collagen with fibroblasts, macrophages removing stuff
 Organization: granulation tissue replacing damaged tissue
o Inflammation
o Wound healing
o Infarct
o Thrombus

Fibroblasts: cytokine-mediated; produce collagen and ECM proteins

Keloid: excessive formation of collagenous tissue resulting in raised area of scar tissue (broad bands of
collagen replacing normal dermal structures
Cirrhosis in liver is result of inflammation  fibrous tissue (collagen) process

Example of organization: pleura following pneumonia, fibrin exudate, forms pleural adhesion

Abcess: focal, localized collection of pus in a newly formed cavity

 Pus in other cavities has different names (empyema in lungs, pyosalpinx in fallopian tubes, etc.)
 Pus = purulent exudate with neutrophils, necrotic cells, edema fluid
 Typically caused by Staphylococci (pyogenic bacteria)
 Appearance:
o Central: necrotic white cells & tissue cells
o Around that: preserved neutrophils
o Outer region: vascular dilation and fibroblastic proliferation (“pyogenic membrane”)
 Can become walled off by connective tissue (body can’t access)
 Can empty through fistula: pathologic channel connecting abcess to internal cavity / body surface

Phlegmon = cellulitis = opposite of an abcess (acute, overwhelming infection spreading along skin – S.
aureus & group A streptococci)

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 Chronic Inflammation:
a prolonged process where acute inflammation and destruction
proceed at the same time as healing / immune response (balance)

Causes: anything that causes acute inflammation (if it persists), infections, autoimmunity (most common in US),
alloimmunity (transplants), foreign materials (insoluble, inanimate)

Clinical classification:
 Primary: de novo cause (no clinically evident acute inflammation)
 Secondary to acute inflammation
Histological classification:
 Macrophagic (diffuse or granulomatous), e.g. TB
 Lymphocytic (diffuse or focal / follicle formation), e.g. autoimmunity
 Supperative (lots of neutrophils, abcess formation) e.g. osteomyelitis

Macrophages: most important cell in chronic inflammation

 From bone marrow precursor
 Circulate in blood as monocytes (half life of 1 day)
 Migrate into tissue, transform into macrophages (half life of several months)
 Roles of macrophages / monocytes: phagocytosis, induce immune reactions via antigen presentation,
release signalling molecules
 Activation: macrophages with increased inflammatory capacities; main function is phagocytosis but also
release lots more substances (NO, ROS, proteases, cytokines, enzymes, grotwh factors, complement…)\
 Can also cause significant tissue damage (hallmark of chronic inflammation)

Macrophagic infiltration:
1. Granulomatous: macrophages arranged into compact masses (follicles); epitheloid appearance like a
fence or barracade.
a. Granuloma = focal area of granulomatous inflammation.
i. Small cluster of epitheloid cells surrounded by lymphocytes
ii. Caseation in middle, then epitheloid layer & macrophagic giant cells; ring of
lymphocytes then fibrous tissue walling off on outside.
iii. E.g. tuberculosis
b. Epitheloid cells: pale, pink, granular cytoplasm & indistinct cell boundaries; hypodense
elongated nucleous
c. Giant cells: fusion of 6-8 macrophages (epitheloid); can contain 20+ small nuclei
i. Langhans giant cell (peripheral/horse-shoe nuclei arrangement): chronic immune
granulomata like TB or sarcoidosis
ii. Foreign body giant cell (scattered nuclei throughout cytoplasm) – e.g. asbestosis
d. Foreign body granuloma: particulate mater in middle (too large for phagocytosis by one Mφ)
e. Immune granuloma: inducing cell-mediated immmunity, Mφ present to T-cells, T-cells produce
cytokines to transform Mφ to epitheloid & giant cells
i. E.g. TB: granuloma (“tubercle”) caused by M. tuberculosis (acid-fast), usually caseating
f. GRANULOMA ≠ GRANULATION TISSUE

2. Non-granulomatous: diffuse spread of macrophages

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Lymphocytic infiltration: hallmark of autoimmune diseases
 Collection of lymphocytes in an organ that doesn’t usually have them
 Diffuse or focal lymphocytic infiltrations
o Focal infiltrations: “ectopic follicles” – look just like lymph node follicles but elsewhere in body
 B-cells in center, T-cells in cortex
 Hashimoto’s thyroiditis: autoimmune reaction against thyroid (focal)
 MS: collection of lymphocytes like follicle in brain

Systemic effects of inflammation

 Fever
o Improve efficiency of leukocyte killing, impair replication of microorganisms
o Coordinated by hypothalamus
 Leukocytosis
o WBC >11,000/uL blood
o Accelerated release of cells from bone marrow (immature neutrophils = bands; “left shift”)
 Bacterial infection: neutrophilia
 Viral infection: lymphocytosis
 Parasitic infection: eosinophilia
 Leukopenia
o WBC < 4,000 / uL
o Typhoid fever, other infections, or when pts overwhelmed (disseminated TB, cancer, HIV)

INFLAMMATION SUMMARY
ACUTE CHRONIC
DURATION Short (days) Long (months-years)
ONSET Acute Insidious
INFLAMMATORY CELLS Neutrophils, macrophages Macrophages, Lymphocytes, Fibroblasts
VASCULAR CHANGES Vasodilation, leakage Angiogenesis (granulation tissue)
EDEMA Yes Usually no
CARDINAL CLINICAL SIGNS Yes Usually no
TISSUE NECROSIS No Yes (ongoing)
FIBROSIS No Yes (ongoing)
SYSTEMIC EFFECTS High fever Low-grade fever, weight loss, anemia
BLOOD CHANGES Neutrophilia, lymphocytosis Variable. Polyclonal
hypergammaglobulinemia

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 Biology of Human Neoplasia: Introduction and Overview

Neoplasia: clonal proliferation of cells with somatic genetic alterations and aberrant regulation of growth
 Benign: don’t threaten life of neoplasm
 Malignant (cancer): ability to invade into normal tissues and metastasize into distant tissues

Neoplasms generally form masses (tumors) but some (e.g. pre-invasive or in situ neoplasms) don’t form visible
masses.

Key genetic defects in cancer cells:

 activate genes that stimulate cell replication (e.g. growth factor receptor kinases)
 inactivate genes that suppress cell replication

Many cancers do have increased growth (↑mitotic figures & growth fraction = proportion of cycling cells).
Others replicate at normal rate & suppress apoptosis (p53, bcl-2, BAX). So if tx only focuses on proliferating cells,
may miss these that are suppressing apoptosis.

Some of these pathways do both (regulate replication & apoptosis) – so these oncogenes can be very important;
blocking their functions can even lead to regression of cancer via ↑apoptosis (“oncogene addiction”)

Invasion & Metastasis

Invasion:
1. Penetrate basement membrane, degrade ECM, migrate in stroma
a. Cancer cells have active role (matrix metalloproteinases & other proteolytic enzymes)
b. Invasion leads to tissue remodeling: stromal reaction (akin to chronic inflammation)
c. Reactive stroma key to diagnosing invasion (is this tissue somewhere where it shouldn’t be?)
d. Invasive cancer actively migrates (reprogramming of integrin gene expression  changes in cell-
substrate adhesions & cytoskeletal dynamics)
e. Microenvironmental cues (oxygen tension, pH) may guide cancer cells to specific stromal structures
2. Adapt to foreign environment
a. Loss of cell-surface receptors (e.g. ↓e-cadherin, ↑other cadherins)
b. Both begin to be able to bind to ECM & lose requirement to be bound to each other
c. Called “epithelial-mesenchymal transition” (EMT) although not as complete as in embryology
(invasive cells still look like epithelial cells of origin)

Metastasis: spread of cancer to distant sites of body (not surgically treatable)

1. Vascular dissemination of malignant cells
a. Spread via lymphatics or blood vessels
b. Pre-requisites: invasion into vascular space & ability to survive in circulation
i. Most non-hematopoietic cells / non-metastatic cancer cells can’t survive shear stress in
circulation. But small % of cancer cells have “stem-like” properties & can survive in circulation.
ii. Most non-malignant cells undergo apoptosis when not attached to solid matrix (“anoikis”). But
resistance to apoptosis already present in cancer cells.
c. Adhere to endothelium & extravasate through vascular walls (processes not well understood
d. Usually inefficient (e.g. peritoneal-venous shunts in cancer pts don’t lead to widespread metastasis)
2. Growth of tumor in secondary site

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 a. Determined in part by routes of vascular & lymphatic drainage
(GI to mesenteric LN / liver, others to regional lymph nodes & lungs)
b. Not entirely dictated by drainage (breast, prostate, lung  bone; breast/lung  CNS)
3. Paget (1889) – “dependence of seed on the soil” (cancer cell on organ)
a. current research: chemokines from cancers & chemokine receptors in receptor organ tissue

Cancer progression (classical paradigm): confined neoplasms  invasive  metastatic.

 Classical: metastasis happens late
 But there is big variability among neoplasms. Probably more likely that certain neoplasms are
programmed to be aggressive or benign from the start depending on mutations. Even small tumors in
some cancers can invade / metastasize early.
 One explanation of why screening hasn’t resulted in huge reduction in cancer mortality

Ability to modify the host environment

 Tumor not just cancer cells: stroma, inflammatory cells, blood vessels
 Angiogenesis: many cancers produce angiogenic substances (e.g. vascular endothelial growth factor,
VEGF; fibroblastic growth factor, FGF); some also produce anti-angiogenic factors.
o Anti-VEGF Ab (bevacizumab) – Tx for some types of cancers
o Low vascularity (hypoxic environment) helps some cancers (e.g. pancreatic) grow. Also makes
resistant to chemotherapeutic drugs because they don’t reach hypoxic areas
 Suppression of immune surveillance: from “self” but altered enough to produce immune response
o Cancer cells evade by secreting things (proteins to inhibit immune cells, cytokines /
prostaglandins to suppress immune response, decoy antigens) or express dummy receptors
 Systemic effects of human cancers: May also secrete humoral factors that affect host physiology
o Ectopic hormones (ACTH, parathyroid-related proteins)
o Cachexins (e.g. TGF) – most not identified yet

Extended doubling potential of tumor cells

 Normal cells: replicate, then eventually reach senescence (telomere shortening). Telomere important in
chromosomal integrity
 Cancer cells: immortality. Increased expression of telomerase to extend the telomeres.
o Kicks in late so cancer cells still have reduced telomere length.
o Could maybe detect cancer via telomerase expression or inhibit telomerase for therapy.

Genomic instability
 Many somatic genetic mutations  Multiple phenotypic alterations
 Most cancer cells aneuploid (abnormal # & structure of chromosomes)
 Continuous rearrangement as cancer cells divide
o Shortening of telomeres – “anaphase bridging” where ends stick together in anaphase
o Inadequate mitotic spindle checkpoint (imperfect alignment & segregation)
o Problems maintaining structure: from defective DNA repair mechanisms (p53, BRCA1&2)
 Leads to non-homologous recombination of broken chromosomes & translocatiosn
o Defective mismatch repair: ↑mutations at sequence level
 Increased microsatellite instability (MSI)
Genomic instability important in carcinogenesis (need many mutations to make cancer) & development of
resistance to chemotherapy.

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Morphology: abnormal, with hyperchromatism (increased chromosomal material) & abnormal, irregular
shape. Structurally abnormal mitosis.

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 Pathology of Human Neoplasia (The Practical Issues)

Classification & nomenclature

 Prefixes = tissue of origin
Benign tumors
 -oma (chondroma = cartilage, adenoma = glandular epithelial)
 Hepatoma, melanoma, astrocytoma are exceptions (malignant)
Malignant tumors
 -carcinoma = epithelial origin
 -sarcoma = mesenchymal (stromal) origin

Ways to characterize:
1. Patterns of differentiation (Epithelial, Mesenchymal, Hematopoetic, Melanocytic, Glial)
2. Sub-types: e.g. for epithelial neoplasm: squamous, glandular (adeno), basal/basaloid, transitional
(urothelial), undifferentiated. Each pattern of differentiation has its own sub-types
3. Morphology: papillary, cystic, polypoid, mucinous, etc.
4. Benign (have very minimal risk of progressing to malignancy) and malignant tumors

Borderline or low malignant potential tumors: don’t fall into these categories well
 E.g. carcinoid tumor – neuroendocrine differentiation; respiratory / digestive systems; big range of
malignancy.
Multiple patterns of differentiation:
 epithelial + mesenchymal = fibroadenoma (benign) or carcinosarcoma (malignant).
 Tetroma: more than one germ cell layer from pleuripotential cells

Pattern of differentiation Benign Malignant

Epithelial
Glandular/ ductal epithelium Adenoma Adenocarcinoma
Squamous epithelium Squamous papilloma Squamous cell carcinoma or epidermoid carcinoma
Liver Hepatic adenoma Hepatoma (a.k.a., hepatocellular carcinoma)
Mesenchymal
Smooth muscle Leiomyoma Leiomyosarcoma
Adipocytes Lipoma Liposarcoma
Cartilage Chondroma Chondrosarcoma
Bone Osteoma Osteosarcoma
Endothelial hemangioma Hemangiosarcoma
Melanocytic Melanocytic nevus Melanoma
Glial Astrocytoma, ependymoma, oligodendroglioma
Hematopoetic Leukemia, lymphoma

Morphological characteristics of neoplasms:

 Solid tissues form tumors (except in situ neoplasia, which is more spread out)
 See below for benign vs. malignant cells

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Characteristics of benign cells
Relatively low nuclear: cytoplasmic ratio
Round nucleus, even distribution of chromatin, small or
inconspicuous nucleoli
Maintenance of cellular polarity and differentiation
Mitoses are uncommon, are located in usual location
(e.g., basal layer), and have typical appearance
Characteristics of malignant cells
Increased nuclear size (high N:C ratio)
Irregular nuclear shape, irregular distribution of
chromatin, prominent nucleoli
Loss of cellular polarity and variable loss of
differentiation
Mitoses are common, located above basal cell layer,
and have atypical appearance.

These are descriptive characteristics, not rules (consideration of all features in context is important)
Cytopathology: characterizing malignancy, etc. based on these features (e.g. Pap smear for aspirated cervical tissue)

Clinical considerations for diagnosis of malignancy (based on clinical experience)

1. Site: smooth mm. tumor in uterus with certain # mitosis = leiomyoma, in colon = leiomyosarcoma
2. Gender: teratoma in ovary with benign appearance = benign course; in testis of adult male = high metastasis potential
3. Age: Benign-appearing teratoma in testis of child = benign course, benign appearance in adult male = malignant

Pre-invasive neoplasia (defies traditional definitions)

 Tubular adenoma – precursor to colorectal cancer, low potential to invade (if excised, good prognosis)
 Carcinoma in situ = “severe dysplasia of squamous mucosa” (e.g. cervix) – high % develops to invasive

Grading & staging neoplasia

 Grade: degree to which cells have malignant features.
o Low grade = close to normal, high grade = large, irregular nuclei & atypical mitosis
o Poorly differentiated / well differentiated (how well does it resemble normal tissue)? Well
differentiated = low grade, poorly differentiated = high grade
o Standardized criteria (differentiation + nuclear features; nuclear dominate). Has variable
predictive validity depending on type of cancer
 Stage: extent of spread of cancer. Better clinical predictor.
o American Joint Committee on Cancer: TNM staging (Tumor, Lymph Nodes, Metastasis)
o Combine information to make TNM grouping (T1, N2, M0 for example) – cut-offs depend on the
type of cancer
o Grouped staging: 0, I-IV (0 = in situ, no invasion; IV = metastatic) – for surgery, etc.

Ancillary techniques
Immunohistochemistry
 No single marker but some are useful (e.g. p63 for normal basal cell layer in prostate; if missing =
cancerous; AMACR overexpressed in most prostate cancers)
 Mostly not helpful for benign vs malignant but can be used to phenotype tumor (e.g. heomatopoetic
neoplasms – use on suspended cells post-flow-cytometry.

Detection of Cancer via Molecular Markers

 Ideal situation: detect & monitor cancer via small markers with minimal invasiveness
 Current: secreted proteins (tumor-specific antigens, e.g. prostate specific antigen/PSA)

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 o PSA: mortality has declined post-PSA introduction
o Associated with over-Dx and over-Tx of disease
o Some mixed studies on benefits in terms of mortality
 Research: better early detection, monitoring disease (mass spec, DNA from cancer cells).
 Still need tissue diagnosis before Tx currently (limits of sensitivity & specificity)

Predictive markers / molecular classification

 Want markers to predict response to therapy or subclassify tumors
 E.g.: Estrogen receptor (ER) in breast cancer: predicts good response to anti-estrogen therapy & better
prognosis.
 Subclassify according to molecular features: e.g. measure multiple genes in parallel (microarray) to form
prognostic indices & determine need for chemotherapy.

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 Molecular genetics of cancer
Theory of genetic basis: need social controls on cells; have a high mutational load of a complex organism.
Average human gene mutated 1010 times in lifetime (almost all somatic)
We handle our mutational load well:
 Protect the germline cells (separation from somatic cells early in embryological development)
 Innate resistance to tumorigenesis (single mutation inadequate)

Neoplasia requires accumulation of somatic mutations: a microevolutionary process

 5-7 rate-limiting events needed (but how?)

 Clonal selection theory: tumorigenesis occurs as serial expansion of successive clones of cells,
punctuated by acquisition of certain mutations which give a cell and progeny a selective growth
advantage over neighboring cells
o Why are so many mutations needed? Downregulation mechanisms protect cells (need multiple
mutations to inactivate downregulatory syndromes & accumulate small effects to cause
selective advantage)
o Clonal changes (present in all cells of a neoplasm) indicate important events
o Genetic / epigenetic heterogeneity arises (even though genetic instability not universal in
neoplasms) – genetic instability just accelerates
o Clone is population that derives from single cell; offspring (subclones) compete to see who can
dominate neoplasm (with selection). Otherwise you’d just end up with heterogenous group &
benign neoplasm. Have to select each time one by one or else tumor mass would be huge
o Subsets with worse prognosis = those with more mutations
o Neoplasms arise from chance events so genetic profile varies from pt to pt (individualize
therapy)
 Pediatric tumors may be exception (arise in window of opportunity & don’t resemble
adults: maybe need fewer mutations & not as many steps)

 Mitogenesis is as important as mutagenesis in tumorigenesis

o Not just environmental exposure to mutagens, but also inflammation & regeneratory processes
 Changes in production of stem cells & ability to differentiate are key for neoplasia (commonly mutated)

Frequently mutated genes:

1. Dominant oncogenes: function activated by mutations
o Think about the signal transduction system from outside to nucleus
o Growth factors
o Growth factor receptors (e.g. EGFR)
o Signal transducers (e.g. RAS, ABL-BCR)
o Nuclear oncoproteins
o Agonists of apoptosis (BCL-2)
o Antagonists of tumor-suppressors (e.g. antagonists of p53)
2. Tumor-suppressor genes: function inactivated by mutations (selective advantage)
o Cell-cell, cell-ECM, differentiation-inducing interactions (e.g. E-cadherin)
o Cytoskeletal
o Regulators of signal transduction
o Cell-division cycle regulation (e.g. p53)
o Apoptosis (ultimate negative regulation: p53, BAX)

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 o Chromatin structure
3. DNA-maintenance genes: genes inactivated by mutations, often before tumorigenesis (need second hit
for selective advantage)
o DNA repair genes (e.g. xeroderma pigmentosum genes)
o Chromosome stability genes (BRCA2, etc.)
4. Passenger mutations: have no special meaning in the neoplasm

Types of mutations:
 Amplification: overproduction of proteins
 Rearrangement / translocation: fusion of two genes from different proteins or oncogene placed behind
strong promoter
 Small mutation: e.g. point mutation, can activate or inactivate gene
 Large deletion: often a second hit – cause inactivation of suppressor gene, or loss of heterozygosity
(LOH), exposing first hit’s mutation
 Viral insertion: can allow viral oncogenes to continue to be expressed
 Telomere shortening: can cause genetic instability, deletions, translocations. Re-activation in
malignancy helps prevent extreme of this process (cell death) in malignant tumor cells

Inherited syndromes: can be due to germline mutations in:

1. Dominant oncogenes (examples are rare: embryonic lethal?)
2. Tumor suppressor genes (more common). Two-hit model: maybe the first hit is inherited, increasing
rate of neoplasm’s occurrence. E.g. familial adenomatous polyposis (FAP)
a. For instance: recessive gene but get LOH with second hit
b. Other examples: hereditary retinoblastoma (RB1), familial breast/ovarian cancer (BRCA 1), Li-
Fraumeni syndrome (p53 – lots of cancers possible)
3. DNA maintenance genes
a. True examples of higher mutation rates (“genomic instability”)
b. Hard to find “genetic instability” in lab, but some conditions do have true chromosomal
instability
c. Examples:
i. Xeroderma pigmentosa (inadequate repair of UV-induced DNA damage if have 2 mutant
copies of the gene)
ii. Hereditary nonpolyposis colorectal carcinoma (can be heterozygous) – inherited cause
of cancer susceptibility
iii. Ataxia telangiectasia (2 mutant copies)
iv. Fanconi anemia & familial breast/ovarian/pancreatic cancer (BRCA2). Two mutant
copies = highest risk, Fanconi anemia. One mutant copy still increases risk (get LOH in
neoplasm)
4. Susceptibility genes: may be very common & are being studied currently

Rational therapy:
Old model: screen all kinds of toxins for ability to kill cancer cells in culture
New model: look for specific biochemical properties

New ideas: augment deficient function(p53 – hard); replace function (hard without gene therapy working);
inactivate a function (Gleevec – very successful); take advantage of neoplastic defect; re-express genes;
augment immune responses

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Acquired drug resistance via mutations: from mutations in drug-binding pocket; mutations causing
compensatory increase in activity, or mutations eliminating cell’s toxic response

Carcinogens
 Dietary / environmental:
o can use Ames assay (expose to potential mutagen; count colonies on plate that have mutated,
subtract background rate), others (cheaper in bacteria, really expensive in animal models).
o End up only screening things that are pretty certain to be carcinogenic
o Some are suspected carcinogens
o Example: Aflatoxin causes p53 mutations in hepatocellular carcinomas in Africa & China
 Infectious causes:
o Indirect mechanism: mitogenesis & inflammation (e.g. HBV & hepatocellular carcinoma, H.
pylori & gastric cancer)
o Direct mechanism: viral proteins that inactivate tumor-suppressor genes (e.g. HPV & cervical
cancer)

Non-mutated genes can also play a role (may be over- or under-expressed in neoplasms & provide good
background for neoplastic development

What is a neoplasm
“A clone of cells distinguished from other tissues by autonomous growth and somatic mutations”
 Mutations in growth-controlling genes
 Supporting, reactive tissues accompany tumor growth
 Grow in conditions that would otherwise be limiting

Caveats:
 All neoplasms have been found to have somatic mutations
 Inciting stimulus usually not shown for neoplasms
 Neoplasms often do control their own proliferation, but control is altered & cell # increases (evidence:
most neoplasms are benign)
 Other masses & proliferations
o Keloids, developmental abnormalities, granulation tissue, synovitis, etc.
o As long as it’s not clonal, it’s not a neoplasm
 Neoplasms are not always masses (e.g. leukemias, etc.)
 Neoplasms are not just a proliferative abnormality (this would just be hyperplasia) but rather a large
increase in stem cell # (clonal)
 Mutations in growth controlling genes can be inherited rather than acquired (insufficient to cause
neoplasms on their own). ADDITIONAL SOMATIC MUTATIONS ALWAYS REQUIRED.

FAP VS HNPCC (Familial Adenomatous Polyposis vs. hereditary nonpolyposis colorectal cancer)
 FAP: first change occurs quickly (lots of early adenomas) but it takes around 20 years to accumulate more hits
 HNPCC: first change occurs slowly, but fast progression afterwards (2 years) – harder to treat

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