Dr .

Sarah Abd Elmonium April 2010

Neoplasia
Tumor nomenclature

Tumor characteristics
Epidemiology

Tumor nomenclature
Definitions Benign tumors Malignant tumors Mixed tumors Confusing terms

Definitions
Neoplasia = literally means new growth Neoplasm =abnormal mass of tissue that grows excessively, and keeps growing even if you remove the stimulus that started it off Neoplasm = is often referred to as a tumor

Definitions
Oncology= is a study of tumors Benign tumor = innocent-acting tumor Malignant tumor = evil-acting tumor and collectively referred to as cancers, derived from Latin word for crab

Cancer = Latin for crab

Definitions
Behaviour:
Benign Tumors Small Slow-growing Non-invasive Well-differentiated Stay localized Malignant Tumors Large Fast-growing Invasive Poorly-differentiated Metastasize

Definitions Structure:
Benign Tumors
o Capsulated o Cells show differentiation o Cells small and uniform in shape
and size o Nucleus compared to the cytoplasm o Mitosis few

Malignant Tumors
Non capsulated Cells are less differentiated Cells large and variable in shape and size Nucleus large and deeply stained (hyperchromatic) Mitosis frequent and may be abnormal Tumour giant cells are frequent Intercellular substance is scanty or absent

o Tumour giant cells are few or

absent o Intercellular substance is present

Definitions

The only indisputable quality of malignancy is

metastasis!
Benign tumors CANNOT metastasize; malignant tumors CAN. If it is metastatic, it MUST BE malignant.

Benign vs. Malignant

Benign Tumors
Usually designated by adding -oma to cell type from which the tumors arises adenoma benign tumor arising from glandular cells leiomyoma benign tumor arising from smooth muscle cells chondroma benign tumor arising from chondrocytes Other benign tumor names papilloma has finger-like projections polyp a mass that projects above a mucosal surface, forming a lump, as in the gut cystadenomas are hollow cystic masses, as in the ovary

Thyroid adenoma

Thyroid adenoma

Thyroid adenoma

Normal thyroid

Leiomyoma

Chondroma

Oral papilloma

Oral papilloma

Head

Stalk

Colon polyp

Colon polyp

Colon polyp

Ovarian cystadenoma

Ovarian cystadenoma

Ovarian cystadenoma

Malignant Tumors
Carcinomas arise in epithelial tissue
adenocarcinoma malignant tumor of glandular cells squamous cell carcinoma malignant tumor of squamous
cells

Sarcomas arise in mesenchymal tissue

chondrosarcoma malignant tumor of chondrocytes angiosarcoma malignant tumor of blood vessels rhabdomyosarcoma malignant tumor of skeletal muscle
cells

Carcinomas
Definition:
Carcinomas are malignant tumours of epithelial tissue Classification: Carcinomas of glandular epithelium: Include Adenocarcinoma Mucoid carcinoma squamous cell carcinoma malignant tumor of squamous cells

Differences Between Sarcomas And Carcinomas

Sarcomas
Mesenchymal in origin Not common Occurs in young age Rapid rate of growth Bulky mass Fleshy consistency High vascularity Necrosis is marked Cells arranged singly with matrix between individual cells Early spread Distant spread mainly by blood

Carcinomas

Epithelial in origin More common Occurs in old age Less rapid rate of growth Doesn't form bulky masses Hard consistency Less vascular Necrosis is less marked Cells in groups. Stroma is found between the groups

Delayed spread Distant spread mainly by lymphatics

Adenocarcinoma

Squamous cell carcinoma

Chondrosarcoma

Angiosarcoma

Rhabdmyosarcoma

Mixed Tumors
Mixed tumors show divergent differentiation Examples pleomorphic adenoma glands + fibromyxoid stroma fibroadenoma glands + fibrous tissue Not to be confused with teratomas originate from totipotential stem cells which have the capacity to differentiate into any of the cell types found in the body

Pleomorphic adenoma

Confusing Terms
Malignant tumors that sound benign lymphoma mesothelioma melanoma seminoma Non-tumors that sound like tumors hamartoma mass of disorganized indigenous tissue choristoma congenital anomaly is described as heterotopic rest of cells Names that seem to come out of nowhere nevus leukaemia hydatidiform mole

Nomenclature
Neoplasm

Benign

Malignant

Carcinoma

Sarcoma

Nomenclature
Neoplasm

Benign adenoma angioma rhabdomyoma

Malignant

Carcinoma

Sarcoma

Nomenclature
Neoplasm

Benign

Malignant

Carcinoma

Sarcoma

squamous cell carcinoma adenocarcinoma

Nomenclature
Neoplasm

Benign

Malignant

Carcinoma

Sarcoma
angiosarcoma rhabdomyosarcoma

Nomenclature of Tumors
Tissue of origin Fat Cartilage Bone Benign Lipoma Chondroma Osteoma Malignant Liposarcoma Chondrosarcoma Osteogenic sarcoma

Synovium
Mesothelium Brain coverings Hematopoietic cells Lymphoid cells Squamous epithelium Glandular epithelium Squamous cell papilloma Adenoma Papilloma Cystadenoma Meningioma

Synovial sarcoma
Mesothelioma Invasive meningioma Leukaemia Lymphoma Squamous cell carcinoma Adenocarcinoma Papillary adenocarcinoma Cystadenocarcinoma

Smooth muscle
Skeletal muscle Melanocytes

Leiomyoma
Rhabdomyoma Nevus

Leiomyosarcoma
Rhabdomyosarcoma Melanoma

Tumor Characteristics
Differentiation and anaplasia Rate of growth Local invasion Metastasis

Differentiation and Anaplasia

Differentiation = how much the tumor cells resemble their cells of origin well-differentiated closely resembles moderately-differentiated sort of resembles poorly-differentiated doesnt resemble Benign tumors are usually well-differentiated Malignant tumors can show any level of differentiation

Thyroid adenoma (well-differentiated)

Squamous cell carcinoma, well-differentiated

Squamous cell carcinoma, moderately-differentiated

Squamous cell carcinoma, poorly-differentiated

Intercellular bridges

Differentiation and Anaplasia

Dysplasia = disorderly (dys-) growth (-plasia)

Dysplasia is used to describe disorderly changes in

non-neoplastic epithelial cells.

Graded as mild, moderate or severe.

Mild-moderate: usually reversible Severe: usually progresses to carcinoma in situ (CIS).

Next step after CIS: invasive carcinoma.

Differentiation and Anaplasia

Anaplasia = a state of complete un-differentiation Literally, to form (-plasia) backwards (ana-) Misnomer! Cells dont de-differentiate. Just means cells are very poorly-differentiated Almost always indicates malignancy

Differentiation and Anaplasia

Anaplastic cells show:
Pleomorphism )marked variation in
size and shape)

Hyperchromatic, large nuclei

Bizarre nuclear shapes, distinct nucleoli

Lots of mitoses, and atypical mitoses

Architectural anarchy

Anaplastic carcinoma

Abnormal mitoses

Both terms describe whether cells look normal or not! But:

differentiation is only used with neoplastic cells,

and dysplasia is only used with non-neoplastic cells!

dysplasia is only used with epithelial cells, but

differentiation can apply to any cell type.

Non-neoplastic epithelial cells

carcinoma in situ mild dysplasia moderate dysplasia severe dysplasia

Neoplastic cells
welldifferentiated moderatelydifferentiated poorlydifferentiated
anaplastic

Normal glands

Normal gland

Mild dysplasia

Moderate dysplasia

Severe dysplasia

Normal squamous epithelium

Moderate dysplasia

Severe dysplasia

Dysplastic epithelium

Normal epithelium

Invasive squamous cell carcinoma

Rate of Growth
Generalizations
Malignant tumors grow faster than benign ones. Poorly-differentiated tumors grow faster than well-differentiated ones. Growth is dependent on: Blood supply Hormonal factors Emergence of aggressive sub-clones

Rate of Growth
Growth fraction = cells that are actively dividing
Age of tumor Early on (subclinical), GF high. Later (clinically detectable), GF low. Type of tumor Leukaemias, lymphomas, small-cell lung cancer: high GF Breast, colon cancer: low GF Important for treatment High GF tumor: treat with chemotherapy/radiation Low GF tumor: treat by debulking

Tumor cells undergoing apoptosis

Malignant tumor invading kidney

Malignant tumor invading kidney

Malignant tumor invading kidney

Carcinoma in situ

Invasive carcinoma

Invasive carcinoma

Metastasizing carcinoma

Liver with multiple metastases

Local Invasion
Benign tumors Stay where they are. Cant invade or metastasize. Usually encapsulated. Malignant tumors Infiltrate, invade, destroy surrounding tissue. Then metastasize to other parts of body. Not encapsulated.

Metastasis
Metastasis = development of secondary tumor implants in distant tissues Half of all patients with malignancies have mets at the time of diagnosis!! Metastasis depends on: Type of tumor Size of tumor Degree of differentiation of tumor

Metastasis
Four ways tumors metastasize
Seeding Lymphatic spread Haematogenous spread Transplantation via mechanical manipulation e.g. surgical incision and needle tracts may occur but is relatively rare

Seeding
Tumor invades body cavity Bits break off and implant on peritoneal surfaces Ovarian carcinoma

Liver seeded with metastatic ovarian carcinoma

Lymphatic Spread
Tumor spreads to local lymph nodes Sentinel lymph node first

Moves through thoracic duct

Empties into subclavian vein Carcinomas like to spread this way

Tumor in lymphatic

Tumor in lymph node

Tumor in lymph node

Haematogenous Spread
Veins are easier to invade than arteries Liver and lungs are most common metastatic destinations Some tumors like other sites better: prostate bone most lung cancers adrenals, brain Sarcomas like to spread this way (but so do carcinomas)

Sarcoma metastatic to lung

Sarcoma metastatic to lung

Epidemiology
Cancer incidence Geographic and racial factors Environmental variables Occupational exposures Age Heredity

Cancer Incidence
1.4 million new cases of cancer (2006) 565,000 deaths from cancer last year (2006) Cancer is 2nd leading cause of death (after heart disease) Most common cancers Men: Prostate33% Women: Breast31% Deadliest cancers Men: Lung31% Women: Lung26%

Cancer Incidence
Death rates have changed over several decades

Decrease in death rates for: Cervical cancer (pap smears) Colon cancer (earlier detection) Breast cancer (earlier detection) Lung cancer in men (less smokers) Some types of leukaemia (new treatment) Increase in death rates for: Lung cancer in women (more smokers)

Geographic and Racial Factors

Breast cancer death rate in US is 5x that in Japan! Stomach cancer death rate in Japan is 7x that in US! Liver cancer infrequent in US, common in Africa. Probably due to enviromental (not hereditary) factors. Most sporadic cancers are caused by environmental factors.

Environmental Variables
Environmental carcinogens
Sunlight: skin cancer Smoking: lung cancer Alcohol: liver, breast cancers HPV: cervical carcinoma

Occupational carcinogens
Asbestos Benzene Beryllium Ethylene oxide Radon roofing, tiles light oil, solvents missile fuel ripening agents, fumigants uranium decay, mines Mesothelioma Leukaemia lung cancer leukaemia lung cancer

Vinyl chloride Nickel

Cadmium

refrigerants ceramics
Batteries

angiosarcoma and liver cancer nose and liver cancers

prostate cancer

Age
Cancer is most frequent at the two extremes of age. Elderly Frequency of cancer increases with age Most cancer deaths occur between 55-75 Children 10% of all childhood deaths Leukaemia,lymphomas, CNS tumors, soft tissue sarcoma and bone sarcomas

Heredity
Three categories of hereditary cancer Inherited cancer syndromes Familial cancers Syndromes of defective DNA repair

Inherited cancer syndromes

Dominantly inherited Retinoblastoma Li-Fraumeni syndrome(various tumors) Melanoma Familial adenomatous polyposis/colon
cancer Neurofibromatosis Breast and ovarian tumor Multiple endocrine neoplasia

Familial cancers
Most common sporadic cancers have
familial forms too, but role of inherited predisposition not clear for each individual Breast(not linked to BRCA1 or BRCA2), Familial polyposis coli, ovary, brain and pancreas Occur earlier, are often deadlier

Familial polyposis coli

Syndromes of defective DNA repair

Recessively inherited Xeroderma pigmentosum Ataxia-telangiectasia Bloom syndrome Fanconi anaemia

Acquired Preneoplastic Syndromes

Persistent regenerative cell replication
Chronic skin fistula squamous cell carcinoma Cirrhosis Liver cancer

Hyperplastic and dysplastic proliferations

Atypical endometrial hyperplasia endometrial carcinoma Dysplastic bronchial mucosa bronchogenic carcinoma Chronic atrophic gastritis gastric carcinoma Chronic ulcerative colitis colorectal carcinoma Leukoplakia squamous cell carcinoma Villous adenomas colorectal carcinoma

THANKs