First Foundations in Pathology

Part 3: Growth and Repair

Paul G. Koles, MD
Asst. Prof. Pathology and Surgery
Director of Pathology Education
Boonshoft School of Medicine at Wright State University
Described Menkes Kinky-hair syndrome in 1962:
Males only, gross abnormalities in hair, deficiency of cupro-enzymes
(e.g., lysyl oxidase which crosslinks collagen and elastin), leading to
weakened connective tissue. Many untreated patients dies of aortic dissection
Parameter Menkes Disease Wilson Disease
Lab findings Increased serum copper
Decreased liver copper
Increased intestinal/kidney
copper
Decreased serum copper
Increased liver copper
Increased urinary copper
excretion
Pathogenesis Increased absorption of
copper from intestine
Decreased excretion of
copper in bile
Treatment Daily Cu-histidine injections Copper chelation therapy
Gene location X chromosome /recessive Chromosome 13/recessive
Overview Part 3
Control of normal cell growth and regeneration
Extracellular matrix & cell-matrix interactions
Repair by connective tissue (fibrosis)
Wound healing
Aaron 17 years later,
with Naomi his wife,
November, 2008
Repair following inflammation:
two simultaneous processes
: replacement of
injured/necrotic cells by cells of same
type, often leaving no evidence of
previous injury
: replacement
of injured/necrotic cells by connective
tissue, leaving a permanent scar
(microscopic or macroscopic)
Regeneration
Fibrosis
Control of cellular population
Stem Cells
Differentiation
Proliferation
Apoptosis
Cell Cycle
PHASES of
Cell Cycle:
G1:
S:
G2:
M:
G0:
presynthetic
DNA synthesis
premitotic
mitotic
quiescent
Correlation of Cell Cycle and Tissue Types
Continuously dividing (labile) cells:
Surface epithelium and excretory ducts of glands
(skin, gi/gu mucosa, biliary tract, pancreas)
Marrow hematopoietic cells
Stem cells in multiple organs (immature,
undifferentiated cells)
Quiescent (stable) cells in G0:
Organ parenchymal cells (liver, kidneys)
Mesenchymal cells (fibroblasts, smooth muscle,
endothelium, chondrocytes, osteocytes)
Nondividing permanent cells (cant re-enter
cell cycle)
Neurons, skeletal & cardiac myocytes
Control of Passage through Cell Cycle
: group of proteins that
control cascade of phosphorylation
pathways at various points in cell cycle
: surveillance
mechanism for ensuring orderly completion
of molecular events, sensing problems in
DNA replication, DNA repair, and
chromosome segregation. If problems
identified, progression to next phase of cell
cycle can be delayed or stopped.
Cyclins
Checkpoints
Mechanism: control of cell cycle
Cyclin E / cdk 2

2 critical checkpoints to insure normal DNA, regulated by:
Cyclins A B / cdk 1 2
G1 /S G2 / S
Cell Growth: molecular overview
Growth Factors or Cytokines
Cell Surface Receptors
Intracellular Activation of Transcription Factors
Changes in Gene Expression (up and down regulation)
Cell Proliferation or Inhibition
Bind to
Initiate
Promote
Resulting in
Modes of Intercellular Signalling
Autocrine
Paracrine
Endocrine
Surface Receptors: 3 classes
Receptors with
intrinsic
Tyrosine kinase
activity
Seven transmembrane
(G protein-coupled)
Receptors
without
intrinsic
tyrosine kinase
activity
Consequences of Receptor Activation
Intrinsic-kinase activity receptors:
Irreversible commitment of cell to enter
(proliferative response)
Receptors without intrinsic kinase activity
(cytokine superfamily):
Activation cytosolic kinases to mediate functional
response (not proliferative)
G-protein coupled (seven spanning) receptors:
Over 1500 receptors identified
Bind various ligands, producing specific intracellular
response
Cell cycle
Signal Transduction by Tyrosine
Kinase Receptors
Growth factors: coming soon!
Clinical
application: if
mutant ras
protein is
permanently
fixed in active
GTP form, what
pathologic
process may
result?
Neoplasia
Transcription Factors
Definition: intracellular proteins that regulate gene
expression, thereby controlling cell growth
Specific domains in transcription factors:

: permits factor to bind specifically to short
sequences of DNA

: allows factor to increase transcription of DNA

:allows factor to decrease transcription of DNA
Transcription factors known to be operative in malignant
neoplasms:
Growth promoting: c-MYC and c-JUN
Cell cycle inhibiting (tumor suppressor gene): p53
DNA-binding
Activation
Repression
Growth Factors
Definition: proteins that bind to cell surface
receptors with
generating cascade response that signals
cell to enter S-phase (cell division).
These factors can also modulate cell
functions: locomotion, contractility,
differentiation, etc.
Intrinsic tyrosine kinase activity
Major growth factors / effects
FACTOR
EGF = epidermal
TGF-a = transforming
VEGF=vascular endothelial
PDGF= platelet-derived


FGF= fibroblast
FGF-1=acidic
FGF-2=basic

EFFECTS
Mitogenic for epithelium & fibroblasts
Mitogenic for hepatocytes
Mitogenic for endothelial cells
Mitogenic for monocytes, fibroblasts,
smooth muscle cells; activates
neutrophils

Angiogenesis, wound repair (mitogenic
for both fibroblasts and keratinocytes)


Tissue Regeneration
Liver from living donor before
transplantation, outlining right
lobe to be used for grafting
into recipient
Liver of donor one week post-
partial hepatectomy, showing
marked growth of left lobe
(compensatory hyperplasia)
without regrowth of right lobe.
Why didnt right lobe regrow also?
Extracellular matrix 1
Definition: macromolecules outside cells,
formed by local secretion and assembled into
network surrounding cells
Functions:
Sequester H2O for turgor; minerals for rigidity
Reservoir for growth factors
Scaffolding within which cells adhere, migrate, and
proliferate
Extracellular matrix (ECM) 2
Groups of macromolecules in ECM:
Fibrous structural proteins: 2 major families
are:

Adhesive glycoproteins
Gel proteins in intercellular junctions and cell
surfaces: proteoglycans & hylauronic acid
Collagens
Elastins
Extracellular matrix (ECM) 3
Macromolecules of ECM assemble into
two types of organizational structure:
: fills spaces
between cells

: closely
associated with cell surfaces
Interstitial matrix
Basal membranes (basement membranes)
Collagen: summary of major types
Skin (80%), bone (90%), tendons
Basal membranes
Genetic deficiency
of type IV in:
Alport syndrome
Collagen synthesis
Nutrient required
for hydroxylation
of alpha chains:
Deficiency of this
nutrient causes
poor wound
healing in
disease called:
Inherited disorders
of collagen
synthesis, leading to
defective fibers:
Vitamin C
Scurvy
Ehlers-Danlos syndromes
Elastic Fibers
Definition: fibers capable of stretching and
recoiling to original size
Present in tissues requiring elasticity:

Structure:
Central core protein:
Peripheral microfibrillary network:
Inherited defect in synthesis of peripheral
microfibrillary network: abnormally weakened
elastic fibers. Syndrome?

Skin, lung, uterus, ligaments, large blood vessels
Elastin
Fibrillin
Marfan syndrome
Cystic medial
degeneration--aortic
dissection
Associated
Vascular
disease?
Adhesion molecules 1
Function:
attach cells to
ECM matrices;
2 glycoprotein
chains held
together by
disulfide bonds;
produced by
fibroblasts,
endothelial
cells, &
monocytes
Fibronectin
Adhesion molecules 2
Most abundant
glycoprotein in
basement
membranes; it
spans basal lamina
and binds to both
cell surfaces and
ECM components:
Laminin
Adhesion molecules 3
Transmembrane
glycoproteins with
alpha and beta chains
that bind to
fibronectin, laminin,
& collagen. This
family of surface
receptors mediate
attachment of cell
membranes to ECM:
integrins
These also mediate
adhesion of which cell
type to endothelium?
neutrophils
Summary: interactions cell-ECM
laminin Major EC structural protein:
fibronectin
integrins
Fig. 3-16, Pathologic Basis of Disease, 7th ed, Elsevier 2005
Collagen
Overview: Repair after injury
ACUTE AND CHRONIC INFLAMMATION
Damage to parenchymal cells and interstitial framework
Regeneration of
parenchymal cells
whenever possible
Replacement of non-regenerated
damaged tissue by what?
Fibrosis
Fibrosis (fibroplasia)
Four components:
: formation new blood
vessels
of fibroblasts into
damaged tissue
of extracellular matrix
Organization fibrous tissue =
angiogenesis
Migration and proliferation
synthesis
remodeling
Sequence of events in repair
24 hrs: proliferation of fibroblasts & endothelial cells
Within 3-5 days:
Granulation tissue
New
capillaries
Proliferation
of young
fibroblasts
Little
mature
collagen
blue-staining collagen
(trichrome stain)
Permanent
result:
Mature scar
Angiogenesis
Definition: pre-existing vessels send out
capillary sprouts to form new vessels
cf. vasculogenesis: the primitive vascular
network established during embryogenesis
Clinical importance:
Repair post-inflammation
Formation collateral circulation (post-MI)
Support growth of neoplasms (therapeutic
implications)
Angiogenesis: 2 mechanisms
ECM proteins affecting angiogenesis
Integrins: formation and maintenance new vv.
Matrix proteins which destabilize cell-matrix
interactions, promoting angiogenesis:
Thrombospondin
SPARC
Tenascin C
Proteases that remodel matrix
Plasminogen activators
Matrix metalloproteinases
Fragment of collagen that inhibits endothelial
proliferation and angiogenesis, with therapeutic
application in neoplasia?

endostatin
Fibrosis (fibroplasia)
Emigration and proliferation of fibroblasts at
injury site, triggered by multiple growth
factors produced by cells in granulation
tissue, most important of which is:
ECM deposition by fibroblasts: fibrillar
collagen synthesis enhanced by growth
factors and cytokines, thus converting
Granulation tissue Into a Fibrous scar
TGF-beta
Tissue remodeling
Conversion granulation tissue into scar
involves changes in composition of ECM.
: enzymes which
degrade ECM components for remodeling.
These enzymes are dependent on
ions for activity.
Matrix metalloproteinases
zinc
Wound Healing
Healing by first intention Healing by second intention
Summary: phases of wound healing
Wound tensile strength: 10% of normal at 7 days;
70-80% of normal at 3 months
Factors influencing wound healing
Local Factors
: most important single cause of delay
Mechanical: too early motion can delay
Foreign bodies: may impede or cause abscess
Location: speed of healing proportional to richness of
blood supply:
face > trunk > extremities
Type of wound: primary intention heals faster than
secondary intention
Infection
Factors influencing wound healing
Systemic factors:
: first of two most important
factors. Most important deficiencies (2):

: second of two most
important factors. Arterial or venous
insufficiency commonly delays healing.
: iatrogenic delay of healing
by blunting the normal inflammatory/repair
response
Nutritional deficiency
Protein and vitamin C
Inadequate blood supply
Steroid therapy
Pathologic complications of healing
: exaggeration normal contraction
of wound, resulting in deformity (palms,
soles, anterior thorax). Common after burns.
Deficient granulation tissue/ scar formation:
: rupture of wound, usually
due to increased mechanical pressure or
inappropriate movement
: usually due to arterial
insufficiency caused by atherosclerosis; venous
stasis also can contribute.
Dehiscence
Ulceration/poor healing
Contracture
Pathologic complications 2
Excessive formation of repair components:







Excessive granulation tissue
Desmoid tumor (aggressive fibromatosis)
Best viewed as low grade neoplasm with stubborn tendency
for recurrences
Keloid (hypertrophic scar)
Fibrosis: Summary
Overview: inflammation & repair
Conclusion
Physicians stand in wonder at the amazing
capacity of the body to restore itself after
injury, usually without loss of normal function.
This represents an advanced kind of
engineering and self-regulated maintenance
function that humbles human technology.