1. Cellular basis of cancer Dr Tim Bracey Consultant Pathologist

2. Outline You will each be allocated a questionYou will each be allocated a question Work in pairs to “brainstorm” each question for 10 minutes before we go through each in turnWork in pairs to “brainstorm” each question for 10 minutes before we go through each in turn I will give some clinical examples!I will give some clinical examples!

3. 1- What are the various factors that regulate the number of cells in a tissue? Balance between proliferation, differentiation and cell deathBalance between proliferation, differentiation and cell death Totipotent cells (zygote)Totipotent cells (zygote) Pluripotent “stem cells” can differentiate into many cell typesPluripotent “stem cells” can differentiate into many cell types Multipotent stem cells in adult organs/tissue replenish specialised cellsMultipotent stem cells in adult organs/tissue replenish specialised cells And gut!

4. Regulation of cell number in the intestinal crypt

5. 2- Can you define the following terms? HypertrophyHypertrophy HyperplasiaHyperplasia AtrophyAtrophy MetaplasiaMetaplasia DysplasiaDysplasia NeoplasiaNeoplasia

6. Hypertrophy Reversible increase in size of whole or part of an organ or tissue by increase in cellular size but not numberReversible increase in size of whole or part of an organ or tissue by increase in cellular size but not number

7. Hyperplasia Increase in size due to increased number of cells eg. BPH, endometrial hyperplasiaIncrease in size due to increased number of cells eg. BPH, endometrial hyperplasia

8. Atrophy Decrease in size due to reduction in cell size and or numberDecrease in size due to reduction in cell size and or number Multifactorial (growth factors, hormones, inflammation etc)Multifactorial (growth factors, hormones, inflammation etc)

9. Metaplasia Reversible change of one differentiated cell type to another e.g. smoker’s respiratory epithelium, cervix “transformation zone”, Barrett’s oesophagusReversible change of one differentiated cell type to another e.g. smoker’s respiratory epithelium, cervix “transformation zone”, Barrett’s oesophagus

10. Dysplasia “bad form” in Greek“bad form” in Greek Common term for pre-cancerous lesionsCommon term for pre-cancerous lesions Abnormal cells with architectural and cytological abnormality but no invasion. Severe dysplasia also called “carcinoma in situ”Abnormal cells with architectural and cytological abnormality but no invasion. Severe dysplasia also called “carcinoma in situ”

11. Neoplasia Literally “new growth”Literally “new growth” Abnormal disorganised growth in a tissue or organ usually forming a distinct massAbnormal disorganised growth in a tissue or organ usually forming a distinct mass Refers to both benign and malignant tumoursRefers to both benign and malignant tumours

12. 3- What is the value of having knowledge of epidemiology of neoplasia? Epidemiology can point to aetiology and risk factorsEpidemiology can point to aetiology and risk factors Common and rare cancersCommon and rare cancers –Planning of health care provision –Screening and prevention –Identify genetic factors and “at risk groups”

13. 13 Name 5 types of cancer with a known cause for each

14. 4- How can we broadly classify different neoplasms? Anatomical classificationAnatomical classification –Lung tumours, breast tumours HistogeneticHistogenetic –Based on presumed cell of origin –Carcinoma, sarcoma, lymphoma Behavioural classificationBehavioural classification –Based on likely behaviour / aggressiveness (malignant potential) –What are the main differences between benign and malignant tumours?

15. 5- What do the terms “grade” and “stage” mean and what is their clinical significance? GradeGrade –How well does the cancer resemble normal tissue? –Low grade = well differentiated –High grade = poorly differentiated StageStage –Extent of spread (TNM most common) Both influence prognosis and treatment (MDT meeting)Both influence prognosis and treatment (MDT meeting)

16. 6- What are the key events in process of metastasis? 1. Local growth 2. Angiogenesis 3. Altered cell motility and cell-cell interactions 4. Altered ECM 5. Invasion of lymph / blood vessels 6. Survival in vessels 7. Arrest at distant site 8. Survival at distant site 9. More local growth and repeat cycle

17. 7- In what ways do neoplastic cells differ from normal cells? Appearance of cellsAppearance of cells –Increased nuclear to cytoplasmic ratio and nuclear pleomorphism –Darker nuclear staining (hyperchromasia) Genetic / Biochemical changesGenetic / Biochemical changes –Altered chromosomal / DNA content (aneuploidy and mutation of key regulatory genes) –Altered antigen expression (evade immunity) Behaviour of cellsBehaviour of cells –Immortality in cell culture (no senescence) –Loss of contact inhibition and anchorage independence –Form tumours in animals

18. 8- What lines of evidence suggest cancer is a genetic disease? Cancer increases according to the sixth power of ageCancer increases according to the sixth power of age Some cancers run in familiesSome cancers run in families Germline mutations lead to early and sometimes multiple cancersGermline mutations lead to early and sometimes multiple cancers Carcinogens alter DNA sequences (mutagens)Carcinogens alter DNA sequences (mutagens) Tumour cells show mutations and chromosomal changes, some of which are characteristic of certain cancers (9;22 in 95% CML cases)Tumour cells show mutations and chromosomal changes, some of which are characteristic of certain cancers (9;22 in 95% CML cases)

19. 9- How do neoplasms present clinically? LocalLocal –SOL, compression, ulceration, bleeding, invasion local structures SystemicSystemic –As above ParaneoplasticParaneoplastic –Anaemia, electrolyte disturbance, inappropriate hormone production, skin changes, dermatomyositis etc. Incidental findingIncidental finding –Screening (“incidentalomas”)

20. 10a- What are oncogenes?

21. Oncogenes A proto-oncogene is a gene involved in growth regulation that can become an oncogene after mutation or overexpressionA proto-oncogene is a gene involved in growth regulation that can become an oncogene after mutation or overexpression Oncogenes are genes that increase the malignant potential of a cellOncogenes are genes that increase the malignant potential of a cell Oncogenes were first discovered in animal virusesOncogenes were first discovered in animal viruses

22. 22 What is the clinical importance of oncogenes? Do you know any examples of “targeted cancer drugs”?

23. 10b- What are tumour suppressor genes?

25. Tumour suppressor genes These are genes that normally act as “brakes” on cell proliferation or which normally promote cell differentiation or apoptosisThese are genes that normally act as “brakes” on cell proliferation or which normally promote cell differentiation or apoptosis Deletion or inactivation of TSGs increases cell malignant potentialDeletion or inactivation of TSGs increases cell malignant potential Inactivation of both copies of a TSG is normally required for this (“two hit hypothesis”)Inactivation of both copies of a TSG is normally required for this (“two hit hypothesis”) Alteration of proto-oncogenes and TSGs are needed for development of malignant tumoursAlteration of proto-oncogenes and TSGs are needed for development of malignant tumours

26. 11- What are the stages of the cell cycle and what are checkpoints?

27. 12- What is p53 and how does it work? TSG altered in at least 70% cancersTSG altered in at least 70% cancers

28. p53 “master controller”

29. 13- What are the molecular events that occur in the genome of neoplastic cells to escape normal growth control?

30. Questions?