1. Neoplasia Lecture 2 Maha Arafah,MD,KSFP Abdulmalik Alsheikh, MD, FRCPC CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASMS EPIDEMIOLOGY CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASMS EPIDEMIOLOGY Foundation block 2012 Pathology

2. Objectives Compare and contrast benign and malignant tumors with respect to: Compare and contrast benign and malignant tumors with respect to: demarcation from surrounding tissue (capsule, local invasiveness. demarcation from surrounding tissue (capsule, local invasiveness. rate of growth rate of growth degree of differentiation (Explain the meaning of differentiation). degree of differentiation (Explain the meaning of differentiation). distant spread (metastases). distant spread (metastases). Describe the morphologic changes associated with poorly differentiated tumors; define and understand the usage of the terms anaplasia, pleomorphism, nuclear atypia, abnormal mitoses and tumor giant cells. Describe the morphologic changes associated with poorly differentiated tumors; define and understand the usage of the terms anaplasia, pleomorphism, nuclear atypia, abnormal mitoses and tumor giant cells. Understand the clinical significance of invasiveness and metastasis. Understand the clinical significance of invasiveness and metastasis. Describe the anatomic pathways utilized by tumors in metastatic spread. Know which pathways are commonly used by carcinomas versus sarcomas. Describe the anatomic pathways utilized by tumors in metastatic spread. Know which pathways are commonly used by carcinomas versus sarcomas. List some common sites of distant metastases. List some common sites of distant metastases. Recognize the epidemiologic data of cancer distribution in regard to age, race, geographic factors, and genetic backgrounds. Recognize the epidemiologic data of cancer distribution in regard to age, race, geographic factors, and genetic backgrounds. List some inherited syndromes with a genetic predisposition to cancer. List some inherited syndromes with a genetic predisposition to cancer.

3. Neoplasia Characteristics of benign and malignant neoplasms Differentiation and anaplasia Differentiation and anaplasia Rate of growth Rate of growth Local invasion Local invasion metastasis metastasis

4. Neoplasia 1. Differentiation and anaplasia: Differentiation means : the extent to which the parenchymal cells of the tumor resemble their normal counterparts morphologically and functionally Differentiation means : the extent to which the parenchymal cells of the tumor resemble their normal counterparts morphologically and functionally

5. Neoplasia well differentiated = closely resemble their normal counterparts well differentiated = closely resemble their normal counterparts Moderately differentiated Moderately differentiated Poorly differentiated Poorly differentiated Undifferentiated ( Anaplasia ) Undifferentiated ( Anaplasia )

6. Neoplasia Benign tumors = well differentiated Benign tumors = well differentiated Malignant tumors = Malignant tumors = well differentiated -----> anaplastic well differentiated -----> anaplastic

10. Neoplasia In the histological examination of a tumor you should look for : In the histological examination of a tumor you should look for : Pleomorphism : variation in size Pleomorphism : variation in size High nuclear/ cytoplasm ratio ( N/C ratio) High nuclear/ cytoplasm ratio ( N/C ratio) Hyperchrmasia ( dark cell ) Hyperchrmasia ( dark cell ) Mitosis ….?abnormal one Mitosis ….?abnormal one

11. Neoplasia Characteristics of benign and malignant neoplasms Differentiation and anaplasia Differentiation and anaplasia Rate of growth Rate of growth Local invasion Local invasion metastasis metastasis

12. Neoplasia Rate of growth: Rate of growth: Benign tumors: Benign tumors: grows slowly grows slowly are affected by blood supply, hormonal effects, location are affected by blood supply, hormonal effects, location Malignant tumors : Malignant tumors : grows faster grows faster Correlate with the level of differentiation Correlate with the level of differentiation

13. Neoplasia Characteristics of benign and malignant neoplasms Differentiation and anaplasia Differentiation and anaplasia Rate of growth Rate of growth Local invasion Local invasion metastasis metastasis

14. Neoplasia Local invasion : Local invasion : Benign tumors : Benign tumors : Remain localized Remain localized Cannot invade Cannot invade Usually capsulated Usually capsulated Malignant tumors : Malignant tumors : Progressive invasion Progressive invasion Destruction Destruction Usually not capsulated Usually not capsulated

17. Neoplasia Characteristics of benign and malignant neoplasms Differentiation and anaplasia Differentiation and anaplasia Rate of growth Rate of growth Local invasion Local invasion Metastasis Metastasis

18. Neoplasia Metastasis : Metastasis : Definition : the development of secondary implants discontinuous with the primary tumor, possibly in remote tissues Definition : the development of secondary implants discontinuous with the primary tumor, possibly in remote tissues

20. Neoplasia Metastasis : Metastasis : Cancers have different ability to metastasize Cancers have different ability to metastasize Approximately 30% patients present with clinically evident metastases. Approximately 30% patients present with clinically evident metastases. Generally, the more anaplastic and the larger the primary tumor, the more likely is metastasis Generally, the more anaplastic and the larger the primary tumor, the more likely is metastasis

21. Neoplasia Metastasis : three pathways Metastasis : three pathways Lymphatic spread : Lymphatic spread : Hematogenous spread : Hematogenous spread : Seeding of the body cavities: pleural, peritoneal cavities and cerebral ventricles Seeding of the body cavities: pleural, peritoneal cavities and cerebral ventricles

22. Neoplasia Lymphatic spread : Lymphatic spread : favored by carcinomas favored by carcinomas Breast carcinoma  axillary lymph nodes Breast carcinoma  axillary lymph nodes Lung carcinomas  bronchial lymph nodes Lung carcinomas  bronchial lymph nodes

23. Neoplasia Hematogenous spread : Hematogenous spread : favored by sarcomas favored by sarcomas Also used by carcinomas Also used by carcinomas Veins are more commonly invaded Veins are more commonly invaded The liver and lungs are the most frequently involved secondary sites The liver and lungs are the most frequently involved secondary sites

25. Neoplasia In the histological examination of a tumor you should look for : In the histological examination of a tumor you should look for : Pleomorphism : variation in size Pleomorphism : variation in size High nuclear/ cytoplasm ratio ( N/C ratio) High nuclear/ cytoplasm ratio ( N/C ratio) Hyperchrmasia ( dark cell ) Hyperchrmasia ( dark cell ) Mitosis ….?abnormal one Mitosis ….?abnormal one

26. Neoplasia Dysplasia : Dysplasia : Definiton: a loss in the uniformity of the individual cells and a loss in their architectural orientation. Definiton: a loss in the uniformity of the individual cells and a loss in their architectural orientation. Non-neoplastic Non-neoplastic Occurs mainly in the epithelia Occurs mainly in the epithelia Dysplastic cells shows a degree of : pleomorphism, hyperchrmasia,increased mitosis and loss of polarity. Dysplastic cells shows a degree of : pleomorphism, hyperchrmasia,increased mitosis and loss of polarity.

27. Neoplasia Dysplasia does not mean cancer Dysplasia does not mean cancer Dyplasia does not necessarily progress to cancer Dyplasia does not necessarily progress to cancer Dysplasia may be reversible Dysplasia may be reversible If dysplastic changes involve the entire thickness of the epithelium it is called : If dysplastic changes involve the entire thickness of the epithelium it is called : CARCINOMA IN-SITU CARCINOMA IN-SITU

29. Neoplasia Carcinoma in-situ Carcinoma in-situ Definition: an intraepithelial malignancy in which malignant cells involve the entire thickness of the epithelium without penetration of the basement membrane. Definition: an intraepithelial malignancy in which malignant cells involve the entire thickness of the epithelium without penetration of the basement membrane. Applicable only to epithelial neoplasms. Applicable only to epithelial neoplasms.

32. Dysplasia Features: Increased rate of multiplication. Disordered maturation. Increased rate of multiplication. Disordered maturation. Nuclear abnormality – Increased N/C ratio – Irregular nuclear membrane – Increased chromatin content Cytoplasmic abnormalities due to failure of normal maturation Nuclear abnormality – Increased N/C ratio – Irregular nuclear membrane – Increased chromatin content Cytoplasmic abnormalities due to failure of normal maturation

33. Dysplasia Uterine cervix Mild Dysplasia Sever Dysplasia

34. Dysplasia (cervical pap smear)

35. Dysplasia Clinical significance: Clinical significance: It is a premalignant condition. It is a premalignant condition. The risk of invasive cancer varies with: The risk of invasive cancer varies with: grade of dysplasia (mild, moderate, sever) grade of dysplasia (mild, moderate, sever) duration of dysplasia duration of dysplasia site of dysplasia site of dysplasia

36. Dysplasia Differences between dysplasia and cancer. Differences between dysplasia and cancer.  lack of invasiveness.  lack of invasiveness.  Reversibility  Reversibility

37. Carcinoma in situ A true neoplasm with all of the features of malignant neoplasm except invasiveness A true neoplasm with all of the features of malignant neoplasm except invasiveness Displays the cytological features of malignancy without invasion of the basement membrane. Displays the cytological features of malignancy without invasion of the basement membrane.

38. Squamous cell Carcinoma Uterine Cervix Dysplasia

39. Neoplasia Epidemiology Epidemiology Will help to discover aetiology Will help to discover aetiology Planning of preventive measures Planning of preventive measures To know what is common and what is rare. To know what is common and what is rare. Development of screening methods for early diagnosis Development of screening methods for early diagnosis

43. Neoplasia Factors affecting incidence of cancer Factors affecting incidence of cancer Geographic and Environmental Geographic and Environmental Age Age Heredity Heredity Aquired preneoplastic disorders Aquired preneoplastic disorders

44. Neoplasia Factors affecting incidence of cancer Factors affecting incidence of cancer Geographic and Environmental Geographic and Environmental Age Age Heredity Heredity Aquired preneoplastic disorders Aquired preneoplastic disorders

45. Neoplasia Geographic and Environmental factors: Geographic and Environmental factors: Rate of stomach carcinoma in Japan is seven times the rate in North America and Europe. Rate of stomach carcinoma in Japan is seven times the rate in North America and Europe. Breast carcinoma is five times higher in North America comparing to Japan Breast carcinoma is five times higher in North America comparing to Japan Liver cell carcinoma is more common in African populations Liver cell carcinoma is more common in African populations

47. Neoplasia Geographic and Environmental factors: Geographic and Environmental factors: Asbestos : mesothelioma Asbestos : mesothelioma Smoking : lung cancer Smoking : lung cancer Multiple sexual partners: cervical cancer Multiple sexual partners: cervical cancer Fatty diets : colonic cancer Fatty diets : colonic cancer Please see table 5-2 for occupational cancers

48. Neoplasia Factors affecting incidence of cancer Factors affecting incidence of cancer Geographic and Environmental Geographic and Environmental Age Age Heredity Heredity Aquired preneoplastic disorders Aquired preneoplastic disorders

49. Neoplasia Age: Age: Generally, the frequency of cancer increases with age. Generally, the frequency of cancer increases with age. Most cancer mortality occurs between 55 and 75. Most cancer mortality occurs between 55 and 75. Cancer mortality is also increased during childhood Cancer mortality is also increased during childhood Most common tumors of children: Leukemia, tumors of CNS, Lymphomas, soft tissue and bone sarcomas. Most common tumors of children: Leukemia, tumors of CNS, Lymphomas, soft tissue and bone sarcomas.

50. Neoplasia Factors affecting incidence of cancer Factors affecting incidence of cancer Geographic and Environmental Geographic and Environmental Age Age Heredity Heredity Aquired preneoplastic disorders Aquired preneoplastic disorders

51. Neoplasia Heredity Heredity Autosomal dominant cancer syndromes Autosomal dominant cancer syndromes Autosomal Recessive Syndromes of Defective DNA Repair Autosomal Recessive Syndromes of Defective DNA Repair Familial Cancers of Uncertain Inheritance Familial Cancers of Uncertain Inheritance

52. Heredity Autosomal dominant cancer syndromes Autosomal dominant cancer syndromes Inheritance of a single mutant gene greatly increases the risk of developing neoplasm Inheritance of a single mutant gene greatly increases the risk of developing neoplasm E.g. Retinoblastoma in children : E.g. Retinoblastoma in children : 40% of Retinoblastomas are familial 40% of Retinoblastomas are familial carriers of the gene have 10000 fold increase in the risk of developing Retinoblastoma carriers of the gene have 10000 fold increase in the risk of developing Retinoblastoma E.g. multiple endocrine neoplasia E.g. multiple endocrine neoplasia See table 5-3 for more example See table 5-3 for more example

53. Heredity Autosomal Recessive Syndromes of Defective DNA Repairir : Autosomal Recessive Syndromes of Defective DNA Repairir : Small group of autosomal recessive disorders Small group of autosomal recessive disorders Characterized by DNA instability Characterized by DNA instability E.g. xeroderma pigmentosum E.g. xeroderma pigmentosum

54. Heredity Familial Cancers of Uncertain Inheritance Familial Cancers of Uncertain Inheritance All common types of cancers occur in familial form All common types of cancers occur in familial form E.g. breast, colon, ovary, brain E.g. breast, colon, ovary, brain Familial cancers usually have unique features: Familial cancers usually have unique features: Start at early age Start at early age Multiple or bilateral Multiple or bilateral Two or more relatives Two or more relatives

55. Neoplasia Factors affecting incidence of cancer Factors affecting incidence of cancer Geographic and Environmental Geographic and Environmental Age Age Heredity Heredity Aquired preneoplastic disorders Aquired preneoplastic disorders

56. Neoplasia Aquired preneoplastic disorders: Some Clinical conditions that predispose to cancer Aquired preneoplastic disorders: Some Clinical conditions that predispose to cancer Dysplastic bronchial mucosa in smokers  lung carcinoma Dysplastic bronchial mucosa in smokers  lung carcinoma Liver cirrhosis  liver cell carcinoma Liver cirrhosis  liver cell carcinoma Margins of chronic skin fistula  squamous cell carcinoma Margins of chronic skin fistula  squamous cell carcinoma