Pathology (Lecture)

NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

Overview DEVELOPMENT OF BLOOD SUPPLY

I. Sustained Angiogenesis
II. Ability to Invade and Metastasize
a) Local Invasion
Ø Angiogenesis is controlled by a balance between
b) Vascular Dissemination and Honing of Tumor angiogenesis promoters and inhibitors; in
Cells angiogenic tumors this balance is skewed in
III. Ability to Evade Host Immune Response favor of promoters.
a) Mechanisms of Tumor Evasion Ø Starved of nutrients, these tumors remain small
b) Genomic Instability or in situ, possibly for years, until an angiogenic
c) Cancer and Inflammation switch terminates this stage of vascular
IV. Dysregulation of Cancer-Associated Genes quiescence.
a) Chromosomal Changes
Ø The molecular basis of the angiogenic switch
b) Epigenetic Changes
c) Noncoding RNAs and Cancer
involves increased production of angiogenic
V. Molecular Basis of Multistep Carcinogenesis factors and/ or loss of angiogenic inhibitors.
VI. Chemical Carcinogenesis These factors may be produced by the tumor
a) Steps Involved in Chemical Carcinogenesis cells themselves or by inflammatory cells (e.g.,
b) Direct-acting vs Indirect Carcinogens macrophages) or other stromal cells associated
c) Molecular Targets with the tumors.
VII. Promotion of Chemical Carcinogenesis Ø Proteases, either elaborated by the tumor cells
a) Radiation Carcinogenesis or by stromal cells in response to the tumor, are
b) Microbial Carcinogenesis
also involved in regulating the balance between
VIII. Clinical Aspects of Neoplasia
a) Local and Hormonal Effects
angiogenic and antiangiogenic factors
b) Paraneoplastic Syndromes
IX. Grading and Staging of Tumors ANTI-ANGIOGENESIS FACTORS
X. Laboratory Diagnosis of Cancer 1) Thrombospondin: platelet factor 4; regulated by
a) Histologic and Cytologic Methods p53
b) Fine-needle Aspiration 2) Angiostatin: cleavage product of plasminogen
c) Cytologic Smears 3) Endostatin: cleavage product of collagen type
d) Immunohistochemistry XVIII
e) Flow Cytometry
4) Vasotatin: cleavage product of trans-thretin
f) Circulating Tumor Cells
g) Molecular and Cytogenetic Diagnostics
XI. Molecular Profiles of Tumors ANGIOGENIC FACTORS
1) Proteases
• From tumor or stromal cells
VI. SUSTAINED ANGIOGENESIS • Release pro-angiogenic basic fibroblast
growth factors (bFGF)
2) Hypoxia
Ø Even if a solid tumor possesses all of the genetic
• Stabilize HIF1-alpha à transcription of
aberrations that are required for malignant
VEGF and bFGF
transformation, it cannot enlarge beyond 1 to 2
ü Proliferation of endothelial cells
mm in diameter unless it has the capacity to
ü Activation of Notch signaling à
induce angiogenesis.
regulate branching and density
Ø Like normal tissues, tumors require delivery of
of new blood vessels
oxygen and nutrients and removal of waste
3) Loss of p53 function
products; presumably the 1- to 2-mm zone
• Decreased expression of anti-
represents the maximal distance across which
angiogenic thrombospondin 1
oxygen, nutrients, and waste can diffuse from
blood vessels. • Increased expression of VEGF

ROLE OF NEOVASCULARIZATION VII. ABILITY TO INVADE AND METASTASIZE

1) Supply nutrients and oxygen
2) Newly formed endothelial cells à secrete growth Ø Invasion and metastasis are the results of
factors (insulin-like growth factor and PDGF) --? complex interactions between cancer cells and
Stimulate growth of adjacent tumor cells normal stroma and are the major causes of
3) Permits access of tumor cells to these abnormal cancer-related morbidity and mortality.
vessels and contributes to metastasis Ø Biological hallmarks of malignant cancer

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
METASTATIC CASCADE
1) Invasion of extracellular matrix
2) Vascular dissemination, homing of tumor cells,
and colonization

INVASION OF EXTRACELLULAR MATRIX

Ø The structural organization and function of

normal tissues is to a great extent determined by
interactions between cells and the ECM.
Ø Tissues are organized into compartments
separated from each other by two types of 2. DEGRADATION OF EXTRACELLULAR MATRIX
ECM: basement membrane and interstitial
connective tissue.
Ø Tumor cells may accomplish this by either
Ø Although organized differently, each of these
secreting proteolytic enzymes themselves or by
components of ECM is made up of collagens,
glycoproteins, and proteoglycans. inducing stromal cells (e.g., broblasts and
Ø Tumor cells must interact with the ECM at inflammatory cells) to elaborate proteases.
Ø Many different families of proteases, such as
several stages in the metastatic cascade.
matrix metalloproteinases (MMPs), cathepsin D,
Ø A carcinoma must first breach the underlying
and urokinase plasminogen activator, have been
basement membrane, then traverse the
implicated in tumor cell invasion. M
interstitial connective tissue, and ultimately
Ø MPs regulate tumor invasion not only by
gain access to the circulation by penetrating
remodeling insoluble components of the
the vascular basement membrane.
basement membrane and interstitial matrix but
Ø This process is repeated in reverse when tumor
also by releasing ECM-sequestered growth
cell emboli extravasate at a distant site.
factors.
Ø Invasion of the ECM initiates the metastatic
cascade and is an active process that can be Ø Cleavage products of collagen and
resolved into several steps proteoglycans also have chemotactic,
angiogenic, and growth-promoting effects.
• “Loosening up” of tumor cell-tumor
Ø For example, MMP9 is a gelatinase that cleaves
interactions
type IV collagen of the epithelial and vascular
• Degradation of ECM
basement membrane and also stimulates
• Attachment to novel ECM components release of VEGF from ECM-sequestered pools.
• Migration and invasion of tumor cells • Benign tumors of the breast, colon, and
stomach show little type IV collagenase
1. LOOSENING OF INTERCELLULAR JUNCTIONS activity, whereas their malignant
counterparts overexpress this enzyme.
• Concurrently, the concentrations of
Ø Normal epithelial cells are tightly glued to each
metalloproteinase inhibitors are reduced so
other and the ECM by a variety of adhesion
that the balance is tilted greatly toward
molecules.
tissue degradation
Ø Cell-cell interactions are mediated by the
• Indeed, overexpression of MMPs and other
cadherin family of transmembrane glycoproteins.
proteases has been reported for many
Ø E-cadherins mediate the homotypic adhesion of
tumors.
epithelial cells, serving to both hold the cells
together and to relay signals between the cells.
Ø In several epithelial tumors, including
adenocarcinomas of the colon, stomach, and
breast, E-cadherin function is lost.
Ø Presumably, this reduces the ability of cells to
adhere to each other and facilitates their
detachment from the primary tumor and their
advance into the surrounding tissues.

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

3. MIGRATION AND INVASION glioblastoma, supporting its role in motility.

VASCULAR DISSEMINATION OF HOMING TUMOR

Ø Normal epithelial cells have receptors, such as CELLS
integrins, for basement membrane laminin and
collagens that are polarized at their basal
surface; these receptors help to maintain the Ø Once in the circulation, tumor cells are
cells in a resting, differentiated state. vulnerable to destruction by a variety of
Ø Loss of adhesion in normal cells leads to mechanisms, including mechanical shear
induction of apoptosis, while, not surprisingly, stress, apoptosis stimulated by loss of
tumor cells are resistant to this form of cell adhesion (termed anoikis), and innate and
death. adaptive immune defenses
Ø Additionally, the matrix itself is modified in ways Ø Within the circulation, tumor cells tend to
that promote invasion and metastasis. aggregate in clumps. This is favored by
Ø For example, cleavage of the basement homotypic adhesions among tumor cells as well
membrane proteins collagen IV and laminin by as heterotypic adhesion between tumor cells and
MMP2 or MMP9 generates novel sites that bind blood cells, particularly platelets
to receptors on tumor cells and stimulate Ø Formation of platelet-tumor aggregates may
migration. enhance tumor cell survival and implantability.
Ø Tumor cells may also bind and activate
coagulation factors, resulting in the formation of
emboli.
Ø Arrest and extravasation of tumor emboli at
distant sites involves adhesion to the
endothelium, followed by egress through the
basement membrane.
Ø Involved in these processes are adhesion
molecules (integrins, laminin receptors) and
proteolytic enzymes, dis- cussed earlier.
Ø Of particular interest is the CD44 adhesion
4. LOCOMOTION molecule, which is expressed on normal T
lymphocytes and is used by these cells to
Ø Migration is a multistep process that involves migrate to selective sites in lymphoid tissues.
many families of receptors and signaling proteins Ø Such migration is accomplished by the binding of
that eventually impinge on the actin CD44 to hyaluronate on high endothelial
cytoskeleton. venules. Solid tumors also often express CD44,
Ø Cells must attach to the matrix at the leading which appears to enhance their spread to lymph
edge, detach from the matrix at the trailing edge, nodes and other metastatic sites.
and contract the actin cytoskeleton to ratchet Ø The site at which circulating tumor cells leave
forward. the capillaries to form secondary deposits is
Ø Such movement seems to be stimulated and related to the anatomic location and vascular
directed by tumor cell-derived cytokines, such as drainage of the primary tumor and the tropism of
autocrine motility factors. particular tumors for specific tissues.
Ø In addition, cleavage products of matrix Ø Most metastases occur in the first capillary bed
components (e.g., collagen, laminin) and some available to the tumor.
growth factors (e.g., IGFs I and II) have Ø Many observations, however, suggest that
chemotactic activity for tumor cells. natural pathways of drainage do not w
Ø Furthermore, proteolytic cleavage liberates Ø holly explain the distribution of metastases. For
growth factors bound to matrix molecules. example, prostatic carcinoma preferentially
Ø Stromal cells also produce paracrine effectors of spreads to bone, bronchogenic carcinomas tend
cell motility, such as hepatocyte growth to involve the adrenals and the brain, and
factor/scatter factor, which binds to the receptor neuroblastomas spread to the liver and bones.
tyrosine kinase MET on tumor cells. Such organ tropism may be related to the
Ø The concentration of hepatocyte growth following mechanisms:
factor/scatter factor is elevated at the advancing • Tumor cells may have adhesion molecules
edge of the highly invasive brain tumor whose ligands are expressed preferentially

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

on the endothelial cells of the target organ. variant proteins that have never been seen by
• Chemokines have an important role in the immune system and are thus recognized as
determining the target tissues for non- self.
metastasis. For instance, some breast Ø Most of these acquired mutations are likely to be
cancer cells express the chemokine “passengers,” mutations that are neutral in
receptors CXCR4 and CCR7. terms of cancer cell fitness and thus unrelated to
the transformed phenotype.
• In some cases, the target tissue may be a
Ø However, by chance, some of these passenger
nonpermissive environment—“unfavorable
mutations may fall in the coding sequences of
soil,” so to speak, for the growth of tumor
genes and give rise to protein variants that serve
seedlings. For example, although well-
as tumor antigens. T
vascularized, skeletal muscle and spleen are
Ø he products of altered proto- oncogenes, tumor
rarely sites of metastasis.
suppressor genes, and “passenger” genes are
translated in the cytoplasm of tumor cells, and
VIII. ABILITY TO EVADE HOST IMMUNE RESPONSE like any cytoplasmic protein, they may enter the
class I MHC antigen-processing pathway and be
Ø Long one of the “holy grails” of oncology, the recognized by CD8+ T cells.
promise of therapies that enable the host Ø In addition, these proteins may enter the class II
immune system to recognize and destroy cancer antigen-processing pathway in antigen-
cells is finally coming to fruition, largely due to a presenting cells that have phagocytosed dead
clearer understanding of the ways by which Ø Ex. RAS, p53
cancer cells evade the host response.
Ø The fact that cancers occur in immunocompetent OVEREXPRESSED OR ABERRANTLY EXPRESSED
individuals indicates that immune surveillance is CELLULAR PROTEINS
imperfect; however, that some tumors escape
such policing does not preclude the possibility
that many others were aborted. Ø Tumor antigens may also be normal cellular
Ø Assuming that the immune system is capable of proteins that are abnormally expressed in tumor
recognizing and eliminating nascent cancers, it cells.
follows that the tumors that do grow out must be Ø One such antigen is tyrosinase, an enzyme
composed of cells that are either invisible to the involved in melanin biosynthesis that is
host immune system or that release factors that expressed only in normal melanocytes and
actively suppress host immunity. melanomas à tyrosinase is normally produced
Ø The term cancer immunoediting has been in such small amounts and in so few normal cells
used to describe the ability of the immune that it is not recognized by the immune system
system to shape and mold the immunogenic and fails to induce tolerance.
properties of tumor cells in a fashion that Ø Another group of tumor antigens, the cancer-
ultimately leads to the darwinian selection of testis antigens, are encoded by genes that are
subclones that are best able to avoid immune silent in all adult tissues except germ cells in the
elimination testis—hence their name.
Ø Although the protein is present in the testis it is
TUMOR ANTIGENS not expressed on the cell surface in an antigenic
form, because sperm do not express MHC class
I antigens.
Ø Antigens found in tumors that elicit an immune
Ø Thus, for all practical purposes these antigens
response have been demonstrated in many
experimentally induced tumors and in some are tumor species.
human cancers. Ø Prototypic of this group is the melanoma
Ø Tumor antigens can be classified according to antigen gene (MAGE) family. Although
their molecular structure and source. originally described in melanomas, MAGE
antigens are expressed by a variety of tumor
types.
PRODUCTS OF MUTATED GENES
Ø For example, MAGE-1 is expressed on 37% of
melanomas and a variable number of lung, liver,
Ø Neoplastic transformation results from genetic
stomach, and esophageal carcinomas.
alterations in proto- oncogenes and tumor
Ø There are several other members of the MAGE
suppressor genes; these mutated genes encode
family, variously called RAGE, GAGE, and other

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
fanciful acronyms. Ø Several mucins have been the focus of
diagnostic and therapeutic studies, including CA-
ONCOGENIC VIRUSES 125 and CA-19-9, expressed on ovarian
carcinomas, and MUC-1, expressed on both
Ø Several viruses are associated with cancers. ovarian and breast carcinomas.
Ø Not surprisingly, these viruses produce proteins Ø Unlike many mucins, MUC-1 is an integral
that are recognized as foreign by the immune membrane protein that is normally expressed
system. only on the apical surface of breast ductal
Ø The most potent of these antigens are proteins epithelium, a site that is relatively sequestered
produced by latent DNA viruses; examples in from the immune system.
humans include human papilloma virus (HPV) Ø In ductal carcinomas of the breast, however,
and Epstein-Barr virus (EBV). the molecule is expressed in an unpolarized
Ø There is abundant evidence that CTLs recognize fashion and contains new, tumor-specific
antigens of these viruses and that a competent carbohydrate and peptide epitopes detectable by
immune system plays a role in surveillance mouse monoclonal antibodies.
against virus-induced tumors because of its Ø The peptide epitopes induce both antibody and
ability to recognize and kill virus-infected cells. T-cell responses in cancer patients and are
Ø In fact, the concept of immune surveillance therefore considered candidates for tumor
against tumors is best established for DNA virus- vaccines in patients with breast cancer and
induced tumors. possibly ovarian cancer as well.

ONCOFETAL ANTIGENS CELL TYPE-SPECIFIC DIFFERENTIATION

ANTIGENS
Ø Proteins that are expressed at high levels on
cancer cells and in normal developing (fetal)
tissues. Ø Tumors express molecules that are normally
Ø Although originally believed to be completely present on the cells of origin.
specific for tumors and fetal tissues, as Ø These antigens are called differentiation anti-
techniques for detecting these antigens have gens because they are specific for particular
improved, it became clear that their expression lineages or differentiation stages of various cell
in adults is not limited to tumors. types.
Ø Amounts of these proteins are increased in Ø Such differentiation antigens are typically normal
tissues and in the circulation in various self-antigens, and therefore they do not induce
inflammatory conditions, and they are even immune responses in tumor-bearing hosts.
found in small quantities in normal tissues. Ø Their importance is as potential targets for
Ø There is no evidence that oncofetal antigens are immunotherapy and for identifying the tissue of
important inducers or targets of antitumor origin of tumors.
immunity. Ø There are now several examples of monoclonal
Ø However, oncofetal proteins are sufficiently antibodies that recognize cell type specific
specific that they can serve as markers that aid antigens that are highly effective anti-tumor
in tumor diagnosis and clinical management. agents.
Ø The two most thoroughly characterized oncofetal Ø Antibodies against CD20, a transmembrane
antigens are carcinoembryonic antigen (CEA) protein that is expressed on the surface of all
and α-fetoprotein (AFP). normal mature B cells, have broad cytocidal
activity against mature B-cell lymphomas and
ALTERED CELL SURFACE PROTEINS leukemias and are widely used in the treatment
of these tumors.
Ø Mucins are high-molecular-weight glycoproteins Ø These antibodies are believed to induce cell
containing numerous O-linked carbohydrate side killing through several mechanisms, including
chains on a core polypeptide. opsonization and phagocytosis of tumor cells,
Ø Tumors often have dysregulated expression of antibody-dependent cell-mediated cytotoxicity
the enzymes that synthesize these carbohydrate and complement fixation.
side chains, which leads to the appearance of Ø Anti-CD20 antibodies also kill normal B cells, but
tumor-specific epitopes on the carbohydrate side because hematopoietic stem cells are spared,
chains or on the abnormally exposed poly- normal B cells reemerge following treatment.
peptide core.

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

ANTITUMOR EFFECTOR MECHANISMS MECHANISMS OF IMMUNE EVASION

Ø Cell-mediated immunity is the dominant 1) Selective outgrowth of antigen negative variants

antitumor mechanism in vivo. • Elimination of strongly immunogenic
Ø Although sera from cancer patients may contain subclones
antibodies that recognize tumors, there is limited 2) Loss or reduced expression of MHC molecules
evidence that they play a protective role under 3) Activation of immunoregulatory pathways
physiologic conditions. a) Down-regulation of co-stimulatory factors on
APCs (e.g. CD28) and activation of inhibitory
CYTOTOXIC T LYMPHOCYTES receptor CTLA4 on effector T cells
b) Up-regulation of PD-L1 and PD-L2 à
Ø The antitumor effect of cytotoxic T cells reacting activation of programmed death-1 (PD-1)
against tumor antigens is well established in receptor on effector T cells à inhibition of T
experimentally induced tumors. cell activation
Ø In humans, CD8+ CTLs have a clear protective 4) Secretion of immunosuppressive factors by
role against virus-associated neoplasms (e.g., cancer cells
EBV- and HPV-induced tumors), and several a) TGF-beta: potent immunosuppressant
studies have shown that the number of tumor- b) Galectins: sugar-rich lectin like factors à
infiltrating CD8+ T cells and the presence of a skew T cell response
“gene signature” associated with CD8+ CTLs c) Others: IL-10, PGE2
correlates with a better prognosis in a variety of
cancers, not only those caused by oncogenic
viruses

NATURAL KILLER CELLS

Ø NK cells are lymphocytes that are capable of

destroying tumor cells without prior sensitization
and thus may provide the first line of defense
against tumor cells.
Ø After activation with IL-2 and IL-15, NK cells can
lyse a wide range of human tumors, includ-ng
many that seem to be nonimmunogenic for T
cells.
Ø While the importance of NK cells in host
response against spontaenous tumors is still not
well established, cytokines that activate NK cells
are being used for immunotherapy.

MACROPHAGES

Ø Activated macrophages exhibit cytotoxicity

against tumor cells in vitro.
Ø T cells, NK cells, and macrophages may
collaborate in antitumor reactivity, because GENOMIC INSTABILITY
interferon-γ, a cytokine secreted by T cells and
NK cells, is a potent activator of macrophages.
Ø Activated macrophages may kill tumors by Ø Genetic aberrations that increase mutation rates
mechanisms similar to those used to kill are very common in cancers and expedite the
microbes (e.g., production of reactive oxygen acquisition of driver mutations that are required
species for transformation and subsequent tumor
progression.
Ø Although humans literally swim in environmental
agents that are mutagenic (e.g., chemicals,
radiation, sunlight), cancers are relatively rare
outcomes of these encounters.

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
Ø This state of affairs results from the ability of remains constant.
normal cells to repair DNA damage, the death of Ø However, in people with HNPCC, these satellites
cells with irreparable and other mechanisms, are unstable and increase or decrease in length
such as oncogene-induced senescence and in tumor cells, creating alleles not found in
immune surveillance. normal cells of the same patient.
Ø Mutations in DNA-repair genes themselves are
not oncogenic, but their abnormalities greatly PATHOGENESIS
enhance the occurrence of mutations in other Ø Germline mutations in the MSH2 and MLH1
genes during the process of normal cell division. genes each account for approximately 30% of
Ø Typically, genomic instability occurs when both cases.
copies of the DNA repair gene are lost; however, Ø The remaining cases have mutations in other
some work has suggested that mismatch repair genes.
haploinsufficiency of at least a subset of these Ø Although HNPCC accounts only for 2% to 4% of
genes may also promote cancer. all colonic cancers, microsatellite instability can
be detected in about 15% of sporadic colon
HEREDITARY NONPOLYPOSIS COLON CANCER cancers.
SYNDROME Ø The cancer genes that are mutated in HNPCC
tumors have not yet been fully characterized but
include the genes encoding TGF-β receptor II,
Ø An autosomal dominant disorder characterized the TCF component of the β-catenin pathway,
by familial carcinomas of the colon affecting BAX, and other oncogenes and tumor
predominantly the cecum and proximal colon suppressor genes.
Ø It results from defects in a family of genes
encoding a group of proteins that work together XERODERMA PIGMENTOSUM
to carry out DNA mismatch repair.
• When a strand of DNA is being
replicated, these proteins act as “spell Ø Individuals with another inherited disorder of
checkers.” DNA repair, xeroderma pigmentosum, are at
• For example, if there is an erroneous increased risk for the development of cancers of
pairing of G with T rather than the the skin particularly following exposure to the UV
normal A with T, the mismatch-repair light contained in sun rays.
factors correct the defect. Ø UV radiation causes cross-linking of pyrimidine
• Individuals with HNPCC syndrome residues, preventing normal DNA replication.
inherit one abnormal copy of a mismatch Such DNA damage is repaired by the nucleotide
repair gene. excision repair system.
• Trouble arises when cells acquire loss- Ø Several proteins are involved in nucleotide
of-function mutations, presumably at excision repair, and an inherited loss of any one
random, in their normal alleles. can give rise to xeroderma pigmentosum.
• With “proofreading” function lost, errors
gradually accumulate throughout the DISEASES IN DEFECTS IN DNA REPAIR BY
genome, and some of these errors may HOMOLOGOUS RECOMBINATION
by chance activate proto-oncogenes or
inactivate tumor suppressor genes. With
time, a cancer may result. Ø Several rare autosomal recessive cancer
• Thus, DNA-repair genes behave like syndromes have been described that are
tumor suppressor genes in their mode of characterized by hypersensitivity to certain kinds
inheritance, but in contrast to tumor of DNA-damaging agents, such as ionizing
suppressor genes (and oncogenes), radiation (Bloom syndrome and ataxia-
they affect cell growth only indirectly by telangiectasia), or DNA cross-linking agents,
allowing mutations in other genes during such as many chemotherapeutic drugs (Fanconi
the process of normal cell division. anemia).
Ø The phenotype of these diseases is complex and
MICROSATELLITE INSTABILITY includes, in addition to predisposition to cancer,
Ø Microsatellites are tandem repeats of one to six features such as neural symptoms (ataxia-
nucleotides found throughout the genome. In telangiectasia), bone marrow aplasia (Fanconi
normal people the length of these microsatellites

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
anemia), and developmental defects (Bloom INDUCING ANGIOGENESIS
syndrome). Ø Inflammatory cells release numerous factors,
including VEGF, which can stimulate
angiogenesis.
CANCER AND INFLAMMATION
ACTIVATING INVASION AND METASTASIS
Ø Infiltrating cancers provoke a chronic Ø Proteases released from macrophages foster
inflammatory reaction, leading some to liken tissue invasion by remodeling the ECM, while
them to “wounds that do not heal.” factors such as TNF and EGF may directly
Ø In patients with advanced cancers, this stimulate tumor cell motility.
inflammatory reaction can be so extensive as to Ø Other factors released from stromal cells, such
cause systemic signs and symptoms, such as as TGF-β, may promote epithelial-mesenchymal
anemia (due to inflammation- induced transitions, which is considered to be a key
sequestration of iron and downregulation of event in the process of invasion and metastasis.
erythropoietin production)
Ø However, studies carried out on cancers in EVADING IMMUNE DESTRUCTION
animal models suggest that inflammatory cells Ø A variety of soluble factors released by
also modify the local tumor microenvironment to macrophages and other stromal cells are
enable many of the hallmarks of cancer. believed to contribute to the immunosuppressive
Ø These effects may stem from direct interactions microenvironment of tumors, including TGF-β
between inflammatory cells and tumor cells, or and a number of other factors that either favor
through indirect effects of inflammatory cells on the recruitment of immunosuppressive T
other resident stromal cells, particularly cancer- regulatory cells or suppress the function of CD8+
associated fibroblasts and endothelial cells. cytotoxic T cells.
Ø Furthermore, there is abundant evidence in
RELEASE OF FACTORS THAT PROMOTE murine cancer models and emerging evidence in
PROLIFERATION human disease that advanced cancers contain
Ø Infiltrating leukocytes and activated stromal cells mainly alternatively activated (M2)
have been shown to secrete a wide variety of macrophages, cells induced by cytokines such
growth factors, such as EGF, and proteases that as IL-4 and IL-13.
can liberate growth factors from the extracellular Ø These macrophages produce cytokines that
matrix (ECM) promote angiogenesis, fibroblast proliferation,
and collagen deposition, all of which are
REMOVAL OF GROWTH SUPPRESSORS commonly observed in invasive cancers.
Ø The growth of epithelial cells is suppressed by Ø In addition, they appear to suppress effective
cell-cell and cell-ECM interactions. host immune responses to cancer cells through
Ø Proteases released by inflammatory cells can mechanisms that remain to be elucidated.
degrade the adhesion molecules that mediate
these interactions, removing a barrier to growth. DYSREGULATION OF CANCER-ASSOCIATED
GENES
ENHANCED RESISTANCE TO CELL DEATH
Ø Detachment of epithelial cells from basement
membranes and from cell-cell interactions can Ø The genetic damage that activates oncogenes or
lead to a particular form of cell death called inactivates tumor suppressor genes may be
anoikis. subtle (e.g., point mutations) or may involve
Ø It is suspected that tumor-associated segments of chromosomes large enough to be
macrophages may prevent anoikis by expressing detected in a routine karyotype.
adhesion molecules such as integrins that
promote direct physical interactions with tumor CHROMOSOMAL TRANSLOCATIONS
cells.
Ø There is also substantial evidence that stromal
Translocations can activate proto-oncogenes in two
cell– cancer cell interactions increase the
ways:
resistance of cancer cells to chemotherapy,
Ø By promoter or enhancer substitution, in which
presumably by activating signaling pathways that
the translocation results in overexpression of a
promote cell survival in the face of stresses such
proto- oncogene by swapping its regulatory
as DNA damage.

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
elements with those of another gene, typically CHROMOSOMAL DELETIONS
one that is highly expressed.
Ø By formation of a fusion gene in which the
coding sequences of two genes are fused in part Ø Deletion of specific regions of chromosomes is
or in whole, leading to the expression of a novel associated with the loss of particular tumor
chimeric protein with oncogenic properties. suppressor genes.
Ø Deletions involving chromosome 13q14, the
BURKITT LYMPHOMA site of the RB gene, are associated with
Ø Overexpression of a proto-oncogene retinoblastoma, and deletion of the VHL tumor
Ø Virtually all Burkitt lymphomas have a suppressor gene on chromosome 3p is a very
translocation involving chromosome 8q24, common event in renal cell carcinomas.
where the MYC gene resides, and one of Ø Ongoing sequencing of cancer cell genomes will
the three chromosomes that carry an undoubtedly reveal many more examples of
immunoglobulin gene. deletions involving tumor suppressor genes, as
Ø At its normal locus, MYC is tightly well as small insertions of DNA from one site into
controlled, and is most highly expressed in another.
actively dividing cells. Ø It should be noted that not all deletions lead to
Ø In Burkitt lymphoma the most common loss of gene function; a few activate oncogenes
translocation moves the MYC-containing through the same mechanisms as chromosomal
segment of chromosome 8 to chromo- translocations.
some 14q32, placing it close to the Ø For example, about 25% of T-cell acute
immuno- globulin heavy chain (IGH) gene. lymphoblastic leukemias have small deletions
Ø The genetic notation for the translocation is of chromosome 1 that juxtapose the TAL1
t(8:14)(q24;q32). proto-oncogene with a nearby active promoter,
Ø The molecular mechanisms of the leading to overexpression of the TAL1
translocation-mediated overexpression of transcription factor.
MYC are variable, as are the precise Ø Similarly, deletions involving chromosome 5 in a
breakpoints within the MYC gene. subset of lung cancers produce an oncogenic
Ø The MYC coding sequences remain intact EML4-ALK fusion gene encoding a constitutively
and the MYC protein is constitutively active tyrosine kinase.
expressed at high levels. Ø It is likely that more “cryptic” deletions that
Ø The almost invariable presence of MYC activate oncogenes will be discovered through
trans- locations in Burkitt lymphomas deep sequencing of cancer genomes.
attests to the importance of MYC
overactivity in the pathogenesis of this
GENE AMPLIFICATION
tumor.

Ø Overexpression of oncogenes may also result

PHILADELPHIA CHROMOSOME from reduplication and amplification of their DNA
Ø characteristic of CML and a subset of B-cell sequences.
acute lymphoblastic leukemias provides the Ø Such amplification may produce up to several
prototypic example of a chromosomal hundred copies of the oncogene in the tumor
rearrangement that creates a fusion gene cell.
encoding a chimeric oncoprotein. Ø In some cases, the amplified genes produce
Ø In this instance, the two chromosome chromosomal changes that can be identified
breaks lie within the ABL gene on microscopically.
chromosome 9 and within the BCR Ø Two mutually exclusive patterns are seen: (1)
(breakpoint cluster region) gene on multiple small extra- chromosomal structures
chromosome 22). called double minutes and (2) homogeneous
Ø Non-homologous end-joining then leads to staining regions.
a reciprocal translocation that creates an Ø The latter derive from the insertion of the
oncogenic BCR-ABL fusion gene on the amplified genes into new chromosomal
derivative chromosome 22 (the so-called locations, which may be distant from the normal
Philadelphia chromosome). location of the involved oncogene.
Ø The affected chromosomal regions lack a normal
pattern of light and dark-staining bands,
•

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 Pathology (Lecture)
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Dr. Arnel Bayotas | December 09, 2020 | Topic 12
appearing homogeneous in karyotypes. divided into the following categories:
Ø From a clinical perspective, the most important • Silencing of tumor suppressor genes by
amplifications are NMYC in neuroblastoma and local hypermethylation of DNA
ERBB2 in breast cancers. • Global changes in DNA methylation
Ø NMYC is amplified in 25% to 30% of • Changes in histones
neuroblastomas, and its amplification is
associated with poor prognosis.
Ø ERBB2 amplification occurs in about 20% of SILENCING OF TUMOR SUPPRESSOR GENES BY
breast cancers. LOCAL HYPERMETHYLATION OF DNA
Ø As already mentioned, antibody therapy directed
against the HER2 receptor encoded by ERBB2
is an effective therapy for this molecular subset Ø Some cancer cells exhibit selective
of breast cancers. hypermethylation of the promoters of tumor
suppressor genes that results in their
transcriptional silencing.
CHROMOTHRYPSIS Ø Typically, hypermethylation occurs on only one
allele and the function of the other copy of the
Ø Genomic sequencing has revealed not only affected tumor suppressor gene is lost through
many simple rearrangements (e.g., small another mechanism, such as a disabling point
deletions, duplications, or inversions) that were mutation or a deletion.
not appreciated by prior methods, but also much Ø One of several examples of a tumor suppressor
more dramatic chromosome “catastrophes” gene that is hypermethylated in several cancers
termed chromothrypsis (literally, chromo- some is CDKN2A, which you will recall is a complex
shattering). locus that encodes two tumor suppressors,
Ø Chromothrypsis is observed in 1% to 2% of p14/ARF and p16/INK4a, that enhance p53 and
cancers as a whole, but is found in up to 25% of RB activity, respectively.
osteosarcomas and other bone cancers and at
relatively high frequency in gliomas as well. GLOBAL CHANGES IN DNA METHYLATION
Ø It appears to result from a single event in which
dozens to hundreds of chromosome breaks Ø The most obvious potential consequence of
occur within part or across the entirety of a global changes in methylation is altered
single chromosome or several chromosomes. expression of multiple genes, which may be
Ø The genesis of these breaks is unknown, but overexpressed or underexpressed compared to
DNA repair mechanisms are activated in normal depending on the nature of local
affected cells that stitch the pieces together in a changes.
haphazard way, creating many chromosome Ø In addition, however, mice engineered to have
rearrangements and also resulting in the loss of hypomethylated genomes also exhibit
some chromosome segments. chromosomal instability; thus, altered DNA
Ø It is hypothesized that such catastrophic events methylation may contribute to tumorigenesis in
by chance simultaneously activate oncogenes several ways.
and inactivate tumor suppressors, thereby
expediting the process of carcinogenesis. CHANGES IN HISTONES

EPIGENETIC CHANGES Ø Cancer cells often demonstrate changes in

histones near genes that influence cellular
behavior.
Ø Epigenetic changes have important roles in
Ø As with changes in DNA methylation, in an
many aspects of the malignant phenotype,
increasing number of instances it appears that
including the expression of cancer genes, the
these alterations have a genetic basis, being
control of differentiation and self- renewal, and
attributable to mutations that affect the activities
even drug sensitivity and drug resistance.
of protein complexes that “write”, “read” and
Ø Methods that allow genome-wide assessment of
“erase” histone marks, or that position
the cell’s epigenome are now available and have
nucleosomes on DNA
begun to reveal widespread epigenetic
alterations in cancers, which can be broadly

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

NONCODING RNAS AND CANCER that encodes an endonuclease that is required

for the processing and production of functional
mIRs.
Ø MicroRNAs (miRs) are small noncoding, single- Ø Thus, DICER is tumor suppressive in certain
stranded RNAs, approximately 22 nucleotides in cellular contexts.
length, that mediate sequence-specific inhibition Ø Whether the tumor suppressive function of
of messenger RNA (mRNA) translation through DICER stems from its involvement in processing
the action of the RNA-induced silencing complex of miRs remains to be established.
(RISC).
Ø Given that miRs control normal cell growth, CHEMICAL CARCINOGENESIS
differentiation, and cell survival, it is not
surprising that they play a role in carcinogenesis.
Ø Altered miR expression, sometimes stemming 1) Initiation
from amplifications and deletions of miR loci, has • results from exposure of cells to a
been identified in many cancers. sufficient dose of a carcinogenic agent;
Ø Decreased expression of certain miRs increases an initiated cell is altered, making it
the translation of oncogenic mRNAs; such mIRs potentially capable of giving rise to a
have tumor suppressive activity. tumor.
Ø Conversely, overexpression of other mIRs • Initiation alone, however, is not sufficient
represss the expression of tumor suppressor for tumor formation
genes; such mIRs promote tumor development 2) Initiation causes permanent DNA damage
and are often referred to as onco-mIRs. DNA damage (mutations); it is therefore rapid
and irreversible and has “memory”
• Tumors are produced even if the
ONCOMIRS
application of the promoting agent is
delayed for several months after a single
Ø miR-200 has been shown to promote epithelial- application of the initiator
mesenchymal transitions believed to be 3) Promoters can induce tumors to arise from
important in invasiveness and metastasis; and initiated cells, but they are nontumorigenic
miR-155, originally identified at the site of by themselves
retroviral insertions in avian lymphomas, is
• Tumors do not result when the
overexpressed in many human B cell
promoting agent is applied before, rather
lymphomas and indirectly upregulates a large
than after, the initiating agent.
number of genes that promote proliferation,
• This indicates that, in contrast to the
including MYC.
effects of initiators, the cellular changes
resulting from the application of
TUMOR SUPPRESSIVE MIRS promoters do not affect DNA directly
and are reversible.
Ø Deletions affecting certain tumor suppressive • Promoters enhance the proliferation of
miRs, such as miR-15 and miR-16, are among initiated cells, an effect that may
the most frequent genetic lesions in chronic contribute to the acquisition of additional
lymphocytic leukemia, a common tumor of older mutations.
adults.
Ø In this context, it appears that their loss leads to DIRECT-ACTING CARCINOGENS
upregulation of the anti-apoptotic protein BCL-2

Ø Direct-acting carcinogens require no metabolic

TUMOR SUPPRESSIVE PROPERTIES OF MIR conversion to become carcinogenic.
PROCESSING FACTORS Ø Most are weak carcinogens but some are
important because they are cancer chemo-
therapeutic drugs (e.g., alkylating agents).
Ø Study of families that are prone to the Ø Tragically, in some instances these agents have
development of an unusual collection of successfully cured, con- trolled, or delayed
neoplasms, including certain rare ovarian and recurrence of certain types of cancer (e.g.,
testicular tumors, unexpectedly identified leukemia, lymphoma, and ovarian carcinoma),
heterozygous germline defects in DICER, a gene only to evoke later a second form of cancer,

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
usually acute myeloid leukemia.
Ø The risk of induced cancer is low, but its
existence dictates judicious use of such agents.

INDIRECT-ACTING CARCINOGENS

Ø Chemicals that require metabolic conversion to

become active carcinogens; the carcinogenic
product of metabolism is called an ultimate
carcinogen.
Ø Some of the most potent indirect chemical
carcinogens—the polycyclic hydrocarbons—
are present in fossil fuels.
Ø Others, for example, benzo[a] pyrene (the
active component of soot, which Potts showed to
be carcinogenic), are formed during the high-
temperature combustion of tobacco in cigarettes
and are implicated in the causation of lung
cancer.
Ø Polycyclic hydrocarbons may also be produced
from animal fats during the process of broiling or
grilling meats and are present in smoked meats
and sh.
Ø The principal active products in many
hydrocarbons are epoxides, which form covalent MOLECULAR TARGETS OF CHEMICAL
adducts (addition products) with molecules in the CARCINOGENS
cell, principally DNA, but also with RNA and
proteins.
Ø The aromatic amines and azo dyes are another Ø Because of their chemical structures, some
class of indirect-acting carcinogens that were carcinogens interact preferentially with particular
widely used in the past in the aniline dye and DNA sequences or bases, and thus produce
rubber industries mutations that are clustered at “hotspots” or that
are enriched for particular base substitutions.
Ø One illustrative example of a chemical
carcinogen associated with a mutational
“hotspot” is alpha atoxin B1, a naturally
occurring agent produced by some strains of a
mold called Aspergillus.
• Aspergillus grows on improperly stored
grains and nuts, and there is a strong
correlation between the dietary level of this
food contaminant and the incidence of
hepatocellular carcinoma in parts of Africa
and the Far East.
Ø Interestingly, alpha atoxin B1-associated
hepatocellular carcinomas tend to have a
particular mutation in TP53, a G:C àT:A
transversion in codon 249 that produces an
arginine to serine substitution in the p53 protein.
Ø In contrast, TP53 mutations are infrequent in
liver tumors from areas where alpha atoxin
contamination of food does not occur, and few of
these mutations involve codon 249.
Ø Similarly, lung cancers associated with smoking
have a 10-fold higher mutational burden on

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
average than lung cancers in nonsmokers, and ULTRAVIOLET RAYS
these excess mutations are strongly skewed
toward particular base substitutions known to be Ø Exposure to UV rays derived from the sun,
caused by carcinogens in cigarette smoke (the particularly in fair-skinned individuals, is
proverbial “smoking gun associated with an in- creased incidence of
squamous cell carcinoma, basal cell carcinoma,
PROMOTION OF CHEMICAL CARCINOGENESIS and melanoma of the skin
Ø The degree of risk depends on the type of UV
Ø Promoters are chemical agents that are not rays, the intensity of exposure, and the quantity
mutagenic, but which instead stimulate cellular of the light-absorbing “protective mantle” of
proliferation. melanin in the skin.
Ø It is self-evident that in the absence of Ø Nonmelanoma skin cancers are associated
proliferation, tumors cannot arise. with total cumulative exposure to UV radiation,
Ø In tissues that are normally quiescent, such as whereas melanomas are associated with intense
the liver, the mitogenic stimulus may be provided intermittent exposure—as occurs with
by the initiating agent. sunbathing.
Ø This occurs if the carcinogenic initiator is toxic Ø The UV portion of the solar spectrum can be
and kills a large number of cells, thereby divided into three wavelength ranges: UVA
stimulating regeneration of the surviving cells (320-400 nm), UVB (280-320 nm), and UVC
Ø Application of promoters leads to proliferation (200-280 nm).
and clonal expansion of initiated (mutated) cells. Ø Of these, UVB is believed to be responsible for
Ø Driven to proliferate, subclones of the initiated the induction of cutaneous cancers.
cells suffer various additional mutations, and Ø UVC, although a potent mutagen, is not
eventually a cancerous clone with all the considered significant because it is filtered out
necessary hall- mark characteristics may by the ozone layer surrounding the earth (hence
emerge. the concern about ozone depletion).
Ø It is likely that many factors contributing to Ø The carcinogenicity of UVB light is due to
oncogenesis in humans also act by stimulating formation of pyrimidine dimers in DNA.
proliferation and thus can be thought of • If the energy in a photon of UV light is
conceptually as tumor promoters; examples absorbed by DNA, the result is a chemical
include unopposed estrogenic stimulation of the reaction that leads to covalent crosslinking
endometrium and breast, and chronic of pyrimidine bases, particularly adjacent
inflammatory processes associated with tissue thymidine residues in the same strand of
repair (e.g., inflammatory bowel disease, chronic DNA.
hepatitis, and Barrett esophagus). • This distorts the DNA helix and prevents
proper pairing of the dimer with bases in the
RADIATION CARCINOGENESIS opposite DNA strand.
• Pyrimidine dimers are repaired by the
nucleotide excision repair pathway
Ø Radiant energy, in the form of the UV rays of
sunlight or as ionizing electromagnetic and
IONIZING RADIATION
particulate radiation, is carcinogenic.
Ø UV light is clearly implicated in the causation of
Ø Electromagnetic (x-rays, γ rays) and
skin cancers, and ionizing radiation exposure
particulate (α particles, β particles, protons,
from medical or occupational exposure, nuclear
neutrons) radiations are all carcinogenic.
plant accidents, and atomic bomb detonations Ø The evidence is so voluminous that a few
has produced a variety of cancers. examples suffice.
Ø Although the contribution of radiation to the total Ø In humans, there is a hierarchy of vulnerability of
human burden of cancer is probably small, the different tissues to radiation-induced cancers.
well-known latency of damage caused by radiant Most frequent are myeloid leukemias.
energy and its cumulative effect require
Ø Cancer of the thyroid follows closely but only in
extremely long periods of observation and make
the young.
it difficult to ascertain its full significance.
Ø In the intermediate category are cancers of the
breast, lungs, and salivary glands.
Ø In contrast, skin, bone, and the
gastrointestinal tract are relatively resistant

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
to radiation-induced neoplasia, even though the TAX GENE
gastrointestinal epithelial cells are vulnerable to Ø Increased pro-growth signaling and cell
the acute cell-killing effects of radiation, and the survival: Tax interacts with PI3K and thereby
skin is “first in line” for all external radiation. stimulates AKT
Ø Nonetheless, the physician must not forget: • These kinases participate in the cascade that
practically any cell can be transformed into a promotes both cell survival and metabolic
cancer cell by sufficient exposure to radiant alterations that enhance cell growth.
energy.
• Tax also directly upregulates the expression
of cyclin D2 and represses the expression of
MICROBIAL CARCINOGENESIS
multiple CDK inhibitors, changes that promote
cell cycle progression.
Ø Many RNA and DNA viruses have proved to be • Finally, Tax can activate the transcription
oncogenic in animals as disparate as frogs and factor NF-κB, which promotes the survival of
primates. many cell types, including lymphocytes
Ø Despite intense scrutiny, however, only a few Ø Increased genomic instability
viruses have been linked with human cancer. • Tax may also cause genomic instability by
interfering with DNA-repair functions and
ONCOGENIC RNA VIRUSES inhibiting cell cycle checkpoints activated by
DNA damage.
• In line with these defects, HTLV-1- associated
HUMAN T-CELL LEUKEMIA VIRUS TYPE 1
leukemias tend to be highly aneuploid.
Ø Causes adult T-cell leukemia/lymphoma
Ø
(ATLL), a tumor that is endemic in certain parts
of Japan, the Caribbean basin, South America, ONCOGENIC DNA VIRUSES
and Africa, and found sporadically elsewhere,
including the United States. Ø As with RNA viruses, several oncogenic DNA
Ø HTLV-1 has tropism for CD4+ T cells, and viruses that cause tumors in animals have been
hence this subset of T cells is the major target identified.
for neoplastic transformation. Ø Of the various human DNA viruses, five—HPV,
Ø Human infection requires transmission of Epstein-Barr virus (EBV), hepatitis B virus
infected T cells via sexual intercourse, blood (HBV), Merkel cell polyoma virus, and Kaposi
products, or breastfeeding. sarcoma herpesvirus, also called human
Ø Leukemia develops in only 3% to 5% of the herpesvirus 8—have been implicated in the
infected individuals, typically after a long latent causation of human cancer.
period of 40 to 60 years.
Ø A high fraction of the leukemias express the
transcription factor FoxP3, a marker of HUMAN PAPILLOMAVIRUS
regulatory T cells (Tregs) that act to suppress
immune responses. Ø Some types (e.g., 1, 2, 4, and 7) cause benign
Ø HTLV-1 does not contain an oncogene, and no squamous papillomas (warts) in humans. In
consistent integration next to a proto- oncogene contrast, high-risk HPVs (e.g., types 16 and 18)
has been discovered have been implicated in the genesis of
Ø The HTLV-1 genome contains the gag, pol, env, squamous cell car- cinomas of the cervix,
and long- terminal-repeat regions typical of all anogenital region, and head and neck
retroviruses, but, in contrast to other leukemia (particularly tumors arising in the tonsillar
viruses, it contains another gene referred to as mucosa).
tax Ø These cancers are sexually transmitted
Ø Tax is essential for viral replication, because it diseases, caused by transmission of HPV.
stimulates transcription of viral RNA from the 5′ Ø In contrast to cervical cancers, genital warts
long terminal repeat. have low malignant potential and are associated
Ø However, Tax also alters the transcription of with low-risk HPVs, predominantly HPV-6 and
several host cell genes and interacts with certain HPV-11.
host cell signaling proteins. Ø Interestingly, in benign warts, the HPV genome
is maintained in a nonintegrated episomal form,
while in cancers the HPV genome is integrated

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12
into the host genome, suggesting that integration EPSTEIN-BARR VIRUS
of viral DNA is important for malignant
transformation.
Ø As with HTLV-1, the site of viral integration in Ø A member of the herpesvirus family, has been
host chromosomes is random, but the pattern of implicated in the pathogenesis of several human
integration is clonal. tumors: the African form of Burkitt lymphoma; B-
Ø Cells in which the viral genome has integrated cell lymphomas in immunosuppressed
show significantly more genomic instability. individuals (particularly in those with HIV
Because the integration site is random, there is infection or undergoing immunosuppressive
no consistent association with a host proto- therapy after organ or bone marrow
oncogene. transplantation); a subset of Hodgkin lymphoma;
Ø Rather, integration interrupts the viral DNA within nasopharyngeal and some gastric carcinomas;
the E1/E2 open reading frame, leading to loss of and rare forms of T-cell lymphoma and natural
the E2 viral repressor and overexpression of the killer (NK) cell lymphoma. T
oncoproteins E6 and E7 Ø he most common EBV-associated tumors are
those derived from B cells and nasopharyngeal
ONCOGENIC ACTIVITIES OF E6 carcinoma
Ø The E6 protein binds to and mediates the Ø EBV infects B lymphocytes and possibly
degradation of p53, and also stimulates the epithelial cells of the oropharynx.
expression of TERT, the catalytic subunit of Ø The virus uses the complement receptor CD21
telomerase, which you will recall contributes to the to attach to and infect B cells.
immortalization of cells. Ø The infection of B cells is latent; that is, there is
Ø E6 from high-risk HPV types has a higher affinity no viral replication and the cells are not killed.
for p53 than E6 from low-risk HPV types. Ø However, B cells latently infected with EBV
Interestingly the E6-p53 interaction may offer express viral proteins that result in the ability to
some clues regarding polymorphisms and risk propagate indefinitely in vitro (immortalization).
factors for development of cervical cancer. Ø The molecular basis of B-cell proliferation
Ø Human TP53 is polymorphic at codon 72, induced by EBV is complex, but as with other
encoding either a proline or arginine residue at viruses it involves the “hijacking” of several
that position. normal signaling pathways.
Ø The p53 Arg72 variant is much more susceptible Ø One EBV gene, latent mem- brane protein-1
to degradation by E6. (LMP-1), acts as an oncogene, in that its
Ø Not surprisingly, infected individuals with the expression in transgenic mice induces B-cell
Arg72 polymorphism are more likely to develop lymphomas.
cervical carcinomas.
LMP-1
Ø LMP-1 activates the NF-κB and JAK/ STAT
ONCOGENIC ACTIVITIES OF E7
signaling pathways and promotes B-cell survival
Ø The E7 protein has effects that complement those
and proliferation, all of which occur autonomously
of E6, all of which are centered on speeding cells
(i.e., without T cells or other outside signals) in
through the G1-S cell cycle checkpoint.
EBV-infected B cells.
Ø It binds to the RB protein and displaces the E2F Ø Concurrently, LMP-1 prevents apoptosis by
transcription factors that are normally sequestered activating BCL2.
by RB, promoting progression through the cell Ø Thus, the virus “borrows” normal B-cell activation
cycle. pathways to expand the pool of latently infected
Ø As with E6 proteins and p53, E7 proteins from cells
high-risk HPV types have a higher affinity for RB
than do E7 proteins from low-risk HPV types. E7
also inactivates the CDK inhibitors p21 and p27.
Ø Finally, E7 proteins from high- risk HPVs (types 16,
18, and 31) also bind and presumably activate
cyclins E and A.

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

EBNA-2 HEPATITIC B AND C VIRUSES

Ø Encodes a nuclear protein that mimics a
constitutively active Notch receptor.
Ø EBNA-2 transactivates several host genes, Ø Oncogenic effects of HBV and HCV are
including cyclin D and the SRC family of proto- multifactorial, the dominant effect seems to be
oncogenes. immunologically mediated chronic inflammation
Ø In addition, the EBV genome contains a gene and hepatocyte death leading to regeneration
encoding a viral cytokine, vIL-10, that was and, over time, genomic damage.
“borrowed” from the host genome. Ø It is also suspected that in the setting of
Ø This viral cytokine can prevent macrophages and unresolved chronic inflammation, as occurs in
monocytes from activating T cells and is required viral hepatitis or chronic gastritis caused by H.
for EBV-dependent transformation of B cells pylori (see later), the immune response may
become maladaptive, promoting rather than
preventing tumorigenesis.
Ø Chronic viral infection leads to the compensatory
BURKITT LYMPHOMA
proliferation of hepatocytes.
Ø This regenerative process is aided and abetted
Ø A neoplasm of B lymphocytes that is endemic in
by a plethora of growth factors, cytokines,
central Africa and New Guinea, areas where it is
chemokines, and other bioactive substances.
the most common childhood tumor.
Ø These are produced by activated immune cells
Ø A morphologically identical lymphoma occurs
and promote cell survival, tissue remodeling, and
sporadically throughout the world. The association
angiogenesis
between endemic Burkitt lymphoma and EBV is
Ø The activated immune cells also produce other
quite strong.
mediators, such as reactive oxygen species, that
• More than 90% of African tumors carry the
are genotoxic and mutagenic.
EBV genome
Ø One key molecular step seems to be activation
• One hundred percent of the patients have of the NF-κB pathway in hepatocytes in
elevated anti- body titers against viral response to mediators derived from the activated
capsid antigens immune cells.
• Serum antibody titers against viral capsid Ø Activation of the NF-κB pathway within
antigens are correlated with the risk of hepatocytes blocks apoptosis, allowing the
developing the tumor dividing hepatocytes to incur genotoxic stress
• it seems that EBV is not directly and to accumulate mutations
oncogenic, but by acting as a polyclonal Ø Although this seems to be the dominant
B-cell mitogen, it sets the stage for the mechanism in the pathogenesis of virus-induced
acquisition of the (8;14) translocation and hepatocellular carcinoma, the HBV genome also
other mutations that ultimately produce a contains genes that may directly promote the
full-blown cancer development of cancer.

HEPATITIC C
Ø Strongly linked to the pathogenesis of liver
NASOPHARYNGEAL CARCINOMA cancer.
Ø 100% of nasopharyngeal carcinomas obtained Ø The molecular mechanisms used by HCV are
from all parts of the world contain EBV. less well defined than are those of HBV.
Ø The structure of the viral genome is identical Ø In addition to chronic liver cell injury and
(clonal) in all of the tumor cells within individual compensatory regeneration, components of the
tumors, excluding the possibility that EBV infection HCV genome, such as the HCV core protein,
occurred after tumor development. may have a direct effect on tumorigenesis,
Ø Antibody titers to viral capsid antigens are greatly possibly by activating a variety of growth-
elevated, and in endemic areas patients develop promoting signal transduction pathways
IgA antibodies before the appearance of the
tumor.
Ø The uniform association of EBV with
nasopharyngeal carcinoma suggests that EBV has
a central role in the genesis

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 Pathology (Lecture)
NEOPLASIA II
Dr. Arnel Bayotas | December 09, 2020 | Topic 12

HELICOBACTER PYLORI CLINICAL ASPECTS OF NEOPLASIA

Ø First incriminated as a cause of peptic ulcers, H. Ø Ultimately the importance of neoplasms lies in
pylori now has acquired the dubious distinction their effects on patients.
of being the first bacterium classified as a Ø Although malignant tumors are of course more
carcinogen. threatening than benign tumors, any tumor, even
Ø Indeed, H. pylori infection is implicated in the a benign one, may cause morbidity and mortality
genesis of both gastric adenocarcinomas and
gastric lymphomas. LOCAL AND HORMONAL EFFECTS
Ø As in viral hepatitis, the inflammatory milieu
contains numerous genotoxic agents, such as Ø Location is a critical determinant of the clinical
reactive oxygen species. effects of both benign and malignant tumors.
Ø There is an initial development of chronic Ø Tumors may impinge upon vital tissues and
gastritis, followed by gastric atrophy, intestinal impair their functions, cause death of involved
metaplasia of the lining cells, dysplasia, and tissues, and provide a nidus for infection.
cancer. Ø A small (1 cm) pituitary adenoma, although
Ø This sequence takes decades to complete and benign and possibly nonfunctional, can
occurs in only 3% of infected patients. compress and destroy the surrounding normal
Ø Like HBV and HCV, the H. pylori genome also gland and thus lead to serious hypopituitarism.
contains genes directly implicated in Ø Cancers arising within or metastatic to an
oncogenesis. endocrine gland may cause an endocrine
Ø Strains associated with gastric adenocarcinoma insufficiency by destroying the gland.
have been shown to contain a “pathogenicity Ø Neoplasms in the gut, both benign and
island” that contains cytotoxin-associated A malignant, may cause obstruction as they
(CagA) gene. enlarge.
Ø Although H. pylori is noninvasive, CagA • Infrequently, peristaltic movement
penetrates into gastric epithelial cells, where it telescopes the neoplasm and its
has a variety of effects, including the initiation of affected segment into the downstream
a signaling cascade that mimics unregulated segment, producing an obstructing
growth factor stimulation. intussusception
Ø Associated with gastric lymphomas
• Symptoms produced by a cancer due to
its position can (ironically) be lifesaving;
GASTRIC LYMPHOMAS for example, the few survivors of
Ø B-cell origin, and because the tumors recapitulate pancreatic cancer are those whose
some of the features of normal Peyer’s patches, tumors “fortuitously” obstruct bile ducts
they are often called lymphomas of mucosa- early in their course, leading to the
associated lymphoid tissue, or MALTomas appearance of jaundice and other
Ø Their molecular pathOgenesis is incompletely symptoms at a stage of the disease
understood but seems to involve strain-specific H. when surgical cure is still possible.
pylori factors, as well as host genetic factors, such • Benign and malignant neoplasms arising
as polymorphisms in the promoters of in am- in endocrine glands can cause clinical
matory cytokines such as IL-1β and tumor problems by producing hormones.
necrosis factor (TNF). • Such functional activity is more typical of
Ø It is thought that H. pylori infection leads to the benign than of malignant tumors, which
appearance of H. pylori-reactive T cells, which in may be so undifferentiated to have lost
turn stimulate a polyclonal B-cell proliferation. such capability.
Ø In chronic infections, currently unknown mutations • A benign beta-cell adenoma of the
may be acquired that give individual cells a growth pancreatic islets less than 1 cm in
advantage. diameter may produce sufficient insulin
Ø These cells grow out into a monoclonal to cause fatal hypoglycemia.
“MALToma” that nevertheless remains dependent
• In addition, nonendocrine tumors may
on T-cell stimulation of B-cell pathways that
elaborate hormones or hormone-like
activate the transcription factor NF-κB.
products and give rise to paraneoplastic
syndromes.

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 Pathology (Lecture)
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Dr. Arnel Bayotas | December 09, 2020 | Topic 12
• The erosive and destructive growth of • In affected patients they can cause
cancers or the expansile pressure of a significant clinical problems and may even
benign tumor on any natural surface, be lethal.
such as the skin or mucosa of the gut, •
may cause ulcerations, secondary They may mimic metastatic disease and
infections, and bleeding. therefore con- found treatment.
• Melena (blood in the stool) and hema-
ENDOCRINOPATHIES
turia, for example, are characteristic of
neoplasms of the gut and urinary tract.
Ø Frequently encountered paraneoplastic
• Neoplasms, benign as well as
syndromes
malignant, may cause problems in
Ø The responsible cancers are not of endocrine
varied ways, but all are far less common
origin and the secretory activity of such tumors is
than our next topic, the cachexia of
referred to as ectopic hormone production.
malignancy.
Ø Cushing syndrome is the most common
endocrinopathy.
CANCER CACHEXIA Ø Approximately 50% of individuals with this
endocrinopathy have carcinoma of the lung,
Ø Individuals with cancer commonly suffer chiefly the small-cell type.
progressive loss of body fat and lean body mass Ø It is caused by excessive production of
accompanied by profound weakness, anorexia, corticotropin or corticotropin- like peptides.
and anemia, referred to as cachexia. Ø The precursor of corticotropin is a large molecule
Ø Cancer cachexia is associated with: known as pro-opiomelanocortin.
• Equal loss of both fat and lean muscle Ø Lung cancer patients with Cushing syndrome
• Elevated basal metabolic rate have elevated serum levels of both
• Evidence of systemic inflammation (e.g., proopiomelanocortin and corticotropin.
an increase in acute phase reactants) Ø The former is not found in serum of patients with
Ø The mechanisms that underlie cancer cachexia excess corticotropin produced by the pituitary.
are not understood.
Ø Inflammation related to the interplay between HYPERCALCEMIA
cancer and the immune system is likely to have
a role. Ø Most common paraneoplastic syndrome; in fact,
Ø TNFα (originally known as cachectin) is a symptomatic hypercalcemia is more often related
leading suspect among several mediators to some form of cancer than to
released from immune cells that may contribute hyperparathyroidism.
to cachexia. Ø Two general processes are involved in
Ø Humoral factors released from tumor cells such cancer-associated hypercalcemia: (1)
as proteolysis inducing factor have been osteolysis induced by cancer, whether primary in
implicated in the loss of muscle mass bone, such as multiple myeloma, or metastatic to
bone from any primary lesion, and (2) the
PARANEOPLASTIC SYNDROMES production of calcemic humoral substances by
extraosseous neoplasms.
Ø Some cancer-bearing individuals develop signs Ø Only the second mechanism is considered to be
and symptoms that cannot readily be explained paraneoplastic; hypercalcemia due to primary or
by the anatomic distribution of the tumor or by secondary involvement of the skeleton by tumor
the elaboration of hormones indigenous to the is not a paraneoplastic syndrome.
tissue from which the tumor arose; these are
known as paraneoplastic syndromes. NEUROMYOPATHIC PARANEOPLASTIC
Ø These occur in about 10% of persons with SYNDROMES
cancer.
Ø Despite their relative infrequency, paraneoplastic Ø Take diverse forms, such as peripheral
syndromes are important to recognize, for neuropathies, cortical cerebellar degeneration, a
several reasons: polymyopathy resembling polymyositis, and a
• They may be the earliest manifestation of an myasthenic syndrome similar to myasthenia
occult neoplasm gravis
Ø The cause of these syndromes is poorly

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Dr. Arnel Bayotas | December 09, 2020 | Topic 12
understood. Ø Bland, small, nonbacterial fibrinous
Ø In some cases, antibodies, presumably induced vegetations sometimes form on the cardiac
against tumor cell antigens that cross-react with valve leaflets (more often on left-sided valves),
neuronal cell antigens, have been detected. particularly in individuals with advanced mucin-
Ø It is postulated that some visceral cancers secreting adenocarcinomas.
ectopically express certain neural antigens. Ø These lesions, called nonbacterial thrombotic
Ø For some unknown reason, the immune system endocarditis are potential sources of emboli that
recognizes these antigens as foreign and mounts can further complicate the course of the cancer.
an immune response.
GRADING AND STAGING OF TUMORS
ACANTHOSIS NIGRICANS
GRADING
Ø Disorder
characterized by Ø Grading of a cancer is based on the degree of
gray- black patches differentiation of the tumor cells and, in some
of thickened, cancers, the number of mitoses or architectural
hyperkeratotic skin features.
with a velvety Ø Grading schemes have evolved for each type of
appearance. malignancy, and generally range from two
Ø It occurs rarely as a categories (low grade and high grade) to four
genetically categories.
determined disease in juveniles or adults Ø Criteria for the individual grades vary in different
Ø In addition, in about 50% of the cases, particularly types of tumors and so are not detailed here, but
in those over age 40, the appearance of such all attempt, in essence, to judge the extent to
lesions is associated with some form of cancer. which the tumor cells resemble or fail to resemble
Ø Sometimes the skin changes appear before the their normal counterparts.
cancer is discovered. Ø Although histologic grading is useful, the
correlation between histologic appearance and
HYPERTROPHIC OSTEOARTHROPATHY biologic behavior is less than perfect.
Ø In recognition of this problem and to avoid
Ø encountered in 1% to 10% of patients with lung spurious quantification, it is common practice to
carcinoma. characterize a particular neoplasm in descriptive
Ø Rarely, other forms of cancer are involved. This terms, for example, well-differentiated, mucin-
disorder is characterized by (1) periosteal new secreting adenocarcinoma of the stomach, or
bone formation, primarily at the distal ends of poorly differentiated pancreatic adenocarcinoma.
long bones, metatarsals, metacarpals, and
STAGING
proximal phalanges; (2) arthritis of the adjacent
joints; and (3) clubbing of the digits. Although the
osteoarthropathy is seldom seen in noncancer Ø The staging of solid cancers is based on the size
patients, clubbing of the finger- tips may be of the primary lesion, its extent of spread to
encountered in liver diseases, diffuse lung regional lymph nodes, and the presence or
disease, congenital cyanotic heart disease, absence of blood- borne metastases.
ulcerative colitis, and other disorders. The cause Ø The major staging system currently in use is the
of hypertrophic osteoarthropathy is unknown. American Joint Committee on Cancer Staging.
Ø This system uses a classification called the TNM
VASCULAR AND HEMATOLOGIC system—T for primary tumor, N for regional
MANIFESTATIONS lymph node involvement, and M for metastases.
Ø TNM staging varies for specific forms of cancer,
but there are general principles.
Ø Migratory thrombophlebitis (Trousseau Ø The primary lesion is characterized as T1 to T4
syndrome) may be encountered in association based on increasing size.
with deep-seated cancers, most often carcinomas Ø T0 is used to indicate an in situ lesion.
of the pancreas or lung. Ø N0 would mean no nodal involvement, whereas
Ø Disseminated intravascular is most commonly N1 to N3 would denote involvement of an
associated with acute promyelocytic leukemia increasing number and range of nodes.
and prostatic adenocarcinoma. Ø M0 signifies no distant metastases, whereas M1

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Dr. Arnel Bayotas | December 09, 2020 | Topic 12
or sometimes M2 indicates the presence of Ø It obviates surgery and its attendant risks.
metastases and some judgment as to their Although it entails some difficulties, such as
number. small sample size and sampling errors, in
experienced hands it is reliable, rapid, and
LABORATORY DIAGNOSIS OF CANCER useful.

OPEN SURGICAL BIOPSY PROTEIN MARKERS

IMMUNOHISTOCHEMISTRY
FROZEN SECTION
Ø Diagnosis is sometimes desirable, for example,
in determining the nature of a mass lesion, in Ø The availability of specific antibodies has greatly
evaluating the margins of an excised cancer to facilitated the identification of cell products or
ascertain that the entire neoplasm has been surface markers.
removed, or in making decisions about what
additional studies beyond histology are needed. CATEGORIZATION OF UNDIFFERENTIATED
Ø This method permits histologic evaluation within MALIGNANT TUMORS
minutes. Ø In many cases malignant tumors of diverse
Ø In experienced, competent hands, frozen- origin resemble each other because of limited
section diagnosis is highly accurate, but there differentiation.
are particular instances in which the better Ø These tumors are often quite difficult to
histologic detail provided by the more time- distinguish on the basis of routine hematoxylin
consuming routine methods is needed—for and eosin (H&E)- stained tissue sections.
example, when extremely radical surgery, such Ø For example, certain anaplastic carcinomas,
as the amputation of an extremity, may be lymphomas, melanomas, and sarcomas may
indicated. look quite similar, but they must be accurately
Ø Better to wait a day or two, despite the delay, identified because their treatment and prognosis
than to perform inadequate or unnecessary are different.
surgery. Ø Antibodies specific to intermediate laments have
proved to be of particular value in such cases,
CYTOLOGIC SMEARS because solid tumor cells often contain
intermediate laments characteristic of their cell of
origin.
Ø This approach is widely used to screen for
Ø Other useful immunohistochemical markers
carcinoma of the cervix, often at an in situ stage,
include lineage-specific membrane proteins
but it is also used to evaluate many other forms
(e.g., CD20, a marker of B-cell tumors) and
of suspected malignancy in which tumor cells
transcription factors.
are easily accessible or shed, such as
endometrial carcinoma, lung carcinoma, bladder
DETERMINATION OF SITE OF ORIGIN OF
and prostatic tumors, and gastric carcinomas; for
METASTATIC TUMORS
the identification of tumor cells in abdominal,
pleural, joint, and cerebrospinal fluids; and, less Ø Many cancer patients present with metastases.
commonly, with other forms of neoplasia. In some the primary site is obvious or readily
detected on the basis of clinical or radiologic
FINE NEEDLE ASPIRATION features.
Ø In cases in which the origin of the tumor is
obscure, immunohistochemical detection of
Ø The procedure involves aspirating cells and
tissue-specific or organ-specfic antigens in a
attendant fluid with a small-bore needle, followed
biopsy specimen of the metastatic deposit can
by cytologic examination of the stained smear.
lead to the identification of the tumor source.
Ø This method is used most commonly for the
assessment of readily palpable lesions in sites
Ø For example, prostate-specific antigen (PSA)
and thyroglobulin are markers of carcinomas of
such as the breast, thyroid, and lymph nodes.
Ø Modern imaging techniques permit extension of the prostate and thyroid, respectively.
the method to lesions in deep-seated structures,
such as pelvic lymph nodes and pancreas.
Ø Fine-needle aspiration is less invasive and more
rapidly performed than are needle biopsies.

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Dr. Arnel Bayotas | December 09, 2020 | Topic 12
DETECTION OF MOLECULES THAT HAVE clinical research, but have the potential to permit
PROGNOSIS OR THERAPEUTIC SIGNIFICANCE earlier diagnosis, to gauge the risk of metastasis,
Ø Immunohistochemical detection of hormone and to provide a minimally invasive means of
(estrogen/progesterone) receptors in breast assessing the response of tumor cells to
cancer cells is of prognostic and therapeutic therapy.
value because these cancers are susceptible to
antiestrogen therapy (In general, receptor- CYTOGENETIC MARKERS
positive breast cancers have a better prognosis
than receptor negative tumors. Ø Conventional karyotyping: detection of
Ø Protein products of oncogenes such as ERBB2 metaphase of chromosomes à leukemia and
in breast cancers can also be detected by lymphoma
immunostaining. Ø Fluorescence in situ hybridization (FISH):
Ø Breast cancers with strong immunohistochemical fresh-samples à breast cancer
staining for the protein product of the ERBB2 Ø Hybridization of tumor: DNA detection à
gene product, HER2, generally have a poor substitute for conventional karyotyping à
prognosis, but are amenable to treatment with diagnosis of brain tumor
antibodies that block the activity of the HER2
receptor.
Ø Because high- level expression of HER2 is NUCLEIC ACID MARKERS
caused by amplification of ERBB2, fluorescent in
situ hybridization (FISH) to confirm ERBB2 gene Ø Chimeric nucleic acid sequences: detected
amplification is sometimes used as an adjunct to chromosomal rearrangements creating fusion
immunohistochemical studies. genes à tumor specific
Ø Similarly, immunohistochemical stains for ALK Ø Single-nucleotide variants and small
protein can be used to identify lung cancers and “indels”: detect point mutations
lymphomas expressing constitutively active ALK Ø Antigen-receptor gene rearrangements:
fusion proteins. distinction of monoclonal (neoplastic) from
polyclonal (proliferative) malignancy
FLOW CYTOMETRY Ø Molecular profiling of cancers

Ø Flow cytometry can rapidly and quantitatively

measure several individual cell characteristics,
but is mainly used to identify cellular antigens REFERENCES
expressed by “liquid” tumors, those that arise • Kumas, Vinay., Abbas, Abul., and Aster, John
from blood-forming tissues. (2020). Robbins & Cotran Pathologic Basis of
th
Ø These include B- and T-cell lymphomas and Disease 10 Edition
leukemias, as well as myeloid neoplasms. • Dr. Bayotas’ video presentation
Ø An advantage of flow cytometry over • Daenerys: Mother of Dragons Transcribed Notes
immunohistochemistry is that multiple antigens
can be assessed simultaneously on individual
cells using combinations of specific antibodies
linked to different fluorescent dyes.
CIRCULATING TUMOR CELLS

Ø Instrumentation that permits detection,

quantification, and characterization of rare solid
tumors cells (e.g., carcinoma, melanoma)
circulating in the blood is being explored as a
diagnostic modality.
Ø Some of the latest devices rely on three-
dimensional ow cells coated with antibodies
specific for tumor cells of interest (e.g.,
carcinoma cells) that efficiently capture rare
tumor cells present in the blood.
Ø Such methods currently fall in the realm of

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Irelia: The Blade Dancer 22