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HIGH-YIELD PRINCIPLES IN

Pathology

“Digressions, objections, delight in mockery, carefree mistrust are signs of ``Cellular Injury 206
health; everything unconditional belongs in pathology.”
—Friedrich Nietzsche ``Neoplasia 219

“You cannot separate passion from pathology any more than you can
separate a person’s spirit from his body.”
—Richard Selzer

The fundamental principles of pathology are key to understanding


diseases in all organ systems. Major topics such as inflammation and
neoplasia appear frequently in questions across different organ systems,
and such topics are definitely high yield. For example, the concepts of
cell injury and inflammation are key to understanding the inflammatory
response that follows myocardial infarction, a very common subject of
board questions. Similarly, a familiarity with the early cellular changes
that culminate in the development of neoplasias—for example,
esophageal or colon cancer—is critical. Finally, make sure you
recognize the major tumor-associated genes and are comfortable with
key cancer concepts such as tumor staging and metastasis.

205

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206 SEC TION II Pathology    
PATHOLOGY—Cellular Injury

PATHOLOGY—CELLULAR INJURY
``

Cellular adaptations Reversible changes that can be physiologic (eg, uterine enlargement during pregnancy) or
pathologic (eg, myocardial hypertrophy 2° to systemic HTN to prevent injury). If stress is excessive
or persistent, adaptations can progress to cell injury (eg, significant LV hypertrophy Ž injury to
myofibrils Ž HF).
Hypertrophy  structural proteins and organelles Ž  in size of cells.
Hyperplasia Controlled proliferation of stem cells and differentiated cells Ž  in number of cells. Excessive
stimulation Ž pathologic hyperplasia (eg, endometrial hyperplasia), which may progress to
dysplasia and cancer.
Atrophy  in tissue mass due to  in size ( cytoskeleton degradation via ubiquitin-­proteasome pathway
and autophagy;  protein synthesis) and/or number of cells (apoptosis). Causes include disuse,
denervation, loss of blood supply, loss of hormonal stimulation, poor nutrition.
Metaplasia Reprogramming of stem cells Ž replacement of one cell type by another that can adapt to a
new stress. Usually due to exposure to an irritant, such as gastric acid (Ž Barrett esophagus) or
cigarette smoke (Ž respiratory ciliated columnar epithelium replaced by stratified squamous
epithelium). May progress to dysplasia Ž malignant transformation with persistent insult (eg,
Barrett esophagus Ž esophageal adenocarcinoma). Metaplasia of connective tissue can also occur
(eg, myositis ossificans, the formation of bone within muscle after trauma).
Dysplasia Disordered, precancerous epithelial cell growth. Characterized by loss of uniformity of cell size
and shape (pleomorphism); loss of tissue orientation; nuclear changes (eg,  nuclear:cytoplasmic
ratio and clumped chromatin). Mild and moderate dysplasias (ie, do not involve entire thickness
of epithelium) may regress with alleviation of inciting cause. Severe dysplasia usually becomes
irreversible and progresses to carcinoma in situ. Usually preceded by persistent metaplasia or
pathologic hyperplasia.

Hyperplasia Change in cell Change in cell


size or type and
number structure
Reversible Generally
Normal cells irreversible Neoplasia
Hypertrophy

Atrophy Severe stress Reversible


or injury
Inability Change in Change in
to adapt cell structure cell type

Irreversible
injury  necrosis
or apoptosis Dysplasia Metaplasia
If chronic irritant
persists
Irreversible

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PATHOLOGY—Cellular Injury SEC TION II 207

Cell injury
Cellular/ Ribosomal/polysomal Rupture of Plasma membrane damage
mitochondrial swelling detachment (↓ protein lysosomes (degradation of membrane
(↓ ATP ↓ activity of synthesis) and autolysis phospholipid) → leakage of


Normal cell Na+/K+ and Ca2+ pumps) cytosolic enzymes into serum,
influx of Ca2+ activating
Reversible lysosomal enzymes
Irreversible Cell death

I n jur y
Nucleus: ↓
Mitochondrial permeability
pyknosis (condensation)
Membrane blebbing or
Nuclear chromatin karyorrhexis (fragmentation)
clumping or
karyolysis (fading)

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208 SEC TION II Pathology    
PATHOLOGY—Cellular Injury

Apoptosis ATP-dependent programmed cell death.


Intrinsic and extrinsic pathways; both pathways activate caspases (cytosolic proteases) Ž cellular
breakdown including cell shrinkage, chromatin condensation, membrane blebbing, and
formation of apoptotic bodies, which are then phagocytosed.
Characterized by deeply eosinophilic cytoplasm and basophilic nucleus, pyknosis (nuclear
shrinkage), and karyorrhexis (fragmentation caused by endonuclease-mediated cleavage).
Cell membrane typically remains intact without significant inflammation (unlike necrosis).
DNA laddering (fragments in multiples of 180 bp) is a sensitive indicator of apoptosis.
Intrinsic Involved in tissue remodeling in embryogenesis. Occurs when a regulating factor is withdrawn
(mitochondrial) from a proliferating cell population (eg,  IL-2 after a completed immunologic reaction
pathway Ž apoptosis of proliferating effector cells). Also occurs after exposure to injurious stimuli (eg,
radiation, toxins, hypoxia).
Regulated by Bcl-2 family of proteins. BAX and BAK are proapoptotic, while Bcl-2 and Bcl-xL are
antiapoptotic.
BAX and BAK form pores in the mitochondrial membrane Ž release of cytochrome C from inner
mitochondrial membrane into the cytoplasm Ž activation of caspases.
Bcl-2 keeps the mitochondrial membrane impermeable, thereby preventing cytochrome C release.
Bcl-2 overexpression (eg, follicular lymphoma t[14;18]) Ž  caspase activation Ž tumorigenesis.
Extrinsic (death 2 pathways:
receptor) pathway ƒƒ Ligand receptor interactions (FasL binding to Fas [CD95] or TNF-α binding to its receptor)
ƒƒ Immune cell (cytotoxic T-cell release of perforin and granzyme B)
Fas-FasL interaction is necessary in thymic medullary negative selection. Mutations in Fas
 numbers of circulating self-reacting lymphocytes due to failure of clonal deletion.
Defective Fas-FasL interactions cause autoimmune lymphoproliferative syndrome.
Intrinsic Extrinsic
(mitochondrial) pathway (death receptor) pathway
Cytotoxic T cell
FasL
DNA damage TNFα
Radiation, ROS, toxins
Fas Granzyme B
TNFR
Misfolded proteins
Hypoxia
Initiator Perforin
caspases
p53 activation
Cytochrome C Executioner Nuclear
BAX/BAK fragmentation
Bcl-2 caspases

Macrophage
Initiator Ligands for
caspases
macrophage cell
Cytoskelet receptors
al dispersion

Cytoplasmic
bleb Apoptotic
body

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Necrosis Enzymatic degradation and protein denaturation of cell due to exogenous injury Ž intracellular
components leak. Inflammatory process (unlike apoptosis).
TYPE SEEN IN DUE TO HISTOLOGY
Coagulative Ischemia/infarcts in Ischemia or infarction; Preserved cellular architecture (cell outlines
most tissues (except injury denatures seen), but nuclei disappear;  cytoplasmic
brain) enzymes Ž proteolysis binding of eosin stain (Ž  eosinophilia;
blocked red/pink color) A
Liquefactive Bacterial abscesses, Neutrophils release Early: cellular debris and macrophages
brain infarcts lysosomal enzymes Late: cystic spaces and cavitation (brain)
that digest the tissue B Neutrophils and cell debris seen with
bacterial infection
Caseous TB, systemic fungi Macrophages wall Fragmented cells and debris surrounded by
(eg, Histoplasma off the infecting lymphocytes and macrophages (granuloma)
capsulatum), Nocardia microorganism
Ž granular debris C
Fat Enzymatic: acute Damaged cells release Outlines of dead fat cells without peripheral
pancreatitis lipase, which breaks nuclei; saponification of fat (combined with
(saponification of down triglycerides; Ca2+) appears dark blue on H&E stain D
peripancreatic fat) liberated fatty
Nonenzymatic: acids bind calcium
traumatic (eg, injury to Ž saponification
breast tissue)
Fibrinoid Immune reactions in Immune complexes Vessel walls are thick and pink E
vessels (eg, polyarteritis combine with
nodosa), preeclampsia, fibrin Ž vessel wall
hypertensive damage (type III
emergency hypersensitivity
reaction)
Gangrenous Distal extremity and Dry: ischemia F Coagulative
GI tract, after chronic Wet: superinfection Liquefactive superimposed on coagulative
ischemia
A B C

D E F

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210 SEC TION II Pathology    
PATHOLOGY—Cellular Injury

Ischemia Inadequate blood supply to meet demand. Mechanisms include  arterial perfusion (eg,
A atherosclerosis),  venous drainage (eg, testicular torsion, Budd-Chiari syndrome), and shock.
Regions most vulnerable to hypoxia/ischemia and subsequent infarction:
ORGAN REGION
Brain ACA/MCA/PCA boundary areasa,b
Heart Subendocardium (LV) A
Kidney Straight segment of proximal tubule (medulla)
Thick ascending limb (medulla)
Liver Area around central vein (zone III)
Colon Splenic flexure,a rectuma
aWatershed areas (border zones) receive blood supply from most distal branches of 2 arteries with
limited collateral vascularity. These areas are susceptible to ischemia from hypoperfusion.
bNeurons most vulnerable to hypoxic-ischemic insults include Purkinje cells of the cerebellum and

pyramidal cells of the hippocampus and neocortex (zones 3, 5, 6).

Types of infarcts
Red infarct Red (hemorrhagic) infarcts A occur in venous occlusion and tissues with multiple blood supplies,
A
such as liver, lung, intestine, testes; reperfusion (eg, after angioplasty). Reperfusion injury is due to
damage by free radicals.
Red = reperfusion.

Pale infarct Pale (anemic) infarcts B occur in solid organs with a single (end-arterial) blood supply, such as
B
heart, kidney, and spleen.

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Inflammation Response to eliminate initial cause of cell injury, to remove necrotic cells resulting from the
original insult, and to initiate tissue repair. Divided into acute and chronic. The inflammatory
response itself can be harmful to the host if the reaction is excessive (eg, septic shock), prolonged
(eg, persistent infections such as TB), or inappropriate (eg, autoimmune diseases such as SLE).
Cardinal signs
SIGN MECHANISM MEDIATORS
Rubor (redness), calor Vasodilation (relaxation of arteriolar smooth Histamine, prostaglandins, bradykinin
(warmth) muscle) Ž  blood flow
Tumor (swelling) Endothelial contraction/disruption (eg, from Endothelial contraction: leukotrienes (C4, D4,
tissue damage) Ž  vascular permeability E4), histamine, serotonin
Ž leakage of protein-rich fluid from
postcapillary venules into interstitial space
(exudate) Ž  oncotic pressure
Dolor (pain) Sensitization of sensory nerve endings Bradykinin, PGE2
Functio laesa (loss of Cardinal signs above impair function (eg,
function) inability to make fist with hand that has
cellulitis)
Systemic manifestations (acute-phase reaction)
Fever Pyrogens (eg, LPS) induce macrophages to
release IL-1 and TNF Ž  COX activity in
perivascular cells of hypothalamus Ž  PGE2
Ž  temperature set point.
Leukocytosis Elevation of WBC count. Type of cell that Leukemoid reaction—severe elevation in WBC
is predominantly elevated depends on (> 40,000 cells/mm³) caused by some stressors
the inciting agent or injury (eg, bacteria or infections (eg, Clostridium difficile).
Ž  neutrophils).
 plasma acute-phase Factors whose serum concentrations change Notably induced by IL-6.
proteins significantly in response to inflammation.
Produced by the liver in both acute and
chronic inflammatory states.

Acute phase reactants More FFiSH in the C (sea).


POSITIVE (UPREGULATED)
Ferritin Binds and sequesters iron to inhibit microbial iron scavenging.
Fibrinogen Coagulation factor; promotes endothelial repair; correlates with ESR.
Serum amyloid A Prolonged elevation can lead to amyloidosis.
Hepcidin  iron absorption (by degrading ferroportin) and  iron release (from macrophages) Ž anemia of
chronic disease.
C-reactive protein Opsonin; fixes complement and facilitates phagocytosis.
Measured clinically as a nonspecific sign of ongoing inflammation.
NEGATIVE (DOWNREGULATED)
Albumin Reduction conserves amino acids for positive reactants.
Transferrin Internalized by macrophages to sequester iron.

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212 SEC TION II Pathology    
PATHOLOGY—Cellular Injury

Erythrocyte Products of inflammation (eg, fibrinogen) coat RBCs and cause aggregation. The denser RBC
sedimentation rate aggregates fall at a faster rate within a pipette tube Ž  ESR. Often co-tested with CRP levels.

 ESR  ESR
Most anemias Sickle cell anemia (altered shape)
Infections Polycythemia ( RBCs “dilute” aggregation
Inflammation (eg, giant cell [temporal] arteritis, factors)
polymyalgia rheumatica) HF
Cancer (eg, metastases, multiple myeloma) Microcytosis
Renal disease (end-stage or nephrotic syndrome) Hypofibrinogenemia
Pregnancy

Acute inflammation Transient and early response to injury or infection. Characterized by neutrophils in tissue A ,
A
often with associated edema. Rapid onset (seconds to minutes) and short duration (minutes to
days). Represents a reaction of the innate immune system (ie, less specific response than chronic
inflammation).

STIMULI Infections, trauma, necrosis, foreign bodies.


MEDIATORS Toll-like receptors, arachidonic acid metabolites, Inflammasome—Cytoplasmic protein complex
neutrophils, eosinophils, antibodies (pre- that recognizes products of dead cells,
existing), mast cells, basophils, complement, microbial products, and crystals (eg, uric acid
Hageman factor (factor XII). crystals) Ž activation of IL-1 and inflammatory
response.
COMPONENTS ƒƒ Vascular: vasodilation (Ž  blood flow and To bring cells and proteins to site of injury or
stasis) and  endothelial permeability infection.
ƒƒ Cellular: extravasation of leukocytes (mainly Leukocyte extravasation has 4 steps: margination
neutrophils) from postcapillary venules and and rolling, adhesion, transmigration, and
accumulation in the focus of injury followed migration (chemoattraction).
by leukocyte activation
OUTCOMES ƒƒ Resolution and healing (IL-10, TGF-β) Macrophages predominate in the late stages
ƒƒ Persistent acute inflammation (IL-8) of acute inflammation (peak 2–3 days after
ƒƒ Abscess (acute inflammation walled off by onset) and influence the outcome of acute
fibrosis) inflammation by secreting cytokines.
ƒƒ Chronic inflammation (antigen presentation
by macrophages and other APCs
Ž activation of CD4+ Th cells)
ƒƒ Scarring

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Leukocyte Extravasation predominantly occurs at postcapillary venules.


extravasation WBCs exit from blood vessels at sites of tissue injury and inflammation in 4 steps:
STEP VASCULATURE/STROMA LEUKOCYTE
 argination and rolling—
M E-selectin (upregulated by TNF and Sialyl-LewisX
defective in leukocyte adhesion IL-1)
deficiency type 2 ( Sialyl- P-selectin (released from Weibel- Sialyl-LewisX
LewisX) Palade bodies)
GlyCAM-1, CD34 L-selectin
 ight binding (adhesion)—
T ICAM-1 (CD54) CD11/18 integrins
defective in leukocyte adhesion (LFA-1, Mac-1)
deficiency type 1 ( CD18 VCAM-1 (CD106) VLA-4 integrin
integrin subunit)
Diapedesis (transmigration)— PECAM-1 (CD31) PECAM-1 (CD31)
WBC travels between
endothelial cells and exits blood
vessel
 igration—WBC travels
M Chemotactic products released in Various
through interstitium to site of response to bacteria: C5a, IL‑8,
injury or infection guided by LTB4, kallikrein, platelet-activating
chemotactic signals factor

PMN

1. Margination & rolling 2. Tight binding 3. Diapedesis 4. Migration

Sialyl-Lewisx

Vessel PMN
lumen PMN
E-selectin
E-s PMN LFA-1 PMN

ICAM-1

Endothelium

Interstitium
Inters
rstit
titium
ium PMN

PMN

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PATHOLOGY—Cellular Injury

Chronic inflammation Inflammation of prolonged duration characterized by infiltration of tissue by mononuclear


cells (macrophages, lymphocytes, and plasma cells). Tissue destruction and repair (including
angiogenesis and fibrosis) occur simultaneously. May or may not be preceded by acute
inflammation.
STIMULI Persistent infections (eg, TB, T pallidum, certain fungi and viruses) Ž type IV hypersensitivity,
autoimmune diseases, prolonged exposure to toxic agents (eg, silica) and foreign material.
MEDIATORS Macrophages are the dominant cells. Chronic inflammation is the result of their interaction with
T lymphocytes.
ƒƒ Th1 cells secrete INF-㠎 macrophage classical activation (proinflammatory)
ƒƒ Th2 cells secrete IL-4 and IL-13 Ž macrophage alternative activation (repair and anti-
inflammatory)
OUTCOMES Scarring, amyloidosis and neoplastic transformation (eg, chronic HCV infection Ž chronic
inflammation Ž hepatocellular carcinoma; Helicobacter pylori infection Ž chronic gastritis
Ž gastric adenocarcinoma).

Granulomatous Bacterial: Granulomas (a pattern of chronic


diseases ƒƒ Mycobacteria (tuberculosis, leprosy) inflammation) are composed of epithelioid
A
ƒƒ Bartonella henselae (cat scratch disease) cells (macrophages with abundant pink
ƒƒ Listeria monocytogenes (granulomatosis cytoplasm) with surrounding multinucleated
infantiseptica) giant cells and lymphocytes. Th1 cells secrete
ƒƒ Treponema pallidum (3° syphilis) IFN-γ, activating macrophages. TNF-α
Fungal: endemic mycoses (eg, histoplasmosis) from macrophages induces and maintains
Parasitic: schistosomiasis granuloma formation. Anti-TNF drugs can
Chronic granulomatous disease cause sequestering granulomas to break down
Autoinflammatory: Ž disseminated disease. Always test for latent
ƒƒ Sarcoidosis TB before starting anti-TNF therapy.
ƒƒ Crohn disease Associated with hypercalcemia due to calcitriol
ƒƒ Primary biliary cholangitis (1,25-[OH]2 vitamin D3) production.
ƒƒ Subacute (de Quervain/granulomatous) Caseating necrosis is more common with
thyroiditis an infectious etiology (eg, TB). Diagnosis
ƒƒ Granulomatosis with polyangiitis (Wegener) of sarcoidosis requires noncaseating
ƒƒ Eosinophilic granulomatosis with granulomas A on biopsy.
polyangiitis (Churg-Strauss)
ƒƒ Giant cell (temporal) arteritis
ƒƒ Takayasu arteritis
Foreign material: berylliosis, talcosis,
hypersensitivity pneumonitis

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Types of calcification
Dystrophic calcification Metastatic calcification
CA2+ DEPOSITION In abnormal tissues In normal tissues
EXTENT Tends to be localized (eg, calcific aortic stenosis) Widespread (ie, diffuse, metastatic)
A  shows dystrophic calcification (yellow star), B  shows metastatic calcifications of alveolar
and thick fibrotic wall (red arrows) walls in acute pneumonitis (arrows)
ASSOCIATED CONDITIONS TB (lung and pericardium) and other Predominantly in interstitial tissues of kidney,
granulomatous infections, liquefactive necrosis lung, and gastric mucosa (these tissues lose
of chronic abscesses, fat necrosis, infarcts, acid quickly;  pH favors Ca2+ deposition)
thrombi, schistosomiasis, congenital CMV, Nephrocalcinosis of collecting ducts may lead
toxoplasmosis, rubella, psammoma bodies, to nephrogenic diabetes insipidus and renal
CREST syndrome, atherosclerotic plaques can failure
become calcified
ETIOLOGY 2° to injury or necrosis 2° to hypercalcemia (eg, 1° hyperparathyroidism,
sarcoidosis, hypervitaminosis D) or high
calcium-phosphate product levels (eg, chronic
renal failure with 2° hyperparathyroidism,
long-term dialysis, calciphylaxis, multiple
myeloma)
SERUM CA2+ LEVELS Patients are usually normocalcemic Patients usually have abnormal serum Ca2+
levels
A B

Lipofuscin A yellow-brown “wear and tear” pigment A associated with normal aging.
A Formed by oxidation and polymerization of autophagocytosed organellar membranes.
Autopsy of elderly person will reveal deposits in heart, colon, liver, kidney, eye, and other organs.

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216 SEC TION II Pathology    
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Free radical injury Free radicals damage cells via membrane lipid peroxidation, protein modification, and DNA
breakage.
Initiated via radiation exposure (eg, cancer therapy), metabolism of drugs (phase I), redox reactions,
nitric oxide (eg, inflammation), transition metals, WBC (eg, neutrophils, macrophages) oxidative
burst.
Free radicals can be eliminated by scavenging enzymes (eg, catalase, superoxide dismutase,
glutathione peroxidase), spontaneous decay, antioxidants (eg, vitamins A, C, E), and certain metal
carrier proteins (eg, transferrin, ceruloplasmin).
Examples:
ƒƒ Oxygen toxicity: retinopathy of prematurity (abnormal vascularization), bronchopulmonary
dysplasia, reperfusion injury after thrombolytic therapy
ƒƒ Drug/chemical toxicity: acetaminophen overdose (hepatotoxicity), carbon tetrachloride
(converted by cytochrome P-450 into CCl3 free radical Ž fatty liver [cell injury
Ž  apolipoprotein synthesis Ž fatty change], centrilobular necrosis)
ƒƒ Metal storage diseases: hemochromatosis (iron) and Wilson disease (copper)

Scar formation Occurs when repair cannot be accomplished by cell regeneration alone. Nonregenerated cells (2°
to severe acute or chronic injury) are replaced by connective tissue. 70–80% of tensile strength
regained at 3 months; little tensile strength regained thereafter.
SCAR TYPE Hypertrophic A Keloid B
COLLAGEN SYNTHESIS  (type III collagen)  (disorganized types I and III collagen)
COLLAGEN ORGANIZATION Parallel Disorganized
EXTENT OF SCAR Confined to borders of original wound Extends beyond borders of original wound with
“claw-like” projections typically on earlobes,
face, upper extremities
RECURRENCE Infrequent Frequent
PREDISPOSITION None  incidence in ethnic groups with darker skin
A B

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Wound healing
Tissue mediators MEDIATOR ROLE
FGF Stimulates angiogenesis
TGF-β Angiogenesis, fibrosis
VEGF Stimulates angiogenesis
PDGF Secreted by activated platelets and macrophages
Induces vascular remodeling and smooth
muscle cell migration
Stimulates fibroblast growth for collagen
synthesis
Metalloproteinases Tissue remodeling
EGF Stimulates cell growth via tyrosine kinases (eg,
EGFR/ErbB1)
PHASE OF WOUND HEALING EFFECTOR CELLS CHARACTERISTICS
Inflammatory (up to Platelets, neutrophils, macrophages Clot formation,  vessel permeability and
3 days after wound) neutrophil migration into tissue; macrophages
clear debris 2 days later
Proliferative Fibroblasts, myofibroblasts, endothelial cells, Deposition of granulation tissue and type
(day 3–weeks after keratinocytes, macrophages III collagen, angiogenesis, epithelial cell
wound) proliferation, dissolution of clot, and wound
contraction (mediated by myofibroblasts)
Delayed wound healing in vitamin C deficiency
and copper deficiency
Remodeling Fibroblasts Type III collagen replaced by type I collagen,
(1 week–6+ months  tensile strength of tissue
after wound) Collagenases (require zinc to function) break
down type III collagen
Zinc deficiency Ž delayed wound healing

Exudate vs transudate
Exudate Transudate
Cellular (cloudy) Hypocellular (clear)
 protein (> 2.9 g/dL)  protein (< 2.5 g/dL)
Due to: Due to:
ƒƒ Lymphatic obstruction (chylous) ƒƒ  hydrostatic pressure (eg, HF, Na+ retention)
ƒƒ Inflammation/infection ƒƒ  oncotic pressure (eg, cirrhosis, nephrotic
ƒƒ Malignancy syndrome)
Light criteria Fluid is exudative if ≥ 1 of the following criteria is met:
ƒƒ Pleural effusion protein/serum protein ratio > 0.5
ƒƒ Pleural effusion LDH/serum LDH ratio > 0.6
ƒƒ Pleural effusion LDH > 2⁄3 of the upper limit of normal for serum LDH

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Amyloidosis Abnormal aggregation of proteins (or their fragments) into β-pleated linear sheets Ž insoluble
fibrils Ž cellular damage and apoptosis. Amyloid deposits visualized by Congo red stain A ,
polarized light (apple green birefringence) B , and H&E stain ( C shows deposits in glomerular
mesangial areas [white arrows], tubular basement membranes [black arrows]).
COMMON TYPES FIBRIL PROTEIN DESCRIPTION
Systemic
Primary amyloidosis AL (from Ig Light chains) Seen in plasma cell disorders Manifestations include:
and multiple myeloma ƒƒ Cardiac (eg, restrictive
Secondary Serum Amyloid A Seen in chronic inflammatory cardiomyopathy,
amyloidosis (AA) conditions, eg, rheumatoid arrhythmia)
arthritis, IBD, familial ƒƒ GI (eg, macroglossia,
Mediterranean fever, protracted hepatomegaly)
infection ƒƒ Renal (eg, nephrotic
syndrome)
Dialysis-related β2-microglobulin Seen in patients with ESRD
ƒƒ Hematologic (eg, easy
amyloidosis and/or on long-term dialysis
bruising, splenomegaly)
ƒƒ Neurologic (neuropathy)
ƒƒ Musculoskeletal (carpal
tunnel syndrome)
Localized
Alzheimer disease β-amyloid protein Cleaved from amyloid precursor
protein (APP)
Type 2 diabetes Islet amyloid polypeptide Caused by deposition of amylin
mellitus (IAPP) in pancreatic islets
Medullary thyroid Calcitonin (A Cal)
cancer
Isolated atrial ANP Common in normal aging
amyloidosis  risk of atrial fibrillation
Systemic senile (age- Normal (wild-type) Seen predominantly in cardiac Cardiac dysfunction more
related) amyloidosis transthyretin (TTR) ventricles insidious than in AL
amyloidosis
Hereditary
Familial amyloid Mutated transthyretin Ventricular endomyocardium 5% of African Americans are
cardiomyopathy (ATTR) deposition Ž restrictive carriers of mutant allele
cardiomyopathy, arrhythmias
Familial amyloid Mutated transthyretin Due to transthyretin gene
polyneuropathies (ATTR) mutation
A B C

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PATHOLOGY—NEOPLASIA
``

Neoplasia and Uncontrolled, clonal proliferation of cells. Can be benign or malignant. Hallmarks of cancer:
neoplastic progression evasion of apoptosis, growth signal self-sufficiency, anti-growth signal insensitivity, Warburg effect
(shift of glucose metabolism away from mitochondria toward glycolysis), sustained angiogenesis,
limitless replicative potential, tissue invasion, and metastasis.
Epithelial
cell layer Basement
membrane

Blood or lymphatic Ž Ž Ž Ž
vessel

               

Normal cells  ormal cells with basal Ž apical polarity. See cervical example A , which shows normal cells
N
and spectrum of dysplasia, as discussed below.
Dysplasia  oss of uniformity of cell size and shape (pleomorphism); loss of tissue orientation; nuclear
L
changes (eg,  nuclear:cytoplasmic ratio) A .
Carcinoma in situ/ I rreversible severe dysplasia that involves the entire thickness of epithelium but does not
preinvasive penetrate the intact basement membrane.
Invasive carcinoma  ells have invaded basement membrane using collagenases and hydrolases (metalloproteinases).
C
Cell-cell contacts lost by inactivation of E-cadherin.
Metastasis  pread to distant organ(s) via lymphatics or blood.
S
“Seed and soil” theory of metastasis:
ƒƒ Seed = tumor embolus.
ƒƒ Soil = target organ is often the first-encountered capillary bed (eg, liver, lungs, bone, brain, etc).
A

Normal Mild dysplasia Moderate dysplasia Severe dysplasia/


carcinoma in situ

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220 SEC TION II Pathology    
PATHOLOGY—Neoplasia

Tumor nomenclature Carcinoma implies epithelial origin, whereas sarcoma denotes mesenchymal origin. Both terms
generally imply malignancy.
Benign tumors are usually well differentiated, well demarcated, low mitotic activity, no metastasis,
no necrosis.
Malignant tumors may show poor differentiation, erratic growth, local invasion, metastasis, and
 apoptosis. Upregulation of telomerase prevents chromosome shortening and cell death.
Terms for non-neoplastic malformations include hamartoma (disorganized overgrowth of tissues in
their native location, eg, Peutz-Jeghers polyps) and choristoma (normal tissue in a foreign location,
eg, gastric tissue located in distal ileum in Meckel diverticulum).
CELL TYPE BENIGN MALIGNANT
Epithelium Adenoma, papilloma Adenocarcinoma, papillary carcinoma
Mesenchyme
Blood cells Leukemia, lymphoma
Blood vessels Hemangioma Angiosarcoma
Smooth muscle Leiomyoma Leiomyosarcoma
Striated muscle Rhabdomyoma Rhabdomyosarcoma
Connective tissue Fibroma Fibrosarcoma
Bone Osteoma Osteosarcoma
Fat Lipoma Liposarcoma
Melanocyte Nevus/mole Melanoma

Tumor grade vs stage Differentiation—degree to which a tumor resembles its tissue of origin. Well-differentiated tumors
(often less aggressive) closely resemble their tissue of origin, whereas poorly differentiated tumors
(often more aggressive) look almost nothing like their tissue of origin.
Anaplasia—complete lack of differentiation of cells in a malignant neoplasm.
Grade Degree of cellular differentiation and mitotic Stage generally has more prognostic value than
activity on histology. Range from low grade grade (eg, a high-stage yet low-grade tumor is
(well differentiated) to high grade (poorly usually worse than a low-stage yet high-grade
differentiated, undifferentiated or anaplastic). tumor). Stage determines Survival.
Stage Degree of localization/spread based on site and TNM staging system (Stage = Spread):
size of 1° lesion, spread to regional lymph T = Tumor size/invasiveness
nodes, presence of metastases. Based on N = Node involvement
clinical (c) or pathology (p) findings. Example: M = Metastases
cT3N1M0 Each TNM factor has independent prognostic
value; N and M are often most important.

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Paraneoplastic syndromes
MANIFESTATION DESCRIPTION/MECHANISM MOST COMMONLY ASSOCIATED TUMOR(S)
Musculoskeletal and cutaneous
Dermatomyositis Progressive proximal muscle weakness, Gottron Adenocarcinomas, especially ovarian
papules, heliotrope rash
Acanthosis nigricans Hyperpigmented velvety plaques in axilla and Gastric adenocarcinoma and other visceral
neck malignancies (but more commonly associated
with obesity and insulin resistance)
Sign of Leser-Trélat Sudden onset of multiple seborrheic keratoses GI adenocarcinomas and other visceral
malignancies
Hypertrophic Abnormal proliferation of skin and bone at Adenocarcinoma of the lung
osteoarthropathy distal extremities Ž clubbing, arthralgia, joint
effusions, periostosis of tubular bones
Endocrine
Hypercalcemia PTHrP Squamous cell carcinomas of lung, head, and
neck; renal, bladder, breast, and ovarian
carcinomas
 1,25-(OH)2 vitamin D3 (calcitriol) Lymphoma
Cushing syndrome  ACTH
Small cell lung cancer
Hyponatremia (SIADH)  ADH
Hematologic
Polycythemia  Erythropoietin Pheochromocytoma, renal cell carcinoma,
Paraneoplastic rise to high hematocrit levels HCC, hemangioblastoma, leiomyoma
Pure red cell aplasia Anemia with low reticulocytes
Thymoma
Good syndrome Hypogammaglobulinemia
Trousseau syndrome Migratory superficial thrombophlebitis
Nonbacterial Deposition of sterile platelet thrombi on heart Adenocarcinomas, especially pancreatic
thrombotic (marantic) valves
endocarditis
Neuromuscular
Anti-NMDA receptor Psychiatric disturbance, memory deficits, Ovarian teratoma
encephalitis seizures, dyskinesias, autonomic instability,
language dysfunction
Opsoclonus- “Dancing eyes, dancing feet” Neuroblastoma (children), small cell lung
myoclonus ataxia cancer (adults)
syndrome
Paraneoplastic Antibodies against antigens in Purkinje cells Small cell lung cancer (anti-Hu), gynecologic
cerebellar and breast cancers (anti-Yo), and Hodgkin
degeneration lymphoma (anti-Tr)
Paraneoplastic Antibodies against Hu antigens in neurons Small cell lung cancer
encephalomyelitis
Lambert-Eaton Antibodies against presynaptic (P/Q-type) Ca2+ Small cell lung cancer
myasthenic syndrome channels at NMJ
Myasthenia gravis Antibodies against postsynaptic ACh receptors Thymoma
at NMJ

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222 SEC TION II Pathology    
PATHOLOGY—Neoplasia

Oncogenes Gain of function mutation converts proto-oncogene (normal gene) to oncogene Ž  cancer risk.
Need damage to only one allele of a proto-oncogene.
GENE GENE PRODUCT ASSOCIATED NEOPLASM
ALK Receptor tyrosine Kinase Lung Adenocarcinoma (Adenocarcinoma of the
Lung Kinase)
BCR-ABL Tyrosine kinase CML, ALL
BCL-2 Antiapoptotic molecule (inhibits apoptosis) Follicular and diffuse large B cell lymphomas
BRAF Serine/threonine kinase Melanoma, non-Hodgkin lymphoma, papillary
thyroid carcinoma
c-KIT Cytokine receptor Gastrointestinal stromal tumor (GIST)
c-MYC Transcription factor Burkitt lymphoma
HER2/neu (c-erbB2) Receptor tyrosine kinase Breast and gastric carcinomas
JAK2 Tyrosine kinase Chronic myeloproliferative disorders
KRAS GTPase Colon cancer, lung cancer, pancreatic cancer
MYCL1 Transcription factor Lung tumor
N-myc (MYCN) Transcription factor Neuroblastoma
RET Receptor tyrosine kinase MEN 2A and 2B, papillary thyroid carcinoma

Tumor suppressor Loss of function Ž  cancer risk; both (two) alleles of a tumor suppressor gene must be lost for
genes expression of disease.
GENE GENE PRODUCT ASSOCIATED CONDITION
APC Negative regulator of β-catenin/WNT pathway Colorectal cancer (associated with FAP)
BRCA1/BRCA2 DNA repair protein Breast, ovarian, and pancreatic cancer
CDKN2A p16, blocks G1 Ž S phase Melanoma, pancreatic cancer
DCC DCC—Deleted in Colon Cancer Colon cancer
SMAD4 (DPC4) DPC—Deleted in Pancreatic Cancer Pancreatic cancer
MEN1 Menin Multiple Endocrine Neoplasia 1
NF1 Neurofibromin (Ras GTPase activating protein) Neurofibromatosis type 1
NF2 Merlin (schwannomin) protein Neurofibromatosis type 2
PTEN Negatively regulates PI3k/AKT pathway Breast, prostate, and endometrial cancer
Rb Inhibits E2F; blocks G1 Ž S phase Retinoblastoma, osteosarcoma
TP53 p53, activates p21, blocks G1 Ž S phase Most human cancers, Li-Fraumeni syndrome
(multiple malignancies at early age, aka, SBLA
cancer syndrome: Sarcoma, Breast, Leukemia,
Adrenal gland)
TSC1 Hamartin protein Tuberous sclerosis
TSC2 Tuberin protein Tuberous sclerosis
VHL Inhibits hypoxia inducible factor 1a von Hippel-Lindau disease
WT1 Transcription factor that regulates urogenital Wilms tumor (nephroblastoma)
development

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Oncogenic microbes
Microbe Associated cancer
EBV Burkitt lymphoma, Hodgkin lymphoma,
nasopharyngeal carcinoma, 1° CNS
lymphoma (in immunocompromised patients)
HBV, HCV Hepatocellular carcinoma
HHV-8 Kaposi sarcoma
HPV Cervical and penile/anal carcinoma (types 16,
18), head and neck cancer
H pylori Gastric adenocarcinoma and MALT lymphoma
HTLV-1 Adult T-cell leukemia/lymphoma
Liver fluke (Clonorchis sinensis) Cholangiocarcinoma
Schistosoma haematobium Bladder cancer (squamous cell)

Carcinogens
TOXIN EXPOSURE ORGAN IMPACT
Aflatoxins (Aspergillus) Stored grains and nuts Liver Hepatocellular carcinoma
Alkylating agents Oncologic chemotherapy Blood Leukemia/lymphoma
Aromatic amines Textile industry (dyes), Bladder Transitional cell carcinoma
(eg, benzidine, cigarette smoke
2-naphthylamine) (2-naphthylamine)
Arsenic Herbicides (vineyard workers), Liver Angiosarcoma
metal smelting Lung Lung cancer
Skin Squamous cell carcinoma
Asbestos Old roofing material, shipyard Lung Bronchogenic carcinoma >
workers mesothelioma
Cigarette smoke Bladder Transitional cell carcinoma
Cervix Squamous cell carcinoma
Esophagus Squamous cell carcinoma/
adenocarcinoma
Kidney Renal cell carcinoma
Larynx Squamous cell carcinoma
Lung Squamous cell and small cell
carcinoma
Pancreas Pancreatic adenocarcinoma
Ethanol Esophagus Squamous cell carcinoma
Liver Hepatocellular carcinoma
Ionizing radiation Thyroid Papillary thyroid carcinoma
Nitrosamines Smoked foods Stomach Gastric cancer
Radon By-product of uranium decay, Lung Lung cancer (2nd leading
accumulates in basements cause after cigarette smoke)
Vinyl chloride Used to make PVC pipes Liver Angiosarcoma
(plumbers)

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224 SEC TION II Pathology    
PATHOLOGY—Neoplasia

Psammoma bodies Laminated, concentric spherules with dystrophic calcification A , PSaMMoma bodies are seen in:
A
ƒƒ Papillary carcinoma of thyroid
ƒƒ Serous papillary cystadenocarcinoma of ovary
ƒƒ Meningioma
ƒƒ Malignant Mesothelioma

Serum tumor markers Tumor markers should not be used as the 1° tool for cancer diagnosis or screening. They may be
used to monitor tumor recurrence and response to therapy, but definitive diagnosis is made via
biopsy. Some can be associated with non-neoplastic conditions.
MARKER IMPORTANT ASSOCIATIONS NOTES
Alkaline phosphatase Metastases to bone or liver, Paget disease of Exclude hepatic origin by checking LFTs and
bone, seminoma (placental ALP). GGT levels.
α-fetoprotein Hepatocellular carcinoma, Endodermal sinus Normally made by fetus. Transiently elevated in
(yolk sac) tumor, Mixed germ cell tumor, pregnancy. High levels associated with neural
Ataxia-telangiectasia, Neural tube defects. tube and abdominal wall defects, low levels
(HE-MAN is the alpha male!) associated with Down syndrome.
β-hCG Hydatidiform moles and Choriocarcinomas Produced by syncytiotrophoblasts of the
(Gestational trophoblastic disease), testicular placenta.
cancer, mixed germ cell tumor.
CA 15-3/CA 27-29 Breast cancer.
CA 19-9 Pancreatic adenocarcinoma.
CA 125 Ovarian cancer.
Calcitonin Medullary thyroid carcinoma (alone and in
MEN2A, MEN2B).
CEA Major associations: colorectal and pancreatic Carcinoembryonic antigen. Very nonspecific.
cancers.
Minor associations: gastric, breast, and
medullary thyroid carcinomas.
Chromogranin Neuroendocrine tumors.
LDH Testicular germ cell tumors, ovarian Can be used as an indicator of tumor burden.
dysgerminoma, other cancers.
PSA Prostate cancer. Prostate-specific antigen.
Can also be elevated in BPH and prostatitis.
Questionable risk/benefit for screening.
Surveillance marker for recurrent disease after
prostatectomy.

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Important Determine primary site of origin for metastatic tumors and characterize tumors that are difficult to
immunohistochemical classify. Can have prognostic and predictive value.
stains
STAIN TARGET EXAMPLES IDENTIFIED
Vimentin Mesenchymal tissue (eg, fibroblasts, endothelial Mesenchymal tumors (eg, sarcoma), but
cells, macrophages) also many other tumors (eg, endometrial
carcinoma, renal cell carcinoma,
meningioma)
S-100 Neural crest cells Melanoma, schwannoma, Langerhans cell
histiocytosis
DesMin Muscle Muscle tumors (eg, rhabdomyosarcoma)
Cytokeratin Epithelial cells Epithelial tumors (eg, squamous cell carcinoma)
GFAP NeuroGlia (eg, astrocytes, Schwann cells, Astrocytoma, Glioblastoma
oligodendrocytes)
Neurofilament Neurons Neuronal tumors (eg, neuroblastoma)
PSA Prostatic epithelium Prostate cancer
TRAP Tartrate-resistant acid phosphatase Hairy cell leukemia
Chromogranin and Neuroendocrine cells Small cell carcinoma of the lung, carcinoid
synaptophysin tumor

P-glycoprotein Also known as multidrug resistance protein 1 (MDR1). Classically seen in adrenocortical
carcinoma but also expressed by other cancer cells (eg, colon, liver). Used to pump out toxins,
including chemotherapeutic agents (one mechanism of  responsiveness or resistance to
chemotherapy over time).

Cachexia Weight loss, muscle atrophy, and fatigue that occur in chronic disease (eg, cancer, AIDS, heart
failure, COPD). Mediated by TNF, IFN-γ, IL-1, and IL-6.

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226 SEC TION II Pathology    
PATHOLOGY—Neoplasia

Cancer epidemiology Skin cancer (basal > squamous >> melanoma) is the most common cancer (not included below).
MEN WOMEN CHILDREN (AGE 0–14) NOTES
Cancer incidence 1. Prostate 1. Breast 1. Leukemia Lung cancer incidence has  in
2. Lung 2. Lung 2. CNS men, but has not changed
3. Colon/rectum 3. Colon/rectum 3. Neuroblastoma significantly in women.
Cancer mortality 1. Lung 1. Lung 1. Leukemia Cancer is the 2nd leading cause
2. Prostate 2. Breast 2. CNS of death in the United States
3. Colon/rectum 3. Colon/rectum 3. Neuroblastoma (heart disease is 1st).

Common metastases Most sarcomas spread hematogenously; most carcinomas spread via lymphatics. However, Four
Carcinomas Route Hematogenously: Follicular thyroid carcinoma, Choriocarcinoma, Renal cell
carcinoma, and Hepatocellular carcinoma.
SITE OF METASTASIS 1º TUMOR NOTES
Brain Lung > breast > melanoma, colon, kidney. 50% of brain tumors are from metastases A B .
Commonly seen as multiple well-circumscribed
tumors at gray/white matter junction.
Liver Colon >> stomach > pancreas. Liver C D and lung are the most common sites
of metastasis after the regional lymph nodes.
Bone Prostate, Breast > Kidney, Thyroid, Lung. Bone metastasis E F >> 1° bone tumors (eg,
Lead (PB) KeTtLe. multiple myeloma, lytic). Common mets to
bone: breast (mixed), lung (lytic), thyroid
(lytic), kidney (lytic), prostate (blastic).
Predilection for axial skeleton G .
A B C G

D E F

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