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ONCOLOGY AND IMMUNOPATHOLOGY :cancer: - Coggle Diagram
ONCOLOGY AND IMMUNOPATHOLOGY :cancer:
PHARMACOLOGY
INTRODUCTION TO CHEMOTHERAPEUTICS
INTRODUCTION TO BIOTHERAPEUTICS
ANTICANCER TARGETS AND DRUGS
THE BASICS OF TUMOUR IMMUNOLOGY/IMMUNOTHERAPIES
CARE OF THE PATIENT WITH CANCER
IMMUNOSUPPRESSIVE AGENTS
ANTI-INFLAMMATORY AGENTS
IMMUNOPATHOLOGY
CONNECTIVE TISSUE DISEASES
RHEUMATOID ARTHRITIS VS OTHER ARTHRITIDES
IMMUNE-RELATED ARTHRITIDES
RHEUMATOID ARTHRITIS
aetiology
genetic predisposition
HLA-DR4
PTPN22
PADI4
environmental factors
smoking
infections
dietary factors
gut microbiome
diagnosis
ACR/EULAR criteria
signs and symptoms
general features:
malaise
weakness
fatigue
musculoskeletal pain
low grade fever
weightloss
inflammation of joints, tendons and bursae
swelling
warmth
pain
tenderness
early morning stiffness (>30 minutes) that is relieved with physical activity
reduced joint function
joint abnormalities occur in severe RA
treatment (combination therapy)
NSAIDs
DMARDs e.g. methotrexate
Glucocorticoids e.g. prednisolone
pathogenesis
cytokine mediated inflammation
autoantibody-mediated inflammation - anti citrullinated protein antibodies or rheumatoid factor
SERONEGATIVE SPONDYLOARTHROPATHIES
absence of rheumatoid factor
HLA-B27 association
commonly associated with the sacroiliac joints
pathological changes in the enthesis rather than the synovium
examples:
ankylosing spondylitis
reactive arthritis
psoriatic arthritis
enteropathic arthritis
NON-IMMUNE RELATED ARTHRITIDES
DEGENERATIVE DISORDERS
OSTEOARTHRITIS
a degenerative joint disease characterised by the progressive erosion of cartilage
signs and symptoms:
pain that worsens with use and eases with rest
short-lived morning stiffness
crepitus
decreased range of movement
wastage of surrounding muscle groups
joint effusion
tenderness
compression of spinal roots of the C-spine
joint involvement:
oligoarticular (usually more than one)
asymmetrical
weight breaing joints
small joints of the hands
small joints of the feet
METABOLIC DERRANGEMENTS
GOUT
INFECTIONS
SEPTIC ARTHRITIS
SYSTEMIC LUPUS ERYTHEMATOSUS, SYSTEMIC SCLEROSIS, SJOGREN'S SYNDROME
SLE
Clinical Manifestations
Skin manifestations
photosensitivity
malar/butterfly rash
lupus profundus
Kidney manifestations
lupus nephritis
Haematological manifestations
anaemia
leukocytopaenia
Cardiopulmonary manifestations
Libman-Sacks endocarditis
Shrinking lung syndrome
Ocular manifestations
Sjogren's syndrome
Diagnostic criteria
American College of Rheumatology criteria = A RASH POINTs MD
Systemic Lupus Internation Collaborating clinic criteria
clinic criteria e.g. arthritis, serositis
immunological crtieria
DIF ANA patterns
homogenous
rim/peripheral
speckled
nucelolar
Lupus specific ANAs
anti-dsDNA
anti-Sm
SYSTEMIC SCLEROSIS
Systemic Sclerosis is a systemic autoimmune disorder that is characterised by chronic inflammation, widespread small vessel damage and progressive perivascular and interstitial fibrosis
T-cells, autoantibodies and pro-fibrotic cytokines activity stimulates fibroblasts
CLINICAL MANIFESTATIONS
skin manifestations - thickened skin, claw-like hands, microstomia,
raynaud's phenomenon
lung manifestations - pulmonary hypertension (main cause of death)
Limited cutaneous systemic sclerosis
anti-topoisomerase I antibody
widespread skin involvement
organ failure within 5 years
Diffuse cutaneous systemic sclerosis
anti-centromere antibody
CREST syndrome
Calcinosis
Raynaud's phenomenon
Esophageal dysmotility
Sclerodactyly
telangiectasia
SJOGREN'S SYNDROME
GENETIC ASSOCIATIATIONS
HLA-DR52
IRF-5 (interferon regulating factor)
STAT4
HLA-DR3, HLA-DQ2 and HLA-B8 seen in caucasians
CLINICAL MANIFESTATIONS
lacrimal glands - keroconjunctivitis sicca, dry eyes
salivary glands - chronic sialoadenitis, xerostomia (dry mouth)
also an increased risk for the development of non-hodgkin's lymphoma
Sjogren's syndrome is the immune mediated destruction of exocrine glands
Common feature: positive antinuclear antibodies
INFLAMMATORY MYOPATHIES AND SYSTEMIC VASCULITIDES
INFLAMMATORY MYOPATHIES
DERMATOMYOSITIS
CLINICAL MANIFESTATIONS
SKIN
heliotrope rash
gottron's papules
shawl sign - erythermatous rash on shoulders, back and trunk
pruritic rash
mechanic's hand - rough surface with lots of cracks
telangectiasia
MUSCLE
progressive and symmetric proximal muscle weakness
fine motor movements affected as the disease progresses
pharyngeal muscles and neck flexors are commonly involved, resulting in dysphagia and head drop
facial and ocular muscles are usually spared
normal sensation and tendon reflexes maintained
anti-M2 antibodies - anti-helicase is dermatomysositis specific
POLYMYOSITIS
bilateral proximal muscular weakness but no rash
poor prognosis if there is interstitial lung disease
CD8+ cytotoxic T cells causing direct injury
20% present with anti-Jo1 antibodies (common to all inflammatory myopathies)
SYSTEMIC VASCULITIDES
LARGE VESSEL VASCULITIS
GIANT CELL ARTERITIS
affects extra cranial branches of the carotid arteries mainly
can go blind
treatment is with steroids
features: multinucleated giant cells in the elastic lamina and the presence of mononuclear infiltrate, scarring with intimal thickening, residual elastic fragmentation and adventitial fibrosis
TAKAYASU'S ARTERITIS
commonly affects the aorta and it's branches
MEDIUM VESSEL VASCULITIS
KAWASAKI DISEASE
affects infants and childre - boys under 4
self-limiting
mucocutaneous lymph node syndrome
CRASH clinical symptoms
Conjunctivitis
Rash
Fever
Adenopathy
Strawberry tongue
Hands and feet - rash and swelling
treatment with IC immunoglobulins
POLYARTERIITIS NODOSA
affects renal and visceral vessels but not pulmonary vessels
affects young adult males
segmental transmural necrotising inflammation
ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA) ASSOCIATED SMALL VESSEL VASCULITIS
MICROSCOPIC POLYANGIITIS
CHURG-STRAUSS SYNDROME
WEGENER'S GRANULOMATOSIS
IMMUNE COMPLEX SMALL VESSEL VASCULITIS
IgA VASCULITIS
HENNOCH SCHNLEIN PURPURA
CLASSIFICATION OF AUTOIMMUNE DISEASES
ORGAN SPECIFIC e.g. inflammatory bowel disease (IBD)
SYSTEMIC e.g. rheumatoid arthritis
GENERAL CHARACTERISTICS OF AUTOIMMUNE DISEASE
middle aged females most commonly affected
genetic predisposition and environmental factors
multi-organ involvement and inflammatory signs
immunological abnormalities e.g. auto antibodies
well defined clinical picture and disease course
chronic and often fluctuates between periods of flares and remission
early diagnosis is crucial
have diagnostic criteria and severity based on disease activity and damage
CLINICAL COURSE OF AUTOIMMUNE DISEASES
TRANSPLANT REJECTION AND GRAFT VS HOST DISEASE
IMMUNODEFICIENCY
ALLERGY
AUTOIMMUNITY AND MALIGNANCY
NEOPLASIA
BASIC CONCEPTS
TUMOUR CLASSIFICATION AND TERMINOLOGY
TUMOUR CHARACTERISATION AND PROGRESSION
CLINICAL ASPECTS OF NEOPLASIA
Direct vs Indirect effects of the tumour on the host
Direct
local
bleeding
infections
rupture or necrosis of the tumour
location of the tumour → can cause impingement of adjacent structures or loss of function
sytemic
neoplastic fever
anaemia
functional activity e.g. effects on hormone production
hypercoaguability
paraneoplastic syndromes
cachexia
tumour spread
Indirect
cytotoxic chemotherapy
chemotherapy-induced apoptosis → non-selective targeting of rapidly growing cells e.g. in bone marrow, or the gastric lining
radiotherapy (effects depend on site and dose of radiation)
skin reactions
pneumonitis
cardiac toxicity
diarrhoea
infertility
secondary malignancies
targeted therapy (these often have less severe side effects than standard chemotherapy)
skin problems (anti-EGFR therapies)
bleeding (anti-VEGF therapies)
impaired wound healing
hepatitis
gastrointestinal perforation
TNM system for staging, T = primary tumour (extent of the primary lesion), N = extent of lymph node involvement, M = metastasis
Paraneoplastic syndromes - These are system complexes that cannot be explained by the local/metastatic spread of the tumour or the hormone production of the host tissue where the tumour arose. They can represent the earliest manifestation of an occult neoplasm and they may be clinically significant, lead to death, and can mimic metastatic disease e.g. acanthosis nigricans
MOLECULAR CARCINOGENESIS - SPORADIC AND INHERITED CANCER
Proto-oncogenes are genes that ar enormally expressed during regulated growth e.g. during embryogeneis or would healing. They are distributed throughout the human genome and have been evolutionarily conserved and hence are indispensable to normal cellular function
Molecular pathology tests used in cacner diagnosis
colorectal cancer
MMR protein IHC = MLH1, MSH2, MSH6, PMS2
KRAS and NRAS
BRAF
breast cancer
HER2
ER and PR IHC
oncotype Dx
melanoma
BRAF
non-small cell lung cancer
KRAS
EGFR
HER2
BRAF
lymphomas and leukemias
BCL2 t(14;18)
JAK2
For proto-oncogenes to become oncogenes that are capable of transformation, they must undergo:
gene amplifaction e.g. HER2 and breast cancer
point mutation e.g. kRAS2 in colon cancer
translocation e.g. t(8;14) in Burkitt's lymphoma and Chronic Myeloid Leukaemia
hypomethylation
The hereditary cancers include:
Retinoblastoma 13q
Breat and Ovarian cancer, BRCA1 on 17q and BRCA2 on 13q
Hereditary non-polyposis colorectal cancer/Lynch syndrome
Familial adenomatous poyposis 5q
Lifraumeni syndrome 17p
ENVIRONMENTAL CAUSES OF CANCER - PHYSICAL, CHEMICAL AND MICROBIAL
Chemical Carcinogenesis
Direct-acting carcinogens (alkylating agents)
Procarcinogens that require metabolic activation
Natural plant and microbial products
most commonly targeted genes are RAS and p53
Radiation Carcinogenesis
Ionising radiation can cause chromosome breaks, double strand breaks, translocations, and less frequently, point mutations
UV rays can cause the formation of pyrimidine dimers and these result in skin cancer
Squamous cell carcinoma, basal cell carcinoma
Melanoma
Xeroderma Pigmentosa
Microbial Carcinogenesis
Viruses
HPV
cervical cancer
EBV
B cell Lymphomas
A subset of Hodgkin's Lymphomas
Indirect pathogenic involvement in Burkitt's lymphoma
Hepatitis B and C
HTLV-1
HIV
Human herpes virus 8
Bacterial
Helicobacter pylori
Worms
CANCER SCREENING
Basic Principles
the condition should be an important health problem
there should be an available treatment for the disease
facilities for diagnosis and treatment should be available
there should be a latent stage of the disease
there should be a suitable test or examination
the test chould be acceptable to the population
the natural history of the disease should be adequately understood
there should be an agreed policy on whom to treat
the cost of case finding should be acceptable
case finding should be a continuous process
Two major components of the early detection of cancer
education to promote early diagnosis
screening
diagnostic test value assessment
sensitivity = true positives
specificity = true negatives
positive predictive value = the proportion of true positivies among all those testing positive
negative predicting value = proportion of true negatives among all those testing negative
lead time bias = apparent improvement in survival that is seen when screening advances the time of diagnosis without any change in the actual time of death
length-time bias = tendency of screening to detect a disproportionate number of cases of slowly progressing cancer compared with more aggressive cases, and aggressive cases may progress during the screening interval
Cancer screening programmes in Ireland
Cervical cancer screening - smear test
Breast cancer screening - mammogram
Colorectal cancer screening - free faecal immunochemical testing
SERUM TUMOUR MARKERS MEASURED IN CLINICAL BIOCHEMISTRY
tumour presence indicators:
location specific issues
tumour secretions
cell/tissue destruction
a good biomarker has:
high specificity - screening
high sensitivity - diagnosis
correlation with tumour stage for monitoring
correlation with patient prognosis for outcome
specific tumour markers used
hCG
gestational trophoblastic disease
AFP
non-malignant liver conditions e.g. cirrhosis, hepatitis, cholestasis
hepatocellular carcinoma/hepatoblastoma
germ cell tumours of the testes/ovaries
CEA
colorectal cancer
CA 125, 19-9, 15.3
ovarian cancer, adenocarcinoma of the pancrease, and carcinoma of the breast (respectively)
PSA
SPECIFIC PATHOLOGICAL EXAMPLES
THE PATHOLOGY OF BONE AND SOFT TISSUE TUMOURS
COMMON BONE TUMOURS
BENIGN BONE-FORMING TUMOURS
Osteoid osteoma
children and young adults
cortical based, long bones, nocturnal pain
osteoblastoma
medullary vertebral column
children and yound adults
MALIGNANT BONE-FORMING TUMOURS
Osteosarcoma
bimodal age distribution, long bones
risk factors: paget's disease, prior irradiation, bone infarction
BENIGN CARTILAGE TUMOURS
osteochondroma
found on the surface of bone
metaphyseal region of the distal femur, upper humerus, tibia and fibula
enchondroma
medullary bone
mainly in the hands and feet
endochromatosis = the presence of multiple enchondromas e.g. with Ollier's disease or Maffucci syndrome
chrondroblastoma
occurs in the epiphyses of long bones of skeletally immature patients
alteration of the K36M region of the H3F3A gene
chondromyxoid fibroma
MALIGNANT CARTILAGE TUMOURS
chondrosarcoma
seen in the pelvis, proximal femur, proximal humerus, distal femur and the ribs in people over 50
often associated with mutations of the IDH1 and/or the IDH2 genes
ROUND CELL TUMOURS
Ewing's sarcoma
round cell diaphyseal intramedullary tumours
long bones > pelvis > ribs
associated with a recurrent chromosomal translocation t(11;22), fusion of the EWS gene on chr 22 to the FLI-1 gene on chr 11, and this results in the formation of a potent transcription factor
GIANT CELL RICH TUMOURS
giant cell tumour
epiphyseal and intramedullary giant cell rich tumours
occur between the ages of 20 and 45
locally aggressive neoplasms with some metastasising to the lungs
aneurysmal bone cyst
skeletally immature patients
primary ABC associated with an alteration in the USP6 gene
chondroblastoma
giant cell rich osteosarcoma
FIBRO-OSSEOUS TUMOURS
fibrous dysplasia
can affect one or multiple bones
commonly found in the jaw, ribs, skull and long bones
most cases are associated with an alteration involving the GNAS gene
osteofibrous dysplasia
occur in the tibia of young patients
rarely progresses to an adamantinoma
VASCULAR BONE TUMOURS
intraosseous haemangioma
benign tumour commonly effecting the spine
epitheliod haemangioendothelioma
malignant vascular tumour
seen most commonly in adults
features epitheliod cells with vacuoles containg red blood cells/blister cells
associated with alteration that results in the fusion of the CAMTA1 and the WWTR1 genes
high-grade angiosarcoma of the bone
malignant vessel-forming tumour of the bone
occurs in adults, is aggressive and often multi-focal
SOFT TISSUE SARCOMAS
LIPOSARCOMA
ANGIOSARCOMA
LEIOMYOSARCOMA
RHABDOMYOSARCOMA
FIBROBLASTIC
myxofibrosarcoma
elderly patients, superficial aspects of limb girdles nd extremeties
desmoid fibromastosis
mainly sporadic but some associated with beta-catenin mutation (CTNNB1), or less commonly an APC gene mutation (Gardner syndrome)
UNCERTAIN LINEAGE
synovial sarcomas
associated with a recurrent translocation involving the ss18 gene t(X;18)
graded using the French Federation of Cancer Centers Sarcoma Group, dependin on mitotic count, necrosis and tumour differentiation
BENIGN AND MALIGNANT PATHOLOGIES OF THE SKIN
EPIDERMAL TUMOURS
SEBORRHEIC KERATOSIS
adults
sharply demarcated and pigmented lesions that protude above the skin surface
can have a greasy appearance
benign proliferation of keratinocytes with horn cysts
VERUCCA VULGARIS
associated with a HPV infection
firm outgrowth of keratinocytes with horn cysts
common on hands and feet
ACTINIC KERATOSIS
common
seen in sun exposed areas
no invasion of the dermis
most are adequately treated with currettage
BOWEN'S DISEASE/SQUAMOUS CELL CARCINOMA-IN-SITU
UV light exposure is a risk factor but can occur in both sun exposed and non-sun exposed areas
SQUAMOUS CELL CARCINOMA
risk factors
UV light exposure
burns
irradiation
immunosuppression
prognosis depends on
size
depth of invasion
lymphovascular invasion
BASAL CELL CARCINOMA
affects the epithelium of the hair follicle rather than squamous cells in the epidermis
locally recurrent
no metastasis
can be associated with Nevoid basal cell carcinoma (Gorlin) syndrome
MELANOCYTIC TUMOURS
BENIGN NAEVI (MOLES)
very common
usually congenital but can occur after this, pay attention to those occuring in the middle/older age groups
can recur
DYSPLASTIC NAEVI
naevi >5mm in diameter
irregular borders
varied pigmentation
changing naevi
multiple naevi
dysplastic naevus syndrome
increased risk of melanoma
autosomal dominant mutation
mutation affecting the CDKN2A gene
100 naevi, both regular and atypical
MELANOMA
prognosis depends on:
depth of invasion
measured using the Breslow thickness scale and the Clark level
presence of ulceration
clinical stage at diagnosis
available therapy:
BRAF inhibitor therapy if BRAF V600 gene mutation present
PDL1 inhibitor therapy if IHC determines eligibility
allows for the avoidance of attack from our own T lymphocytes
malignant melanocytes invading into the dermis
risk factors:
UV light exposure
family history
multiple naevi
immunosuppression
SYNDROMES ASSOCIATED WITH ADNEXAL NEOPLASMS
BROOKE SPIEGLER SYNDROME
germline mutation in the cylindromatosis gene on chromosome 16
autosomal dominant disorder
cylindromas
spiradenomas
trichoepitheliomas
MUIRR-TORRE SYNDROME
autosomal sominant mutation in the MLH1 and MSH2 mismatch repair genes
a lynch syndrome variant
patients at risk for: colorectal and endometrial adenocarcinoma, and cutaneous sebaceous tumours
COWDEN SYNDROME
autosomal dominant mutation in the PTEN tumour suppressor gene
multiple hamartomas
increased life time risk of thyroid, breast, endometrial, colorectal cancer and melanoma
skin manifestations
facial fibrous papules
trichilemmomas
palmar/plantar keratoses
BURT HOGGE DUBE SYNDROME
autosomal dominant mutation in the BDH or FLCN gene on chromosome 17 coding for the folliculin protein
skin lesions (occur mainly on the face and upper chest)
fibrofolliculomas
trichodiscoma
angiofibroma
patients are also at risk fro developing lung cysts with pneumothorax and renal cell carcinoma, in particular bilateral chromophobe renal cell carcinoma and oncocytoma
adnexal tumours arise from sebaceous glands, hair follicles and sweat ducts
BENIGN AND MALIGNANT PATHOLOGIES OF THE BREAST
BENIGN BREAST DISEASE
cysts
fluid filled dilated breast gland (acinus)
treatment with aspiration
duct ectasia
peri-areolar abscess
affects ducts of the breast
dilatation
accumulation of secretions
inflammation and fibrosis
causes
smoking
bacteria
hyperprolactinaemia
treatment with subareolar exploration and removal of tissue
fibroadenoma
phyllodes tumour
surveillance of tumour or excision, depending on the grade of the tumour
radial scar
complete excision to exclude malignancy
spiculate lesion with irregular outline
benign tubules in the sclerotic stroma
papilloma
remove by excision to exclude malignancy
benign lesion with a duct
MALIGNANT BREAST DISEASE
Molecular classification:
luminal = HER2 negative, ER/PR positive
HER2 rich = HER2 positive
triple negative = HER2 negative, ER/PR negative
chemo useful for:
lymph node positive
HER2 positive
triple negative
chemo not useful for:
small tumours
grade 1 tumours
lymph node negative
ER positive
HER2 negative
predictive indices (response to treatment)
hormone receptor status
human epidermal growth factor status
multigene panel studies
mutational studies
prognostic indices
tumout type
tumour grade
tumour size
lymph node status
types:
ductal no-special type
special type carcinoma
mixed type
RISK FACTORS
fmaily history (BRCA1 gene)
reproductive profile - uninterrupted oestrogen stimulation e.g. with nuns, abstinence
exogenous hormones - the pill, HRT
lifestyle - alcohol, diet, smoking
environmental - radiation
sociodemographic
THE PATHOLOGY OF BENIGN AND MALIGNANT(SOFT TISSUE) PAEDIATRIC TUMOURS
NEUROBLASTOMA
extra-cranial tumour of the autonomic nervous system
25% of cases are congenital, but otherwise they occur before the age of 5
found:
adrenal medulla
paravertebral
retroperitoneal
posterior mediastinum
50-60% present with metastases
other neuroblastic tumours include ganglioneuroblastoma and ganglioneuroma, which are more benign than neuroblastoma
treatment:
intensive chemotherapy in tandem with a bone marrow transplant
if ALK mutation present, crizotinib (an ALK kinase inhibitor) can be used
anti-GD2 immunotherapy
RHABDOMYOSARCOMA
soft tissue tumour that usually appears in the first decade of life
malignant
commonly found:
head and neck
extremities
GI tract
bladder
pelvis
orbit
vagina
combined treatment
WILMS TUMOUR
renal tumour
cases peak between 1 and 5 years of age
presents with
pain
haematuria
hypertension
signs of rupture
huge mass
clinical and genetic associations
WAGR
DRASH
WT1 gene on 11p
genetic imprinting disorders e.g. Beckwith Wiedmann syndrome
hemihypertrophy
loss of heterozygosity on chromosome 1p and 16q
HEPATOBLASTOMA
primitive embryonic tumour of the liver
commonly seen in premature babies and very low birth weight infants
associated syndromes:
familial adenamatous polyposis
Beckwith Wiedmann syndrome
Li-Fraumeni syndrome (p53 mutation)
trisomy 18
mutation in the betacatennin pathway and APC gene inactivation
features
rasied AFP
mass
abdominal pain
vomiting
failure to thrive
EWINGS SARCOMA
bone/soft tissue tumour
found in the chest wall and the long bones
confirmation with CD99 IHC staining
most commonly associated with translocation t(11;22)
LANGERHAN'S CELL HISTIOCYTOSIS
affects multiple systems of the body
if BRAF mutation present, then it can be treated with vemurafenib (a BRAF inhibitor)
CD1a cell surface marker can be identified on IHC
MKI = the mitotic karryhorhectic index and it measures how rapidly cells are dividing/dying and is measured as a percentage. The lower the percentage, the better the prognosis and the higher the percentage, the worse the prognosis
