Oncology Flashcards
(166 cards)
1
Q
6 modalities/hallmarks of cancer
A
- Growth factor independence (GOF)
- Loss of response to anti-growth signals/differentiation signals (LOF)
- Resistance to apoptosis
- Recruitment of blood/lymph
- Invasion and metastasis
- Limitless replicative potential
2
Q
Growth factor independence
A
- typically related to gain of function oncogenes
3
Q
Proto-oncogenes
A
normal genes with important roles in regulating division, differentation, survival, movement –> mutate to oncogenes (GOF)
4
Q
PI3K Pathway
A
- PI3K phosphorylates lipid on the cytoplasmic side of membrane
RTK (e.g. EGF receptor) –> activate PI3K–> converts PIP2 –> PIP3 –> docking site for PH domains (e.g. in AKT)–> AKT/PKB –> phosphorylation of proteins
- Involved in many signaling events
- Disregulation can have significant oncogenic downstream effects
5
Q
Warburg effect
A
elevated AKT activity due to PI3K mutation –> increased glucose transport & glycolysis (basis of PET)
6
Q
PTEN
A
- most common mutation leading to elevated PI3K activity
- PTEN converts PIP3–> PIP2 (opp. of PI3K)
- usually via deletion of PTEN or silencing of locus
- LOF is usually more common than GOF
7
Q
Tumor suppressor
A
genes in which loss of function promotes cancer (e.g. PTEN)
8
Q
p53
A
- tumor suppressor gene
- activates cell cycle arrest & apoptosis
- most cancers have p53 mutation
- DNA-binding transcription factor
- regulates
- p21 cyclin inhibitor
- GADD45- DNA repair
- Bax, Puma, Noxa- pro apoptosis
- MDM2- self-regulation
- accumulates in cancer cells b/c loss of autoregulation
9
Q
Li-Fraumeni Syndrome
A
patients with one germ-line mutant copy of p53 gene –> prone to leukemias, sarcomas, breast, brain cancers associated with loss of remaining functional p53 allele in those cells –classic example of “loss-of-heterozygosity” (LOH).
10
Q
Apoptosis
A
- highly ordered, ATP-dependent process-proteins, subcellular components dismantled by proteases (“caspases”)and nucleases
- membrane blebbing produces “apoptotic bodies” containing cellular debris, which are then engulfed by macrophages and other cells
- avoids release of cellular components that could trigger a damaging inflammatory response.
11
Q
Caspases
A
- proteases that use conserved cysteine residue in their active site to cleave other proteins after aspartate residues in apoptosis
- initiators
- effectors/exectuioners
- present as procaspases until stimulus initates apoptosis
12
Q
Intrinsic apoptotic pathway
A
mitochondrial membrane loses integrity –> cytochrome C released from mitochondria –> binds Apaf 1 to form apoptosome –> recruits procaspase 9 –> cleaves executioner caspases –> apoptosis
13
Q
BCL related proteins
A
- promote apoptosis - Bax, Bax
- inhibit apoptosis - Bcl2
- apoptosis determined by equilbirium of these stress-responding factors
14
Q
Extrinsic apoptotic pathway (death receptor)
A
- Fas (or other TNF death receptor) receptor binds FasL/–> recruits FADD/TRADD—> recruits intiators 8 and 10 which autoactivate and trigger effectors 8/10 –> DISC
15
Q
Ways cancers bypass apoptosis
A
- over expressing antiapoptotics like Bcl2
- downregulating proapoptotics like Bax, Bak
- losing p53 which induces proapoptotics Bax, Puma, Noxa
- downregulating death receptors Fas, Trail
16
Q
Hayflick Limit
A
- replicative senescence:
- most cells: division of cell –> some DNA lost –> limits number of replications
- if continued replication –> breakage fusion bridge cycle would occur –> inappropriate fusing of chromosomes
17
Q
Telomerase
A
- telomerase adds extra telomeric DNA to some some cells (stem cells, lymphocytes)
- dysregulation ensures stable chromosomes for cancer
18
Q
Angiogenic switch
A
- recruitment of blood vessels to ensure tumor growth > 2mm
- balance between
- inhibitors
- statins
- thrombospondin
- activators
- VEGF
- FGF
- EGF
- PDGFB
- inhibitors
19
Q
Tumor vasculature
A
highly anomalous because of inconsistent equilibrium between pro/anti angiogenic factors
20
Q
VEGF
A
- vascular endothelial growth factor –> stimulates EC division, survival, differentiation, movement –> master regulator
- main form = VEGF A
- binds to tks on ECs (VEGFR1 and 2) –> angiogenesis
21
Q
VEGF blockers
A
antiangiogenic therapy
- bevacizumab = mab
- sunitinib/sorafenib = kinase inhibitors
22
Q
Seed and Soil Metastasis
A
- cancer cells follow venous and lymphatic drainage
- some tumor cells may adher in or survive better in certain organs
23
Q
Importance of Philadelphia chromosome
A
- encodes fusion protein BCR-ABL = oncogene with abnormal tk activity
- t (9;22) –> BCR intiator, ABL gene
- present in 100% CML, 30% AML
- Tx: Gleevec/Imatinib
24
Q
FFPE
A
Formalin fixed parafin embedded –> cut tumor specimen –> laser capture DNA –> PCR –> identify markers, resistance
25
BRAF mutation
* GOF V600E most common (val/glu)
* predicts resistance to Vemurafinib
* BRAF mutation
* 40-60% melanoma
* 40-70% papillary thyroid
* 10% metstatic colorectal
26
Sequencing Read Length
number of sequential images taken
27
Sequencing Read Depth
number of DNA fragments for a given position
28
Reactive/benign disorders
* polyclonal expansion of different kinds of cells
* leukemoid reaction - expansion of granulocytes in response to bacterial infection
* lymphadenitis- inflammation of lymph nodes
29
Neoplasms
* clonal expansion of a single cell
* uncontrolled expnasion --\> organ replacement --\> functional compromise --\> death
30
Leukemia
* neoplasms that involve bone marrow and spill into peripheral blood
* blood forming elements:
* granulocytes
* red cells
* megakaryocytes
* all lymphoblast-related are leukemias
31
Lymphoma
* solid mass tumor of lymph nodes, spleen, extranodal sites (GI tract, skin)
* neoplasm of mature lymphocytes
32
Acute/precursor neoplasm
* immature early undifferentiated state
* **blast**
33
Chronic/peripheral neoplasm
mature differentiated cell neoplasm
34
Lymphomas- morphology
* size: small vs large (size of a mature lymphocyte vs. histiocyte nucleus)
* growth pattern: nodular vs. diffuse
* morphology is not the best predictor of behavior since some small cell lesions can be aggressive and indolent lesions can be unresponsive to therapy
35
Secondary lymphoid follicles
* follicle which develops after antigen presentation with B cells undergoing class switch and somatic hypermut.
* **germinal center:** C10+BCL6+BCL2- --\> need apoptosis working during proliferation so must be **bcl2-**
* dark zone: proliferating centroblasts
* light zone: mature centrocytes
* mantle of **naiive B cells:** CD10-BCL6-**BCL2+**
* undelrying CD21+ follicular dendritic meshwork
* mantle of plasma cells
36
Lymphomas- immunophenotype
* expression pattern of a surface and intracellular proteins in a cell population
* benign (polytypic) vs. neoplastic (monoclonal)
* lineage (CD3/T vs CD19/B)
* stage of diff. (Tdt vs. surface Ig)
* aberrant expressions
* CD5+ B cells
* mature T cells w/o pan-t antigens
* assessed by:
* flow cytometry
* immunohistochemistry
37
Immature B cell markers
**Tdt**- expressed by immature lesions
**CD19**
38
Mature B cell markers
**all:** CD19, CD20
**mature:** k/l light chains
**germinal:** CD10, BCL6 (secondary follicles)
**all except germinal:** BCL2
39
Immature T cell markers
**Tdt**
**CD1a**
**cCD3**
40
Mature T cell markers
**CD2**
**sCD3**
**CD5**
**CD7**
also: CD4/8
41
Lymphomas-genotype
* gross chromosomal rearrangements that lead to abnormal gene expression
* B cells undergo mutlipel rounds of damage --\> more common neoplasms
* Ig rearrangement in marrow
* somatic hypermut./class switch
* Examples:
* Burkitt's = t(8;14) IgH/Myc
* Follicular = t(14;18) IgH/BCL2
42
What does lymphoma genotype prove?
1. clonality
2. specific tumor subtype
43
Lymphomas- normal cell counterpart
neoplastic cells recapitulate morphology, immunophenotype of progenitor cells
44
Lymphomas-clinical features
* variable: asymptomatic vs. constitutional
* "type B" symptoms: fever, night sweats, weight loss
* dictated by affected site & tumor biology
* lymph nodes = lymphadenopathy
* extranodal = organ dysfunction
* marrow involvement = suppression
* plasma cell = bone destruciton
45
Lymphomas-characterization by clinical features
* lymphoblastic = pediatric
* extranodal marginal zone = mucosal spread
46
B Cell NHL
* derived from **mature** B cells
* neoplasms capitulate function of progenitors
* bone marrow involvement common (stage IV) --\> interstitial except follicular
* liver/spleen involvement common
* difficult to cure
* can transform to aggressive
* IgH/14 involved in some important translocations
1. indolent: follicular, cll/sll, marginal
2. aggressive: DLBCL
3. highly aggressive: Burkitt's
47
Follicular lymphoma immunophenotypic profile
B: CD19+/CD20+/CD(2-8)-/
Germinal Center: **CD10+**
Aberrant: **BCL2+**
low **Ki67** --\> disease of cells surving a long time//not a disease of cells proliferating
48
CLL/SLL immunophenotypic profile
B: CD19+/CD20+
T: **CD5+**
Non-germinal: CD10-/BCL6-/BCL2+
49
Marginal lymphoma immunophenotypic profile
**No distinct marker**
B: CD19+CD20+
Not Germinal: CD10-/BCL6-/BLC2+
50
Follicular lymphoma- clinical features
* t(14;18) --\> BCL2+
* General lymphadenopathy
* BM involvement common (Stage IV) --\> represents hematogenous spread
* nonaggressive
* spleen and liver involvement common
* fine diffuse nodularity --\> expansion of splenic white pulp
* in extensive disease --\> red pump also
* occasional peripheral blood involvement --\> small cleaved cells
* extranodal involvement uncommon
51
Follicular lymhoma- prognosis
* Indolent- waxing/waning course --\> 8 years
* largely incurable
* Often transforms to diffuse B cell lymphoma --\> 1 year survival
* Tx: observation, symptom relief, anti-CD20
52
Follicular lymphoma- morphology
* germinal center B cells
* nodular appearance- lots of germinal centers
* crowded, back to back
* lack polarity (thick/thin ends)
* no tingible body macrophages
* no discernable mantle
* paratrabecular aggregates
* grade 1 = more nodular and more centrocytes --\>indolent
* grade 2/3 = more than 5 centroblasts/hpf
53
CLL/SLL: Chronic lymphocytic leukemia/Small lymphocytic lymphoma
* spectrum cancer
* circulating cells --\> leukemia
* solid mass --\> lymphoma
* CLL = most common adult leukemia
* SLL = uncommon
54
CLL/SLL-clinical features
* 13q/trisomy 12/deletion 11q/deletion 17p
* usually asymptomatic//6th decade presentation
* general lymphadenopathy
* low grade lymphoma for most of life
* usually progresses to **Stage IV**
* common hepatosplenomegaly
* peripheral blood involvement
* immune dysregulation
* autoimmune RBC/platelet
* AIHA
* thrombocytopenia
55
CLL/SLL- prognosis
* variable survival
* Group 2 \> Group 1 prognosis
* transformations
* prolymphocytic leukemia
* richter's transformation --\> DLBCL
56
Richter's transformation
* transformation of CLL/SLL to DLCBL
* same mechanism employed in all indolent lymphomas
57
CLL/SLL- morphology
* unknown source
* diffuse effacement of architecture
* proliferation centers: "pseudofollicles"
* prolymphocytes/paraimmunoblasts
* small round lymphocytes with condensed chromatin, scant cytoplasm, and fewer large cells. also see smudge cells 
* interstitial marrow infiltrate: nodular or diffuse
58
CLL/SLL Group 1 and 2
1. unmutated IgV
* no SHM/naive
* **Zap70+**
* aggressive
2. hypermutated IgV
* post GC/mature
* **Zap70-**
* indolent
59
Marginal zone lymphoma
* 3 diseases
* nodal marginal zone lymphoma
* splenic marginal zone lymphoma
* extranodal marginal zone (MALT) --\> most common
60
MALT MZL-clinical features
* t(1;14) API2-MALT1
* t(11;18) IgH/BCL10
* t(14;18) IgH/MALT-1
* associated with chronic inflammation (e.g. pylori, jejuni, borrelia, chlamydia)
* low grade with transformation to DLCBL
* Tx: antibiotics/antiviral
61
S-MZL
splenic marginal zone lymphoma associated with Hep C
62
MALT/MZL
1. small lymphocytes
2. monocytoid margin B cells (lots of clear cytoplasm)
3. plasma cells
* 
4. destruction of epithelial structures like glands
* [](http://radiographics.rsna.org/content/21/6/1491/F17.large.jpg)
63
NF-kB pathway
* responsible for stimulating cell survival and proliferation
* MALT--\> BCL10 or API2MALT1 --\> binds MALT1 --\> induction of NF-kB
64
Plasma cells
* terminally differentiated B cells:
* CD19+, CD138+, CD56-
* in lymphoma, CD56+ hone plasma cells to marrow
* lymph nodes and bone marrow
* clockface nuclear chromatin, perinuclear clear zone, gray cytoplasm, eccentric nuclei
65
Multiple Myeloma
* plasma cell neoplasm
* most common lymphoid neoplasm in AA, 2nd most in whites
66
Multiple Myeloma- clinical features
* multifocal --\> areas of hematopoeisis (vertebrae--\>emergency!!!), ribs, skull)
* anemia (from marrow replacement and renal failure)
* hypercalcemia (osteoclast activation)
* rouleaux/blood viscosity increase --\>neurologic/thrombotic
* bone destruction
* pain
* osteolytic lesions --\> "punchout"
**Crab Plaits**
C - calcium is high
R - renal failure
A - anemia
B - bone disease, bone pain, Bence-Jones protein (a paraprotein)
P - paraproteins (useful for monitoring patient)
L - LDH (again for monitoring)
A - amyloidosis (a complication)
I - immune paresis (suppression of Ig, a complication)
T - thalidomide (treatment)
S - stem cell transplant (treatment)
67
Multiple Myeloma- morphology
* increased clusters and sheets of plasma cells
* replaced marrow
* destruction and resorption of bone
* osteopenia (thinning of trabecular bone)
* flame cell (IgA)
[![]()](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=VCxDAqnLynF1lM&tbnid=2rAgxFGgUev7PM:&ved=&url=http%3A%2F%2Fstatlab.tumblr.com%2Fpost%2F4453518508%2Fa-flame-cell-a-plasma-cell-variant-that&ei=Ml8RUdGWLemy0QHonYHADA&bvm=bv.41867550,d.dmQ&psig=AFQjCNH7f_PdwfYemYmi-kM331MAfCK83A&ust=1360179379305456)
* mott cell (intracytoplasmic Ig_)_[![]()](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=evqyNZ9tTv8YXM&tbnid=kJKwTJBxGTConM:&ved=&url=http%3A%2F%2Fwww.med-ed.virginia.edu%2Fcourses%2Fpath%2Finnes%2Fwcd%2Fmyeloma.cfm&ei=oF8RUcW_CaWR0QGW5oGQCA&bvm=bv.41867550,d.dmQ&psig=AFQjCNHHb7ItCGKRn3wLxnkejTQYq1cy0Q&ust=1360179482095586)
* atypia (wild nuclei)
[![]()](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=XQmbw3l4W-rlWM&tbnid=gVy4amFoWhgDRM:&ved=&url=http%3A%2F%2Fwww.pathpedia.com%2Feducation%2Featlas%2Fhistopathology%2Fbone_marrow%2Fplasma_cell_myeloma.aspx&ei=KWARUd-DBMKA0AHPyYGIBQ&psig=AFQjCNFfDHiW9wM27NwJlhxbOOQf2soXMw&ust=1360179625715516)
68
Paraprotein/Bence Jones
* M (monoclonal component) Ig from plasma cells in monoclonal gammopathies
* benign = MGUS (monoclonal gammopathy of undetermined significance)
* malignant = Multiple Myeloma
* Bence Jones = excess heavy or light chains secreted in MM --\> measure in urine--\> severity
* 50% IgG K\>L
* 25% IgA K\>L
* Consequences
* Cryoglobulinemia (Raynauds)
* Renal failure
* Amyloidosis
* Bleeding
* Immunosuppression
69
Humoral Immune Paresis
suppression of normal polyclonal Ig production in myeloma patients
70
Cast nephropathy
excess light chains settle out in aggregates in distal nephron forming obstructive tubular casts --\> myeloma kidney
[](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=O_rkv0HtsMQvbM&tbnid=PwHbNo1PQ8AruM:&ved=&url=http%3A%2F%2Fcueflash.com%2Fdecks%2Fonc_11&ei=PGMRUaOnG66H0QGDkoGQCA&psig=AFQjCNEWsGm4J5NiFOBsipkK-VrFLej9sw&ust=1360180413046281)
71
Amyloidosis
oversecreted clonal serum Ig settle out in beta-pleated sheets to form tissue deposits in end organs (e.g. renal glomeruli)
72
Multiple Myeloma- anemia
1. cast nephropathy
2. proximal tubulopathy from hypercalcemia and toxic reabsorption of light chains
3. amyloidosis
results in uremia/hypovolemia, loss of epo (+marrow infiltration) --\>anemia
73
DLBCL
* common NHL
* evolves from low grade lymphoma or denovo
* presents at single site-nodal or extranodal
74
DLBCL-clinical features
* rapidly enlarging symptomatic mass at single nodal or extranodal site (vs. indolent)
* commonly GI
* rare BM involvement
* associated with immunocompromise
* **EBV**
75
DLBCL-gross pathology
* homoegenous fish-flesh tissue replacement
* hemorrhage, necrosis, fibrosis
76
DLBCL-morphology
* CD19+/CD20+/Ig+/**Ki67+**
* diffuse architectural defacement
* large cells
* mitotically active, invasive, necrotic
* GCB (CD10+/BCL6+/MUM1) phenotype does better than ABC
* centroblastic: medium/large, oval nuclei, multiple nucleoli, low cytoplasm
* immunoblastic:large, single nucleolus, plasmacytoid (cytoplasm)
[](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=_RHNsEquaP0T8M&tbnid=fGk3gFJRnm2G1M:&ved=&url=http%3A%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS1756231709002230&ei=LmkRUaP7G8yv0AHX-4HYAg&bvm=bv.41934586,d.dmQ&psig=AFQjCNFwqz0p4tpylmPEPoOLpdLMJvhgOw&ust=1360181934863790)
77
International Prognostic Index (IPI)
* most useful predictor of prognosis in DLBCL (50% do poorly)
78
Burkitt's Lymphoma
1. endemic (malaria belt) --\> EBV in kids
2. sporadic (western) --\>rare in adults
3. immunodeficiency --\> HIV/EBV
79
Burkitt's Lymphoma- clinical features
* high LDH
1. endemic: facial bones (sometimes ovary, kidney, breast)
2. sporadic: ileocecal/abdominal (sometimes ovary, kidney, breast; rare LN)
3. immunodef: LN/BM
* **EMERGENCY!!!**
80
Burkitt's Lymphoma- morphology
* Cd19+/CD20+/**CD10+/BCL6+/BCL2-/Ki67+** --\>germinal
* monotonous infiltrate of medium cells
* high proliferation/apoptosis
* tingible body macrophages
* round nuclei
* basophilic
* **starry sky**[](http://www.google.com/imgres?um=1&hl=en&client=firefox-a&tbo=d&rls=org.mozilla:en-US:official&biw=1680&bih=920&tbm=isch&tbnid=q5tF54xoIR1CCM:&imgrefurl=http://hy4theusmle.blogspot.com/2007/04/burkitts-lymphoma-is-high-yield-for.html&docid=sb5WgrwtRv0c7M&imgurl=http://www.pathguy.com/lectures/l3.jpg&w=600&h=400&ei=XG4RUbiOHdPV0gGgtIHYBg&zoom=1&ved=1t:3588,r:1,s:0,i:85&iact=rc&dur=263&sig=106104689980081344486&page=1&tbnh=180&tbnw=239&start=0&ndsp=27&tx=114&ty=69)
81
cMYC pathway
* endemic: defective t cell immunity --\> EBV B cell proliferation --\> t(8,14) --\> cMYC overexpression
* sporadic/immunodef. also cMYC related
82
Cancer screening ages:
Cervical
Colon
Prostate
Breast
Cervical: 21 every 3y
Colon: 50 annual fobt, colonoscopy//fs//dcbe every 10y
Prostate: 45 PSA yearly
Breast: 21 CBE every 3y; 40, annual mammogram
83
TNM Cancer Staging
* T: size/extent of involvement of tumor (1-4)
* N: nodal involvement 0/1
* M: presence of metastasis 0/1
84
Cachexia Syndrome
fatigue & weight loss due to inflammatory factors like TNF during cancer
85
Paraneoplastic Syndrome
tumor produces pseudo/hormones:
* PTH = hypercalcemia
* gastrin = ulcers
* EPO = polycythemia
* paraprotein = hyperviscosity
86
Rationale for radiation therapy
cancer cells are rapidly dividing/less able to repair damage and their DNA is more susceptible to ionizing radiation
87
Direct vs. Indirect ionization
* Direct = damage directly to DNA
* Indirect = damage to DNA via reactive intermediates
88
2 methods of radiation delivery
1. external beam rt (EBRT)
2. internal rt (brachytherapy)
89
3 main types of EBRT
1. Photons (x rays from linear accelerator)
2. Light charged particles (electrons)
3. Heavy charged particles (protons, carbon)
90
Radiosensitivity
in vitro survival of cells vs. dose
91
Radioresponsiveness
measurable change in tumor size during/after treatment --\> correlates with radiosensitivity
92
Therapeutic Index
relative effect of treatment on tumor compared to damage of normal tissue
93
Acute vs. Late Toxicity
cells rapidly turning over (skin, oral mucosa, GI epithelium) respond before other tissue loss
94
Fractionation and the 4 R's of radiobiolo's
* need to split up RT dose to minimize tissue damage
1. reassortment
2. reoxygenation
3. repair
4. repopulation
95
Neoadjuvant vs. Adjuvant RT
preop vs. post op decision about how much RT to give to patient
96
Chemotherapy as a radiosensitizer - 5 effects
concurrent chemo during RT can help make radiation work better//help eliminate micrometastases
1. enhancement of radiation damage
2. inhibit cell repair
3. accumulate cells in radiosensitive cell cycle stage
4. work against hypoxic cells
5. inhibit accelerated repopulation of tumor cells
97
Bragg Peak Effect
A pronounced peak on the Bragg curve which plots the energy loss of ionizing radiation during its travel through matter. For protons, α-rays, and other ion rays, the peak occurs immediately before the particles come to rest. The phenomenon is exploited in particle therapy of cancer, to concentrate the effect of light ion beams on the tumor being treated while minimizing the effect on the surrounding healthy tissue.
98
Proton therapy in Hodgkin Lymphoma
mediastinal radiation puts heart, lung, breast tissue at risk in young patients --\> proton accelerator --\> high energy protons
99
Hodgkin Lymphoma
* lymphoma with
1. a significant minority of neoplastic Reed-Sternberg cells
2. a larger and pleomorphic background of non-neoplastic reactive inflammatory cells
* constitutive activation of NF-kB
* activation of JAK-STAT
* relatively uncommon --\> bimodal age dist.
* associated conditions: EBV, immunodeficiency, HIV, social class
100
Hodgkin Lymphoma- clinical features
* painless supradiaphragmatic (cervical) lymphadenopathy
* anterior mediastinum = nodular sclerosis
* axial/centripetal node involvement
* fever, weight loss, night sweats
* cytokine soup --\> B symptoms
* opportunistic infections --\> TB, fungi, HSV
* unifocal disease --\> predictable lymphatic spread
101
Hodgkin Lymphoma- morphology
* excisional lymph node biopsy
* normal nodal architecture is effaced
* sea of reactive inflammatory cells
* Reed-Sternberg "owl eye" cell
102
Reed-Sternberg cell
* germinal center B cell derived
* associated with Hodgkin Lymphoma
* owl eye bilobed nucleus
* abundant cytoplasm
* eosinophilic nucleoli
* many variants
* often express CD30 (nonspecific TNF family)
*
103
Classical Hodgkin Lymphoma/CHL
* diffuse or nodular growth
* class RS cells
* CD15+/CD30+/PAX5+CD20+/-/CD45-
* background = more t cells
* stage ii or iii
4 types
1. nodular sclerosis
2. mixed cellularity
3. lymphocyte depletion
4. lymphocyte rich
104
Nodular Sclerosis
* commonest CHL
* nodular pattern + fibrotic/sclerotic bands
* necrosis common
* lacunar RS cells
* staging
1. one nodal
2. two nodes on same side
3. both sides of diaphragm
4. disseminated
5. A: absence of symptoms
6. B: presence of weight loss, fever, night sweats 
* Tx: ABVD multidrug chemo (risk of sterility, AML) or BEACOPP
*
105
Acute leukemia
* hematologic malignancy in which rapidly progressive marrow failure occurs --\> bm replacement by undifferentiated tumor cells --\> arrested at blast stage
* most common pediatric cancer
* require small number of cooperating mutations (promote growth + impair differentiation)
106
Acute leukemia-clinical features
* t(9;22) BCR-ABL or t(15;17) PML-RARa
* abrupt onsent of bone marrow failure
* pancytopenia of normal blood cells
* infections, fatigue, bruising, bleeding
* increased blood viscosity
* sludging and microthrombi--\> leukostasis
107
Acute leukemia-morphology
* maturational arrest at blast phase
* cytoplasmic granulation
* Auer rod: azurophilic cytoplasmic inclusion in myeloblasts --\> myeloid related
108
PML-RARa Pathway
* defective retinoic acid receptor fails to initatie gene expression in response to physiologic dose ofretinoids
* associated with acute promyelocytic leukemia
* Tx: ATRA --\> restores transcription
109
Left-shift
relative increase in immature hematopoietic development from what is expected
110
Leukemoid Reaction
**normal** release of polyclonal immature and maturing cells into circulation in response to stress or medications
111
Lymphoid Cells
B/T lymphocytes, plasma cells, NK cells
112
Myeloid Cells
granulocytic, monocytic, erythrocytes, and magakaryocytes
113
Chronic Myeloproliferative Neoplasms/Disorders
* clonal expansion of transformed stem--\> terminally differentiated cells
* predisposed to transformation to acute leukemia
* tk dysregulation
* bone marrow cavity fibrosis
* hepatosplenomegaly
1. polycythemia vera = erythrocytes
2. essential thrombocythemia = platelets
3. cml = neutrophil, monocyte, eosinophil, basophil
114
Chronic Myelogenous Leukemia (CML)
* t(9;22) BCR-ABL --\> philadelphia chromosome
* middle aged
* abnormal growth and proliferation of white blood cells (myeloid)
* neutrophils and then other granulocytes accumulate[](http://upload.wikimedia.org/wikipedia/commons/f/fc/Chronic_Myeloid_Leukemia_smear_2009-04-09.JPG)
* Tx: imatinib/Gleevec --\> tk inhibitor with specificity for ABL-BCR
* SE: myelosuppression, fluid retention, muscle cramps
115
Classical MPN-Polycythemia Vera
* endogenous erythroid colony formation (EEC)--\> growt without epo (JAK mutation)
* upregulation of BCL-X (like BCL2)
* Tx: phlebotomy, aspirin, hydroxyurea, interferon, **Jak2 inhibitors**
116
Chronic Myelogenous Leukemia- clinical features
* commonly asymptomatic --\>incidental finding
* splenomegaly
* weight loss, fatigue
* high blood count
* hyperuricemia --\> gout/stones
* pseudohyperkalemia, hypoxemia, hyopglycemia
* left shift
* very high b12, high LDH
* phases
1. chronic-months to years
2. accelerated-1 year
3. blast crisis (acute leukemia) -3-6 months survival
117
"Classical" MPN
* Philadelphia chromosome negative
* excess production of one or more lineages of mature blood cells and/or bone marrow fibrosis
* complicated by predisposition to bleeding/thrombosis, extramedullary hematopoeisis
118
Classical MPN-Polycythemia Vera-clinical features
* may be asymptomatic with high hemoglobin
* clots
* hypermetabolism (gout, stones, sweating)
* hyperviscosity (from high hematocrit) --\> congestion (e.g. retinal)
* aquagenic pruritis
* ruddy cyanosis
* vasomotor symptoms (erythromelalgia)
* bleeding
* splenomegaly
119
Classical MPN-Essential thrombocytosis
* BCR-ABL-
* JakV617F
* lease likely to evolve to AML
* too many bone marrow megakaryocytes
* Tx: observation, aspirin, interferon, hydroxyurea
[](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=m13ndKwH7mQ_SM&tbnid=ECwRs7vbz1t0HM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.clevelandclinicmeded.com%2Fmedicalpubs%2Fdiseasemanagement%2Fhematology-oncology%2Fchronic-myeloproliferative-disorders%2F&ei=tK4RUf6vO-rr0QGWwoDgCg&bvm=bv.41934586,d.dmQ&psig=AFQjCNF8C9P_wue_CWsn75Mc9ZtR2YKu5Q&ust=1360199717288498)
120
Classical MPN-Essential thrombocytosis-clinical features
* asymptomatic
* clots
* bleeding
121
Classical MPN-Primary myelofibrosis (PMF)
* myeloproliferative disease in which the proliferation of an abnormal type of bone marrow stem cell results in fibrosis, or the replacement of the marrow with collagenous connective tissue fibers
* highest risk of transformation to AML
* Tx: palliative, thalidomide, JAK2 inhibitors (ruxolitinib), stem cell transplant
122
Classical MPN-Primary myelofibrosis-clinical features
* anemia, abnormal platelets and wbc
* fatigue, weight loss, fever "B" symptoms
* splenomegaly
* leukoerythroblastic blood smear
* bone marrow fibrosis
123
Classical MPN-Primary myelofibrosis-morphology
* CD34+ --\>circulating stem cells escaped from marrow
* smear:
* teardrop forms
* nucleated RBCs
* left shifted granulocytes
[](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=IOPZardMoCTv4M&tbnid=BUyBcG-_ynAg8M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.pubcan.org%2Fimage.php%3Fid%3D2050&ei=CbARUezQM8yC0QGq-4HIDQ&bvm=bv.41934586,d.dmQ&psig=AFQjCNFA9xACGJIJ-RfwINlKq77ylfPZEw&ust=1360200048427003)
* bm biopsy:
* abnormal megakaryocytes
* intrasinusoidal hematopoeisis
* osteosclerosis
124
p53 vs Rb phosphorylation
* when p53 is phosphorylated = do not enter cell cycle
* when Rb is phosphorylated = enter cell cycle
125
4 key effects of chemotherapy
1. damage DNA
2. inhibit DNA synthesis
3. inhibit DNA replication
4. inhibit mitosis
126
4 reasons cancer cells are susceptible to chemo
1. contain mutations
2. have impaired DNA repair mechanisms
3. are addicted to specific signals
4. divide regularly
127
Log-kill model
* cell kill is proportional to tumor mass
* chemo killing follows first order kinetics
* single dose won't affect noncycling cells'
* probably true for small tumors but not in large:
1. cumulative toxicity
2. tumor heterogeneity
3. development of resistance (by the time enough doses delivered)
128
Norton-Simon hypothesis
* cell-kill is a function of tumor growth rate
* fast tumors = large % kill
* indicates dose dense therapy
[](http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=nkoVkRvEVYnElM&tbnid=KAMhwfI9vslENM:&ved=&url=http%3A%2F%2Fopeni.nlm.nih.gov%2Fdetailedresult.php%3Fimg%3D1064124_bcr1007-1%26query%3Dthe%26fields%3Dall%26favor%3Dnone%26it%3Dnone%26sub%3Dnone%26uniq%3D0%26sp%3Dnone%26req%3D4%26simCollection%3D468678_bcr909-1%26npos%3D11%26prt%3D3&ei=jrQRUZ2qNeiv0AGruoCYDQ&bvm=bv.41934586,d.dmQ&psig=AFQjCNFyYcNsBO0L8pzDn8WAHk5pYKGoIw&ust=1360201231658056)
129
Gompertzian growth
exponential growth of cancer cells cannot go on forever
130
Modes of chemo drug resistance
* intrinsic
* sanctuary sites
* chemical properties
* acquired
* multidrug resistance
* enhanced DNA repair
* mutation of drug targets
131
Acquired resistance- MDR
mediated by p-glycoprotein (ATP pumps that remove drugs from cells)
132
Acquired resistance- Enhanced DNA Repair
* mediated via enzymes that repair damaged DNA
* AGT:
* PARP1
* XCCR1: base excision repair
* cisplatin: DNA excision repair
133
Acquired resistance- alteration of drug targets
drugs that target receptors or enzymes are most prone b/c of gatekeeper mutations in tk's that can up/down regulate enzymatic targets
134
Pharmacologic Sanctuaries
* hard to reach tissues via transport constraint
* brain/testis
* high intratumor pressure --\> dense tumor stroma
135
Goldie-Coldman Hypothesis
* likelihood that drug-resistant cancer cells are present at diagnosis
* suggests:
* multidrug treatment
* short dose tiem
* early in cancer is better
136
Chemotherapy Classes
1. direct DNA damaging agents (cross linkers, alkylators, intercalators) --\> **S phase**
2. inhibitors of chromatin remodeling (topoisomerase I and II inhibitors) --\> **S phase**
3. inhibitors of DNA synthesis (pyridine analogs) --\> **S phase**
4. tubulin interactive drugs (microtubule stablizers/destabilizers) --\> **M phase**
137
Direct DNA Damaging Agents; Cross-linkers-Cisplatin
* stable in aqueous environments with chlrodie
* binds DNA in cell and forms adducts (b/c of low chloride instability)
* cell cycle arrest and apoptosis
138
Resistance
Direct DNA Damaging Agents; Cross-linkers-Cisplatin
1. decreased cellular drug uptake
2. reactive platinum species bind to thiol containing proteins
3. enhanced repair of DNA adducts
4. tolerance of DNA adducts
139
Direct DNA Damaging Agents; Alkylating Agents
-Cyclophosphamide & Ifosfamide
* mustard derivatives
* pro-drugs --\> cytotoxic after hydroxylation by cytochrome p450 and breakdown to phosphoramide mustard and acrolein
* phosphoramide mustard reacts with DNA
140
Resistance
Direct DNA Damaging Agents; Alkylating Agents
-Cyclophosphamide & Ifosfamide
* DNA repair enzymes
* decreased cellular permeability
* reaction of drug with thiols like glutathione
141
Inhibitors of chromatin remodeling-Topoisomerase II Inhibitors-Doxo**rubicin**
* natural anthracylcine antibiotic
* enters nucleus and binds DNA --\> intercalation of multiple molecules results in a "knot" topoisomerase cannot unwind --\> inhibition
142
Inhibitors of chromatin remodeling-Topoisomerase I inhibitors-Topo**tecan** & Irino**tecan**
* S-phase specific
* binds enzyme-DNA complex prevents re-ligation of single strand breaks
143
Resistance
Inhibitors of chromatin remodeling-Topoisomerase inhibitors
* P-glycoprotein
* membrane pumps
* detoxifciation with glutathione
* decreased expression/mutation of topoisomerase
* enhanced DNA repair
* decreased metabolic conversion of drug
144
Inhibitors of DNA synthesis- pyridine analogs
* 5FU --\> competes with uridine for binding to TS (thymidylate synthase) --\> thymidine not synthesized --\> DNA replication stop --\> S phase arrest
* methotrexate --\> impairs production of dihydrofolate reductase --\> no tetrahydfolic acid precursor for TS--\> DNA replication stop --\> S phase arrest
145
Resistance
Inhibitors of DNA synthesis-pyridine analogs-methotrexate
* decreased cellular transport
* cellular efflux pumps
* decreased polyglutamylation
* increased polyglutamate hydrolases
* increase in DHFR gene copy number
*
146
Tubulin interactive drugs-microtubule stabilizers-**taxanes**
* Paclitaxel --\> binds B tubulin--\> no depolymerization --\> inhibition of DNA synthesis --\> mitotic block at anaphase --\> apoptosis
147
Tubulin interactive drugs-microtubule destabilizers-**vincas**
* prevent formation of microtubules
148
Resistance
Tubulin interactive drugs-microtubule stabilizers-taxanes-paclitaxel
* P-glycoprotein
* microtubule associated proteins (MAPS) which impair binding of taxanes to tubulin
149
Resistance
Tubulin interactive drugs-microtubule destabilizers-vincas
* Efflux by P-glycoprotein
* tubulin mutations
* altered expression of tubulin isoforms
150
Inhibition of angiogenesis
* Bevacizumab blocks VEGF--\> no vascular proliferation,permeability, and reduced upregulation of antiapoptosis
* mTOR inhibitors --\> block hypoxia inducible factors --\> reduce VEGF production
* tk inhibitors --\> block VEGF 1/2 receptors vascular endothelial cells
151
Anti-CTLA4 drug and mechanism
Ipulimumab: blocks CTLA4 --\> upregulates T cell activation
*metastatic melanoma*
152
Anti-SERM (selective estrogen receptor modulator) drug and mechanism
Tamoxifen
*breast cancer*
153
Anti-CD20 drug and mechanism
Rituximab: targets mature B cells --\> depletion and immune suppression
154
Anti-HER1/2 drug and mechanism
Trastuzumab: blocks epidermial growth factor receptors
*breast cancer*
155
Anti-c-abl/c-kit/tk inhibitor and mechanism
Imatinib/Gleevac: high specificity for BCR-ABK receptor --\> arrest of growth and apoptosis
*CML*
156
anti-VEGF drug and mechanism
Bevacizumab: binds VEGF --\> reduces angiogenesis
157
Stem cell classes
* totipotent = germ cells
* pluri = stem cells, induced
* uni/oligo = hematopoeitic
158
TPO mimetics
Romiplostim and Eltrombopag
* stimultae megakaryocyte proliferation and differentiation
159
Fanconi Anemia
* recessive xlinked disorder of DNA repair
* ID: pancytopenia, congenital abnormalities, MDS/AML, bm failure
* Dx: DEB/MMC cross link test
160
Dyskeratosis Congenita
* telomeric
* ID: pancytopenia, leukoplakia, bone marrow failure, nail dystrophy, pigmentation
161
Diamond Blackfan Anemia
* autosomal dominant ribosomopathy
* ID: red cell aplasia, congenital abnormalities
* Dx: red cell adenosine deaminase
162
How do we distinguish acquired from inherited bone marrow failure?
1. no congenital abnormalities
2. repsonsive to immunosuppression
3. not heritable
4. low risk of transformation
163
Hairy Cell Leukemia
* NHL B **CD103/CD25/CD11c**/**ANXA1/Cyclin D1 (pl-binding protein)**
* infiltration of spleen, bm, liver, but not lymph nodes
* ID: pancytopenia, splenomegaly, fried egg cytology
*
164
Which HCLv have the worst prognosis?
those with IGHV4-34
165
What genetic lesion is implicated in HCL?
**BRAF V600E-**-\>MAP kinase pathway to cell proliferation
166
Main BRAF inhibitor
Vemurafenib
