Waqas A. Gill Pathophysiology Exam 2 - Review Ch.

6 Cell Death Know the 4 types of injuries to tissues o Adaptation: Change in a cell structure or function in response to changes in the Environment, meaning the following changes are revertible: i. Physiological: Inc. in size & # of cells (Ex. Uterine changes during pregnancy) ii. Pathological: Temporary inc. in size of myocardial (heart) cells (Ex. High BP) o Cell Injury: Caused by any factor that alters cellular structures, like physical injury of the body, which leads to deprivation of O2 or nutrients: Reversible injury (Sub-lethal) & Irreversible injury (Lethal) Classifications: Chemical, Hypoxic (Lack of O2), Free Radical (Oxidative stress or ROS), Unintentional, Intentional, Infectious agents, Inflammatory o Ageing: Long-term effects on cells, where general processes, including those that help repair and maintain the cell, begin to slow down over time. o Cell Death: Injured cells must repair or die. The 3 forms of cell-death are: i. Apoptosis: Programmed cell-death (during development) Cell-shrinkage, budding, Caspases, p53) a. Nuclear: Nuclear/Chromatin margination, non-random DNA cleavage b. Cellular: Shrinkage, apoptotic bodies, membrane-upkeep, budding c. Biochemical: Caspases/p53/Cyto-C release, ATP upkeep, no inflame Cytochrome-C is a mitochondrial protein that activates Caspase in the presence of ATP (which is why Cyto-C is found in Apoptosis, not Necrosis). ii. Necrosis: Tissue-death (cell/organelle-swelling, loss of membrane integrity) Once Mito function is lost & ATP-levels fall (>30%), the cell will auto-switch from Apoptosis Necrosis (aka Oncosis). Na+/K+ pumps will fail, thus causing an imbalance of concentration gradient so that H2O/Ca2+ will follow Na+ into the cell (cell-swelling). Swelling of ER/Mito, Blebbing w/out budding, no caspases, high intracellular Ca2+ levels (activates proteases), and has inflammation. iii. Autophagy: Cellular self-eating (induced by metabolic stress/starvation) Toxicant-dependent: Ca2+ changes, Oxidants, Cisplatin, Cyclosporine Beclin-1: Facilitates formation of autosome by regulating P13K Measurements: Morph (what it looks like) & Biochemical (how its activated): a. Morphological: Cell-size, Plasma-membrane integrity (wall-strength), and Organellemembrane (mitochondria & nucleus) integrity. b. Biochemical: Leakage of intracellular enzymes & activation of proteins (caspases, p53, proteases).

Know what cellular adaptation is, different types of cellular adaptation, and examples: o The ability of our cells to adapt to environmental changes to induce better protection & response to injury & abnormalities. i. Atrophy: Dec. in cell size (Malnutrition - less ER/Mito, and acidosis) Acidosis: Lactic acid, O2/CO2 imbalance, lysosomal ruptures ii. Hypertrophy: Inc. in cell size (opposite of , Muscle, kidney, heart) Signals: Mechanical (stretch) & Trophic (growth hormones) iii. Hyperplasia: Inc. in cell # - Type of dysplasia (Skin/liver calluses) Multi-step processes of inc. cellular division & synthesis i. Compensatory: Allows healing (Ex. 70% liver-regeneration) Prometheus - Greek myth of eagle eating liver daily. ii. Hormonal: Physiological in estrogen-dependent organs Ex. Breast-size inc. during pregnancy/puberty iii. Pathological: Abnormal inc. of cells, receptors, menstruation Ex. Benign prostrate hyperplasia (BPH) iv. Metaplasia: Reversible replacement of one mature cell by another less Mature/differentiated cell (mixture of cells). Signal-dependent, potentially cancerous, & re-programs cells v. Dysplasia: Abnormal change in cell size, shape, org. (like hyperplasia) Usually found in epithelial cells, close to cancer cells. Know the general types of cellular injuries and examples of each General Mechanisms: Less ATP, reactive O2 species, Ca2+/permeability alteration i. Hypoxia: Lack of O2 (less air/Hb/RBCs, respiratory disease, Mito. Dysfunction, less ATPedema) Ischemia (Dec. blood flow clots/edema) & Anoxia (No blood flow) Cellular responses: a) Dec. in ATP Failure of Na+/K+ pumps and Na+/Ca2+- exchange b) Cellular swelling Inc. osmolarity of cells (pulls in more H2O) c) Reperfusion Injury Oxidative-stress damage caused by the flow of nonoxygenated blood to tissues, followed by a surge of O2-rich blood. ii. Infection: Microbial Pathogenicity (virulence) & Disease-producing potential: Invasion/destruction, Toxin-production, & Hypersensitivity reactions. iii. Chemical: Induced by all chemicals (drugs) which can lead to injury (its all about dosage/time): Toxicology: Exposure to low doses (Autophagy & Apoptosis), high doses (Necrosis) Begins w/ biochemical interaction b/w chemical & membrane (active/passive) which is what sets it apart from Hypoxia (begins with dec. in ATP levels). Mechanisms: Direct toxicity (organelles) & Indirect toxicity (free-radicals) Defense: Cyto-P450 Monooxygenase (ER Bioactivation & Detoxification) Offense: CCl4 CCl3 + O2, where although its not oxidative, CCl3 its still a strong radical that can induce liver damage Dec. pH Auto-digestion. iv. Genetic factors: Nuclear or structural alterations (Ex. Sickle-cell anemia, DMD)

v.

Free-radical (ROS): Electrically uncharged (group of) atom(s) w/ unpaired electrons Induce Oxidative-stress (Lipid peroxidation, alternation of DNA & proteins) Unpaired e- causes instability, so it is either given away or paired with another ROS-formation follows: Initiation, Propagation, Termination Common radicals: O2- & ONOO-, OH Free radicals are always present, and terminated w/ anti-oxidants.

Know the mechanisms by which free radicals induce injury and how they are terminated

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Know the differences between apoptosis, autophagy and necrosis, including differences in nuclear, cellular and biochemical characteristics Apoptosis Can affect single cells Decrease in cell size (shrinkage) Necrosis Affects multiple cells Increases in cell size (swelling) Organelle function lost early Plasma membrane integrity lost early Organelle membrane integrity lost early Nuclear structure changes (shrinks) Blebs form with no organelles No chromatin margination Random DNA cleavage Loss of no intracellular contents Inflammation No phagocytosis No caspase activation No PARP cleavage No TUNEL staining Autophagosis

Organelle function maintained late Plasma membrane integrity maintained until later phases Organelle membrane integrity maintained until later phases Nucleus dissolves Blebs form with organelles Chromatin margination Non-random DNA cleavage Little loss of intracellular contents No inflammation Phagocytosis Caspase activation PARP cleavage TUNEL staining

Know the mechanisms involved in autophagy, apoptosis, and necrosis If the injury is severe enough, cells will die. Theres 3 ways of dying, however, cell-death leads to tissue-death, which is always called Necrosis. 1. Autophagy: Auto-digestion caused by the rupture of lysosomes. This mechanism is cell/toxicantdependent (Ca2+, oxidants, cisplatin, cyclosporine) 2. Apoptosis: (Initiation) Intrinsic mechanisms are activated by cell injury, like DNA lesions, which activate P53, leading to minor pores in the mitochondria. These pores allow Ca2+ and Cytochrome-C to

enter the Cytosol, where it will activate Caspase-9, which will begin to cleave proteins throughout the cytosol, exponentially. Extrinsic mechanisms involve an external signal, like TNF, that binds to an extracellular receptor, and activates intracellular Caspase-8, which progresses to cleave cytosolic proteins. (Execution & Phagocytosis) Cleavage of DNA will be induced by a Caspase who activates DNase by removing its
inhibitor. The DNase will cleave DNA at regular intervals of 180 base-pairs.

Cleavage of the cytoskeleton occurs through Caspase-3, which targets actin fibers, thus causing the cell to lose its structural integrity. Once this happens, the cell can begin blebbing with budding, where mitochondria and DNA will fall into these apoptotic bodies (vesicles) as they bud off of the cell, small enough for phagocytes to digest them. This budding process is completed at a slow but steady rate to avoid inflammation in nearby cells and tissue.

3. Necrosis: The resultant mechanism of death once ATP levels decline over 30%.Generally, the presence of cell-membrane damage will always lead to Necrosis. Necrosis is characterized by the premature death of cells, thus making it more fatal in most cases. Biochemically, it is understood as the cell failing to maintain ion homeostasis, usually due to lowered levels of O2 and ATP. Loss of ER and mitochondrial function lead to lower levels of ATP, which lowers Na+/K+-pump activity as well. This leaves Na+ in the cell, thus causing an influx of H2O/Ca2+ into the cell due to the increased osmolarity. This influx of water leads to cellular swelling and membrane rupture. Increased Ca2+ levels lead to the activation of Proteases, which go on to damage cell membranes, cytoskeletal components, and nuclear chromatids. As the structural integrity is lost early on, the cell will begin blebbing, but will not bud. Eventually, after organelles have been deactivated, the plasma membrane will eventually lyse, releasing all cellular contents into the cytosol at once, thus leading to inflammation of the cell. (Control) (Apoptosis) (Necrosis)

(Apoptosis & Necrosis)

Understand the role of caspases, p53 and Ca2+ in cell death o Caspases: Family of cysteine proteases crucial to Apoptosis that has 15 members in 3 groups: Initiator: Caspase-2, 8, 9, 10, 12 (Activate executioner-cascade through: Intrinsic pathway: Mito, ER, or Nuclear-mediated Extrinsic pathway: Receptor mediated Executioner (downstream): Caspase-3, 6, 7 Cytokine: Caspase-1, 4, 5, 13, 14 o P53: Tumor-suppressor protein that mediates cellular processes (growth, death, cycle) Induce Caspases in response to nuclear damage & regulates apoptosis: Help promote apoptotic cell-death, which is why >50% of human cancers are found to have mutated P53 proteins, meaning that Apoptosis is more difficult to undergo in cancerous cells. 2+ o Ca : Necrotic death used to be associated with Ca2+-overload, not to mention, several Apoptotic functions have been found to be dependent on Ca2+-signaling. Know the differences in the types of necrotic tissues discussed and examples of each. i. Coagulative: In response to hypoxia, protein-denaturation (kidney & heart) ii. Liquefactive necrosis: From ischemia (neural cells), soft, liquefies (E.Coli, Strep) iii. Caseous necrosis: TB pulmonary infection, combines Coagulative & Liquefactive Dead cells disintegrate, but not digested (soft & granular, like clumped-cheese) iv. Fat Necrosis: Abdominal organs appear chalky-white as lipases breakdown triglycerides and release fatty0-acids, so that the acids may recombine w/ Ca2+, Mg2+, and Na+ to form soaps. v. Gangrenous Necrosis: Death of tissue from severe hypoxia, as a result of arteriosclerosis & arterial obstruction. Dry Gangrene: Coagulative & Wet Gangrene: Neutrophil-driven Liquefactive necrosis (Coagulative) (Liquefactive) (Caseous)

(Fat)

(Gangrenous)

Ch. 11 Biology of Cancer (Dr. Raj Govindarajan) What is a tumor? Know the differences between benign and metastasized tumors. o A tumor is essentially a new growth (neoplasm) i. Malignant: Rapid, non-encapsulated, invasive growth that is poorly differentiated with a high mitotic index, meaning that it can spread over long distances (metastasize) ii. Benign: Slow, encapsulated, non-invasive growth that is well differentiated with a low mitotic index, meaning that it cannot spread over long distances (metastasize) Know tumor nomenclature for both benign and metastasized tumors. o Benign: Named based on the tissues that they come from, ending in oma. Lipoma (lipids), Hepatoma (Liver), Osteoma (Bones), Myoma (Muscles) o Metastasis: Also named based on the tissues that they come from, but w/ some exceptions Epithelial (Carcinoma), Connective (Sarcoma), Lymphatic (Lymphoma), Blood (Leukemia Carcinoma in situ (CIS): Pre-invasive epithelial malignant tumors that are still in-place, meaning they havent broken the basement membrane and spread to other tissues just yet. This is the earliest detectable type of growth, for Dysplasia is mutated, but its too small.

(Control)

(Benign differentiated Cell w/ irregular lumen & multiple rows of cells)

(Malignant, well Differentiated tumor Membrane has been Broken)

(Poorly differentiated malignant tumor, with no clear basement membrane)

(Completely undifferentiated, Anaplastic cell, meaning its Original cell cant be traced)

(Benign tumor)

Normal Adult Stem cells vs. Cancer stem cells: Stem-cell Properties: i. The capacity to self-renew (daughter-cell maturing to main cell in case main cell dies) ii. Its unlimited potential to become any terminally differentiated cell. Undifferentiated cells that can be manipulated to mature into a particular cell. o All cells have a small percentage of dormant stem-cells in case of cell-injury, in which case they will begin to differentiate to regenerate the tissue. Cancer stem-cell are the dormant stem-cells of a cancer-infected cell. We do not know whether cancer takes over a cells stem-cells, or if it induces the synthesis of its own, but what we do know are particular properties related to these cancerrelated stem cells, regardless of where they originated from. They are: Extremely resistant to chemotherapeutic agents, so while the therapy may potentially kill 99.9% of cancerous cells, these 0.1% of cancer stem-cells will survive, and over the course of a few months, can potentially repopulate the entire tumor with fresh cancer cells! This is why targeting these particular cancer stem-cells has become a key goal in Oncology. Understand what a tumor cell marker is and how its used. o Biological markers/substances produced by cancer cells & found on cell membranes, blood, CSF, or urine (Ex. Hormones, enzymes, genes, & antigens). o These markers are used to identify, diagnose, & observe the course of tumors. Understand what must go wrong in order for a tumor to form (genes, signaling) o Cancerous tumors are predominantly caused by ageing cells (most cancers are in older generations). o Cancerous properties include those that give selective advantages over its neighbors ( Apoptosis). o Gene Mutations: Can occur in an array of areas, such as: Growth factors To increase their mitotic index (rapid growth) Growth receptors To keep it in the On position (unregulated growth) Ras Signaling protein A ProtoOncogene that is mutated to increase triggering cell division Rb//P53 suppressor Tumor-suppressors that are mutated to lose their good-guy properties

Unregulated growth, similar to signal amplification Mutations of growth factors, suppressors, etc work together Tumor-growth is proportional to the # of mutations present. Invasive Carcinoma is what we would refer to as the cancer

Angiogenesis: Tumor-mechanism to induce the growth of new vessels from surrounding tissues to bum off of their O2 & nutrients.

6 Hallmarks of Cancer: Know these characteristics of what differentiates cancer-cell functions.

Hallmark combination 1: Shows 8 genes, 2 of which are the same, meaning those 2 genes will combine to help advance Metastasis. All 8 of these genes work together to exhibit the 6 cancerous traits depicted in the circular-diagram. Hallmark combination 5: Shows the opposite possibility, where only 5 genes will exhibit all 6 cancerous traits, since 1 of the genes has dual-traits (sustains angiogenesis & evades Apoptosis). Know the differences in Oncogenes, Tumor Suppressors, and Proto-genes: o Oncogenes: Mutant genes that Direct protein synthesis & cellular growth in their non-mutant state o Tumor-suppressors: Anti-Oncogenes Encode proteins that negatively regulate proliferation in their normal state o Proto-Oncogene: A normal, nonmutant gene that codes for cellular growth

2 sister-chromatids are combined through gene-translocation. The result of this was C-Myc & ABL proteins. The C-Myc is now under the control of another strong gene-promoter (immunoglobulin)Oncogene (blue) ABL is fused from 2 proteins: BCR + ABL ProtoOncogene Can now create more Oncogenes C-Myc: Gene is intact, promoter switched, whereas ACL: Fusion of 2 genes

Understand gene mutations: o Mutation of tumor-suppressor genes: P53 Allows unregulated cellular growth since Apoptosis has been suppressed. o Loss of heterozygosity: d Both chromosome copies of a gene are inactivated o Gene silencing Whole regions of chromosomes are shut off in some, but not all genes. 1st hit = The 1st mutation, which results in 1 mutated (blue) gene, and a normal sister-chromatid. This mutation is considered a reversible, heterozygous condition, since it can be repaired. 2nd hit = The 2nd mutation, which results in the loss of an entire genepair. This Loss of Heterozygosity (LOH) is bad, because you irreversibly lose the function of that gene. o Exposure to Mutagens: Somatic cells = Non-reproductive cell (22 of the 23 chromosomal-pairs are somatic) May cause tumors in host-organism, but will not pass to next generation. Germline cells = Sex chromosome cells (sperm + oocytes) Vertical transmission Can transmit mutations to the next generation through meiosis.

Know that viruses can lead to cancer: o Hep-B/C, Epstein-Barr (EBV), Kaposi sarcoma herpes (KSHV), T-cell Leukemia (HTLV) o HPV Horizontal, sexual transmission of Human Papillomavirus from one person to another Bacterially induced cancers: o Helicobacter Pylori (H. pylori): Chronic infections associated with: Peptic ulcers, stomach carcinoma, and Lymphoma of the mucosal region Gene vs. Environmental factors affecting Cancer progression: o Factors leading to the emergence of cancer are dependent on location, environment, and gene history.

Understand the role of inflammation in cancer. o Inflammation can lead to the release of cytokines & growth-hormones that will stimulate cellproliferation, along with radical-formation. o These mechanisms, although beneficial under normal conditions, will aid the cancerous growth in metastasizing even further. Understand risk factors and the cancer types given: The best way to reduce risk is physical activity.
o Tobacco: Multipotent carcinogenic mixture linked to cancers of the lung, lower urinary tract, aerodigestive tract, liver, kidney, pancreas, cervix, uteri, and myeloid leukemia. The nicotine gets absorbed into the blood, forcing organs like the kidneys and liver to work harder and become exposed, increasing those organs chances for developing cancer. Radiation: X-rays, radioisotopes, Gamma-rays Exposure to these emissions has commonly caused cell-death & mutations in the past. Alter gap-junction intracellular communication, leading to depressed info exchange.

o o o

UV-radiation: Caused basal-cell carcinoma, squamous-cell, and melanoma UV-A: shorter frequency/longer wavelength (Much more invasive and dangerous) UV-B: longer frequency/shorter wavelength (Much less invasive & easy to fix) Alcohol consumption: Converted to Acetyl-Aldehydes (acidic) in the body Create RoSs, and increase the chances for oral, throat, and liver cancers. Occupational hazards: Carcinogenic agents Asbestos, dyes, rubber, paint (lead), explosives, heavy metals, air-pollution, Radon Diet: Xenobiotics Toxic, mutagenic, and carcinogenic chemicals that we obtain from cooking fat, meat, & proteins. Activation: Phase-I activation enzymes ; Defense: Phase-II detox enzymes Obesity: Correlates with our BMI, and can lead to Hyperinsulinemia, which is a condition where the increased free-floating fatty-acids cause give rise to the amount of insulin the body Imbalance of proteins This can give way to colon, breast, pancreatic, & endometrial cancers.

Depicts the interconnectedness of environmental factors and their effects on the body and its internal mechanisms.

Ch. 12 Metastasis & Tumor Spread (Dr. Raj Govindarajan) Know what invasion/tumor spread is and its mechanisms. o Direct: Known as local spread of contiguous organs Local Spread of malignant neoplasms that enter the thin-walled Lymph vessels (easy) + blood vessels. This process may lead to the spread of metastatic tumors in several organs (liver, lungs) but not kidneys, due to the lack of CXCL12 receptors (some preference there). 3 Step Theory i. Tumor-cell attachment: a. Fibronectin/Laminin: Substances that help break down the basement membrane ii. Degradation of the Matrix: Lytic enzymes a. Enzymes: Help create pores to exit from iii. Locomotion into the Matrix: a. Invadopodia: Foot-like projections o Metastasis: Spread of cancer cells to adjacent and distant sites through the lymph and blood supply. Implantation: A very rare form of metastatic spread induced by cross-contamination of other tissues during surgical procedures or biopsies. Phases of Tumor spread: i. Transformation: The process by which a cell is converted into a tumor-cell. ii. Growth: The progression of a single-cell becoming a clinically detectable mass This growth takes about 30 doublings to become a detectable 1 gram cell. iii. Local invasion: Proliferation of genetically unstable cells as they accumulate rapid/random mutations and invade local or adjacent cells. iv. Distant metastasis: Tumor growth of heterogeneous cells along with metastasis. o Anoikis: A specialized form of Apoptosis, where cell-death is due to the loss of attachment. When normal cells are detached, they usually die by Anoikis, but cancer-cells evade this process, just like they evade Apoptosis. Know the mechanisms how neoplastic cells survive during metastasis. o Neoplastic/Tumor cells mutated P53 proteins not only allow them to avoid Apoptosis and Anoikis, but the mutations that it obtains over time are geared towards adapting to Hypoxic environments, so even though tumors will eventually Angiogenerate their way to nutrition, they are designed to thrive in uninhabitable conditions, thus aiding in their survival during metastasis. o They release certain lytic enzymes that help them get into the lymph and blood vessels, so that they can journey to almost any part of the body and find more suitable conditions. .

Know tumor staging nomenclature. o Involves the size of the tumor, degree to which it has invaded, and the extent to which it has spread

i. ii. iii. iv.

Stage 1: Cancer is confined to its organ-of-origin Stage 2: Locally invasive Stage 3: Regional structures Stage 4: Distant sites

Know the clinical symptoms of cancer. o Pain: Not associated with early stages of cancer, which is why its harder to detect. Influences: Fear, anxiety, sleep-loss, fatigue, and muscle loss. Causes: Pressure, obstruction, invasion, stretching, tissue-destruction, inflammation. o Fatigue: Tiredness, weakness, inability to concentrate, lack of motivation Causes: Sleep disturbance, cytokines, nutrition, environment, level of activity o Cachexia: Most severe form of malnutrition, present in 80% of cancer patients at death. Includes: Anorexia, anemia, asthenia, taste alterations, altered bodily metabolism. o Anemia: A decrease in blood-Hb (hemoglobin) levels Mechanism: Chronic bleeding (Fe2+-deficiency), malnutrition, & malignancy in organs. o Leukopenia & Thrombocytopenia: Direct tumor-invasion to the bone-marrow Causes: Leukopenia/Thrombocytopenia, & worse because chemotherapy is toxic to marrow. o Paraneoplastic Syndrome: Headaches, migraines, etc (non-definitive symptoms) Symptom-complexes that cannot be explained by local/distant spread of the tumor or by the effects of hormones released by the tissue from which the tumor arose o Infection: Risk increases as Neutrophil and Lymphocyte (WBCs) counts drop. Know the different types of general treatments for cancer and their targets. o Chemotherapy: The use of non-selective cytotoxic drugs that are used to target both cancer-cells and normal cells metabolic pathways, cell-growth, and replication. Goal: To kill enough tumor cells, so that the bodys immune-system can take care of the rest. Compartments: 1. Mitosis & Cytokinesis: Usually takes a day, but happens quicker when cancerous o Targeting tubulin formation would be one way of inhibiting mitosis. 2. Cells enter G1 phase:

3. Non-dividing cells: Highly specialized, differentiated cell that will die a natural death Mechanism: Initial exposure to Chemo usually quickly kills the bulk of cancerous cells, but small % of resistant cells will survive.. Problems: The small percentage of surviving resistant cancer cells has the potential to repopulate the entire tumor. Types of Chemotherapy: i. Single-agent chemotherapy: Will usually have the largest impact, initially ii. Combination chemotherapy: Helps with countering resistance development. iii. Principle of dose intensity: Toxicity is an important factor to consider. iv. Therapeutic index: Narrow range of maximal effectiveness vs. minimal toxicity v. Neoadjuvant chemotherapy: Primary chemo used before surgery to help reduce the bulk to make the surgical removal of tissue easier.

o Ionizing radiation: Aids in damaging the cancer cells DNA Goals: Eliminate cancer w/out excessive toxicity & avoid damage to normal structures. o Surgery: Biopsy & Lymph-node sampling (sentinel nodes __ ) Debulking or Palliative surgery o Hormone-therapy: Interferes w/ cell-growth and signaling Through the activation or inhibition of certain receptors. o Immunotherapy: In theory, the best way to eradicate tumors Anti-tumor responses are made to selectively kill cancer cells, while sparing normal cells. Meaning you have selectivity, but not as much efficacy, which can be a bad trade-off. Immune-memory is long lived, which is not that useful in cancer treatments, since cancers are rarely the same when you come back for the 2nd round of treatment. Numerous immunologic mechanisms are capable of rejecting different types of cancer Biologic response modifiers (BRMs) o Cancer Side Effects: Gastrointestinal tract Bone marrow Hair and skin Reproductive tract

(Combination Chemotherapy)