PATHOLOGY OF TUMOURS PART 3

1. PATHOLOGY OF TUMOURS PART 3 GRADING AND STAGING PROGNOSIS

2. PROGNOSIS THE PREDICTION OF FUTURE PROGRESS OF A DISEASE OR TUMOUR

3. PROGNOSIS • BENIGN TUMOURS – GENERALLY GOOD….. • BUT DEPENDS ON SITE, TYPE ETC • MALIGNANT TUMOURS • SITE • e.g. visceral versus superficial • 2. INHERENT NATURE OF THE TUMOUR • PROGNOSIS ACCORDING TO THESE TWO • FACTORS DEPENDS ON:- • PAST EXPERIENCE OF • EACH TYPE OF TUMOUR

4. MENINGIOMA – A FAIRLY BENIGN TUMOUR ARISING FROM THE DURA. PRODUCES SYMPTOMS ACCORDING TO THE REGION OF THE BRAIN IN WHICH IT ARISES. CAN BE FATAL AS IT IS A “SOL”

5. BENIGN MENINGIOMA – DIAGRAM TO ILLUSTRATE HOW THE TUMOUR ERODES BONE BY PRESSURE ATROPHY AND COMPRESSES THE UNDRELYING BRAIN RAISED INTRA-CRANIAL PRESSURE

6. BENIGN HAEMANGIOMA OF THE LIVER – THE COMMONEST BENIGN TUMOUR OF THE LIVER – CAN BLEED SEVERELY DUE TO MINOR TRAUMA TO THE ABDOMEN

7. BENIGN LEIOMYOMA OF THE SMALL BOWEL – CAN CAUSE INTESTINAL OBSTRUCTION AND OFTEN BECOMES MALIGNANT ( c.f. UTERINE FIBROID)

8. BENIGN ADENOMA OF THE PARATHYROID GLAND. CAUSES SEVERE METABOLIC DERANGEMENTS WHICH CAN BE FATAL PARATHYOID ADENOMA NORMAL PARATHYROID GLAND

9. CALCIUM DEPOSITED IN THE INTERSTITIUM OF THE KIDNEY NEPHROCALCINOSIS

10. PROGNOSIS • OVERALL PROGNOSIS DEPENDS ON 3 FACTORS:- • GROWTH - • RAPID GROWTH = BAD PROGNOSIS • 2. EXTENT – • THIS FORMS THE BASIS OF – • THE “TNM” CLINICAL STAGING • OF TUMOURS • a. SIZE OF PRIMARY TUMOUR T0-4 • WHERE T0 = IN SITU MALIGNANCY • b. LYMPH NODE SPREAD N0-3 • c. DISTANT METASTASES – M0-4 • 3. DIFFERENTIATION – HISTOLOGICAL GRADE

11. PROGNOSIS THE CLINICAL STAGING OF TUMOURS a. SIZE OF PRIMARY TUMOUR - T0-4 WHERE T0 = IN SITU MALIGNANCY b. PRESENCE/ABSENCE OF LYMPH NODE INVOLVEMENT – N0-3 c. PRESENCE/ABSENCE OF METASTASES –M0-4

12. HISTOLOGICAL GRADE • OF THE TUMOUR REFERS TO THE • TISSUE AND CELLULAR DIFFERENTIATION • WELL DIFERENTIATED • 2. MODERATELY DIFFERENTIATED • 3. POORLY DIFFERENTIATED

13. 3) Tumour Grading • Measure of prognosis • Example of breast cancer: • A) Glandular differentiation • B) Cellular pleomorphism • C) Mitotic activity (per 10 HPF) • Scored as 3 – 9 • = (modified) Bloom & Richardson grading

14. DIFFERENTIATION IN A SQUAMOUS CARCINOMA LIES IN THE TUMOUR’S ABILITY OR FAILURE TO FORM KERATIN

15. SQUAMOUS METAPLASIA IN BRONCHIAL MUCOSA

16. Mild dysplasia

17. Moderate dysplasia

18. Severe dysplasia / carcinoma in situ

19. CIN III/SEVERE DYSPLASIA  CA-IN-SITU

20. SQUAMOUS CARCINOMA IN SITU – i.e. CONFINED BY THE BASEMENT MEMBRANE

21. WHEN THE TUMOUR CELLS BREAK THROUGH THE BASEMENTMEMBRANE THEY FORM CORDS OF CELLS INFILTRATING THE UNDERLYING STROMA

22. Text IN WELL-DIFFERENTIATED TUMOURS THE CELLS ARE ABLE TO PRODUCE KERATIN SEEN HERE AS PINK MATERIAL WITHIN A SPIRAL ARRANGEMENT CALLED A “KERATIN PEARL”

23. CONCENTRIC LAYERS OF KERATIN-CINTAINING CELLS IN A WELL- DIFFERENTIATED SQUAMOUS CARCINOMA

24. AS THE TUMOUR BECOMES LESS WELL DIFFERENTIATED ONLY SOME OF THE CELLS SHOW KERATIN FORMATION AND-INTER-CELLULAR BRIDGE FORMATION

25. POORLY OR UNDIFFERENTIATED TUMOURS, WHETHER SQUAMOUS OR GLANDULAR IN ORIGIN CONSIST OF SHEETS OF UNDIFFERENTIATED CELLS WITH NUMEROUS AND OFTEN ABNORMAL MITOTIC FIGURES

26. IN ADENO-CARCINOMAS THE DEGREE OF GLANDULAR STRUCTURE FORMATION WILL DETERMINE THE DEGREE OF DIFFERENTIATION

27. ADENOCARCINOMA – THE GLANDULAR ACINI ARE WELL- FORMED IN THIS WELL DIFFERENTIATED TUMOUR

28. ANAPLASTIC CARCINOMA – i.e. POORLY OR UNDIFFERENTIATED TUMOUR WITH NUMEROUS MITOTIC FIGURES ()

32. BREAST MASS EXCISED AT SURGERY. THE CUT SURFACE SHOWS THE TYPICAL YELLOWISH-WHITE TUMOUR TISSUE INFILTRATING THE SURROUNDING FIBRO-FATTY BREAST TISSUE

33. NORMAL BREAST TISSUE INFILTRATING CARCINOMA

34. FAIRLY SOLID SHEET OF TUMOUR CELLS WITH SOME DUCTAL DIFFERENTIATION

35. Tumour Grading

36. Staging • A uniform TNM system for staging cancer according to its anatomic extent at the time of diagnosis is extremely useful for many reasons, chiefly for comparing treatment results from different centres

37. 4) Tumour Staging • Measure of prognosis • TNM classfication T(umour size) N(ode numbers) M(etastasis) • [Dukes and Astler-Coller Large intestine – see later]

39. 5) Prognosis • Depends on grade and stage • Also tumour type – NB breast, lung, melanoma (very unpredictable) • Site VIP (superficial vs. deep visceral) • Immune status, nutrition, pain threshold, etc • (No evidence that “positive thinking,” homeopathy and miracles can cure cancer!!) • General principle, earlier/smaller tumours have better prognosis – therefore: • Importance of surveillance programs – PAP smears, mammography, PSA, colonoscopy

40. Local invasion Lymphatic spread Haematogenous Transcoelomic Implantation Fascial planes, ducts, Carcinoma. Permeation and embolisation. Retrograde spread Sarcomas. Early to lung Pleura, peritoneum, meninges. Example is Krukenberg tumour Rare due to good surgical practice Spread of Tumours

41. CARCINOMA • Majority (90%) of malignant tumours • Prevalence increases with age (cf sarcoma) • Variable geographic differences (cf sarcoma) • “ENVIRONMENTAL” (cf sarcoma) • NB. All epithelia have a basement membrane therefore • Always a defined “pre-malignant” phase • = DYSPLASIA (mild, moderate, severe)

42. PROGNOSIS OF A MALIGNANT TUMOUR

45. Text

46. ADENO-CARCINOMA SHOWING GLAND FORMATION

48. CIN III/SEVERE DYSPLASIA  CA-IN-SITU