Transcript PATHOLOGY OF TUMOURS PART 3

PATHOLOGY OF TUMOURS
PART 3
1. GRADING AND STAGING
2. PROGNOSIS
PROGNOSIS
THE PREDICTION OF
FUTURE PROGRESS
OF A DISEASE
OR TUMOUR
PROGNOSIS
1.BENIGN TUMOURS – GENERALLY GOOD…..
BUT DEPENDS ON SITE, TYPE ETC
2.MALIGNANT TUMOURS
1. 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
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”
BENIGN MENINGIOMA – DIAGRAM TO ILLUSTRATE HOW THE
TUMOUR ERODES BONE BY PRESSURE ATROPHY AND COMPRESSES
THE UNDRELYING BRAIN  RAISED INTRA-CRANIAL PRESSURE
BENIGN HAEMANGIOMA OF THE LIVER – THE COMMONEST BENIGN
TUMOUR OF THE LIVER – CAN BLEED SEVERELY DUE TO MINOR
TRAUMA TO THE ABDOMEN
BENIGN LEIOMYOMA OF THE SMALL BOWEL – CAN CAUSE INTESTINAL
OBSTRUCTION AND OFTEN BECOMES MALIGNANT
( c.f. UTERINE FIBROID)
BENIGN ADENOMA OF THE
PARATHYROID GLAND.
CAUSES SEVERE METABOLIC
DERANGEMENTS WHICH CAN
BE FATAL
PARATHYOID ADENOMA
NORMAL
PARATHYROID
GLAND
CALCIUM DEPOSITED IN THE
INTERSTITIUM OF THE KIDNEY
NEPHROCALCINOSIS
PROGNOSIS
OVERALL PROGNOSIS DEPENDS ON 3 FACTORS:1.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
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
HISTOLOGICAL GRADE
OF THE TUMOUR REFERS TO THE
TISSUE AND CELLULAR DIFFERENTIATION
1. WELL DIFERENTIATED
2. MODERATELY DIFFERENTIATED
3. POORLY DIFFERENTIATED
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
DIFFERENTIATION IN A SQUAMOUS CARCINOMA LIES IN
THE TUMOUR’S ABILITY OR FAILURE TO
FORM KERATIN
SQUAMOUS METAPLASIA IN BRONCHIAL MUCOSA
Mild dysplasia
Moderate dysplasia
Severe dysplasia / carcinoma in situ
CIN III/SEVERE DYSPLASIA  CA-IN-SITU
SQUAMOUS CARCINOMA IN SITU –
i.e. CONFINED BY THE BASEMENT MEMBRANE
WHEN THE TUMOUR CELLS BREAK THROUGH THE
BASEMENTMEMBRANE THEY FORM CORDS OF CELLS
INFILTRATING THE UNDERLYING STROMA
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”
CONCENTRIC LAYERS OF KERATIN-CINTAINING CELLS IN A WELLDIFFERENTIATED SQUAMOUS CARCINOMA
AS THE TUMOUR BECOMES LESS WELL DIFFERENTIATED ONLY SOME
OF THE CELLS SHOW
KERATIN FORMATION AND-INTER-CELLULAR BRIDGE FORMATION
POORLY OR UNDIFFERENTIATED TUMOURS, WHETHER SQUAMOUS OR
GLANDULAR IN ORIGIN CONSIST OF SHEETS OF UNDIFFERENTIATED CELLS
WITH NUMEROUS AND OFTEN ABNORMAL MITOTIC FIGURES
IN ADENO-CARCINOMAS THE DEGREE OF GLANDULAR STRUCTURE
FORMATION WILL DETERMINE THE DEGREE OF DIFFERENTIATION
ADENOCARCINOMA – THE GLANDULAR ACINI ARE
WELL- FORMED IN THIS WELL DIFFERENTIATED TUMOUR
ANAPLASTIC CARCINOMA – i.e. POORLY OR UNDIFFERENTIATED
TUMOUR WITH NUMEROUS MITOTIC FIGURES ()
BREAST MASS EXCISED AT SURGERY. THE CUT SURFACE SHOWS THE
TYPICAL YELLOWISH-WHITE TUMOUR TISSUE INFILTRATING THE
SURROUNDING FIBRO-FATTY BREAST TISSUE
NORMAL BREAST TISSUE
INFILTRATING CARCINOMA
FAIRLY SOLID SHEET OF TUMOUR CELLS
WITH SOME DUCTAL DIFFERENTIATION
Tumour Grading
Grade
Score
5-year survival (%)
7-year survival (%)
1
3–5
95
90
2
6–7
75
65
3
8-9
50
45
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
4) Tumour Staging
• Measure of prognosis
• TNM classfication
T(umour size)
N(ode numbers)
M(etastasis)
• [Dukes and Astler-Coller
Large intestine – see later]
STAGE
Definition
5-year % 7-year %
survival
survival
I
< 2cm without
nodal or regional
mets
96
92
II
> 2 < 5 cm with
+ve nodes OR >
5 cm without
nodes
81
71
III
Any size but with
fixation to skin,
chest wall, etc
52
39
IV
Tumour any size but distant
metastases
18
11
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
Spread of Tumours
• Local invasion
• Fascial planes, ducts,
• Lymphatic spread
• Carcinoma. Permeation and
embolisation. Retrograde spread
• Sarcomas. Early to lung
• Haematogenous
• Transcoelomic
• Pleura, peritoneum, meninges.
Example is Krukenberg tumour
• Implantation
• Rare due to good surgical
practice
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)
PROGNOSIS OF A MALIGNANT TUMOUR
Text
ADENO-CARCINOMA SHOWING GLAND FORMATION
CIN III/SEVERE DYSPLASIA  CA-IN-SITU