PATHOLOGY

I. INTRODUCTION, CELLULAR RESPONSES TO STRESS & TOXIC INSULTS

Pathology (Greek pathos = suffering, logos = study)

HISTOPATHOLOGY
Father of clinic-pathologic correlation Giovanni B. Morgagni
Father of museum in pathology John Hunter
Father of clinical pathology Paul. Ehrlich
Father of cellular pathology Rudolf Virchow
Father of blood transfusion Carl Landsteiner
Father of Exfoliative cytology George N. Papanicolaou

Stain/dye Tissue/cell/substance
Perl's stain, Prussian blue Sideroblast (iron, hemosiderin)
Alizarin red Calcium
Von kossa Mineralized bone
Rubeanic acid Copper
Masson Fontana Melanin
PAS Glycogen
Mucicarmine (Best's carmine) Acid mucin
Von Gieson's, Mason's trichrome Collagen
Phosphotungstic acid-Hematoxylin (PTAH) Muscle and glial filaments
Luxol fast blue Myelin
Bielschowsky's silver Axons
Grimehus Argyrophil cells
Oil Red O, Sudan black, Osmium tetroxide Lipid
Congo red, Thioflavin T and 5, Toluidine blue Amyloid
Acrydine orange, Methyl green-pyronine DNA & RNA

Stains for microorganisms

Fite-Wade Leprosy bacilli
Grocott's methanamine silver Fungi
Shikata's orciein Hepatitis B surface antigen

• Eosin is acidophilic and stains positively charged structures in the cell(mitochondria)

• Hematoxylin is basic and stains negatively charged structures like DNA and RNA
• 10% formalin is the preservative of specimens for Histopathological study

Fixatives
• Light microscopy - 10% neutral buffered formalin
• Electron microscopy - 4% gluteraldehyde

CELLULAR RESPONSES TO STRESS & TOXIC INSULTS

Metaplasia Dysplasia Anaplasia
• Replacement of one • Carcinoma in situ (dysplasia • Loss of differentiation
differentiated cell type by involving entire thickness of • Irreversible
another epithelium but intact • Loss of polarity
• Reversible basement membrane) • Hallmark of malignancy
• No loss of polarity • Reversible in early stages • Pleomorphism - high grade
• Reprogramming of stem cells • Loss of polarity (architectural • ↑↑Mitoses; Atypical mitotic
• Pleomorphism absent orientation) figures
• Most common epithelial • Pleomorphism - low grade • Hyperchromatic nuclei
metaplasia is columnar to • Hyperchromatic nuclei • Tumor giant cells
 squamous • ↑ mitoses; Typical mitotic
figures
• Does not necessarily progress
to cancer

• Presence of goblet cells in the non-respiratory terminal bronchioles (where they are normally absent) of a
chronic smoker is an example of Metaplasia
• increase in goblet cells in the main stem bronchus (where they are normally present) is an example of
Hyperplasia

Hyperplasia Hypertrophy
• Increase in cell number without increase in cell • Increase in cell size without increase in number
size • DNA content more than normal cells
• DNA content same as in normal cells • ↑in size is not due to cellular swelling, due to
• Due to growth factor driven proliferation of synthesize of more cellular proteins (↑ growth
mature cells factors)
• Associated with a switch of contractile proteins
from adult to fetal or neonatal forms

REVERSIBLE & IRREVERSIBLE INJURIES

Reversible cell injury Irreversible cell injury
• Cellular swelling - first manifestation of injury • Cytoplasm - Myelin figures, moth eaten
• Plasma membrane - blebbing, blunting, loss of microvilli appearance
• Fatty change - lipid vacuoles in cytoplasm • Lysosomal swelling
• Myelin figures in cytoplasm • Plasma membrane damage/disruption
• Mitochondrial swelling and small amorphous densities • Decreased basophilia, Increased
• Dilation of ER, detachment of polysomes • Eosinophilia
• Nucleus - disaggregation of granular and fibrillar • Marked dilation of mitochondria with large
elements • amorphous densities
• Clumping of nuclear chromatin • Nuclear changes - pyknosis, karyolysis,
karyorrhexis

NECROSIS
Morphology
• Increased eosinophilia
• Glassy homogenous appearance(loss of glycogen particles)
• Myelin figures
• Nuclear changes
o Pyknosis - nuclear shrinkage, increased basophilia
o Karyorrhexis - fragmentation of nucleus
o Karyolysis - nuclear dissolution, decreased basophilia

Coagulative necrosis Liquefactive necrosis Caseous necrosis

• Architecture of the dead cell • Enzymatic destruction • Liquefactive + Coagulative
preserved for some days • Abscess formation necrosis
• Denaturation of structural • e.g: Hypoxic death of brain • Granuloma formation
proteins and enzymes cells. focal bacterial & fungal • Cheese like appearance of
• E.g. Myocardial infarction infections necrotic material
• E.g. Tuberculosis

• A localized area of coagulative necrosis is called - infarct

• Gangrenous necrosis:
o Limb that has lost its blood supply (dry gangrene) undergoes coagulative necrosis
o Superimposed bacterial infection causes liquefactive necrosis - wet gangrene
• Fat necrosis is seen in Acute pancreatitis
Fibrinoid Necrosis
• Seen in Immune complex vasculitis (PAN), Malignant hypertension, Aschoff bodies (RHD)
• No Fibrin deposition

APOPTOSIS
• Regulated mechanism of cell death that serves to eliminate unwanted and irreparably damaged cells, with
the least possible host reaction
Morphological changes
• Cell shrinkage (cellular swelling is seen in other forms of cell injury)
• Chromatin condensation (Pyknosis) is the most characteristic feature
• Cytoplasmic blebs and apoptotic bodies
• DNA fragmentation
• Phagocytosis of apoptotic cells/cell bodies, usually by macrophages
• Plasma membranes remain intact until last stages

INITIATION PHASE
Intrinsic (Mitochondrial) Pathway - major mechanism of apoptosis
Initiated by
• Growth factor withdrawal
• DNA damage (by radiation, toxins, free radicals)
• Protein misfolding (ER stress)
Pro-apoptotic factors Anti-apoptotic factors Sensors (only 1 BH domain)
(4 BH domains) (4 BH domains) • Sensors of cellular stress and damage
• Regulate the balance between the other two
groups
• BAX • BCL-2 • BAD • Puma
• BAK • BCL-XL • BIM • Noxa
• p53 • MCL-1 • BID
• Cytochrome c binds to a protein called APAF-1 (apoptosis-activating factor-1), which forms apoptosome
• Caspase-9 - initiator caspase

Extrinsic (Death Receptor-Initiated) Pathway

• Initiated by receptor-ligand interactions
• Responsible for elimination of self-reactive lymphocytes and damage by cytotoxic T lymphocytes
• Death receptors (pro-apoptotic)

Type 1 TNF receptor (TNFR1)

Fas (CD95)
• Initiator caspases: caspase-8 and caspase-10.

EXECUTION PHASE: Executioner caspases: caspase-3 and caspase-6

Dysregulated apoptosis
• Defective apoptosis and increased cell survival - autoimmune diseases
• Increased apoptosis and excessive cell death
o Neurodegenerative diseases
o Ischemic injury (MI, stroke)
o Viral infections

Apoptosis Necrosis
• Physiological or Pathological • Always pathological
• Active process • Passive process
• Death of a single cell • Death of many contiguous cells
• Cell size decreases • Cell size increases (Swelling)
• Plasma membrane intact • Plasma membrane disrupted
 • Lysosomes intact • Lysosomes breakdown and release hydrolases
• Inflammation absent • Inflammation present
• Nucleus fragments • Nucleus: pyknosis  karyorrhexis  karyolysis
• Electrophoresis: Step ladder pattern • Electrophoresis: Smear pattern

• Annexin V staining is commonly used to identify apoptotic cell

Disease Misfolded protein

Cystic fibrosis CFTR
Familial hypercholesterolernia LDL receptor
Tay-Sachs disease Hexosaminidase B subunit
Alpha-1-antitrypsin deficiency Alpha-1 -antitrypsin
Cruetzfeldt-Jacob disease Prions
Alzheimer disease AB peptide

NECROPTOSIS
• Morphologically resembles necrosis (loss of ATP, swelling of the cell and organelles, generation of ROS,
release of lysosomal enzymes and rupture of the plasma membrane)
• Mechanistically resembles apoptosis (triggered by genetically programmed signal transduction)
• Also called programmed necrosis or caspase-independent programmed cell death (no caspase activation)
• Triggered by ligation of TNFR1, and viral proteins of RNA and DNA viruses 4
• Involves two unique kinases called receptor associated kinase 1 and 3 (RIP1 and RIP3)
• Examples:
o Formation of the mammalian bone growth plate
o Cell death in steatohepatitis, acute pancreatitis, reperfusion injury
o Neurodegenerative diseases such as Parkinson disease.
o Backup mechanism in host defense against viruses that encode caspase inhibitors (e.g.CMV)

PYROPTOSIS
• Accompanied by the release of fever inducing cytokine IL-1
• Microbial products that enter the cytoplasm of infected cells can activate the inflammasome
• inflammasome activates caspase-1, (interleukin-1B converting enzyme)
• Caspase-1 cleaves a precursor form of IL-1 and releases its biologically active form.
• Caspase-1 and caspase-1 1 also induce death of the cells.
• This pathway of cell death is characterized by swelling of cells, loss of plasma membrane integrity, and
release of inflammatory mediators

Intracellular accumulations
FATTY CHANGE IN HEART
• Moderate hypoxia due to profound anemia - tigered effect (yellowed myocardium alternating with bands of
darker, red-brown, uninvolved myocardium)
• Profound hypoxia and Myocarditis (e.g. diphtheria) - uniformly affected myocytes

PROTEINS
• Excess Ig produced by plasma cells - distended ER with inclusion bodies - Russel bodies
• Alcoholic hyaline - keratin intermediate filaments
• Pathologic protein deposition - Amyloidosis

Cytoskeletal proteins
• Microtubules: 20 - 25 nm
• Thin actin filaments: 6 - 8 nm
• Thick myosin filaments: 15 nm
• Intermediate filaments: 10 nm
o 5%. Provides flexible intracellular scaffold that organizes cytoplasm
o Resists forces applied to the cell
Five classes of intermediate filaments
• Keratin - epithelial cells (e.g: alcoholic hyaline in alcoholic liver disease)
• Neurofilaments - neurons (e.g: neurofibrillary tangle in Alzheimer disease)
• Desmin - muscle cells
• Vimentin - connective tissue cells
• Glial - astrocytes

PIGMENTS
Exogenous pigments Endogenous pigments
Carbon or coal dust (most common) • Lipofuscin (Lipochrome) wear and tear aging
• Anthracosis pigment
• Coal worker's pneumoconiosis • Melanin
• Hemosiderin

Lipofuscin
• Lipofuscin is not injurious to the cell or its functions
• Presence of lipofuscin is a tell-tale sign of free radical injury and lipid peroxidation
• Yellowish brown (brown lipid)
• Prominent in liver and heart of aging patients, severe malnutrition, cancer cachexia

Psammoma bodies are seen in

• Dystrophic calcification • Serous cystadenoma ovary
• Papillary carcinoma thyroid • Meningioma
• Papillary carcinoma kidney • Protactinoma
• Papillary carcinoma of salivary gland • Glucaganoma

CALCIFICATION
Dystrophic calcification Metastatic calcification
• Occurs in the areas of necrosis • Calcification (both forms) of normal tissues
• Calcium (crystalline form) deposition in • Raised serum calcium level
• dying tissues • Principally affects - gastric mucosa, kidneys, lungs,
• Normal serum calcium level systemic arteries, and pulmonary veins
• Psammoma bodies are seen Examples
Examples • Hyperparathyroidism
• Atheromatous plaque • Multiple myelorna
• Damaged heart valves in RHD • Paget's disease
• Tuberculous node • Sarcoidosis
• Aneurysms • Vitamin D intoxication
• Chronic pancreatitis • Malignancy, leukemia
• Periventricular calcification in CMV • Basal ganglia calcification in hypoparathyroidism
• infections • Renal failure
• Asbestosis (Ca and Fe salts – Dumbbell • Idiopathic hypercalcemia of infancy (William's
form) disease)
• Calcinosis cutis

• Lungs are the most common site of metastatic calcification

• Calcification begins in mitochondria of all organs (except kidney - basement membrane)

CELLULAR AGEING
Cellular Senescence
• After a fixed number of divisions, all somatic cells become arrested in a terminal non-dividing
• state (senescence)
• Telomeres are short repeated sequences of DNA (TTAGGG) at the linear ends of chromosomes
 • Important for ensuring the complete replication of chromosome ends and protecting the ends from fusion
and degradation
• In human cells, with each cell division, there is incomplete replication of chromosome ends (telomere
shortening) which ultimately results in cell cycle arrest
• Telomere length is normally maintained by an enzyme telomerase
• Telomerase activity is
o Highest - germ cells
o Lower levels - stem cells
o Undetectable - most somatic cells
o Benign tumors - normal telomerase activity
o Malignant tumors - increased telomerase activity (no loss of genetic material after multiple cell
divisions)

Sirtuins
• Sirtuins have histone deacetylase activity
• They promote expression of several genes, whose products increase longevity
• These protein products increase metabolic activity, reduce apoptosis, stimulate protein folding and inhibit
harmful effects of oxygen free radicals
• Sirtuins also increase insulin sensitivity and glucose metabolism (may be targets for diabetes treatment)
• A constituent of red wine may activate Sirtuins and thus increase life span
• The most effective way of prolonging life span - calorie restriction
• Caloric restriction increases longevity both by
o Reducing the signaling intensity of the IGF-1 pathway
o Increasing sirtuins

Syndromes associated with premature ageing

• Cockayne syndrome
• Ataxia telangiectasia
• Werner syndrome

ANTIOXIDANTS
Enzymatic Non enzymatic
• Superoxide dismutase • Vitamin E
• Catalase • Cysteine & Glutathione (sutfhydryl containing)
• Glutathione peroxidase • Albumin, Cerruloplasmin, Transferrin

• Most destructive free radicals - hydroxyl (OH-)

• Vit C is the best neutralizer of hydroxyl free radicals
• Zone Ill hepatocytes in liver are most susceptible to hypoxic injury
• Fatty change of heart in anemia - tigered effect
• Chaperons - involved in protein folding and transportation; prevent protein misfolding.
 II. ACUTE & CHRONIC INFLAMATION, TISSUE REPAIR, HEMODYNAMIC
DISORDERS

Scientists
• Phagocytosis - Metchnikoff
• Four cardinal signs of inflammation - Celsus
o Rubor (redness)
o Tumor (swelling)
o Color (heat)
o Dolor (pain)
• Fifth sign (loss of function) - Virchow

ACUTE INFLAMMATION
VASCULAR CHANGES
• First change - vasoconstriction (transient)
• Vasodilation
o First involves the arterioles
o Responsible for redness and warmth
• Increased permeability (responsible for swelling/edema) is due to
o Endothelial gaps (due to contraction of endothelial cells) - immediate transient response - most
common mechanism
o Endothelial injury
o Transcytosis - increased transport of fluids and protein through endothelial cell
• Engorgement of small vessels with slowly moving red cells - stasis

LEUKOCYTE RECRUITMENT
LEUKOCYTE ADHESION
• Extravasation is the sequence of events in the journey of leukocytes form vessel lumen to interstitial tissue
which include the following steps
o Margination - leukocytes assume peripheral portion of lumen along endothelial surface
o Rolling - leukocytes adhere transiently, detach and bind again and finally adhere firmly
o Rolling is mediated by Selectins (P, L and E-selectins)
o Firm adhesion is mediated by Integrins (LFA-1. MAC-1, VLA-4, α4B7)
o Pavementing - endothelium virtually lined by leukocytes

LEUKOCYTE MIGRATION
• Diapedesis or transmigration
o Leukocyte migration through endothelium
o Occurs mainly in post capillary venu les
o D Adhesion molecules involved - CD31 or PECAM-1 (platelet endothelial cell adhesion molecule)

CHEMOTAXIS
• Leukocyte migration toward the site of injury
• Locomotion oriented along chemical gradient
• Chemo-attractants
o Exogenous - bacterial products (most common)
o Endogenous

Cytokines, particularly - IL-8

Complement, particularly - C5a

Arachidonic acid metabolites particularly - LTB4
• Neutrophils predominate in the inflammatory infiltrate during the first 6 to 24 hours
• Neutrophils are replaced by monocytes in 24 to 48 hours
• In Pseudomonas infection - cellular infiltrate is dominated by neutrophils for several days
 • In viral infections, lymphocytes may be the first cells to arrive

PHAGOCYTOSIS
• Recognition and attachment
• Engulfment - phagolysosome formation
• Killing and degradation.
o Reactive oxygen species - respiratory burst
o Nitric oxice
o Lysosomal enzymes and proteins - Lysozyme, Lactoferrin, Major basic protein, Defensins, Cathelicidins

Opsonisation
• Coating of bacteria with proteins (opsonins) enhances the efficiency of phagocytosis
• Opsonins

C3b

IgG antibody

Fibrinogen

Mannose binding lectin

C reactive protein

Neutrophil extracellular traps (NET)

• Extracellular fibrillar networks that provide a high concentration of antimicrobial substances at sites of
infection
• Prevent the spread of the microbes by trapping them in the fibrils
• Produced by neutrophils in response to infectious pathogens and inflammatory mediators

MEDIATORS OF INFLAMMATION
Cell derived Plasma protein derived
Preformed Newly synthesized
• Histamine • Prostaglandins • Complement products
• Serotonin • Leukotrienes • Kinins
• Lysosomal • Platelet-activating factor • Proteases activated
enzymes • Nitric oxide during
• Cytokines • coagulation

• Active mediators are produced only in response to various stimuli

• Most of the mediators are short-lived
• One mediator can stimulate the release of other mediators.

Vasodilation Vasoconstriction Increased vascular Chemotaxis, leukocyte Pain

permeability recruitment
Prostaglandins Thromboxane A2, Histamine, Serotonin TNF, IL-1 PGs
Nitric oxide Leukotrienes C4, D4, C3a, C5a C5a Bradykinin
Histamine E4 Bradykinin Leukotriene 84 Substance P
Leukotrienes C4,D4,E4 Chemokines
PAF Hydroxyeicosatetraenoi
Substance P c acid (HEM)

• Histamine dilates arterioles but constrict large arteries

• Principal mediator of the immediate transient phase of increased vascular permeability
• Mast cells - richest source of histamine
• PAF causes leukocyte priming
• Prostacylin(PGI2) is a vasodilator and potent inhibitor of platelet aggregation
• NO is synthesized from L-arginine by the enzyme nitric oxide synthase
• Lipoxins are inhibitors of inflammation
Major cytokines in
Acute inflammation Chronic inflammation
• TNF • IL-12
• IL-1 • IFN-y
• IL-6 • IL-17
• Chemokines
• IL-17

Tumor Necrosis Factor (TNF) and Interleukin-1 (IL-1)

• Endothelial activation
• Activation of leukocytes and other cells
• Systemic acute-phase response

CHEMOKINES
C-X-C (α- C-C (β chemokines) C (γ-chemokine) CX3C
chemokines)
• Act on Specific for • Fractalkine
• Acts on monocytes, basophils, eosinophils
neutrophils lymphocytes • Acts on
• and lymphocytes but not neutrophils e.g.
• IL-8 monocytes
• Monocyte chemoattractant protein-1(MCP-1) lymphotactin
and T cells
• Eotaxin, RANTES
• Macrophage inflammatory protein (MIP-1α)

Pro-inflammatory cytokines Anti-inflammatory cytokines

• IL-1 • TGF-B
• IL-6 • IL-4
• TNF-α • IL-10
• IFN-γ • IL-11
• IL-12 • IL-13
• IL-17 • 1FN-α,β
• 1L-18 • IL-6

Morphologic patterns of acute inflammation

• Serous inflammation
o Exudation of cell-poor fluid
o Fluid is not infected by destructive organisms
o Fluid does not contain large numbers of leukocytes
• Fibrinous inflammation
o Fibrinous exudate develops when the vascular leaks are large or there is a local procoagulant stimulus
(e.g., cancer cells)
o Characteristic of inflammation in the lining of body cavities - meninges, pericardium, pleura
• Purulent (Suppurative inflammation)
o Production of pus, an exudate consisting of neutrophils, debris of necrotic cells and edema fluid
o A common example - acute appendicitis
• Ulcers

CHRONIC INFLAMMATION
Characterized by
• Infiltration with mononuclear cells - macrophages, lymphocytes, and plasma cells
• Tissue destruction
• Attempts at healing accompanied by angiogenesis and fibrosis

Macropphages
• Dominant cells in most chronic inflammatory reactions
Classical Macrophage activation Alternative Macrophage activation
• Induced by - Microbial products (endotoxin), T • Induced by cytokines other than IFN-γ, such as IL-
cell derived signals (cytokine IFN-γ), Foreign 4 and IL-13
substances • Alternatively activated (M2) macrophages -main
• Classically activated (M1) macrophages produce function is in tissue repair.
NO and ROS  upregulate lysosomat enzymes • They secrete growth factors that promote
 kill ingested organisms, and secrete cytokines angiogenesis, activate fibroblasts, and stimulate
that stimulate inflammation collagen synthesis

CD4+ T cells
• TH1 cells produce the cytokine IFN-γ, which activates macrophages by the classical pathway.
• TH2 cells secrete IL-4, IL-5, and IL-13 are responsible for the alternative pathway of macrophage activation.
• TH17 cells secrete IL-17 - induce the secretion of chemokines responsible for recruiting neutrophils (and
monocytes)

 In some chronic inflammatory reactions, the accumulated lymphocytes, antigen-presenting cells, and plasma
cells cluster together to form lymphoid tissues resembling lymph nodes. These are called tertiary lymphoid
organs (seen in Rheumatoid arthritis, Hashimoto thyroiditis)

RANULOMATOUS INFLAMMATION
• Type of chronic inflammation
• Collection of epithelioid cells (activated macrophages), surrounded by a collar of lymphocytes and
occasionally plasma cells
• Foreign body granuloma - no T cell mediated immune response
• Immune granuloma - persistent T cell-mediated immune response
• Multinucleated giant cells found in granulomas are called Langerhans giant cell
• In Tuberculosis, there is a zone of central necrosis caseous necrosis
• Leprosy, Sarcoidosis, Crohn's disease, foreign body granuloma - no central necrosis -noncaseating
• Touton giant cell - Xanthoma

Bacterial Parasitic Others

• Tuberculosis (caseating and • Schistosomiasis • Sarcoidosis
noncaseating) • Filariasis • Crohn's disease
• Cat scratch disease (stellate Fungal • Wegener's granulomatosis
granuloma) • Histoplasma • Rheumatoid arthritis
• Granuloma inguinale • Blastomycosis • Giant cell arteritis
• Leprosy • Coccidiomycosis • Primary biliary cirrhosis
• Brucellosis • Cryptococcosis • Hodgkins disease
• Syphilis (gumma) • Berylliosis
• Tularemia • Silicosis
• Glanders • Foreign body granulomas
• Actinomycosis

Durck granuloma (not a granuloma) is seen in the brain of cerebral malaria.

Pyrogenic cytokines Classical acute phase proteins

• IL-1 • C-reactive protein (CRP)
• Tumor necrosis factor (TNF) • Fibrinogen
• Prostaglandins • Serum amyloid A (SAA) protein
• Ciliary neurotrophic factor (CNTF) • Hepcidin
• Interferon-a (IFN-a)
• IL-6

TISSUE REPAIR
Tissue repair - essentially 2 types
• Regeneration
• Scar formation

REGENERATION
• Tissues are able to replace the damaged components and essentially return to a normal state
• Occurs by proliferation of cells that survive the injury and retain the capacity to proliferate
• E.g: rapidly dividing epithelia of the skin and intestines, and in some parenchymal organs (liver)

SCAR FORMATION
• If the injured tissues are incapable of complete restitution, or if the supporting structures of the
tissue are severely damaged, repair occurs by the laying down of connective (fibrous) tissue

Steps in scar formation

• Angiogenesis
• Deposition of connective tissue - Transforming growth factor-B (TGF-B) – most important cytokine for the
synthesis and deposition of connective tissue proteins
• Remodeling of connective tissue - accomplished by matrix metalloproteinases (MMPs),

ANGIOGENESIS stimulating factors

Growth factors ECM proteins
• Vascular endothelial growth factor (VEGF) • Integrins
(VEGF-A most important) • Matricellular proteins (thrombospondin 1,
• Fibroblast growth factor 1 and 2 (FGF) SPARC, tenascin C)
• Angiopoietins 1 and 2 (Ang 1 and Ang 2) • Proteinases (plasminogen activators, MMPs )
• Platelet derived growth factor(PDGF)
• Transforming growth factor B (TGF B)

• Notch signaling pathway regulates the sprouting and branching of new vessels
• Hepatocyte growth factor (HGF) or Scatter factor has no role in angiogenesis
• Endostatin, tumstatin and thrombospondin inhibit angiogenesis

Healing by first intention (primary union)

Wounds with opposed edges
Injury involves only the epithelial layer (principal mechanism of repair - epithelial regeneration)
Clean, uninfected wounds
3 phases: Inflammation, Proliferation & Maturation
< 24 hours Clot formation
Neutrophil infiltration
24 - 48 hours Epithelial cells move from wound edge and deposit basement membrane
components producing a thin continuous epithelial layer that closes the wound
By 3rd day Neutrophils are largely replaced by macrophages
Granulation tissue (hallmark of tissue repair) invades incision space Angiogenesis &
Fibroblast proliferation
Collagen fibres seen at margin but do not bridge
By 5th day Granulation tissue fills entire wound area
Maximum neovascularization
Bridging collagen fibres
Full epithelial thickness
During 2nd week Continued collagen accumulation and fibroblast proliferation.
Leukocyte infiltrate, edema, and increased vascularity are substantially diminished.
Blanching begins - increasing collagen deposition and regression of vascular channels
End of 1 month Scar comprises a cellular connective tissue devoid of inflammatory cells Covered by
an essentially normal epidermis.
Healing by second intention
• When cell or tissue loss is more extensive
• Repair process involves a combination of regeneration and scarring
• Abundant granulation tissue formation
• At first matrix containing fibrin, plasma fibronectin, and type III collagen is formed
• In about 2 weeks this is replaced by a matrix composed primarily of type I collagen
• Wound contraction requires myofibroblasts which are altered fibroblasts that have some characters of
smooth muscle cells

Wound strength
• 10% of unwounded skin - when sutures are removed from an incisional surgical wound at the end of 1st
week
• 70-80% tensile strength of unwounded skin - 3 months
• Recovery of tensile strength
o During first 2 months of wound healing - due to excess collagen synthesis
o Later - due to structural modifications of collagen (cross linking, increased fibre size)

Factors that delay wound healing

• Nutrition: Protein deficiency, Vitamin C deficiency
• Diabetes mellitus - due to microangiopathy
• Arteriosclerosis, Varicose veins - due to impaired venous drainage Et poor blood supply
• Glucocorticoids - inhibit collagen synthesis, anti-inflammatory effects
• Infection, Early mobility, Foreign bodies

COLLAGEN
Collagen type Tissue distribution Genetic disorders
Fibrillar collagen
_I
I Ubiquitous in hard and soft tissues Osteogenesis imperfect, Ehlers - Danlos
Predominant in adult skin type syndrome (arthrochalasias type)
II Cartilage, intervertebral discs, vitreous Achondroplasis type II, spondylo- epiphyseal
dysplasia syndrome
III Hollow organs, soft tissues Vascular Ehlers-Danlos syndrome
V Soft tissues, blood vessels Classical Ehlers-Danlos syndrome
IX Cartilage, vitreous Stickler syndrome
Basement membrane collagen
IV Main component of basement membrane Alport syndrome
Other collagens
VI Microfibrils Bethlem myopathy
VII Anchoring fibrils at dermal-epidermal junctions Dystrophic epidermolysis bullosa
IX Cartilage, intervertebral discs Multiple epiphyseal dysplasias

Types of cells
• Permanent cells - never divide
• E.g: neurons, skeletal muscle cells, cardiac myocytes

Labile cells Quiescent/stable cells

• Regenerate throughout life • Low level of replication
• Surface epithelium of skin, oral cavity, vagina, • Usually in GO phase; enters G1 phase and
cervix undergo rapid division in response to stimuli
• Lining mucosa of all excretory ducts of glands • Parenchymal cells of liver kidney and pancreas
• Epithelium of GIT, uterus, urinary tract • Mesenchymal cells- fibroblasts, smooth muscle,
• Cells of bone marrow, hematopoietic cells vascular endothelial cells, lymphocytes and
 leukocytes, osteocytes

STEM CELLS - Posses two important properties

Self-renewal: ability to go through numerous cycles of cell division while maintaining undifferentiated state
Pluori-Potency: capacity to differentiate into specialized cell types
• Totipotent (omnipotent) cells - can form entire organism. E.g: Zygote
• Pluripotent stem cells - the descendants of totipotent cells and can differentiate into cells derived from any
of the three germ layers
• Multipotent stem cells can form multiple cell lineages, but cannot form all cells of the body. E.g:
Hematopoietic stem cell
• Oligopotent stem cells - can form only a few cell lineages. E.g: Neuron stem cells, lymphoid/myeloid stem
cells
• Unipotent stem cells - can produce only one cell type, their own, but have the property of self-renewal,
which distinguishes them from non-stem cells. E.g: progenitor cells, muscle stem cells

Stem cells are present at special sites called niches

Stem cell Location
Oval cells Canal of Herring (Liver)
Satellite cells Basal lamina of myotubules
Limbus cells Canal of Schlemm
Ito cells Subendothelial space of Disse
Paneth cells Base of crypts

HEMODYNAMIC DISORDERS
EDEMA
Edema due to t hydrostatic pressure Edema due to i plasma oncotic pressure
Impaired venous return Arteriolar dilation Hypoproteinemia
• Congestive heart failure • Heat • Protein losing glomerulopathies
• Constrictive pericarditis • Neurohumoral • Liver cirrhosis
• Ascites dysregulation • Malnutrition
• Venous obstruction • Protein losing gastroenteropathy

• Sodium and water retention - causes both ↑ hydrostatic pressure & ↓ vascular colloid osmotic pressure

Congestion
• Heart failure cells (Hemosiderin laden macrophages) - Chronic pulmonary congestion
• Nut meg liver - Chronic passive hepatic congestion

HEMOSTASIS
Sequence of events leading to hemostasis at a site of vascular injury
• Arteriolar vasoconstriction
• Primary hemostasis - formation of platelet plug
• Secondary hemostasis - deposition of fibrin
• Clot stabilisation and resorption

THROMBOSIS
• Virchow's triad is required for thrombus formation
o Endothelial injury
o Alterations in normal blood flow (turbulence or stasis)
o Hypercoagulability

Hypercoagulable states
Genetic Acquired (Secondary)
 • Factor V mutation (Leiden mutation) – most • Prolonged immobilization/bed rest
common inherited cause of hypercoagutability • Tissue injury (Surgery, Fracture, Burns)
• Prothrombin mutation • Cancer
• Increased levels of factors VII, IX, X or fibrinogen • Myocardial infarction, Prosthetic heart valves
• Antithrombin III deficiency • Atrial fibrillation
• Protein C deficiency • DIC
• Protein S deficiency • Heparin induced thrombocytopenia
• Antiphospholipid antibody syndrome

Arterial thrombus Venous thrombus

Pathology: Endothelial injury Pathology: Stasis of blood
Active blood flow Sluggish blood flow
Coronary, cerebral and femoral arteries Superficial and deep leg veins
Growth: Retrograde manner from the point of Growth: Anterograde manner from the point of
attachment attachment
Lines of Zahn present Absent
White thrombi (pale platelet layer alternating with dark Red thrombi (Red cells with less number of
red cell layer) platelets)
Incomplete lumen occlusion Complete occlusion of lumen

ANTIPHOSPHOLIPID ANTIBODY SYNDROME

Antiphospholipid antibodies
• Antibodies against cardiolipin - aCL
• Antibodies against beta 2 glycoprotein I - B2GPI
• Lupus anticoagulant - LA
• Antibodies against phospholipids/cholesterol complexes

Clinical manifestations
• Superficial and deep vein thrombosis, cerebral venous thrombosis, retinal vein thrombosis
• Signs and symptoms of intracranial hypertension, pulmonary emboli, pulmonary arterial hypertension, and
Budd-Chiari syndrome
• Livedo reticularis
• Arterial thrombosis - migraines, cognitive dysfunction, transient ischemic attacks, stroke, myocardial
infarction, ischemic leg ulcers, digital gangrene, avascular necrosis of bone, retinal artery occlusion, renal
artery stenosis, and, infarcts of spleen, pancreas, and adrenals.
• Premature atherosclerosis - a rare feature of APS
• Coombs-positive hemolytic anemia and thrombocytopenia
• Libman-Sacks endocarditis
• Fetal loss does not appear to be explained by thrombosis, but rather seems to stem from antibody-mediated
interference with the growth and differentiation of trophoblasts, leading to a failure of placentation
• Discontinuation of therapy, major surgery, infection, and trauma may trigger Catastrophic APS

Diagnosis: one clinical + one laboratory criterion

Clinical criteria Laboratory criteria
• Vascular thrombosis in any tissue or organ Antiphospholipid antibodies - at intermediate or high
• Pregnancy morbidity titres on two occasions, 12 weeks apart
o One or more unexplained deaths of a • Antibodies against cardiolipin - aCL
morphologically normal fetus at or beyond the • Antibodies against beta 2
tenth week of gestation glycoprotein I - B2GPI
o One or more premature births of a • Lupus anticoagulant - LA
morphologically normal neonate before the
thirty-fourth week of gestation because of
eclampsia, severe preeclampsia, or placental
 insufficiency
o A 3 or more unexplained consecutive
spontaneous abortions before the 10th week of
gestation.

Treatment
• After the first thrombotic event, patients should be placed on warfarin for life aiming to achieve an INR
ranging from 2.5 to 3.5, alone or in combination with 80 mg of aspirin daily.
• Pregnancy morbidity is prevented by a combination of heparin with aspirin 80 mg daily.
• Intravenous immunoglobulin 400 mg/kg qd for 5 days may also prevent abortions, while glucocorticoids are
ineffective.
• Aspirin 80 mg daily protects patients with SLE positive for aPL antibodies from developing thrombotic
events.

HOMOCYSTINURIA
• Elevated levels of homocysteine contribute to arterial and venous thrombosis and atherosclerosis
• Pro-thrombotic effects of homocysteine is due to thioester linkages between its metabolites and fibrinogen
• Elevations of homocysteine - caused by deficiency of cystathione β-synthetase or 5,10- methylene-
tetrahydrofolate reductase
• Folic acid, B12, B6 supplements can ↓ plasma homocystine levels but fail to lower risk of thrombosis

Postmortem clots (chicken fat clot)

• On the dependent parts of the body
• Not attached to the underlying wall

Venous thrombi
• MC site of formation: deep veins of legs
• Majority of venous thrombi lodge in the lungs

SYSTEMIC THROMBOEMBOLISM
• 80% arise from intracardiac mural thrombi
• Most common site of lodging: lower extremities (75%) or brain (10%)

AIR EMBOLISM
• Air may enter the circulation during obstetric or laparoscopic procedures or after chest wall injury
• An excess of 100 cc is required to have clinical effect in pulmonary circulation
• 2 mL of air in the cerebral circulation can be fatal
• 0.5 mL of air into a coronary artery can cause cardiac arrest
• Decompression sickness is a form of air embolism
o Bends: rapid formation of gas bubbles within skeletal muscles and joints - painful condition
o Chokes: respiratory distress due to gas bubbles in pulmonary circulation
o Caisson disease: chronic form of decompression sickness

INFARCTS
• Characteristic - ischemic coagulative necrosis
• Except brain - liquefactive necrosis

Red (hemorrhagic) infarcts White (anemic) infarcts

 Arterial occlusion in loose tissues or organs with
Arterial occlusion in solid organ with end arterial
dual blood supply
circulation
• Ovary and testes (venous occlusion)
• Heart
• Lung (dual circulation, loose tissue)
• Kidney
• Small intestine(dual circulation)
• Spleen
• Heart (after angioplasty)

TGF - α TGF - β
• Has intrinsic tyrosine kinase activity • Involved in chemotaxis, angiogenesis and
• Replication of hepatocytes (important after production of bone morphogenic protein
resection) • Growth inhibitor for most epithelial cell types
• Malignant transformation of normal cells and leukocytes
• Over expression in astrocytoma and • Potent fibrogenic and strong anti-inflammatory
hepatocellular carcinoma Can promote invasion and metastasis during
tumor growth

• Hallmark of acute inflammation - increased vascular permeability

• Hallmark of chronic inflammation - tissue destruction
• Most effective bactericidal system in neutrophils H2O2-MPO-Halide system
• Selectins - responsible for rolling of neutrophils; β2-integrins - neutrophil adhesion molecules
• Delayed separation of umbilical cord - selectin or CD11a:CD18 deficiency
• Epithelioid cell - are macrophages activated by IFN-gamma from CD4 helper cells
• Macrophages - key cellular constituents of tissue repair
• TGF-B - most important fibrogenic agent
• Vitamin C is required for the hydroxylation of procollagen (hence impaired wound healing in scurvy)
• Matrix metalloproteinases (MMPs) - degradation of collagen and ECM (basement membrane)
• ADAM-17 is also known as TACE (TNF converting enzyme)
• Most abundant glycoprotein in basement membrane - laminin
• Exuberant granulation - excessive amounts of granulation tissue, which protrudes above the level of the
surrounding skin (proud flesh)
 III. GENETICS
• The human genome contains roughly 3.2 billion DNA base pairs
• About 1.5% of human genome codes for proteins
• Humans have 20000 genes that code for proteins
• Chargaff's rule - amount of purine is equal to the amount of pyrimidine
• Exon - the part of DNA which is expressed
• Intron - the part of DNA in the intervening region
• The two most common forms of DNA variations in the human genome
o Single-nucleotide polymorphisms (SNPs)
o Copy number variations (CNVs)
• Epigenetics - heritable changes in gene expression that are not caused by alterations in DNA sequence
• Genomics - study of all DNA sequences
• Proteomics - measurement of all proteins expressed in cell or tissue

Micro-RNAs (mi-RNAs)
• Discovered by Andrew Fire & Craig Mello (Noble prize in 2006)
• 21 - 30 nucleotides in length
• Do not encode proteins
• Posttranscriptional silencing of gene expression by miRNA is a fundamental and well-conserved mechanism
of gene regulation

Small interfering RNAs (siRNAs)

• Short RNA sequences that can be introduced experimentally into cells.
• Synthetic siRNAs targeted against specific mRNA species have become useful to study gene function (so-
called knockdown technology)
• Being developed as possible therapeutic agents to silence pathogenic genes, such as oncogenes involved in
neoplastic transformation.

Long Noncoding RNA (IncRNA) - modulate gene expression

Mutations - permanent change in the DNA

• Point mutations (single nucleotide base substituted by a different base)
o Silence mutation - same amino-acid formed even by the changed codon
o Missense mutation - replacement of one amino acid by another (e.g. sickle cell anemia)
o Non sense mutation - replacement of amino acid by a stop codon (e.g. beta-thalassemia)
• Frame-shift mutations (insertion or deletion of base pairs resulting in alteration in reading frame of DNA
strand)
• Trinucleotide repeat mutations - amplification of a sequence of 3 nucleotides

Single gene disorders Multifactorial, Polygenic or Chromosomal disorders

(Mendelian disorders) Complex disorders
• Autosomal dominant • Diabetes mellitus type 2 Autosomes
• Autosomal recessive • Congenital heart disease • Down syndrome
• X linked dominant • Coronary heart disease • Edward syndrome
• X linked recessive • Hypertension • Patau syndrome
• Asthma Sex-chromosomes
• Mental illness • Turner syndrome
• Gout • Klinefelter syndrome
• Cleft lip and cleft palate
• Pyloric stenosis

X-LINKED DOMINANT DISORDERS

• Affected heterozygous female transmits to half her sons and half her daughters
 • Affected male transmits to all his daughters but none of his sons, if the female parent is unaffected

• Vitamin D resistant rickets

• Oro-facial-digital syndromes
• Incontinentia pigmenti
• Alport syndrome
• Rett syndrome

X-LINKED RECESSIVE DISORDERS

• An affected male does not transmit the disorder to his sons
• Females are carriers only (disease is not manifest)
• Females transmit mutant genes to 50% of sons
Nervous Metabolic Hematologic
• Fragile X syndrome • Diabetes lnsipidus • Hemophilia A and B
• Color blindness • Lesch-Nyhan syndrome • Chronic granulomatous
Immune • Hunter syndrome diseases
• Agamma globulinemia • Fabry disease • G6PD deficiency
• Wiskott-Aldrich syndrome Musculoskeletal
• Duchene muscular dystrophy

AUTOSOMAL DOMINANT DISORDERS

• Mutated genes can express themselves in heterozygous state
• So at least one parent of an index case is usually affected
• Homozygotes usually dies in utero
• Both males and females are affected, and both can transmit the condition
• Usually defects of structural proteins or receptors (enzyme proteins not affected)
• With every autosomat dominant disorder, some proportion of patients do not have affected
parents. Many new mutations seem to occur in germ cells of relatively older fathers
• Incomplete penetrance (gene inherited but the individual can be phenotypically normal)
• Variable expressivity (a trait is seen in all individuals carrying mutant gene, but expressed differently among
different individuals. E.g: in Neurofibromatosis 1, manifestations range from brownish spots on the skin to
multiple skin tumors and skeletal deformities)
• In many conditions age of onset is delayed
• Generally milder than recessive disorders
CNS Hematologic Metabolic
• Huntington's chorea • Hereditary spherocytosis • Familial
• Neurofibromatosis 1 & 2 • Von Willebrand disease hypercholesterolemia
• Myotonic dystrophy Skeletal • Acute intermittent porphyria
• Tuberous sclerosis • Marfan syndrome Gastrointestinal
Urinary • Ehler Danlos syndrome • HNPCC
• Adult Polycystic kidney • Osteogenesis imperfect • Familial adenomatous
• Achondroplasia polyposis
Ear
• Otosclerosis

Types of mutations in AD inheritance

• Gain of function mutation - Huntington's disease
• Loss of function mutation Osteogenesis imperfecta, Marfan & Ehler-Danlos syndrome

AUTOSOMAL RECESSIVE DISORDERS

• Mutant genes can express only in homozygous state
• Usually causes defect in synthesis of an enzyme protein
• The trait does not usually affect the parents of the affected individual, but siblings may show the disease
 • Offsprings-1 /4th normal, 1 /4th affected & half carriers
• Early onset - usually in childhood
• Expression is more uniform than AD disorders
• Complete penetrance is common
• More common in consanguineous marriages
• Although new mutations occur, they are rarely detected clinically
CNS Endocrine Hematologic Skeletal
Friedrich ataxia Congenital adrenal Sickle cell anemia Ehler Danlos syndrome
Spinal muscular atrophy hyperplasia Thalassemias (type VI, Vlic)
Alkaptanuria
Metabolic disorders
Cystic fibrosis Galactosemia Lysosomal storage diseases
Albinism Homocystinuria Glycogen storage diseases
Phenylketonuria Wilson disease α -Antitrypsin deficiency
Hemochromatosis
ALMOST ALL INBORN ERRORS OF METABOLISM-AUTOSOMAL RECESSIVE

Single gene disorders with non-Mendelian inheritance

• Mitochondrial inheritance
• Genomic imprinting
• Triple Repeat mutations
• Germ line mosaicism

MARFAN SYNDROME
• Autosomal dominant
• Defect in a protein called fibrillin-1 coded by fibrillin 1 (FBN1) gene in Chromosome 15q
• Mutations in FBN2 gene in chromosome 5q give rise to congenital contractural arachnodactyly
• Principal manifestations in - skeleton, cardiovascular system and eyes
• Two fundamental mechanisms by which loss of fibrillin leads to the clinical manifestations
o Loss of structural support in microfibril rich connective tissue
o Excessive activation of TGF-β signaling.

Skeletal defects
• Most common and most striking
• Tall stature, ↑ lower segment length, long extremities
• Lax joint ligaments (double joint)
• Arachnodactily (long slender fingers & hands)
• Long headed (dolicocephalic) with bossing frontal eminences, prominent supraorbital ridges
• Pigeon chest deformity
• High-arched palate and high pedal arches or pes planus

CVS defects Ocular defects

• Mitral valve prolapse (floppy valve) - Mitral • Bilateral subluxation or dislocation of lens
regurgitation more frequent, clinically less (usually superotemporal) - Ectopia lentis
important • Myopia
• Cystic medionecrosis - dilation of ascending • Retinal detachment
aorta, aortic dissection, severe aortic
regurgitation
• MCC of death - rupture of aortic dissections

Other common features

• Spontaneous pneumothorax
• Dural ectasia
• Striae atrophicae
 • Inguinal and incisional hernias are common

 Clinical diagnosis by Ghent criteria

 Long term β-adrenergic blockade, (atenolol 1-2 mg/kg orally daily) retards the rate of aortic dilation

EHLER DANLOS SYNDROME

• Defect in structure or synthesis of fibrillar collagen
• Hyperextensible skin cigarette paper skin
• Hyperextensible joints
• Type 3 is most common

EDS types Inheritance Clinical features Gene defects

Classical (I/II) AD Skin and joint hypermobility, Type V collagen (COL5A1 &
atrophic scars, easy bruising COL5A2) gene mutation
Hypermobility (Ill) AD Hypermobility, pain, Unknown
dislocations
Vascular (IV) AD Thin skin, arterial or uterine Type III collagen (COL3A1)
rupture, bruising, small joint
hyperextensibility
Kyphoscoliosis (VI) AR Hypotonia, congenital ↓ Lysyl hydroxylase
scoliosis, ocular fragility
Arthrochalasia (Vila, b) AD Defect in the conversion of COL1A1 & COL1A2
Dermatosparaxis (VIIc) AR type I procollagen to collagen Procollagen N peptidase

PIROMOSOMAL DISORDERS
Types of chromosomes based on the position of centromere

Cytogenetic analysis
• Mitosis is arrested in metaphase by using colchicine
• Cells used in routine chromosomal analysis

Prenatal - amniocytes or chorionic villi

Postnatal - lymphocytes, bone marrow, skin fibroblasts
• Cells are isolated at metaphase or prometaphase and treated chemically or enzymatically to reveal
chromosome bands

Technique Q banding G banding R banding C banding

Dye Quinacrine Trypsin - Giemsa Alkaline solution - Giemsa Chemical - Giemsa
mustard
Features Temporary Permanent For analyzing For studying
Not used MC used for rearrangements involving transolocations
routinely Cytogenetic the terminal ends of involving centromere
analysis chromosomes

DOWN'S SYNDROME
• Most common chromosomal disorder
• Most common genetic cause of mental retardation
 • Risk is 1 in 1550 if the maternal age < 20 years; 1 in 100 if 40-44 years; 1 in 25 if > 45 years

Genetics
• Meiotic non-disjunction of chromosome 21
o Seen in 95% cases with trisomy 21
o Strong relationship with maternal age
• Not related to maternal age - Robertsonian translocation (4%) and Mosaicism (1%) (mitotic non-disjunction)
• If a translocation is identified in a child, parental chromosome studies must be performed to determine
whether one of the parents is a translocation carrier, which carries a high recurrence risk for having another
affected child.
• Translocation (21;21) carriers have a 100% recurrence risk for a chromosomally abnormal child
• Robertsonian translocations, such as t(14;21), have a 5-7% recurrence risk when transmitted by females

Indicators of Down syndrome

Maternal serum Ultrasound
1st trimester • Thickened nuchal fold (75% sensitive)
• Elevated free β- hCG • Absent nasal bone
• Elevated PAPP-A • A shortened femur or humerus
2nd trimester • Hyper-echogenic bowel
• Low maternal serum AFP • Pyelectasis - dilatation of collecting system in the kidneys
• Low unconjugated estriol • Choroid plexus cyst
• Elevated inhibin-A • Echogenic intracardiac focus
• Elevated total hCG • Duodenal atresia

Clinical features
CNS
• Hypotonia
• Poor Moro reflex
• Developmental delay
• Mental and physical retardation

Cardiovascular Craniofacial Musculoskeletal

• Endocardial Cushion • Flat face • Joint hyperflexibility
• defects - most common • Upward slanted palpebral fissures • Short neck, redundant skin
• Ventricular septal defect (mongoloid slant) • Short metacarpals and
• Atrial septal defect • Epicanthal folds phalanges
• Patent ductus arteriosus • Speckled irises (Brushfield spots) • Short 5th digit with
• Pulmonary hypertension • Three fontanels clinodactyly
Gastrointestinal • Delayed fontanel closure • Single transverse palmar
• Duodenal atresia • Frontal sinus and midfacial creases
• Annular pancreas hypoplasia • Wide gap between 1st and
• Trachea-esophageal fistula • Mild microcephaly, 2nd toes (sandal gap)
• Hirschprung disease • Brachycephaly • Pelvic dysplasia
• Imperforate anus • Short hard palate • Short sternum
• Neonatal cholestasis • Small nose, flat nasal bridge • Two sternal manubrium
• Protruding tongue, open mouth ossification centers
• Small dysplastic ears

• Major cause of early mortality is the cardiac lesions

• Ail patients with 21 trisomy develop Alzheimer's disease
• Abnormal immune responses → serious infections, particularly lungs, and thyroid autoimmunity
Increased (sk of
CNS Sensory Musculoskeletal Endocrine
• Seizures • Congenital or acquired hearing • Atlantoaxial • Congenital or acquired
• Autism spectrum loss instability • hypothyroidism
• disorders • Serous otitis media • Hip dysplasia • Diabetes mellitus
• Behavioral • Refractive errors (myopia) • Slipped capital • Infertility
• disorders • Congenital or acquired femoral epiphyses • Obesity
• (disruptive) cataracts • Avascular hip • Hyperthyroidism
• Depression • Nystagmus, Strabismus necrosis
• Glaucoma • Recurrent joint
dislocations
Gastrointestinal Hematologic Respiratory Cutaneous
• Celiac disease • Transient rnyeloproliferative • Obstructive sleep • Hyperkeratosis
• Delayed tooth syndrome apnea • Seborrhea
eruption • Acute lymphocytic leukemia • Recurrent infections • Xerosis
• Acute myelogenous leukemia • Perigenital folliculitis
• (M7)

Edward syndrome (Trisomy 18) Patau syndrome (Trisomy 13)

• Hypertonia • Microcephaly
• Elongated skull, prominent occiput • Holoprosencephaly with incomplete development
• Low set, malformed ears of forebrain
• Short neck • Microphthalmia, hypotelorism, coloboma of iris,
• Micrognathia retinal dysplasia and cataract
• Shield shaped chest, Short sternum • Cleft lip, cleft palate
• Short dorsiflexed hallux • Deafness
• Overlapping fingers. very short fourth digit with • Capillary hemangiomas
only a single crease • Polydactyly, long and hyperconvex nails
• Limited hip adduction • Umbilical hernia
Common features: Mental retardation, Cardiac defects (VSD, PDA), Renal defects, Rocker bottom feet
Trisomy 22 (Cat eye syndrome) - vertical colobomas of eyes

Chromosome 22q11,2 deletion syndrome

• Previously, considered as two different disorders—DiGeorge syndrome and velocardiofacial syndrome
• Congenital heart defects
• Abnormalities of the palate
• Facial dysmorphism
• Developmental delay
• T-cell immunodeficiency
• Hypocalcemia
• High risk for psychotic illnesses - schizophrenia and bipolar disorders
• ADHD is seen in 35% affected children

KLINEFELTER SYNDROME
• Most common cause of hypogonadism and infertility in males
• Most common sex chromosome aneuploidy in humans
• Male hypogonadism; occurs when there are two or more X chromosomes & one or more Y chromosomes.
• Most common sex chromosomal aneuploidy in males
• Increased maternal age predisposes to meiotic nondisjunction of X chromosorna (most common)
• XXY/XY mosaicism have a better prognosis

Clinical features
• Phenotypic males
 • Tall, slim and underweight with disproportionately long arms and legs (eunuchoid proportions)
• Failure of development of secondary sexual characters
• Small testis with hyalinized seminiferous tubules; leydig cells show hypertrophy
• Azoospermia and infertility are usual; Hypospadiasis and cryptorchidism may be present
• Antisperm antibodies have been detected in one quarter of tested specimens
• Gynecomastia
• Anxious, immature, excessively shy, or aggressive, and they may engage in antisocial acts
• Fire-setting behavior has been observed in some of these children
• The mean IQ is lower than normal but mental retardation is uncommon
• ↑ incidence of type 2 diabetes, breast cancer, extragonadal germ cell tumors, Mitral valve prolapse and
autoimmune diseases
• Increased gonadotrophins (FSH & LH) and decreased testosterone
• Plasma estradiol levels are elevated
• High-resolution MRI  reduction in left temporal lobe gray matter volumes (less so in testosterone-treated
subjects)

TURNER SYNDROME
• Caused by the complete or partial Monosomy of X chromosome (45, X or 45, XX)
• Phenotypic females
• Most common cause of primary amenorrhea ('menopause before menarche')
• Advanced maternal age is not associated with an increased incidence

Classic Turner syndrome (45, XO Gonadal Dysgenesis)

Infancy Childhood Adulthood
• High arched palate • Short stature • Primary amenorrhea - Ovarian
• Webbed neck • Cubitus valgus • failure/dysgenesis - bilateral
• Cystic hygroma • Short 4th and 5th • streak ovaries
• Lymphedema of dorsum of • metacarpals a metatarsals • No breast development
hands and feet • Short neck • Little pubic hair
• Low posterior hairline • Madelung deformity • Hypertension
• CVS: hypoplastic left heart, • (chondrodysplasia of distal • Obesity, dyslipidemia
pretruncal coarctation of the • radial epiphysis) • Type 2 Diabetes mellitus insulin
aorta, bicuspid aortic valve • Hypoplastic nails • resistance
• Neonatal pedal edema • Micrognathia • Autoimmune thyroid disease
• Horse-shoe kidney • Otitis media, SNHL • Inflammatory bowel disease
• Congenital hip dislocation • Multiple nevi • Increased risk of colon cancer
• Patella dislocation • Keloid formation

45,X0/46,XX and 45,X0/46, XY Mosaicism

• Tend to be taller and may have more gonadal function and fewer other manifestations of Turner syndrome.
• High risk for gonadoblastoma; require a prophylactic gonadectomy

Prenatal USG signs

• Nuchal cystic hygroma - increased nuchal translucency
• Horseshoe kidney
• Left-sided cardiac anomalies
• Non immune fetal hydrops

Laboratory features
• Elevated FSH and LH
• GH and IGF-1 levels are normal
• Normal gonadotropin levels

NOONAN SYNDROME
 • Autosomal dominant
• Both males and females are affected
• Mutations in genes of chromosome 12
• Short stature, webbing of the neck, pectus excavatum, cubitus valgus
• Hypertelorism, epicanthus, downward slanted palpebral fissures, ptosis, micrognathia
• CVS - pulmonary valvular stenosis, hypertrophic cardiomyopathy, atrial septal defect
• Hematologic disorders - low clotting factors XI and XII

SINGLE GENE DISORDERS WITH NONCLASSIC INHERITANCE

RINUCLEOTIDE REPEAT DISORDER

Disease Gene -Protein Repeat

Expansions affecting non-coding regions
Fragile X syndrome FMR1 - FMR-1 protein CGG
Friedreich ataxia (Chr 9q) FXN - Frataxin GAA
Myotonic dystrophy (Chr 19q) DMPK - Myotonic dystrophy protein kinase CTG
Expansions affecting coding regions
Spinobulbar muscular atrophy AR - Androgen receptor CAG
(Kennedy disease)
Huntington disease HTT - Huntingtin CAG
Dentatorubral-pallidoluysian atrophy ATNL - Atrophin-1 CAG
(Haw river syndrome)
Spinocerebellar ataxia types 1 to 3 & 7 ATXN 1 to 3 & 7 - Ataxin 1 to 3 & 7 CAG
Spinocerebellar ataxia type 6 a1A-Voltage-dependent Ca channel subunit CAG

Unstable repeats cause diseases by one of the following mechanism

• Loss of function: Fragile X syndrome
• Toxic gain of function by alteration of protein structure: Huntington disease, Spinocerebellar ataxia
• Toxic gain of function mediated by mRNA: Fragile X tremor-ataxia syndrome

FRAGILE X SYNDROME
• X-linked disorder characterized by mutation in the familial mental retardation-1 gene (FMR-1)
• Second most common cause of mental retardation after Down's syndrome

Genetics
• Cytogenetic alteration is seen as a discontinuity of staining or constriction in the long arm of X-chromosome
when cultured in folate deficient media - fragile sites
• 30-50% of carrier females are affected
• Normal: 6-55 repeats; Premutation: 55-200 repeats; Full mutations: 200-4000 repeats
• During oogenesis (not spermatogenesis) premutations are converted into full mutations by triplet repeat
amplification
• Shermon's paradox: risk of mental retardation is more in grandsons than brothers of transmitting males
• Anticipation: clinical features worsen with each successive generation

Clinical features
• Long face with large mandible, Large everted ears
• Large testicles/macroorchidism (most distinct feature, present in 90% prepubertal males)
• Hyperextensible joints, High arched palate, Mitral valve prolapse

Function of the familial mental retardation protein (FMRP)

• Selectively binds mRNAs associated with polysomes and regulates their intracellular transport to dendrites
• Translation regulator

FRAGILE X TREMOR/ATAXIA SYNDROME

 • Females carrying the premutation (carrier females) have premature ovarian failure
• Premutation-carrying males (transmitting males) exhibit a progressive neurodegenerative syndrome
characterized by intention tremors and cerebellar ataxia and may progress to parkinsonism.

MITOCHONDRIAL INHERITANCE
• Organs having large mitochondria are affected - CNS, skeletal and cardiac muscles, liver, kidneys
• Males cannot transmit the disease to progeny
• Only females can transmit the disease
• Examples
o Leber's optic neuropathy
o Leigh's disease
o MELAS (mitochondrial encephalopathy, lactic acidosis and stroke like syndrome)
o NARP syndrome (neuropathy, ataxia, retinitis pigmentosa)
o Kearns=Sayre syndrome
o Chronic progressive external ophthalmoplegia
o Pearson syndrome

GENOMIC IMPRINTING
• Imprinting involves transcriptional silencing of the paternal or maternal copies of certain genes during
gametogenesis
• Loss of the functional (not imprinted) allele by deletion gives rise to diseases
• Differential expression of a gene based on chromosomal inheritance from maternal or paternal origin

Microdeletion in Chromosome 15
Deletion on Paternal chromosome Deletion on Maternal chromosome
Prader Willi syndrome Angelman syndrome
• Mental retardation • Mental retardation
• Short stature, small hands and feet • Seizures
• Hypogonadism • Ataxia
• Hypotonia • Inappropriate laughter (Happy puppets)
• Profound hyperphagia
• Obesity
• ↑ Ghrelin levels

GERMLINE/GONADAL MOSAICISIN
• Phenotypically normal parents have more than one affected child
• Mutation occurs postzygotically during early embryonic development
• Seen in - Osteogenesis imperfecta, tuberous sclerosis

PCR & Detection of DNA Sequence Alterations

• Sanger sequencing - still considered gold standard for sequence determination
• Pyrosequencing

More sensitive than Sanger sequencing, allowing for detection of as little as 5% mutated alleles in a
background of normal alleles.

Used to analyze DNA obtained from cancer biopsies, in which tumor cells are often contaminated with
large numbers of admixed stromal cells

• Single-base primer extension

Useful approach for identifying mutations at a specific nucleotide position

Sensitive - can detect 1 to 2% mutated alleles

Disadvantage - producing only one base pair of sequence data
• Restriction fragment length analysis
• Amplicon length analysis
• Real time PCR

Most often used to monitor the frequency of cancer cells bearing characteristic genetic lesions in the
blood or in tissues (e.g., the level of BCR-ABL fusion gene sequences in patients with CML), or the infectious
load of certain viruses (e.g., HIV, EBV).

Also be used to detect somatic point mutations in oncogenes such as KRAS and BRAF

Molecular Analysis of Genomic Alterations

• Fluorescence in Situ Hybridization (FISH)

Uses DNA probes that recognize sequences specific to particular chromosomal regions

Rapid diagnosis can be obtained

Can be performed on prenatal samples, peripheral blood cells, touch preparations from cancer
biopsies, and even fixed archival tissue sections.

Used to detect numeric abnormalities of chromosomes (aneuploidy); subtle microdeletions or complex
translocations that are not demonstrable by routine karyotyping; and gene amplification

Chromosome painting is an extension of FISH.
• Multiplex Ligation-Dependent Probe Amplification (MLPA)

MLPA blends DNA hybridization, DNA ligation, and PCR amplification to detect deletions and
duplications of any size, including anomalies that are too large to be detected by PCR and too small to be
identified by FISH
• Southern Blotting - Changes in the structure of specific loci can be detected
• Cytogenomic Array Technology - genomic abnormalities without prior knowledge can be detected

Array-Based Comparative Genomic Hybridization (Array CGH)

SNP Genotyping Arrays - routinely used to uncover copy number abnormalities in pediatric patients
when karyotype is normal but a structural chromosomal abnormality is still suspected.

• Epigenetics - study of heritable chemical modification of DNA or chromatin that does not alter the DNA
sequence itself
• Next-generation sequencing (NGS) - newer DNA sequencing technologies that are capable of producing
large amounts of sequence data in a massively parallel manner

PEDIGREE ANALYSIS
• Mitochondrial inheritance - Only females will transmit the disease to the offsprings
• X-linked recessive - Only males are affected, tend to skip generations,
• X-linked dominant - Males transmit disease only to the daughters (not sons), Females transmit disease to
50% daughters and 50% sons, does not skip generations
• Autosomal recessive - both sexes with equal frequency, tend to skip generations, affected offspring are born
to unaffected parents
• Autosomal dominant - both sexes with equal frequency, does not skip generations, affected offspring must
have an affected parent

Female Male

Affected

Unaffected
 IV. DISEASES OF THE IMMUNE SYSTEM
AMYLOIDOSIS
• Amyloid is a pathologic proteinaceous substances deposited in tissues (95% fibril proteins)
• Electron microscopy all types of amyloid consists of continuous, non-branching fibres of diameter 7.5 to
10nm
• X-ray crystallography and infrared spectroscopy demonstrate a characteristic cross B-pleated sheet
conformation
• The regular B-sheet structure exhibits a unique "apple green" birefringence by polarized light microscopy
when stained with Congo red dye
• Amyloidosis results from abnormal folding of proteins, which are deposited as fibrils in extracellular tissues
and disrupt normal function

Stains
• Most widely used - Congo red
• Unfixed specimen or histological section - Iodine staining
• Thioflavin T and S - gives immunofluorescence with UV light
• PAS - positive

Classification
SYSTEMIC (GENERALIZED) AMYLOIDOSIS
AL AMYLOIDOSIS AA AMYLOIDOSIS AB2M AMYLOIDOSIS
• I mmunocyte dyscrasias with • Reactive systemic Hemodialysis-associated amyloidosis
amyloidosis (1- amyloidosis) amyloidosis (secondary • Chronic renal failure
• Multiple myeloma, non- amyloidosis) • Major fibril protein: AB2
Hodgkin's lymphoma, • Chronic inflammatory microglobulin
Waldenstrom's conditions • Usually presents as carpal
macroglobulienemia • AA(amyloid associated) - tunnel syndrome(first
• AL (amyloid light chain) - Non Ig protein; ynthesized in symptom) persistent joint
derived from Ig light chain liver effusions,
produced in plasma cells • Only type of systemic spondyloarthropathy, or
• Usually occurs after age 40 amyloidosis that occurs in cystic bone lesions
• Kidneys - mc organ involved children
• Heart - second mc organ • Usually begins in kidneys
involved
• Cardiac involvement - mcc of
death
• Macroglossia
pathognomonic sign
• Functional hyposplenism in
the
• absence of significant
splenomegaly
• Easy bruising, periorbitai
ecchymoses (raccoon-eye)
• Nail dystrophy, alopecia,
amyloid
• arthropathy

HEREDITARY AMYLOIDOSIS LOCALIZED AMYLOIDOSIS

Familial Mediterranean fever • Senile cerebral amyloidosis - Alzheimer
• Autoinflammatory syndrome disease - AB (APP)
• Abnormally high production of IL-1 • Medullary carcinoma thyroid - A Cal
• Autosomal recessive • (calcitonin)
• Gene - pyrin • Islet cells in type 2 DM - AIAPP (islet
• Amyloid deposited: AA amyloid polypeptide or amylin)
Familial amylodotic polyneuropathies • Isolated atrial amyloidosis – AANF (atrial
• Mutant form ATTR is deposited natriuretic factor)
• Autosomal dominant • Prion disease -APrP (prion protein)
• Autonomic neuropathy - diarrhea, weight loss, orthostatic • Cerebral amyloid angiopathy – Acys
hypotension (Cystatin C)
• Vitreous opacities - pathognomic • Endocrinopathy - Apro (Prolactin)
Senile systemic amyloidosis
• Deposition of structurally normal transthyretin
• Deposited in heart, results in restrictive cardiomyopathy

 ATTR (transthyretin, prealbumin): A normal serum protein that transports thyroxine and retinol

Kidneys
• The most frequently involved organ and most serious form of organ involvement
• More commonly in secondary amyloidosis
• Kidneys shrunken in advanced cases because of ischemia
• Nephrotic range proteinuria, hypoalbuminemia, hypertension
Heart
• Second most common organ involved
• Mostly in primary amyloidosis
• Major organ involved in senile systemic amyloidosis (restrictive cardiomyopathy)
• ECG shows pseudoinfarct pattern
• MRI with gadolinium - Subendocardial enhancement
Splenic involvement
o Sago spleen(amyloid deposition in the splenic follicles)
o Lardaceous spleen(amyloid deposition in splenic sinuses)
• Liver: amyloid appears first in the space of Disse
• Nodular deposition in the tongue cause macrogtossia (tumor forming amyloid-AL)
• Amy[old deposition in patients on long term HD are most prominent in the carpal ligament of wrist,
• resulting in compression of median nerve (carpal tunnel syndrome)
• Other sites involved are liver, heart, pituitary, adrenals, thyroid, GIT and peripheral nerve

Diagnosis
• Biopsy of kidney when renal manifestations are present
• In systemic amyloidosis rectum or gingival tissues are biopsied
• Examination of abdominal fat aspirates stained with congo red is specific but low sensitivity
• Scintigraphy with radiolabelled serum amyloid P(SAP) is rapid and specific

Prognosis
• Generalized and Myeloma associated amyloidosis - poorer prognosis
• Reactive systemic amyloidosis - somewhat better prognosis
• New therapeutic strategies - correction of protein misfolding and fibrillogenesis

SYSTEMIC LUPUS ERYTHEMATOSUS

• Female-to-male ratio is 9 : 1 during the reproductive age group
• The fundamental defect - failure of the mechanisms that maintain self-tolerance
• Exposure to ultraviolet (UV) light exacerbates the disease
• Categories of ANAs

Antibodies to DNA

Antibodies to histone

Antibodies to non-histone proteins bound to RNA

Antibodies to nucieolar antigens

Antibody Clinical utility

Anti-nuclear (ANA) Best screening test (98% prevalence)
Highly sensitive
Anti-ds DNA SLE specific, correlate with disease activity, nephritis, vasculitis
Anti-Smith SLE specific, no clinical correlation
Anti-histone Ab Drug induced lupus
Anti-Ro (55-A) Subacute cutaneous lupus, Neonatal lupus, Congenital heart
Anti-La (55-B) block; Decreased risk of nephritis (also anti-La)
Anti-Ribosomal Ab Psychosis due to CNS lupus
Anti-neuronal (anti- Correlates with CNS lupus activity
glutamate receptor)
Antiphospholipid Fetal loss, clotting, thrombocytopenia

• Antinuclear antibodies are sensitive and not specific

• Presence of anti-ds DNA and anti-Smith is virtually diagnostic of SLE (specific)
• High titres of ds DNA is associated with active renal disease
• Serum complement levels are low during flare-ups & normal levels seen during remissions

Clinical and Laboratory criteria for diagnosis Drugs causing SLE

• Skin • Hydralazine
o Malar rash (Butterfly rash) • Procainamide
o Discoid rash • Isoniazid
o Photosensitivity • Methyldopa
• Oral ulcers-usually painless • Chlorpromazine
• Alopecia • Minocycline
• Serositis-pleuritis and pericarditis • Quinidine
• Renal disorder (> 0.5 g/d proteinuria or a. 3+ • Interferon
dipstick proteinuria or Cellular casts) • TNF inhibitors
• Neurological disorder (seizures or psychosis)
• Hematological disorder (100%) - hemolytic
anemia, leukopenia, thrombocytopenia
• Positive Antinuclear antibody
• Immunologic (anti-DNA or anti-Sm or anti-
phospholipid, low serum complement. +ve direct
Coomb's test)
Any 4 among (atleast 1 in each category) is required for diagnosis

Musculoskeletal manifestations
• Intermittent polyarthritis, most common in hands, wrist and knees
• Non-erosive synovitis with little deformity

 The most common manifestation of diffuse CNS lupus: cognitive dysfunction

 The most common pulmonary manifestation: pleuritis with or without pleural effusion
 Life threatening pulmonary manifestation: shrinking lung syndrome
 The most common cardiac manifestation: pericarditis
 The most serious cardiac manifestation: myocarditis and Libman-Sack's endocarditis
 Libman Sacks endocarditis most commonly causes mitral regurgitation
 The most common hematological manifestation: anemia
  MCC of death during early years - opportunistic infections followed by renal or CNS involvement
 MCC of death during later years - accelerated atherosclerosis

Classification of Lupus Nephritis

Class I: Minimal mesangial lupus nephritis
• Light microscopy - no changes seen
• Immunofluorescence - mesangial immune deposits

Class II: Mesangial proliferative lupus nephritis

• Light microscopy - mesangial cell proliferation or mesangial matrix expansion with mesangial immune
deposits
• IF or electron microscopy - few subepithelial or subendothelial deposits
• Glomerular capillaries not involved

Class III: Focal lupus nephritis

• Involves < 50% of glomeruli involved, with focal subendothelial deposits
• Swelling and proliferation of endothelial and mesangial cells
• Leukocyte accumulation, capillary necrosis, hyaline thrombi
• Can heal completely or result in glomerular scarring

Class IV: Diffuse lupus nephritis

• Involves > 50% of glomeruli
• Diffuse subendothelial deposits
• Wire-loop lesions on light microscopy
• Most severe and most common form

Class V: Membranous lupus nephritis - subepithelial immune deposits

Class VI: Advanced sclerotic lupus nephritis: ≥ 90% of glomeruli sclerosed without residual activity

Not seen in SLE

• Uveitis
• Joint erosions/deformity
• Lung cavitations
• Parotid enlargement

Chronic discoid lupus erythematosus

• Skin plaques, scarring and skin atrophy surrounded by an elevated erythematous border
• Systemic manifestations are rare
• 35% of patients show a positive test for generic ANAs
• Antibodies to double-stranded DNA are rarely present

Subacute cutaneous lupus erythematosus

• Widespread, superficial, and nonscarring skin lesions
• Mild systemic symptoms consistent with SLE.
• Strong association with antibodies to the SS-A antigen and HLA-DR3

Drug induced lupus

• The sex ratio is nearly equal
• Renal and CNS involvement is distinctly uncommon
• Antibodies specific for double-stranded DNA and low complement levels - rare
• High frequency of antibodies specific for histones
• The disease remits after withdrawal of the offending drug

Treatment
• Skin rashes and joint symptoms - Hydroxychloroquine
 • Glomerulonephritis, hemolytic anemia, pericarditis or myocarditis, alveolar hemorrhage, CNS involvement,
thrombotic thrombocytopenic purpura - Prednisone
• Steroid resistant cases - Cyclophosphamide, mycophenolate mofetil, azathioprine

SJOGREN SYNDROME
• More common in females in 50-60 age group
• Immune mediated destruction (predominantly CD4 T cells) of lacrimal and salivary glands
o D Dry eyes (keratoconjunctivitis sicca)
o Dry mouth (xerostomia)
• Primary - Sicca syndrome
• Secondary - associated with other autoimmune disorders, most commonly Rheumatoid arthritis
• 75% are rheumatoid factor positive
• 50-80% are ANA positive
• Anti-ribonucleoprotein antibodies
o SS-A (Ro) early onset and long duration disease, extra-glandular manifestations
o SS-B (La)
• Earliest histologic change - periductal and perivascular lymphocytic infiltration
• Increased risk of B cell lymphomas
• Diagnosis: Lip biopsy

SYSTEMIC SCLEROSIS
• Three cardinal features of the disease
o Widespread damage to small blood vessels
o Chronic inflammation (due to autoimmunity)
o Progressive interstitial and perivascular fibrosis in skin and multiple organs
• Females, age 50-60 years
• Skin is most commonly affected (usually fingers, forearms, face, neck)
• Alimentary tract - second most common
o Most severe in esophagus - reflux, strictures, Barret's metaptasia
o Large-mouthed diverticuli occur in the jejunum, ileum, and colon
• Raynaud phenomenon is usually the initial manifestation

Subtype Antibodies Characteristic clinical association

Diffuse scleroderma Anti-DNA topoisomerase Tendon friction rubs, cardiac involvement, renal
(Scl-70) crisis, pulmonary fibrosis, poor prognosis
Limited scleroderma Anti-Centromere Digital ischemia, isolated pulmonary artery
(CREST syndrome) hypertension
Diffuse cutaneous Anti-RNA polymerase Ill Extensive skin, tendon friction rubs, renal crisis

CREST syndrome
C - Calcinosis
R - Raynaud phenomenon
E - Esophageal dysmotility
S - Sclerodactyly
T - Tetangiectasia

Autoantibodies
Autoantibodies Disease
Anti-acetylcholine receptor Myasthenia gravis
Anti-TSH receptor Grave's disease
Anti-basement membrane Good Pasture's syndrome
Anti-centromere Limited scleroderma
Anti-endomysial(IgA) Anti-gliadin(IgA) Celiac disease
Anti-tissue transglutaminase (IgA)
 Anti-nuclear SLE, Systemic sclerosis, Dermatomyositis
Anti-dsDNA; Anti-Smith(Sm) SLE
Anti-SS-A(Ro); Anti-SS-B(La) Sjogren's syndrome
Anti-intrinsic factor; Anti-parietal cell Pernicious anemia
Antimicrosomal; Anti-thyroglobulin Hashimoto's thyroiditis
Anti-topoisomerase Diffuse scleroderma
Anti-mitochondrial Primary biliary cirrhosis
Anti-myeloperoxidase(p-ANCA) Microscopic polyangitis
Anti-proteinase-3(c-ANCA) Wegener's granulomatosis
Anti-ribonucteoprotein Multiple connective tissue disease(MTCD)
Anti-histidyl t-RNA synthetase(Jo-1) Inflammatory myopathies

IgG4-related disease
• Most often affects middle-aged and older men
• Tissue infiltrates dominated by IgG4 antibody-producing plasma cells and lymphocytes, particularly T cells
• Storiform fibrosis
• Obliterative phlebitis
• Increased serum IgG4
• Can affect any organ of the body
• Common presenting manifestations - enlargement of submandibular glands, proptosis from periorbital
infiltration, retroperitoneal fibrosis, mediastinal fibrosis, inflammatory aortic aneurysm, and pancreatic mass
with autoimmune pancreatitis
 V. NEOPLASIA
Malignant tumors
• Sarcoma - Arising from mesenchymal tissue
• Carcinoma - Tumor of epithelial origin

Not actual tumors

• Choristoma
o Ectopic rest of normal tissue (normal tissue at different anatomical site)
o E.g: pancreatic substance present in the submucosa of stomach or duodenum.
• Hamartoma
o Disorganized but mature specialized cells present at a normal site
o E.g: disorganized mass of blood vessels, cartilage, bronchial, lymphoid tissue in the lung

Characteristics of Neoplasia
• Anaplasia (absence of differentiation) - hallmark of malignant transformation
• Pleomorphism
• Loss of polarity
• Increased growth rate (increased mitoses)
• Dysplasia
• Local invasion (2nd most reliable feature after metastasis to differentiate cancers from benign tumors)
o First step - Dissociation of cancer cells from one another due to alterations in intercellular adhesion
molecules
o Second step - Degradation of the basement membrane and interstitial connective tissue
o Third step - Changes in attachment of tumor cells to ECM proteins
o Final step - locomotion, propelling tumor cells through degraded basement membranes
• Metastasis - most reliable feature
o Direct seeding of body cavities - Carcinoma ovary
o Lymphatic spread - typical of carcinomas, but seen in some sarcomas
o Hematogenous spread - typical of sarcomas, but seen in some carcinomas
o Cancers which rarely metastasize - Gliomas, Basal cell carcinoma of skin
o Oncogenes promoting metastasis - SNAIL, TWIST
o Genes promoting metastasis Ezrin (Rhabdomyocarcoma and Osteosarcoma)
o Genes inhibiting metastasis - NM23, KAI-1(prostate cancer) & Ki55 (malignant melanoma)

Epidemiology of cancer
Most common cancer in the world Lung cancer
Second most common cancer in the world Breast cancer
Most common cause of cancer death in the world Lung cancer
Most common cancer in males Prostate cancer
Most common cancer in females Breast cancer
Second most common cancer in males and females Lung cancer
Most common cancer in < 20 years (males and females) Leukemia
Most common cancer in females 20 - 60 years Breast cancer
Most common cancer in females > 60 years Lung cancer
Most common cancer death in males and females Lung cancer
More common in developed countries Lung, Breast, Prostate, Colorectal
More common in less developed countries Liver, Cervix, Esophagus

Rates of growth
• Smallest clinically detectable mass - 109cells (1 gram)
• Largest mass compatible with life - 1012cells (1 kg)
• The average volume doubling time
 o < 1 month for some childhood cancers
o 2 to 3 months for colon and lung cancers
o > 1 year for salivary gland tumors

Changes in Cell Physiology - Hallmarks of cancer

• Self-sufficiency in growth signals
• Insensitivity to growth inhibitor signals
• Altered cellular metabolism - Warburg effect or Aerobic glycolysis (hallmark effect)
• Evasion of apoptosis
• Limitless replicative potential (immortality) due to telomerase activity
• Sustained angiogenesis
• Tissue invasion and metastasis
• Ability to evade the hose immune response

PROTOONCOGENES
• Proto-Ooncogenes: Normal genes required for cell proliferation and differentiation
• Oncogenes: mutated proto-oncogenes that promote autonomous cell growth in cancer cells
• Oncoproteins: Proteins encoded by oncogenes that drives increased cell proliferation

Protooncogene Associated human cancer

PDGF-β chain & TGF-α Astrocytoma
Fibroblast growth factors
HST-1 Osteosarcoma
FGF3 Stomach, Bladder & Breast cancer, Melanoma
HGF Hepatocellular cancer, Thyroid cancer
EGF receptor family
ERB-B1 Adenocarcinoma of lung
ERB-B2 Breast carcinoma
RET Multiple endocrine neoplasia 2A and 2B
Familial medullary carcinoma thyroid
KIT Gastrointestinal stromat tumors
Seminomas, leukemia
ALK Adenocarcinoma of lung, Neuroblastoma
GTP binding proteins
K-RAS Colon, lung and pancreatic cancers
H-RAS Bladder and kidney cancers
N-RAS Melanoma, hematologic malignancies
GNAQ Uveal melanoma
GNAS Pituitary adenoma, other endocrine tumors
ABL CML, ALL
BRAF Melanoma, leukemia, colon cancer
NOTCH1 Leukemia, lymphoma, breast carcinoma
JAK2 Myeloproliferative disorders, ALL
β-catenin Hepatoblastoma, Hepatocellular carcinoma
MYC Burkitt lymphoma
N-MYC LNeuroblastoma
CYCLIN D1 Mantle cell lymphoma, Multiple myeloma
Breast, Esophageal cancer
CDK4 Glioblastoma, Melanoma. Sarcoma
FOS Osteosarcomas

• Mutations of RAS family genes - MC type of abnormality involving proto-oncogenes in human tumors
Cell cycle
• Presynthetic phase - G1
• DNA synthesis - S
• Premitotic phase - G2
• Mitotic phase - M

 Quiescent cells that have not entered the cell cycle are in GO state
 Rate limiting step for replication (Restriction point) G1-S transition
 S phase is the point of no return in the cell cycle
 G1 phase is the most variable phase in the cell cycle

Cell cycle check points

G1-S check point Monitors integrity of DNA before replication
Defects in the G1 /S checkpoint are more important in
cancer
G2-M check point Monitors DNA after replication
Important in cells exposed to ionizing radiation

Cell cycle component Main function

Cyclin dependent kinases (CKD)
CDK4 Cyclin D-CDK4 complex phosphorylates RB allowing the cell progress through the G1
restriction point
Cell cycle inhibitors
CIP/KIP family Blocks the cell cycle by binding with cyclin-CDK complexes p21 is induced by the tumor
p21, p27 (CDKN1A-D) suppressor gene p53
INK4/ARF family p16/INK4a binds to cyclin D-CDK4 and promotes inhibitory effects of RB p14/ARF
(CDKN2A-C) increases p53 levels by inhibiting MDM2 activity
Check point components
RB Tumor suppressive "pocket" protein - binds E2F transcription factors in its
hypophosphorylated state, preventing Gl/S transition
p53 Causes cell cycle arrest and apoptosis
Acts mainly through p21 to cause cell cycle arrest
Causes apoptosis by inducing transcription of pro-apoptotic genes such as
BAX
p53 levels are negatively regulated by MDM2
p53 is required for the G1 /S check point and G2/M check point

Atleast one of four key cell cycle regulators are dysregulated in vast majority of human cancer
• p16/INK4a
• Cyclin D
• CDK4
• RB

TUMOR SUPPRESSOR GENES

RB
• Governor of proliferation
• First tumor suppressor gene discovered
• A key negative regulator of the G1 /S cell cycle transition
• Active (hypophosphorylated) state forms a complex with E2F (transcription factor) in quiescent
• cells
• Cyclin D-CDK4 complex phosphorylates RB protein and releases E2F
• Activated E2F results in transcription of target genes essential for progression through S phase
• E7 protein of high-risk human papilloma viruses, binds to RB and prevents binding of E2F

TP53
 • Guardian of the Genome or Molecular policeman
• Most frequently mutated gene in human cancers
• Assists DNA repair by causing cell cycle arrest in late G1 phase & inducing DNA repair genes
• Thwarts neoplastic transformation by three interlocking mechanisms
o Activation of temporary cell cycle arrest (quiscence)
o Induction of permanent cell cycle arrest (senescence)
o Triggering of programmed cell death (apoptosis)
• E6 protein of high-risk human papilloma viruses, binds to p53 and promotes it degradation
• MDM2 proteins inhibits p53 TP53

Tumor suppressor gene & Location on chromosome

p53 17p NF2 22q
RB 13q14 VHL 3p
APC 5q21 WT1 11p
PTEN 10q23 BRCA1 17q
NF1 17q BRCA2 13q

• APC - Gatekeeper of Colonic Neoplasia

• p63 - differentiation of stratified squamous epithelia
• p73 -_proapoptotic effects after DNA damage caused by chemotherapeutic agents

Tumor suppressor gene Familial syndromes Sporadic cancers

APC Familial colonic polyps and carcinomas Carcinomas of stomach, colon,
pancreas melanoma
NF1 Neurofibromatosis type 1 Neuroblastomas
NF2 Neurofibromatosis type 2 (Acoustic Schwannomas
schwannomas, Meningiomas) Meningiomas
PTCH (Patched) Gorlin syndrome (basal cell carcinoma, Basal cell carcinoma
medulloblastoma) Medulloblastoma
PTEN (Phosphatase and Cowden syndrome Many carcinomas and lymphoid
tensin) tumors
SMAD2, SMAD4 Juvenile polyposis syndrome Colon and pancreatic cancer
RB Familial Retinoblastoma syndrome Retinoblastoma, Osteosarcoma
Ca of breast, colon, lung
CDKN2A Familial melanoma Pancreatic, breast, and esophageal
carcinoma, melanoma
VHL VHL syndrome Renal cell carcinoma
STK11 Peutz-Jeghers syndrome Variety of cancers
SDHB, SDHD Familial paraganglioma Paraganglioma
Familial pheochromocytoma
CDH1 (E-cadherin) Familial gastric cancer Gastric cancer, Lobular breast cancer
TP53 (p53) Li-Fraumeni syndrome Most human cancers
BRCA1 and Familial breast and ovarian carcinoma; Rare
BRCA 2 carcinomas of male breast;
chronic lymphocytic leukemia (BRCA2)
MSH2, MLH1, MSH6 HNPCC Colon and endometrial cancer
WTI Wilm's tumor Wilm's tumor
MEN 1 Multiple endocrine neoplasia 1 Pituitary, pancreatic, parathyroid
tumors
 Disorders of Defective DNA repair
Nucleotide excision repair (Autosomal recessive) Xeroderma pigmentosum (Increased risk of development
of skin cancers when exposed to UV rays)
Recombination repair (Autosomal recessive) Ataxia-telangiectasia Bloom syndrome
Fanconi anemia
Mismatch repair (hallmark - microsatellite instability) HNPCC
(Autosomal dominant)

Oncogenes created by Translocations

Malignancy Translocation Affected genes
Chronic myelogenous leukemia (9;22) ABL-BCR
Acute myeloid leukemia (AML) (8;21) AML-ETO
(15;17) PML-RARA
Burkitt lymphoma (8;14) MYC-IGH
Mantle cell lymphoma (11;14) CCND1-IGH
Follicular lymphoma (14;18) IGH-BCL2
Ewing sarcoma (11;22) FL1-EWSR1
Prostatic adenocarcinoma (7;21) ETV1-TMPRSS2
(17;21) ETV4-TMPRSS2

AUTOSOMAL DOMINANT CANCERS Familial cancers

• Retinoblastoma • MEN 1 & 2 • Breast cancer
• Li-Fraumeni syndrome • Melanoma • Ovarian cancer
• Peutz Jeghers syndrome • HNPCC • Pancreatic cancer
• Familial adenomatous polyposis • Cowden syndrome • Colon cancer
• Nevoid basal cell cancer syndrome • Breast cancer
• Von Hippel Lindau syndrome • Ovarian cancer
• Neurofibromatosis 1 & 2

Chromothrypsis (Chromosome shattering)

• Dramatic chromosome catastrophes (other than simple deletions, duplications or inversions)
• A single event in which dozens to hundreds of chromosome breaks occur across single or several
chromosomes
• Observed in 1% to 2% of cancers as a whole
• Found in higher frequencies in osteosarcomas and bone cancers; and gliomas
• DNA repair mechanisms are activated that stitch the pieces together in a haphazard way, creating many
chromosome rearrangements

Epigenetics
• Factors other than the sequence of DNA that regulate gene expression
• Epigenomic Regulatory Genes can be mutated which may cause defective
o DNA methylation - Acute myeloid leukemia
o Histone methylation - Acute leukemia in infants, Follicular lymphoma
o Histone acetylation - Diffuse large B cell lymphoma
o Nucleosome positioning/chromatin remodelling - Ovarian clear cell carcinoma, Endometrial
carcinoma, Malignant rhabdoid tumo, Renal carcinoma

RADIATION CARCINOGENESIS
UV rays Ionizing radiation
• UV-B is most carcinogenic • X-rays, gamma rays and beta particles
• Exposure  pyrimidine dimers in DNA resulting • Exposure  cross linking and chain break in
in mutations of oncogenes and tumor suppressor nucleic acids
genes • Papillary carcinoma of thyroid and leukemias
 (except CLL)

CHEMICAL CARCINOGENESIS
Steps
• Initiation - exposure to a carcinogen
• Permanent DNA damage - tumors produced even if the application of the promoting agent is delayed
• Promoters - induce tumors to arise from initiated cells, but they are nontumorigenic by themselves

Directly acting carcinogens (require no metabolic conversion to become carcinogenic)

Alkylating agents Acylating agents
• β-Propiolactone, Dimethyl sulfate, • 1-acetyl-imidazole
Diepoxybutane • Dimethylcarbamyl chloride
• Anticancer drugs (cyclophosphamide,
chlorambucil, nitrosoureas etc.)

Procarcinogens that require metabolic activation

Hydrocarbons Amines, amides Natural Others
• Benzanthracene • β-naphthylamine • Aflatoxin B1 • Nitrosamines
• Benzopyrene • Benzidine • Griseofulvin • Vinyl chloride
• Dibenzanthracene • 2-acetylaminoflurane • Cycasin • Nickel, chromium
• 3- • Butter yellow • Safrole • Insecticides
methylchloranthrene • Betel nuts • Fungicides

Chemical carcinogen Associated cancer

Aflatoxin Hepatocellular carcinoma
Aikylating agents AML, Bladder cancer
Arsenic Cancer of skin, lung, hemangiosarcoma
Asbestos Bronchogenic ca, pleural mesothelioma, GIT cancer
Benzene AML, Hodgkin lymphoma
Beryllium, Chromium, Nickel, Silica Bronchogenic carcinoma
Cyclophosphamide, 13-naphthylamine Transitional cell carcinoma of urinary bladder
Cadmium Lung cancer
Diethylstilbesterol (Prenatal) Clear cell carcinoma of vagina, cervix
Estrogens Cancer of endometrium, liver, breast
Nitrogen mustard gas Cancer of lung, head and neck, nasal sinuses
Nickel Cancer of lung, nasal sinuses
Oral contraceptives Bladder and cervical cancer
Polycyclic hydrocarbons Squamous cell carcinoma: oral cavity, mid esophagus, larynx,
lung
Adenocarcinoma: distal esophagus, pancreas
Transitional cell carcinoma: urinary bladder, renal pelvis
Squamous cell carcinoma of scrotal skin
Phenacetin Cancer of renal pelvis and bladder
Vinyl chloride Liver angiosarcoma

MICROBIAL CARCINOGENESIS
• HTLV-1: Tax gene gene (not present in other retroviruses) increases pro-growth signalling and survival and
increases genomic instability by inhibiting DNA repair
• EBV: LMP-1 gene promotes B cell survival and proliferation; activates BCL2 and prevents apoptosis
• HPV: E6 and E7 viral genes cause inactivation of p53 and RB genes respectively
E7 protein E6 protein
• Binds to the RB protein, displaces E2F • Binds to and mediates degradation of p53
transcription factors, promoting progression • Stimulates expression of TERT (subunit of
 through cell cycle telomerase)
• Inactivates CDKIs p21 and p27

• Ames test - simple invitro test for carcinogenicity, tests ability of carcinogens by their potential to induce
mutations in Salmonella typhimurium

Cancers associated with infectious agents

Condition Etiologic agent Associated neoplasms
Opisthorchis, Cholangitis Liver flukes (Opisthorchis viverrini) Cholangiosarcoma, Colon carcinoma
Chronic cholecystitis Bacteria, Gallstones Gall bladder cancer
Gastritis/Ulcers Helicobacter pylon Gastric adenocaranoma, MALT
Hepatitis Hepatitis B and C virus Hepatocellular carcinoma
Infectious mononucleosis Epstein Barr virus B-cell NHL and HL
AIDS HIV, HHV 8 NHL, squamous cell carcinoma, KS
Osteomyelitis Bacterial infection Carcinoma in draining sinuses
PID, Chronic cervicitis Gonorrhea, Chlamydia, HPV Ovarian carcinoma, cervical/anal ca
Chronic cystitis Schistosomiasis Bladder, liver, rectal carcinoma

Infections associated with specific types of cancer

Cancer Immune abnormality Organism

Multiple myeloma, CLL Hypogammaglobulinemia S. pneumoniae, H. influenzae, N. meningitidis
Acute myetocytic or Granulocytopenia, skin and Extracellular gram-positive and gram-negative
lymphocytic leukemia mucous-membrane lesions bacteria, fungi
Hodgkins disease, hairy Abnormal T cell function Intracellular pathogens (M. tuberculosis,
cell leukemia Listeria, Salmonella, Cryptococcus, M. avium)
NHL, ALL Glucocorticoid therapy, T Pneumocystis
and B cell dysfunction
Colon and rectal tumors Local abnormalities Streptococcus bovis (bacteremia)

PARANEOPLASTIC SYNDROMES
Clinical syndromes Major underlying cancers Causal mechanism
Cushing syndrome Lung caner (small cell, bronchial ACTH
carcinoid, adeno, squamous)
Thymoma
Medullary thyroid cancer
Pancreatic carcinoma
Neural tumors
Pancreatic cancer, lung cancer, Corticotropin-releasing hormone
prostate cancer, carcinoid (CRH)
SIADH Small cell carcinoma of Lung ADH or atrial natriuretic hormone
Intracranial neoplasms
Hypercalcemia Squamous cell cancer (Head a neck, Parathyroid hormone-related
(most common lung, skin) peptide (PTHRP) TGF-a, TNF, IL-
paraneoplastic Breast carcinoma 1
syndrome) Gastrointestinal a Genitourinary
tumors
Adult T cell leukemia/Lymphoma 1,25 dihydroxyvitamin D
Renal carcinoma, lung carcinoma Prostaglandin E2
Lung cancer, Ovarian cancer Parathormone
Hypoglycemia Ovarian carcinomaSarcomas, Insulin or insulin like substance
Mesenchymal tumors
 Polycythemia Renal carcinoma Erythropoietin
Cerebellar hemangioma
Hepatocellular carcinoma
Myasthenia Bronchogenic carcinoma Immunologic
Acanthosis nigricans Gastric carcinoma Immunologic, Epidermal growth factor
Lung carcinoma
Uterine carcinoma
Dermatomyositis Bronchogenic carcinoma Immunologic
Breast carcinoma
Hypertrophic Bronchogenic carcinoma Unknown
osteoarthropathy and Thymic neoplasms
clubbing of fingers
Venous thrombosis Pancreatic carcinoma Tumor products (mucins that activate clotting)
(Trousseau phenomenon) Bronchogenic carcinoma
DIC Acute promyelocytic leukemia Tumor products that activate clotting
Prostatic carcinoma
Oncogenic osteomalacia Hemangiopericytomas, Phosphatonin (fibroblast growth factor 23-
steoblastomas, fibromas, sarcomas, FGF23)
giant cell tumors

Cancer cachexia
• Equal loss of both fat and lean muscle
• Elevated basal metabolic rate
• Evidence of systemic inflammation (e.g., an increase in acute phase reactants)
• TNFα (cachetin) plays an important role

Paraneoplastic neurologic syndromes

Syndrome Antibody
Encephalomyelitis, subacute sensory neuronopathy Anti-Hu
Cerebellar degeneration Anti-Yo, Anti-Tr
Cerebellar degeneration, opsoclonus Anti-Ri
Encephalomyelitis, chorea, optic neuritis, uveitis, Anti-CV2/CRMP5
peripheral neuropathy
Limbic, hypothalamic, brainstem encephalitis Anti-Ma proteins
Stiff-person syndrome, encephalomyelitis Anti-amphiphysin, glycine receptor
Cancer-associated retinopathy (CAR) Recoverin, bipolar cell antibodies
Melanoma-associated retinopathy (MAR)
Stiff-person, cerebellar syndromes Anti-GAD
Lambert-Eaton myasthenic syndrome Anti-VGCC

Chronic inflammatory states and cancer

Condition Associated neoplasm
Asbestosis, Silicosis Mesothelioma, Lung carcinoma
Bronchitis Lung carcinoma
Cystitis Bladder carcinoma
Gingivitis, Lichen planus Oral squamous cell carcinoma
inflammatory bowel disease Colorectal carcinoma
Lichen sclerosis Vulvar squamous cell carcinoma
Chronic pancreatitis Pancreatic carcinoma
Barrett esophagus Esophageal carcinoma
Sialadenitis Salivary gland carcinoma
 Sjogren syndrome, Hashimoto thyroiditis MALT lymphoma

Grading of cancers Staging of cancers

• Degree of differentiation • Size of primary lesion
• Number of mitoses • Extent of spread to regional lymph nodes
• Architectural features • Presence or absence of blood borne metastases

TUMOR MARKERS
Markers Associated cancers Non neoplastic conditions
Human chorionic gonadotropin Trophoblastic tumors, non- Pregnancy
seminomatous testicular tumors
Calcitonin Medullary carcinoma of thyroid
Catecholamine and Pheochromocytoma
metabolites
a-fetoprotein (AFP) Liver ca, non-seminomatous Cirrhosis, hepatitis
testicular germ cell tumors
(especially yolk sac tumors)
Carcinoembryonic antigen Cancer of colon, pancreas, lung, Pancreatitis, hepatitis, smoking,
(CEA) stomach, heart inflammatory bowel disease
Prostatic acid phosphatase, Prostate cancer Prostatitis, prostatic hypertrophy
PSA
Neuron specific enolase Small cell cancer of lung,
neuroblastoma
CA-125 Ovarian cancer, some lymphomas Menstruation, peritonitis, pregnancy
CA-19-9 Colon, pancreatic & breast Pancreatitis, ulcerative colitis
cancer, Cholangitis, patients who lack the
Cholangiocarcinoma Lewis blood type antigen
CA-15-3, CA 27-29 Breast cancer
S-100, HMB-45 Melanoma
CD 30 Hodgkin's disease, Anaplastic
large cell carcinoma

Oncofetal antigens
• Proteins expressed at high levels on cancer cells and in normal developing (fetal) tissues
• Eg: CEA a AFP

New molecular markers Cancer

TP53, APC, RAS mutations in stool and serum Colon cancer
TP53, RAS mutations in stool and serum Pancreatic cancer
TP53, RAS mutations in sputum and serum Lung cancer
TP53 mutations in urine Bladder cancer

Immunohistochemical markers used in diagnosis of Carcinoma of Unknown Primary (CUP)

TISSUE MARKER DIAGNOSIS
Estrogen and progesterone receptors, BRSR-1, Breast cancer
Gross cystic disease fibrous protein-15
Thyroid transcription factor 1 Lung and thyroid cancer
Chromogranin, synaptophysin, CD56 Neuroendocrine cancer
CDX-2 Gastrointestinal cancer
Calretinin, Mesothelin Mesothelioma
HMB-45, tyrosinase, Melan-A Melanoma
URO-Ill, thrombomodulin Bladder cancer
 WT-1, estrogen receptor Mullerian/ovarian cancer
RCC, CD 10 Renal cell carcinoma

HMB45 is positive in
• Malignan melanoma • Melanocytosis
• Angiomyolipoma of various sites • PEComa
• Clear cell sarcoma of soft tissue • Pheochromocytoma
• Clear cell "sugar" tumor • Pigmented Schwannoma
• Lymphangioleiomyomatosis • Tuberous sclerosis complex components

Type of tumors associated with intermediate filaments

Intermediate filament Normal tissue expression Tumor
Cytokeratin Epithelial cells Carcinoma
Vimentin Mesenchymal cells Sarcoma
Desmin Muscles Leiomyoma
Rhabdomyosarcoma
Glial fibrillary acidic Glial cells Astrocytoma
protein Ependymoma
Neurofilament Neurons Pheochromocytoma
Neuroblastoma

Markers of cell proliferation

• PCNA (proliferating cell nuclear antigen)
• Ki-67 (MKI67)
• MCM-2 (minichromosome maintaince)
• p-27
• Topoisomerase II-α
• AGNOR (argyrophilic nuclear organization region)
• BrdUrd (bromodeoxyuridine)
• Cyclins

Flow cytometry
• Rapidly and quantitatively measure membrane antigens and the DNA content of the cell
• Useful in identification & classification of tumors arising from T and B lymphocytes and mononuclear cells

Immunohistochemistry
• Categorization of undifferentiated malignant tumors
• Determination of site of origin of metastatic tumors
• Detection of molecules that have prognostic or therapeutic significance
DNA microarray analysis and proteomics: Used to obtain gene expression signatures (molecular profiles) of cancer
cells

FDA approved molecularly targeted agents used in cancer treatment

Drug Molecular target Disease
All-trans retinoid acid (ATRA) PML-RARa oncogene AML M3
Imatinib, Dasatinib, Nilotinib Bcr-Abl, c-Abl, c-Kit, PDGFR-α/β CML, GIST

Sunitinib c-Kit, VEGFR-2, PDGFR- α/β GIST, renal cell cancer

Sorafenib RAF, VEGFR-2, PDGFR- α/β, RCC, hepatocellular carcinoma
Flt-3, c-Kit
Erlotinib EFGR Non-small cell lung ca,
pancreatic ca
Geftinib EFGR Non-small cell lung cancer
Bortezomib Proteasome Multiple myeloma
Tumor regulatory antibodies
Transtuzumab HER2/neu (ERBB2) Breast cancer & GI cancers expressing HER2/neu
Oftumumab CD20 CLL
Cetuximab EFGR Colon cancer, squamous cell carcinoma of the head and
neck
Panitumumab EFGR Colon cancer
Rituximab CD20 B cell lymphomas and leukemias that express CD20
Bevacizumab VEGF Metastatic colorectal cancer, non-small cell lung cancer,
renal cancer, glioblastoma
Immunoregulatory antibodies
Alemtuzumab CD52 Chronic lymphocytic Leukemia, T cell lymphomas
Ipilimumab CLTA4 Melanoma
Pembrolizumab PD-1 Melanoma
 VI. ENVIRONMENTAL, INFANT & CHILDHOOD DISEASES
Effects of tobacco smoke components
Nicotine Ganglionic stimulation, Tumor promotion
Not a direct cause of tobacco related diseases
Tar, Polycyclic aromatic hydrocarbons Benzopyrene , Carcinogenesis
Nitrosamine

Tobacco & Cancer Alcohol & Cancer Obesity & Cancer

Oral cavity Pancreas Oral Liver Esophagus Endometrium
Larynx Bladder Cavity Pancreas Pancreas Kidney
Lung Kidney Larynx Breast Colorectal Thyroid
Esophagus Cervix Esophagus Head & Breast Gall bladder
Stomach Bone marrow Stomach Neck
? Colo-rectal Head & Neck
Acute myeloid leukemia

• Passive smoke inhalation in non-smokers can be estimated by measuring the blood levels of cotinine (a
metabolite of nicotine)

Hematopoietic changes after total body irradiation

• Lymphopenia within hours
• Neutropenia within days (after transient rise in neutrophil count)
• Thrombocytopenia by the end of first week
• Anemia after 2-3 weeks

HYDROPS
Immune hydrops
• Hemolytic disease in the newborn caused by blood group incompatibility between mother & child
• Two major antigens are ABO and Rh antigens
• Rh isoimmunization is preventable
• No effective protection is available against ABC) reactions

Non immune hydrops

• CVS defects are the most common cause
• Chromosomal anomalies and fetal anemia are the other major causes

Morphology
• In hydrops due to anemia, fetus and placenta are pale
• Liver and spleen are enlarged due to cardiac failure
• Bone marrow shows compensatory hyperplasia and extramedullary hematopoiesis in liver, spleen,
lymphnodes and other tissues such as kidneys, lungs and even heart

HUMAN DISEASES ASSOCIATED WITH OCCUPATIONAL EXPOSURES

Nasal cancer Isopropyl alcohol, wood dust
Lung cancer Radon, asbestos, silica, bis-ether, nickel, arsenic, chromium, mustard gas,
uranium
COPD Grain dust, coal dust, cadmium
Fibrosis of lung Silica, asbestos, cobalt
Bladder cancer Naphthylamines, 4-aminobiphenyl, benzidine, rubber products
Male infertility Lead, Phthalate plasticizers, cadmium
Female infertility Lead, mercury
Teratogenicity Mercury, polychlorinated biphenyls
Leukemia Benzene
Liver angiosarcoma Vinyl chloride
CYSTIC FIBROSIS (MUCOVISCIDOSIS)
• Disorder of ion transport in epithelial cells affecting fluid secretion in exocrine glands and the epithelial
lining of respiratory, reproductory and gastrointestinal tracts
• Autosomal recessive
• Incidence 1 in 2500 live births
• The primary disorder is the abnormal function of an epithelial chloride channel protein encoded by the
cystic fibrosis transmembrane conductance regulator(CFTR) gene in chromosome 7q31.2
• ENaC (epithelium sodium channel of exocrine epithelial cells) is responsible for sodium uptake from the
luminal fluid, rendering it (the luminat fluid) hypotonic
• ENaC is inhibited by normally functioning CFTR
• In CF, ENaC activity increases, markedly augmenting sodium uptake
• Exception - ENaC activity in sweat ducts decreases as a result of CFTR mutation - sweat with high sodium
and chloride content (salty sweat - sine qua non of classic cystic fibrosis)
• In some CFTR mutants chloride transport is completely or substantially preserved, while bicarbonate
transport is markedly abnormal
• Single deletion at 508 position of the protein (∆F508) is the most common mutation

Respiratory tract
• Main cause of mortality is lower respiratory tract infections caused by S.aureus, H.influenzae,
Ps.aeruginosa
• Burkholderia cenocepacia causes a fulminant illness - cepacia syndrome
• Complications - Nasal polyps, digital clubbing, spontaneous pneumothorax, cor pulmonale
• The right upper lobe displays the earliest and most severe radiological changes
• Persistent chest radiograph abnormalities (bronchiectasis, atelectasis, infiltrates, hyperinflation)
• Mycobacterium tuberculosis infection is rare
• Diagnostic biophysical hallmark is the raised trans-epithelial electric potential difference

Pancreatic abnormalities (90%)

• Recurrent acute pancreatitis
• In severe cases the ducts are completely plugged causing atrophy of exocrine glands
• Impaired fat absorption  deficiency of fat soluble vitamins
• Meconium ileus (common clinical presentation in neonatal period)
• Pancreas-sufficient phenotype (mild CFTR mutation) is not associated with other GI complications
• Endocrine pancreatic insufficiency (i.e., diabetes) is uncommon

GIT - distal intestinal obstruction syndrome, rectal prolapsed

Liver - hepatic steatosis, focal biliary cirrhosis, gall stones,

Genito-urinary tract
• Delayed puberty in both males and females
• Azoospermia and infertility are found in 95% of the males who survive to adulthood
• Congenital bilateral absence of vas deferens - obstructive azoospermia
Salt-loss syndromes: acute salt depletion, chronic metabolic alkalosis

Diagnosis
• Elevated sweat chloride (> 60 mEq/L) is the reliable and diagnostic test. Level obtained by pilocarpine
iontophoresis confirms diagnosis (often the mother makes the diagnosis by recognizing her infant's
abnormally salty sweat)
• A normal sweat chloride test does not exclude the diagnosis
• Sequencing of CFTR gene is the gold standard for the diagnosis of Cystic fibrosis
• D-xylose absorption test is abnormal; Trypsin in the duodenal juice and stool is reduced

Treatment
 • Clearance of lower airway secretions - postural drainage, chest percussion or vibration techniques, positive
expiratory pressure (PEP) or flutter valve breathing devices
• Inhaled recombinant human deoxyribonuclease- decreasing sputum viscosity, improves FEV1, reduces the
risk respiratory exacerbations and the need for intravenous antibiotics
• Antibiotics, Inhaled bronchodilators
• Ivacaftor for patients with a G551D mutation. Ivacaftor is a potentiator of the CFTR channel that works by
increasing the time the channel remains open after being activated
• CFTR corrector therapy for the most common mutation (DeltaF508) is currently under trial

NEUROBLASTOMA
• Third most common pediatric cancer (8%)
• Most common extracranial solid tumor of childhood
• Most frequently diagnosed neoplasm in infants
• Most cases are sporadic
• Familial cases result from mutation in ALK (anaptastic lymphoma kinase) gene

Morphology
• Small round blue cell tumor
• Background - faintly eosinophilic fibrillary material (neuropil)
• Homer-Wright pseudorosettes can be seen in few cases
• Stains positive for neuron specific enolase

Clinical features
• Most common site of the primary tumor is the adrenal gland followed by paravertebral sympathetic chain
in abdomen and posterior mediastinum
• MC presentation - asymptomatic abdominal mass found incidentally (excellent prognosis)
• The most common sites of metastasis are the long bones and skull. Lung metastases are rare
• In new born babies disseminated neuroblastomas may present with multiple cutaneous metastases with
deep blue discoloration to skin (blue-berry muffin baby)
• Paraneoplastic syndrome - ataxia or opsomyoclonus (dancing eyes and dancing feet). The primary tumor is
in the chest or abdomen, and the brain is negative for tumor
• 90% of the tumors produce catecholamines

Investigations
• On plain X-ray or CT the mass often contains stippled calcification and hemorrhage. Wilms tumor, another
common flank mass in a young child, usually does not calcify
• The gold standard for diagnosis - histopathology and immunohistochemistry
• Tumor markers: ↑ homovanillic acid (HVA) and vanillylmandelic acid (VMA) in urine
• Nuclear scanning with I123 or I131MIBG detects tumors and metastasis accurately

Staging
IV Tumor with disseminated to distant nodes, bone, bone marrow and other organs (except IV-S)
IV-S Localized primary tumor as defined for stage 1 or 2 with dissemination limited to liver, skin,
and/or bone marrow (not bone)
Stage IV-S is limited to infants < 1 year

Variable prognosis Favorable prognosis Unfavorable prognosis

Stage I, II, IV-S Ill, IV
Age < 18 months > 18 months
 Histology
Schwanian stroma and
gangliocytic
differentiation
Present Absent
Mitosis-Karyorrhexis index
<200/5000 cells >200/5000 cells
Intratumoral calcification
Present Absent
DNA ploidy Hyperdiploid (whole
chromosomal gains) Near-diploid (Segmental chromosomal losses;
chrornothripsis)

MYCN oncogene Not amplified Amplified

Chromosome 1p & 11q loss Absent Present
TRKA expression Present Absent
Mutations in neuritogenesis Absent Present
genes
Hemizygous loss of Absent Present
chromosome 1 p36,
11q
The most pertinent prognostic factors
• Age and stage are the most important determinants of outcome
• Stages 1, 2A, or 2B tend to have an excellent prognosis, irrespective of age (except N-myc amplification)
• The age of 18 months has emerged as a critical point of dichotomy in terms of prognosis
• Morphology is an independent prognostic variable
• Amplification of the MYCN oncogene - possibly the most profound impact on prognosis
• Ploidy

Treatment
• Stage 1 and 2 - surgery
• Chemotherapy is the mainstay of treatment in advanced stage

WILM'S TUMOR (NEPHROBLASTOMA)

• Most common malignant tumor of kidney
• 2nd most common malignant abdominal tumor in childhood (Most common - Neuroblastoma)
• Usually occurs in children between 2-5 yr of age
• Wilms tumor gene, WT1, is located at 11p13

Associated syndromes
Denys Drash syndrome Beckwith Wiedemann syndrome WAGR syndrome
• 90% risk of Wilm's tumor • Genetic abnormality - • 33% risk of Wilm's
• Genetic abnormality - dominant- • Genomic imprinting tumor
negative missense mutation • Macroglossia • Genetic abnormality -
• Male pseudohermaphroditism • Gigantism deletions
(gonadal dysgenesis) • Umbilical hernia • Aniridia (PAM gene)
• Diffuse mesangial sclerosis (early • Hemihypertrophy • Genital anomalies
onset nephropathy) • Organomegaly • Mental Retardation
• Congenital nephrotic syndrome • Omphalocele
• ↑ risk of gonadoblastoma • Adrenal cytomegaly

• Others - Horse-shoe kidney, hypospadias, cryptorchidism

• Other diseases with increased risk of Wilms's tumor: Pearlman syndrome, Sotos syndrome,
neurofibromatosis (von Recklinghausen disease), and von Willebrand disease

Clinical features
• Most patients present with an asymptomatic abdominal mass
• Hematuria, hypertension, abdominal pain, fever, anorexia and vomiting
 • Increased risk of sporadic Aniridia, Benito-urinary anomalies, Sotos syndrome, NF-1, vWD

Morphology
• Nephrogenic rests are putative precursor lesions of Wilms tumor
• Triphasic combination of blastemal, stromal and epithelial cell types
• 5% of tumors reveal anaplasia. The presence of anaplasia correlates with the presence of TP53 mutations
and the emergence of resistance to chemotherapy

Management
• USG is the most important investigation as it can differentiate solid from cystic mass
• CT and MRI provide details about the extent of the tumor

Staging
I Tumor confined to kidney and completely excised
II Tumor extends beyond kidney but completely excised
III Tumor infiltrates renal fat, residual tumor after surgery,
LN involvement at hilum, paraaortic region and beyond
IV Metastasis in lung or liver
V Bilateral renal involvement

• Diploid tumors have better prognosis than hyperploid tumors

• Therapy includes surgery+chemotherapy+radiotherapy
• The immediate treatment of unilateral disease is removal of affected kidney
• Preoperative chemotherapy with vincristin and actinomycin
• For advanced disease vincristine + actinomycin D + adriamycin + abdominal radiation

Small round blue cell tumors Neoplasms that exhibit sharp peaks in incidence in children younger
than age 10 years
• Neuroblastoma • Leukemia (principally ALL)
• Wilm's tumor • Neuroblastoma
• Hepatoblastoma • Wilms tumor
• Lymphoma • Hepatoblastoma
• Oat cell carcinoma • Retinoblastoma
• Rhabdomyosarcoma • Rhabdomyosarcoma
• Ewing sarcoma • Teratoma
• Retinoblastoma • Posterior fossa tumors (Juvenile astrocytoma, Medulloblastoma,
Ependymoma
Hemangiomas are the most common tumors of Infancy

Diseases/Agents of bioterrorism
Category A Category B Category C
• Anthrax • Brucellosis • Ricin toxin from Ricinus Emerging
• Botulism • Epsilon toxin of communis infectious
• Plague Cl.perfringens • Staphylococcal disease threats
• Small pox • Food safety threats enterotoxin B such as Nipah
• Tularemia (Salmonella, E.coli, • Typhus fever virus and
• Viral h'gic fevers Shigella) • Viral encephalitis Hantavirus
(filoviruses Ebola, • Glanders • Water safety threats (V.
Marburg] • Melioidosis cholera, ryptosporidium
arenaviruses • Psittacosis parvum)
[Lassa, achupo]) • Q fever
 VII. RED BLOOD CELLS
RBCs
• Biconcave shaped: 7 - 8 μm diameter
• Unequal RBC sizes - anisocytosis
• Different RBC shapes - poikilocytosis

Reticulocytes
• Reticulocyte count - indicator of erythropoietic activity of bone marrow
• Reticulocyte index - poor man's bone marrow aspirate

Embryonic Hb
• Hb Portland (2ζ/2γ ) (ζ - zeta; y - gamma)
• Hb Gower I (2 ζ /2ε ) (ε - epsilon)
• Hb Gower II (2α/2 ε)

Types of normal Hb
• HbA (2α/2β globin chains) 97% in adults
• HbA2(2α/2δ globin chains) 2% in adults
• HbF (2α/2γ globin chains) 1% in adults

Adult reference ranges for red cells

Measurement (Units) Men Women
Hemoglobin (gm/dL) 13.6 - 17.2 12.0 - 15.0
Hematocrit (%) 39 - 49 33 - 43
Red cell count (x 106/μL) 4.3 - 5.9 3.5 - 5.0
Reticulocyte count (%) 0.5 - 1.5
MCV (fL) 82 - 96
MCH (pg) 27 - 33
MCHC (gm/dL) 33 - 37
Red cell distribution width 11.5 14.5

Classification of anemia (based on MCV)

Normocytic anemia (MCV 82 - 96 fL)
High reticulocyte count Low reticulocyte count
• Hereditary spherocytosis • Aplastic anemia
• Sickle cell anemia • Renal failure
• G6PD (and other RBC enzyme) • Anemia of chronic disease
• deficiency • Non endocrine thyroid gland failure
• Paroxysmal nocturnal hemoglobinuria • Copper deficiency
• Autoimmune hemolytic anemia • Bone marrow infiltration (cancer metastasis)

Microcytic (MCV < 80 fL) Macrocytic (MCV > 100 fL)

Non megaloblastic (MCV 100-110fL)
• Iron deficiency • Thiamine deficiency • Pregnancy
• Thalassemia • Alcohol, Liver disease • Acute myeloid leukemia
• Sideroblastic anemia • Hypothyroidism • Myelodyplastic states
• Lead poisoning • Orotic aciduria • Aplastic anemia, marrow
• Cadmium poisoning • Reticulocytosis infiltration
• Anemia of chronic disease • Copper deficiency • Multiple myeloma
• Zinc deficiency • Posthemorrhagic • Acquired sideroblastic
anemia
• Phenytoin & Cytotoxic drugs
 Megaloblastic (MCV >110fL)
• B12 deficiency
• Folate deficiency
• DNA synthesis inhibitors

HEMOLYTIC ANEMIAS
• Shortened red cell life span
• Elevated erythropoietin levels and increased erythropoiesis in the marrow and other sites
• Increased number of erythroid precursors (normoblasts) in the marrow
• Prominent reticulocytosis in the peripheral blood

Intracorpuscular defect Extracorpuscular defect

Hereditary: Infections
RBC membrane defect • Malaria
• Hereditary spherocytosis • Hook worm
• Hereditary elliptocytosis Antibody mediated
• Stomatocytosis • Blood transfusion reactions
• Acanthocytosis • Erythroblastosis fetalis
RBC enzyme defect Mechanical trauma
• G6PD deficiency • Thrombotic thrombocytopenic purpura
• Hexokinase deficiency • Hemolytic uremic syndrome
• Pyruvate kinase deficiency • Disseminated intravascular coagulation
Hb synthesis defect: Thalassemia Sequestration
Acquired: Paroxysmal nocturnal hemoglobinuria • Hypersplenism

Hemolysis Extravascular Intravascular

Site Spleen, Bone marrow, Liver Circulating blood
Cause RBCs rendered foreign or less Mechanical injury, complement
deformable fixation, malaria, exogenous toxins
Se ferritin N↑ ↓
Se haptoglobin N/↓ ↓↓
Se bilirubin(unconjugated) ↑↑ ↑
Se LDH ↑ ↑↑
Hemoglobinemia - +
Se methemoglobin - +
Hemoglobinuria - +
Hemosiderinuria - +
Examples Hereditary spherocytosis Paroxysmal nocturnal hemoglobinuria
Thalassemia Paroxysmal cold hemoglobinuria
Sickle cell anemia Falciparum malaria, Sepsis
Autoimmune hemolytic anemia Microangiopathic (Mechanical injury)
G6PD deficiency Mismatched blood transfusion
March hemoglobinuria
G6PD deficiency, Favism

HEREDITARY SPHEROCYTOSIS
• Autosomal dominant; some severe forms are autosomal recessive
• Intrinsic defect in the red cell membrane that render the red cells spherical, less deformable, vulnerable to
splenic sequestration and destruction (extravascular hemolysis)
• Caused by mutations affecting the proteins of RBC membrane skeleton
o Ankyrin (most common)
o Band 3
o Spectrin
 o Band 4.2 (Palladin)
o Glycophorin A
• Life span of red cells reduced to 10-20 days (Normal 120 days)
• Mutations in spectrin are the most common cause in hereditary elliptocytosis

Clinical features
• Anemia, Jaundice, Splenomegaly are classical features
• Gallstones, Leg ulcers
• Aplastic crisis may be triggered by Parvovirus B19 infection
• Hemolytic crisis may be precipitated by Infectious mononucleosis

Lab features
• Spherocytosis in peripheral smear lacking central pallor (hyperchromic)
• MCV ↓ MCHC ↑ (the only condition where MCHC is increased)
• Osmotic fragility increased - main diagnostic test (RBCs abnormally susceptible to lysis in hypotonic media)
• Diagnosis: based on red cell morphology and a modified version osmotic fragility test (pink test)

Treatment
• Splenectomy is the TOC but not before the age of 4 years
• Pneumococcal vaccination before splenectomy

GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY

• X-linked recessive
• Commonly manifests as hemolysis on exposure to oxidant stress
• Cause episodic extravascular and intravascular hemolysis

Conditions precipitating hemolysis in G6PD deficiency

Definite risk of hemolysis Infections (most common trigger)
• Dapsone • Viral hepatitis
• Antibiotics: Cotrimoxazole, Nalidixic acid, • Pneumonia
• Nitrofurantoin, Niridazole • Typhoid
• Analgesic: Penazopyridine, Acetanilide Ingestion of fava beans (favism)
• Antimalarials: Primaquine, Chloroproguanil
• Rasburicase
• Methylthioninium chloride (Methylene blue)
• Naphthalene
• Tolonium chloride (toluidine blue)

Safe drugs in G6PD deficiency

Analgesics CVS drugs CNS drugs Antibiotics Antimalarials
Acetaminophen Procainamide Trihexyphenidyl Chloramphenicol Quinine
Aspirin Quinidine Levodopa Isoniazid Pyrimethamine
Phenytoin Probenezid

• When exposed to oxidant stress, globin chains become denaturated and form precipitates - Heinz bodies
(best stained with methyl violet) - which cause severe membrane damage
• Red cells that appear to have had parts of them bitten away (bite cells/blister cells/helmet cells)
• The most typical feature is the presence of bizarre poikilocytes, with red cells that appear to have unevenly
distributed hemoglobin (hemighosts)
• Older red cells are more prone to hemolysis
• Hemotysis stops when only young red cells remain (episodic hemolysis, self-limited)
• Splenomegaly and gall stones are absent as hemolysis occurs in intermittent episodes
• Peripheral smear: Spherocytes, polychromasia, anisocytosis
• Reduced G6PD levels between hemolytic episodes. (normal during or shortly after a hemolytic episode
during the period of reticulocytosis)
  Protects against Plasmodium falciparum malaria
 Seems to have less coronary artery disease, fewer cancers and greater longevity
 Increased risk of neonatal jaundice

SICKLE CELL DISEASE

• Normal adult red cells contain mainly HbA(α2β2), along with small amounts of HbA2(αδ2) and fetal
hemoglobin HbF(α2γ2)
• Sickle cell disease is caused by a point mutation at the 6th codon of β globin chain leading to substitution of
glutamine by valine
• Sickle cell trait (heterozygotes) gives protection against falciparum malaria
• In sickle cell trait 40% is HbS and rest is HbA

Pathogenesis
• Deoxygenated HbS undergo aggregation and polymerization, producing a distorted sickle or holly-leaf
shaped RBC which block microcirculation
• Initial sickling is reversible on oxygenation, but after repeated aggregation, sickling is irreversible
• HbF inhibit polymerization of HbS; hence infants are asymptomatic until 6 months
• In hereditary persistence of HbF - the disease is less severe
• HbC (lysine is substituted for glutamate in the 6th amino acid residue of β globin) has greater tendency to
form aggregates than HbS - but disease is milder in HbSC

Factors precipitating sickling

• Dehydration (↑MCHC)
• Hypoxia
• Acidosis (↓ pH)
• Increased transit time of red cells through microvascular beds
• Infections

Clinical features
• Vaso-occlusive crisis or Pain crisis (hall mark) - most common clinical manifestation
• Bones (especially the back and long bones) and the chest are commonly affected
• Plugging of small vessels in bones - dactylitis (hand and foot syndrome)
• Avascular necrosis of femoral head, Osteomyelitis due to Salmonella
• Acute chest syndrome

D. Most common cause of death in adults

D. Chest pain, tachypnea, fever, cough, and arterial oxygen desaturation

Pulmonary infarction and pneumonia are the most frequent underlying conditions
• Extramedullary hematopoiesis prominent cheek bones and crew-hair cut appearance of skull
• Occlusion of vertebral arteries - fish mouth deformity of vertebrae
• Sequestration crisis - massive sequestration of sickled red cells leads to rapid splenic enlargement,
hypovolemia and shock.
• In chronic disease due to repetititve infarction, there is progressive shrinkage of spleen following repeated
episodes of sequestration crisis - autosplenectomy
• Children are more prone for Pneumococcus pneumoniae and H influenzae septicemia and meningitis with
capsulated organisms like pneumococci
• Aplastic crisis - transient cessation of marrow erythropoiesis due to an acute infection with parvovirus B19.
Unlike other crisis reticulocyte count is low
• Stroke is especially common in children and less common in adults
• Priapism may result in permanent impotence
• Increased break down of hemoglobin can cause pigment gallstones and hyperbilirubinemia
• Leg ulcers, delayed puberty, pulmonary hypertension, retinopathy
• Granulocytosis is common
• Female gender: less severe manifestations since HbF is high
Diagnosis
• Peripheral blood: sickled cells, target cells, Howell-Jolly bodies,
• Anemia (extravascular hemolysis), reticulocytosis
• ↓ESR (raised in other anemias)
• Metabisulfite and sodium dithionite which consumes oxygen in a sample of blood, precipitates sickling if
HbS is present - useful screening test
• Definite diagnosis by - Hemoglobin electrophoresis (which reveal 60% HbS)
• HbA2 is normal; HbF in varying concentrations: HbA absent

Management
• Vaso-occlusive crisis managed by aggressive rehydration, oxygen therapy, analgesia and antibiotics
• For sequestration crisis and acute chest syndrome exchange transfusion needed
• A high HbF level inhibits sickling. Hydroxyurea induce increased synthesis of HbF
• Omega-3 fatty acid supplementation may reduce vaso-occlusive episodes
• Alkali denaturation method - to determine concentration of HbF (HbF is relatively resistant to denaturation
by strong alkali)
• Quantitative estimation of HbF - Kleihauer test

Sickle cell trait

• Hematologically normal - no anemia, normal red blood cells on peripheral blood smear
• Hemoglobin electrophoresis - 40% of hemoglobin is hemoglobin S
• Sudden cardiac death and rhabdomyolysis during vigorous exercise, especially at high altitudes.
• Increased risk for venothromboembolism
• Renal papillary necrosis leads to hyposthenuria (inability to concentrate urine) and gross hematuria (less
common in sickle cell disease)

Sickle thalassemia
• Low Hb concentration within RBC and High HbF  Less sever hemolysis and higher Hb than sickle cell
disease patients
• MCV is low (normal in Sickle cell disease), and the red cells are hypochromic

Hemoglobin SC disease
• Lesser degrees of hemolytic anemia
• Greater propensity for the development of retinopathy and aseptic necrosis of bones

Other abnormal hemoglobin

Type Globin chain, Position, Mutation Clinical events
HbC β, 6, Glutamine  Lysine Mild anemia, Interacts with HbS
HbE β, 26, Glutamine  Lysine Microcytic anemia, splenomegaly, thalassemic phenotype
Koln β, 98, Valine  Methionine Hemolytic anemia, Heinz bodies when splenectomized
Yakima β, 99, Aspartate  Histidine High affinity hemoglobin, Polycythemia
Kansas β, 102, Asparagine  Lysine Low affinity hemoglobin, pseudoanemia
HbM α, 87, Histidine  Tyrosine High affinity hemoglobin, Methemoglobinemia

• Silence mutation - no change in the end product even when the codon is changed
• Missense mutation - a point mutation may alter the code in a triplet of bases and lead to the replacement of
one amino acid by another. E.g. sickle cell disease
• Nonsense mutation - a point mutation may change an amino acid codon to a chain terminator or stop
codon. E.g.β°thalassemia

THALASSEMIA
• The two α chains in HbA are encoded by an identical pair of a-globin genes on chromosome 16
• The two β chains are encoded by a single β-globin gene on chromosome 11
 • Thalassemia is caused by inherited mutations that decrease the synthesis of either the α-globin or β-globin
chains

β THALASSEMIAS
• Caused by point mutations that diminish the synthesis of B-globin chains
o β0 mutations: absent β-globin synthesis
o β+ mutations: reduced (but detectable) β-globin synthesis
• Splicing mutations: Most common cause of β+ thalassaemia
• Promoter region mutations: also associated with β+ thalassaemia
• Chain terminator mutations: Most common cause of β0 thalassemia
• ↓ synthesis of structurally normal β chains coupled with increased production of α chains
• Imbalance between α- and β-globin synthesis  Unpaired achains precipitate within red cell precursors 
membrane damage  apoptosis  ineffective erythropoiesis

[THALASSEMIA MAJOR or COOLEY'S ANEMIA] (β+/ β+ or β+/ β0 or β0/ β0)

Clinical features
• Anemia manifests 6 - 9 months after birth as Hb synthesis switches from HbF to HbA
• Ineffective erythropoiesis  Increased absorption of dietary iron  secondary hemochromatosis
(hemosiderosis)
• Extramedullar hematopoiesis  Frontal bossing, prominent facial bones (chipmunk facies) and dental
malocclusion, hepatosplenomegaly

Lab features
• Microcytic hypochromic anemia, anisocytosis, poikilocytosis
• Target cells, basophilic stippling, nucleated red cells (normoblasts)
• MCV, MCHC, MCH and TIBC decreased
• Osmotic fragility decreased
• Serum iron, ferritin and % saturation of transferring are increased
• Bone marrow hypercellular, myeloid: erythroid ratio reversed
• Hb electrophoresis is the gold standard investigation
• X-ray shows crew hair cut appearance and hair on end appearance of skull bone
• NESTROFT (Naked Eye Single Tube Red cell Osmotic Fragility Test) is used for screening

Treatment
• Transfusion dependent
• Bone marrow transplantation offers curative therapy

β Thalassemia intermedia
• Chronic hemolytic anemia
• Transfusions needed during periods of stress or aplastic crises

β Thalassemia minor or Thalassemia trait(β+/β or β0/β)

• Asymptomatic, mild or no anemia
• No need for transfusions
• Resistance against falciparum malaria

Features Normal Thalassemia minor Thalassemia intermedia Thalassemia major

HbA 97 - 99% 80 - 95 % 0 - 30% 0 - 10%
HbA2 1-3% 4-8% 0-10 4 - 10 %
HbF < 1% 1-5% 6-100% 90 - 96 %

α THALASSEMIAS
• Usually caused by deletions of one or more of the 4 alpha globin genes
• No change in the proportions of hemoglobins A, A2, and F on Hb electrophoresis
 • Basophilic stippling is absent
Hydrops fetalis Tetramers of excess γ globin chains (Barts Hb)
--/-- Very high affinity for O2
Invariably leads to IUD without transfusion
Hemoglobin H disease Tetramers of excess β globin (HbH)
--/-α High affinity for O2, resemble thalassemia intermedia
Most common in Asians with moderately severe hemolytic anemia
Usually do not need transfusions except during crises
MCV is low (60-70 fL)
Reticulocyte count is elevated and RBC count is normal
or elevated
HbH forms inclusions in erythroblasts and precipitates in
circulating RBC
--/αα or -α/-α Similar to β-thalassemia minor
α-Thalassemia-1 trait Asymptomatic
MCV is low (60-75 fL)
Acanthocytes (cells with irregularly spaced spiked
projections) Reticulocyte count and iron parameters are
normal.
Silent carrier -α/αα No red cell abnormality
α Thalassemia-2 trait

Transfusion hemosiderosis
• A unit of packed RBCs contains 250-300 mg iron (1 mg/mL)
• The iron assimilated by two units of packed RBCs is thus equal to 1 to 2year intake of iron
• Vitamin C should not be supplemented because it generates free radicals in iron excess states
• The ferritin level rises
• Endocrine dysfunction (glucose intolerance and delayed puberty), cirrhosis, cardiomyopathy, and
pseudoxanthoma elasticum (calcification and fragmentation of the elastic fibers of the skin, retina, and
cardiovascular system)
• The superconducting quantum-interference device (SQUID) is accurate at measuring hepatic iron but not
widely available
• Desferoxamine (parenteral) or Deferasirox (oral) are iron chelating agents

Methods for assessing iron stores

• Serum iron and % saturation of transferrin are elevated early in the course, but specificity is tow
• The serum ferritin concentration is usually a good index of body-iron stores
• An increase of 1 mg/L in serum ferritin level reflects an increase of about 5 mg in body stores

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA

• The only hemolytic anemia caused by acquired intrinsic defect in the cell membrane
• Mutations in phosphatidylinositol glycan A(PIGA) gene - essential for the synthesis of GPI-linked proteins
• The somatic mutations occur in pluripotent stem cells; hence all its clonal progeny (red cells, white cells and
platelets) are deficient in GPI-linked proteins
• Blood cells are deficient in 3 GPI-linked proteins that regulate complement activity and hence unusually
susceptible to complement mediated lysis
o Decay accelerating factor (CD55)
o Membrane inhibitor of reactive lysis (CD59)
o C8 binding protein
• CD 59 is most important; inhibits C3 convertase and thus prevents spontaneous activation of alternative
pathway.

Clinical features
• Classic triad: Hemolysis, Pancytopenia & Thrombosis
• Intravascular Hemolysis of red cells caused by C5b-C9 membrane attack complex
 • Chronic hemolysis without dramatic hemoglobinuria is more common
• Hemolysis precipitated during exercise (paroxysmal) or sleep (nocturnal)
• Hemoglobinuria is most often noticed in the first morning urine due to the drop in blood pH white sleeping
that facilitates this hemolysis
• Thrombocytopenia, but venous thrombosis is also seen
• Thrombosis is the leading cause of death
• Intra abdominal veins are the most common site of thrombosis in PNH
• Increased risk of developing AML, myelodysplastic syndrome or aplastic anemia

Laboratory diagnosis
• Bone marrow is hyperplastic
• Hemoglobinuria can vary dramatically from day to day, and even from hour to hour
• Leukocyte alkaline phosphatase is reduced
• Sucrose lysis test(not reliable) - red cells lyre on addition of sucrose and complement in the medium
• HAM's acidified serum test - reliable but not readily available
• Flow cytometry - Gold standard
• The FLAER assay (fluorescein-labeled proaerolysin) by flow cytometry is even more sensitive

Treatment
• Blood transfusion with leucocyte depleted blood (to prevent complement activation & hemolysis)
• Eculizumab - monoclonal antibody against C5, prevents formation of membrane attack complex and
decreases intravascular hemolysis (but increases the risk of Neisseria meningitidis infections)
• Only definitive cure: Bone marrow transplantation

IMMUNO HEMOLYTIC ANEMIA

Warm antibody type Cold agglutinin type Cold hemolysins
• Most common form • IgM antibody directed against • Paroxysmal cold
• IgG antibody (sometimes IgA) I antigen on RBCs • Hemoglobinuria
• Active at 37°C • Can activate complement • IgG antibodies directed
• Extravascular destruction of • Active at < 37'C (0°C to 4°C) against P blood group antigen
red cells in the spleen • Extravascular hemolysis • Intravascular hemolysis
• Moderate splenomegaly
Primary (idiopathic) Primary - idiopathic Bind to red cells at low
Lymphomas and leukemias Mycoplasma temperatures, fix complement
SLE, RA Infectious mononucleosis and cause hemolysis when
Antigenic drugs - penicillin, CMV temperature is raised above
cephalosporin, quinidine Influenzae virus 30°C - Donath-Landsteiner
Tolerance breaking drugs - α- HIV antibody in syphilis
methyldopa Chronic - lymphoma Mycoplasma pneumonia
Fludarabine Measles, Mumps, Flu syndromes

 Coomb's test is positive in immune hemolytic anemias

Coomb's negative hemolytic anemia

• Mechanical trauma to RBCs
• TTP, HUS, DIC, HELLP syndrome
• Babesiosis, Malaria, Clostridia) sepsis
• Hereditary spherocytosis, Thalassemia, Sickle cell disease
• PNH

AEGALOBLASTIC ANEMI
Vitamin B12 deficiency Folic acid deficiency
 • Vegetarianism
• Alcoholism
• Intrinsic factor deficiency
• Malabsorption

Pernicious anemia
• Drugs:
• Gastrectomy

Anticonvulsants
• Malabsorption

Oral contraceptives

Diffuse intestinal disease

Folic acid antagonists

Real resection, ileitis
• Hemodialysis

Fish tape worm (D Tatum) infection
• Increased requirement (Pregnancy,
• Bacterial overgrowth in blind loops & diverticula of
infancy, increased hernatopoiesis)
bowel

Laboratory features
• Pancytopenia, Anisopoikilocytosis
• Few tear drop cells and normocytes are seen
• Macrocytic and oval (macro-ovalocytes) red cells (TMCV) lacking central pallor - characteristic
• Hyperchromic red cells (MCH ↑ but MCHC is not /)
• Decreased reticulocyte count
• Large neutrophils with hypersegmented nucleus (mean neutrophil lobe counts greater than four or the
finding of six [or greater]-lobed neutrophils) - earliest manifestation
• Hypercellular marrow with reversal of erythroid: myeloid ratio
• Nuclear changes are seen in the immature granulocyte precursors and a characteristic appearance is that of
'giant' metamyelocytes with a large 'sausage-shaped' nucleus.
• Nucleus to cytoplasmic asynchrony seen in erythroid series
• ↑ serum ferritin, ↑ plasma LDH, ↑homocysteine and ↑ methyl malonic acid(95%cases)

Cobalamin deficiency
• Bilateral peripheral neuropathy or degeneration (demyelination) of the posterior and pyramidal tracts of
the spinal cord (Subacute combined degeneration - demyelination of dorsal and lateral tracts)
• Paresthesias, poor memory, visual disturbances
• Impotence, depression, hallucinations
• Atrophic glossitis (shiny, glazed and beefy tongue)

Psychiatric disturbance - in both fokate and cobalamin deficiencies

• Intrahepatic stores of B12 are sufficient for atteast 3 years - even if intake or absorption is completely absent

PERNICIOUS ANEMIA
• Severe lack of IF due to gastric atrophy
• Autoimmune disorder against parietal cells of the stomach
• Associated with other autoimmune diseases (thyroid diseases, vitiligo, hypoparathyroidism, Addison's
disease), hypogammaglobulinemia, premature graying or blue eyes, and persons of blood group A
• Autoantibodies
o Type I: blocks binding of B12 to IF
o Type II: prevent binding of B12-IF complex to its heal receptor
o Parietal cell antibody
• Gastric biopsy
o Atrophy of all layers of body and fundus (antral mucosa is well preserved)
o Absence of parietal and chief cells
o Intestinalization of stomach (intestinal metaptasia)
• Serum gastrin level is raised, and serum pepsinogen I levels are low.

Juvenile Pernicious anemia

• Occurs in older children and resembles PA of adults.
• Gastric atrophy, achlorhydria, and serum IF antibodies are all present
• Parietal cell antibodies are usually absent.
Schilling's test
• Used to diagnose pernicious anemia
• Inability to absorb an oral dose of cobalamine assessed by urinary excretion of radiolabelled
cyanocobalamine

Folate deficiency
• Folate deficiency arises within weeks to months if intake is inadequate
• No neurological abnormalities
• Serum homocysteine levels are increased, but methylmalonate concentrations are normal

IRON DEFICIENCY ANEMIA

• Most common type of anemia worldwide
• Chronic blood loss is the most common cause of iron deficiency

Iron absorption increased by Iron absorption reduced by

• Heme iron (10-20% absorbed) • Non heme iron (1-5% absorbed)
• Ferrous form (Fe2+) • Plant foods
• Animal foods • Ferric form (Fe 3+)
• Acid pH • Alkali pH
• Vitamin C • Iron overload
• Increased erythropoiesis • Achlorhydria
• Pregnancy • Phytates, tannates in tea
• Hypoxia • Decreased erythropoiesis
• Amino acids, Sugar • Inflammatory disorders
• Iron deficiency

 On an average, only 10% to 15% of ingested iron is absorbed

 The major iron transporter from the diet across the intestinal lumen - ferroportin
 Iron absorbed from the diet or released from stores circulates in the plasma bound to transferrin, the iron
transport protein

• Within the erythroid cell, iron in excess of the amount needed for hemoglobin synthesis binds to a storage
protein, apoferritin, forming ferritin
• Serum ferritin level is the most useful test to diagnose iron deficiency
• Serum ferritin level is the most convenient laboratory test to estimate iron stores
• Average Se ferritin levels: Adult males - 100 μg/L; adult females - 30 μg/L
• Marrow iron stores are absent when the serum ferritin level is <15 μg/L.
• Transferrin receptor protein (TRP) - increased in absolute iron deficiency
• MCCs of increased red cell protoporphyrin levels - absolute or relative iron deficiency and lead poisoning.

Hepcidin
• Iron absorption is negatively regulated by hepcidin, - by promoting degradation of ferroportin
• In iron defieicncy - hepcidin levels are low
• When the body iron stores are high - high hepcidin levels interfere with iron absorption
• In anemia of chronic disease, IL-6 causes increase hepatic hepcidin production decreased iron absorption
• Hepcidin activity is inappropriately tow in both primary and secondary hemochromatosis (systemic iron
overload)

Stages of Iron deficiency

Negative iron balance Iron deficient erythropoiesis Iron deficiency anemia
• Demands exceed the body's • Marrow iron stores depleted • Decreased Hb
ability to absorb iron from  Serum iron decreases  • Decreased hematocrit
diet TIBC & Red cell • Transferrin saturation: 10 -
• Serum ferritin decrease protoporphyrin levels 15%
• Stainable iron on bone increases  Transferrin • Hb < 7g/dL: target cells and
 marrow aspirations decrease saturation decreases  first poiki locytes
• Serum iron, TIBC, red cell appearance of microcytic
protoporphyrin levels, RBC cells, hypochromic
indices, L morphology - reticulocytes
normal

Treatment
• 300mg elemental iron daily
• Reticulocyte count begins to rise within 4-7 days after initiation of therapy
• Failure of response to iron therapy is usually due to noncompliance
• Parenteral Iron indications - intolerance to oral iron, refractoriness to oral iron, gastrointestinal disease, and
continued blood loss

X-LINKED SIDEROBLASTIC ANEMIA

• Results from the deficient activity of the erythroid form of ALA-synthase
• Refractory hemolytic anemia, pallor, and weakness during infancy
• Secondary hypersplenism, iron overload and hemosiderosis
• Peripheral blood smears reveal a hypochromic, microcytic anemia with striking anisocytosis, poikilocytosis,
and polychromasia
• Hemoglobin content is reduced, and the MCV and MCHC are decreased
• The severe anemia may respond to pyridoxine supplementation.

ANEMIA OF CHRONIC DISEASE

• Decreased utilization of iron from the storage form (ferritin)
• Certain inflammatory mediators, particularly IL-6, stimulate increased hepatic production of hepcidin
• Erythropoietin levels are inappropriately tow
• Red cells are typically normocytic and normochromic, and reticulocytes are decreased
• The gold standard for diagnosis is a bone marrow biopsy with iron stain
o Absent iron staining indicates iron deficiency
o Positive iron staining in marrow macrophages indicates pure anemia of inflammation

Normal values
Serum iron 50 - 150 μg/dL
Serum ferritin 50 - 300 μg/L
Total iron binding capacity 300-360 μg/dL
Transferrin saturation 25-50%

Parameter Iron deficiency β thalassemia Anemia of

Sideroblastic anemia
anemia chronic disease
Serum iron ↓ N to ↑ ↓ N to ↑
Serum ferritin ↓ N to ↑ ↑ ↑
TIBC ↑ N ↓ N
Transferrin saturation ↓ N to ↑ ↓ N to ↑
Iron stores ↓ N to ↑ ↑ ↑
RDW ↑ N N

• Liver disease: peripheral blood smear may show spur cells and stomatocytes

Acquired Inherited
Idiopathic: Primary stem cell defect PNH • Fanconi anemia
Secondary: Pregnancy • Dyskeratosis congenita
Chemicals and Drugs Whole body irradiation Autoimmune • Schwachman-Diamond
Viral infections diseases syndrome
• Hepatitis (unknown virus) Drugs: chloramphenicol, phenytoin, • Reticular dysgenesis
• CMV, EBV, VZV phenylbutazone, gold salts, • Down syndrome
 • Parvovirus B19 sulfonamides, carbarnazepine, • Telomerase defects
quinacrine, tolbutamide

FANCONI ANEMIA
• Autosomal recessive disorder
• Caused by defects in DNA repair
• Marrow hypofunction becomes evident in early life
• Short stature, café au lait spots
• Multiple congenital anomalies (hypoplasia of kidney, spleen, thumb, radius)
• Increased risk of malignancy

DYSKERATOSIS CONGENITA
• Mucous membrane leukoplasia, dystrophic nails, reticular hyperpigmentation,
• Development of aplastic anemia in childhood
• Due to mutations in genes of the telomere repair complex
• X-linked variety is due to mutations in the DKC1 (dyskerin) gene

SCWACHMAN-DIAMOND SYNDROME
• Presentation is early in life with neutropenia with pancreatic insufficiency and malabsorption
• Mutations in SBDS that may affect both ribosomal biogenesis and marrow stroma function

Clinical features of aplastic anemia

• Bleeding is the most common early symptom
• Splenomegaly absent (characteristic)
• Frequent infections

Lab features of aplastic anemia

• Red cells are macrocytic and normochromic
• Pancytopenia, reticulocytopenia
• Markedly hypocellular bonemarrow
• Bone marrow aspirate yields only little material (dry tap)

Severe aplastic anemia

• Absolute Neutrophil count < 500/μL
• Platelet count < 20000/μL
• Corrected Reticulocyte count < 1% (or absolute reticulocyte count <60,000/μL)
• Bone marrow cellularity < 20%

Treatment
• Mild cases
o Erythropoietic (epoetin or darbepoetin) or myeloid (filgrastim or sargramostim) growth factors
o Androgens (fluoxymesterone) - partially correct telomere length maintenance defects and increase the
production of endogenous erythropoietin
• Severe caes
o Young patients (< 40 years) with HLA matched sibling - allogenic bone marrow transplantation
o Adults over age 40 years or those without HLAmatched donors - Immunosuppression with equine
antithymocyte globulin (ATG) plus cyclosporine
o ATG should be used in combination with corticosteroids (prednisone or methylprednisolone
o Thrombopoietin mimetic, eltrombopag, increase platelets, RBCs and WBCs in refractory cases

Differential diagnosis of pancytopenia

Pancytopenia with hypocellular Pancytopenia with cellular marrow
marrow
Acquired aplastic anemia Primary bone marrow diseases: Secondary to systemic diseases:
Constitutional aplastic anemia Myelodysplasia SLE
(Fanconi's anemia, dyskeratosis PNH Hypersplenism
congenita) Myelofibrosis Myelophthisis B12, folate deficiency
Some myelodysplasia Bone marrow lymphoma Hairy cell Alcohol
Some acute lymphoid leukemia leukemia Aleukemic leukemia Brucellosis
Some lymphomas of bone marrow Sarcoidosis
Tuberculosis
Leishmaniasis

Hypocellutar marrow + cytopenia

• Q fever
• Legionnaires disease
• Anorexia nervosa, starvation
• Mycobacterium

PURE RED CELL APLASIA

• Marked hypoplasia of marrow erythroid precursors but normal granulopoiesis and thrombopoiesis
• 1o or 2o neoplasms (thymomas, large granulocytic leukemia), autoimmune or Parvovirus infections
• Drugs: phenytoin, azathioprine, chloramphenicol, procainamide, isoniazid, erythropoietin
• In most of the patients resection of thymic tumor is followed by hematologic improvement
• Plasmapheresis used in refractory cases

Myelophthisic anemia
• Marrow failure as space-occupying lesions replace normal marrow elements
• Most common cause - metastatic cancer (most often breast, lung, prostate)
• Abnormal release of nucleated erythroid precursors Et immature granulocytic forms (leukoerythroblastosis)
• Teardrop-shaped red cells

POLYCYTHEMIA
• Polycythemia - high red cell count + high hemoglobin
• Absolute polycythemia - increase in total red cell mass
• Relative polycythemia - reduced plasma volume (Hemoconcentration) e.g. dehydration
• Gaisbock syndrome or Stress polycythemia - Hypetension, Obesity, Stress

Absolute polycythemia
• Primary polycythemia (Low erythropoietin)
o Polycythemia vera
o Inherited erythropoietin receptor mutations
• Secondary polycythemia (High erythropoietin)

Secondary polycythemia
• COPD • Smoking
• High altitude living • Erythropoietin secreting tumors (Renal ca, liver
• Cyanotic heart disease (Right to Left shunts) ca, cerebellar hemangioplastoma)
• Obstructive sleep apnea • High affinity hemoglobin
• Morbid obesity (Pickwickian syndrome) • Inherited defects that stabilize (Hypoxia induced
• Aneurysm or arteriosclerotic narrowing of renal factor) HIF-1 α
vessels o Chuvash polycythemia (VHL mutation)
o Prolyl hydroxylase mutations

Morphological abnormalities of RBCs

Spherocytes Dacrocytes Elliptocytes Schistocytes
RBCs lacking central Teardrop-shaped cells Elliptical-shaped red cells Helmet-shaped cells
pallor
• Hereditary • Hemolytic anemias • Inherited defect in • Microangiopathic
spherocytosis • Severe iron the red cell hemolytic anemia
• Clostridial sepsis deficiency membrane • Fragmentation of red
• Al hemolytic anemia • Thalassemias • Iron deficiency cells on an artificial
• Cirrhosis • Myelofibrosis • Myelodysplastic heart valve
• G6PD deficiency • Myelodysplastic syndrome
• ABO incompatibility syndrome • Megaloblastic
• Burns • Sideroblastic anemia
• Snake venom anemia • Thalassemias

Echinocytes (Burr cells) - spiculated Acanthocytes (spur cells) - Stomatocytes - Target cells - area of central
RBCs with evenly spaced spikes spiculated RBCs irregularly RBCs with slit-like pallor that contains a dense
(reversible) distributed spikes central pallor center, or bull's eye
(irreversible)
• Artifact of abnormal drying of • Liver disease • Artifact in a • Classically in thalassemia
the blood smear • Renal disease • Dehydrated • Liver disease
• Reflect changes in stored • Abetalipoproteinemia blood smear • Iron deficiency
blood • Splenectomy • Inherited • Cholestatic liver disease
• Renal failure • RBC • Hemoglobinopathies
• Malnutrition • membrane • Improper slide making
• Liver disease • defect
• Burns • Alcoholism
• Microangiopathic haemolytic
anemia

SIDEROCYTES
• Red cells containing granules of non-haem iron.
• These granules stain positively with Prussian blue reaction as well as stain with Romanowsky dyes -
Pappenheimer bodies
• Normally not present in the human peripheral blood
• A small number may appear following splenectomy

SlDEROBLASTS
Nucleated red cells (normo-blasts)
• Contain siderotic granules which stain positively with Prussian blue reaction

Zieve's syndrome: Hemolytic anemia (with spur cells and acanthocytes) in patients with severe alcoholic hepatitis

Increased osmotic fragility Decreased osmotic fragility

• Hereditary spherocytosis • Iron deficiency anemia
• Immune hemolytic anemia • Thalassemia
• Hemolytic disease of newborn • Reticulocytosis
• Malaria • Sickle cell anemia
• Pyruvate kinase deficiency • Post splenectomy

↓ESR ↑ESR
• Polycythemia • Pregnancy, Menstruation
• CCF • New born
• Sickle cell anemia • Multiple myeloma
• Afibrinogenimia • Leucocytosis
• Anemia (except Sickle cell anemia)
 VIII. PLATELET & BLEEDING DISORDERS
Partial thromboplastin time (PTT) Prothrombin time (PT) Bleeding time (BT)
• Tests intrinsic and common • Tests extrinsic & common • Normal 2-8 mins
pathways of coagulation pathways
• Normal 11-16 seconds

Prolonged aPTT Prolonged PT Prolonged aPTT and PT

• Deficiencies of factor I, II, • ↓ factors I, II, V, VII, X • ↓ Factor II, V, X, or fibrinogen
• V, VIII, IX, X, XI, XII, Lupus • Vitamin K deficiency–early • Vitamin K deficiency–late
anticoagulant • Warfarin anticoagulation • Direct thrombin inhibitors
• Heparin

Prolonged Bleeding time Prolonged thrombin time Abnormal clot solubility

• Platelet dysfunction or • Heparin or heparin like • Factor XIII deficiency
deficiency inhibitors • Inhibitors or defective
• von Willebrand disease • Dys/Afibrinogenemia cross-linking

 Vitamin K dependent clotting factors: Factors II, VII, IX, X

 Defect in extrinsic pathway of clotting: ↑ PT
 Defect in intrinsic pathway of clotting: ↑aPTT
 Defect in common pathway of clotting: ↑ PT & ↑ aPTT

Platelet function tests

Screening tests Special tests
• Platelet count • Platelet adhesion tests - retention in a glass
• Bleeding time bead column
• Examination of fresh blood film too see • Platelet aggregation tests - aggregometry using
morphologic abdormalities ristocetin, collagen or ADP
• Clot retraction test • Granular contents and their release - measured
• Activated clotting time by electron microscopy
• Platelet function assay (PFA-100) • Platelet coagulant activity - Prothrombin
consumption index
• Flow cytometry

ANTICOAGULANTS
EDTA 3.2% TriSodium citrate Heparin
• Blood cell counts and • Coagulation testing • Osmotic fragility test
morphology • Platelet studies • WBC function and immuno-
• ESR phenotyping

Platelets
• Normal count: 150 - 300 x 103/μL (1.5 to 4 lakhs/mm3)
• Life span: 7 - 10 days
• Thrombocytopenia is < 100,000 platelets/μL
• Platelet counts 20,000 to 50,000 platelets/μL - aggravates posttraumatic bleeding
• Platelet counts < 20,000 platelets/μL - spontaneous (nontraumatic) bleeding.

DISORDERS OF PLATELET FUNCTION

Inherited Acquired
Disorders of platelet adhesion
• Bernard-Soulier syndrome • Uremia
• Von Willebrand disease • Acquired vWD
 Disorders of platelet aggregation
• Glanzmann thrombasthenia • Ticlopidine
• Afibrinogenemia • Gpllb/Illa inhibitors
Disorders of granule release
• Oculocutaneous albinism • Cardiopulmonary bypass
• Chediak-Higashi syndrome • Myeloproliferative disease
• Gray platelet syndrome • NSAIDs

GLANZMANN THROMBASTHENIA BERNARD SOULIER SYNDROME STORAGE POOL DISORDERS

• Autosomal recessive • Autosomal recessive • Autosomal dominant
• Defective platelet • Defective adhesion of platelets • Abnormalities of platelet
aggregation to subendothelial matrix granule formation, defective
• Deficiency or dysfunction of Deficiency of platelet release of mediators of platelet
glycoprotein llb-Illa, an membrane glycoprotein activation (thromboxanes,
integrin that participates in complex lb-IX which is the granule-bound ADP)
bridge formation between receptor for vWF • Gray platelet syndrome -
platelets by binding • Abnormally large platelets defective alpha granules
fibrinogen • Defective aggregation in • Albinism associated storage pool
response to ristocetin, but disease - defective dense
aggregation in response to other granules
agonists is normal

IMMUNE THROMBOCYTOPENIC PURPURA (ITP)

CHRONIC ITP
• More common form
• Adult women < 40 yrs
• Can be associated with connective tissue diseases, tymphoprotiferative disease, medications and infections
(hepatitis C virus and HIV)
• Auto-antibodies (mostly IgG) against platelet membrane glycoproteins (Ilb-Illa or lb-IX)
• Spleen is the major site of destruction of platelets
• Petechiae, ecchymosis, easy bruising, bleeding from nose and gums, menorrhagia
• Splenomegaly & lymphadenopathy - rare
• Subarachnoid and intracerebral hemorrhage are rare but fatal complications
• Wet purpura (blood blisters in the mouth)
• Peripheral smear shows abnormally large platelets (megathrombocytes) & low platelet count
• Bone marrow - hypercellular & increased megakaryocytes
• Bleeding time prolonged
• PT and PTT are normal

Treatment
• Initial: Glucocorticoids (Prednisone or Dexa) ± IV immunoglobulin or anti-D or anti-CD20 antibody (rituximab)
• Two-thirds of patients respond to initial treatment, but most people relapse following reduction of the
corticosteroid dose.
• Relapse: Splenectomy
• Refractory cases: Thrombopoietin receptor agonists (Romiplostim and eltrombopag) or splenectomy

ACUTE ITP
• Disease of childhood
• Affects both sexes equally
• Onset is abrupt
• Many cases are preceded by viral illness
• The usual interval between the infection and onset of purpura is 2 weeks
• Self-limited, spontaneous resolution in 6 months
• 20% children (those without viral prodrome) have persistent low platelet counts after 6 months
  Evans syndrome - Autoimmune hemolytic anemia + ITP
 Drugs that cause thrombocytopenia - quinine, quinidine, vancomycin

HEPARIN INDUCED THROMBOCYTOPENIA

• After exposure to heparin for 5-14 days; occurs before 5 days in those who were sensitized to heparin (PF4
antibodies disappear from circulation by -100 days following exposure)
• Usually not severe, counts rarely <20,000/μL
• Not associated with bleeding
• Formation of IgG antibodies to heparin-platelet factor 4 (PF4) complexes
• More common after unfractionated heparin (UFH) therapy than tow-molecular-weight heparin (LMWH)

• 4 t's in HIT

Thrombocytopenia

Timing of platelet count drop

Thrombosis (Venous and arterial)

Other causes of thrombocytopenia not evident
• HIT is diagnosed clinically; antibodies can be detected by ELISA
• Treatment:

Discontinue heparin

Direct thrombin inhibitors argatroban and lepirudin are effective in HIT thrombosis

Patients can be transitioned to warfarin, with treatment usually for 3-6 months

Warfarin is contraindicated as initial treatment of HIT

THROMBOTIC THROMBOCYTOPENIC MICROANGIOPATHIES

Thrombotic Thrombocytopenic Purpura Hemolytic Uremic Syndrome
• ↓ of vWF metalloprotease (ADAMTS 13) that • Usually in children, often following bloody diarrhea
cleaves ultra large multimers of vWF (D+ or Endemic HUS)
• Persistence of ultra large multimers of vWF leads to • Deficieny of Complement regulatory proteins {D-or
platelet aggregation and microthrombi formation Atypical HUS)
• More common in HIV and pregnant women • Neurological symptoms
• Thrombocytopenia (Severe) • Thrombocytopenia (mild)
• Fluctuating neurological manifestations • Treatment - mainly supportive, dialysis
• Fever
• Treatment - Plasma exchange
Common features of TTP & HUS
• Microangiopathic hemolytic anemia (schistocytes - fragmented RBCs)
• Renal failure
• Thrombocytopenia
• Normal coagulation tests (PT and PTT)
• Coombs test negative (except in pneumococci-induced HUS)
Laboratory features Laboratory features
• D-dimers - usually normal or mildly elevated • Fibrin degradation products or D-dimer tests are
• Fibrinogen - high to high-normal range frequently elevated
• Mild elevation of urea and creatinine • Microscopic hematuria
• Low-grade proteinuria
• High urea and creatinine
• Atypical HUS - C3 level low in 50%

Causes and associations of HUS

Epidemic Non epidemic Miscellaneous
E. coli strain Alternative complement pathway • Drugs (cyclosporine, chemotherapeutic
0157:117 or 0145 inhibitor deficiencies agents)
(Endothelial • Factor H • Radiation
damage by Shiga • Factor I • Bone marrow transplantation
like toxin) • Membrane cofactor protein • Infections (HIV, Pneumococcal sepsis)
(CD46) • Autoimmunity (SLE, HIV)
• Higher mortality in D-HUS (cases not preceded by diarrhea)

 The PT and aPTT are characteristically normal in TTP or HUS

 Inherited TTP - Upshaw-Schulman syndrome

Causative organisms of HUS

 Shiga Toxin producing Enterohemorrhagic E.coli (most common)
 Shigetla dysentriae type 1
 Streptococcus pneumoniae

Clotting factor abnormalities: Unlike bleeding seen with thrombocytopenia bleeding often occurs into the
gastrointestinal and urinary tracts and into weight-bearing joints (hemarthrosis)

VON WILLEBRAND DISEASE

• Most common inherited bleeding disorders of human
• Type 1 - AD,. Most common type. Usually.
• Type 2 - type 2A is AD, qualitative defects in vWF
• Type 3 - AR. Extremely low levels of vWF. Severe clinical manifestations.

Pathogenesis
• vWF is synthesized by endothelial cells, platelets and megakaryocytes (a-granules) [and possibly placental
syncytio-trophoblasts - emedicin.medscape.com]
• Weibel-Palade bodies - glue factory of endothelial cells; synthesize

P-selectin adhesion molecule for leukocytes

vWF - adhesion molecule for platelets
• vWF is responsible for platelet adhesion (bridge between extracellular collagen matrix and platelet surface
receptors)
• GP lb-IX is a major receptor for vWF
• vWF acts as a carrier for factor VIII and important for its stability and prolongs half life
• Factor VIII is synthesized normally but has 1 half-life due to deficiency of carrier molecule

Type 1 Type 2 Type 3

• Autosomat dominant • 2A - Autosomal. dominant • Autosomal recessive
• Due to missense mutation • Missense mutations • Deletions or frame-shift
• Most common type • Qualitative defects of vWF mutations
• Reduced quantity of vWF • Mild to moderate • Extremely low levels of vWF
• Mild to moderate bleedeing • Severe clinical manifestations

Clinical features
• Bleeding is uncommon in infancy and manifest in late childhood
• The most common symptoms - sponatenous mucosal bleeding(e.g.epistaxis), excessive bleeding from
wounds, menorrhagia
• Frequently mild vWD manifests first during wisdom tooth extraction or tonsillectomy
• Defects in platelet function despite normal platelet count
• Acquired vWD is most commonly seen in MGUS; other conditions - multiple myetoma; Waldenstrom's
macroglobulinemia

Diagnosis
 • Increased BT
• Normal aPTT, PT (except in severe disease)
• Plasma level of active vWF, measured as Ristocetin (an antibiotic) cofactor activity is reduced
• Hess' test positive (Torniquet test)

Treatment
• Type 1: DDAVP (desmopressin) IV/intranasally
• For other types - vWF replacement

HEMOPHILIA A (CLASSICAL HEMOPHILIA)

• Deficiency of factor VIII
• Inheritance: X-linked recessive
• Most common hereditary disease associated with life-threatening bleeding
• Factor VIII and Factor IX circulate in an inactive form
• When activated, these 2 factors cooperate to cleave and activate factor X, a key enzyme that
• controls the conversion of fibrinogen to fibrin
• Inversion of X chromosome causes severe hemophilia A
• Clinical severity of the disease

< 1% activity of factor VIII - severe disease

2-5% - moderate disease

6-50% - mild disease
• Easy bruising, massive hemorrhage after trauma and surgery
• Recurrent hemarthroses is a common manifestation of severe disease
• Retroperitoneal hemorrhages can accumulate large quantities (pseudotumor syndrome)
• Petechiae are characteristically absent
• BT, PT and platelet count - normal
• aPTT - prolonged

Treatment
• Mild to moderate disease - DDAVP
• Transfusion of recombinant factor VIII concentrates (stored at 4oC)
• Bleeding in the gums, gastrointestinal tract, and during oral surgery  oral antifibrinolytic drugs EACA or
tranexamic acid to control local hemostasis

Hemophilia B
• Christmas disease
• Factor IX deficiency
• Treatment: factor IX concentrate

DISSEMINATED INTRAVASCULAR COAGULATION

• Activation of coagulation sequence  microthrombi formation throughout the microcirculation
• There is consumption of platelets, fibrin and coagulation factors and secondarily activation of fibrinolytic
mechanisms (consumption coagulopathy)
• Most common cause - obstetric complications; Second most common - carcinomatosis
• Two major mechanisms trigger DIC

Release of tissue factor or thromboplastic substances (placenta in obstetric complications, cytoplasmic
granules of acute PML, mucus from certain adenoCA) into the circulation

Widespread injury to endothelial cells

Clinical features
• Most common symptom is bleeding
• Acute renal failure, shock, GI bleeding
• Microangiopathic hemolytic anemia (schistocytes)
• Widespread deposition of fibrin in the microcirculation - ischemia of vulnerable organs
• Most common sites of thrombi: Brain, heart, lungs, kidney, adrenals, spleen and liver
 • Waterhouse-Friderichsen syndrome massive adrenal hemorrhage due to fibrin thrombi in the
microcirculation
• Sheehan postpartum pituitary necrosis is a form of DIC complicating labor and delivery
• In giant hemangiomas, thrombi form within the neoplasm (unusual form of DIC - Kasabach-
• Merritt syndrome)
• Purpura fulminans - severe form of DIC resulting from thrombosis of extensive areas of the skin
• Acute DIC(obstetric complications or major trauma) is dominated by bleeding diathesis
• Chronic DIC(cancer) present with thrombotic complications

Drugs causing DIC

• Fibrinolytic agents
• Aprotinin
• Warfarin (especially in neonates with protein C deficiency)
• Prothrombin complex concentrates
• Recreational drugs (amphetamines)

Lab features
• Platelets, coagulation factors and natural anticoagulant factors are depleted
• In early DIC, the platelet count and fibrinogen levels may remain within the normal range
• Thrombin time, PT and PTT are prolonged
• The most sensitive test for DIC is the FDP level (increased)
• Elevated D-dimers (fibrin degradation products) - more specific
• Fragmented RBCs (schistocytes) in peripheral smear

Treatment
• The only definitive treatment is to remove or treat the inciting cause
• Supportive therapy - intravenous fluids to maintain fluid volume and organ perfusion is vital
• Blood components: FFP, cryoprecipitate, packed red cells and platelet concentrates
• In cases of refractory bleeding - Low doses of heparin
• Contraindications for heparin in DIC

If the platelet count cannot be maintained at 50,000/mcL

In cases of central nervous system/gastrointestinal bleeding

Placental abruption

Any condition that is Likely to require imminent surgery
• Fibrinolysis inhibitors may be considered in patients with refractory DIC

 1 unit of FFP increases most coagulation factors by 3% in an adult without DIC

Laboratory findings in Hemostatic disorders

Coagulation disorders Platelet disorders
TEST Hemophilia vWD Vit K ↓ Liver ITP TTP Hepari DIC Aspiri Warfari
A&B failure n n n
BT N ↑ N ↑ ↑ ↑ ↑ ↑ ↑ N
Platelet N N N ↓ BT
↓ ↓ ↓ ↓ N N
PT N N ↑ ↑ N N N ↑ N ↑
aPTT ↑ ↑ ↑ ↑ PT
N N ↑ ↑ N ↑
FDP - - - - - +/- - + - -
 IX. WHITE BLOOD CELLS
• Most common cause of agranulocytosis - drug toxicity
• Dohle bodies -sky-blue cytoplasmic puddles (detached endoptasmic reticulum) in neutrophils
• Tingible body macrophages are seen in

Chronic non-specific lymphadenitis (follicular hyperplasia)

Burkitt lymphoma

HEMOPHAGOCYT1C LYMPHOHISTIOCYTOSIS (LHH)

• Also called Macrophage activation syndrome
• Systemic activation of macrophages and CD8+ cytotoxic T cells
• Activated macrophages phagocytose blood cell progenitors in the marrow
• Released mediators suppress hematopoiesis and produce symptoms of systemic inflammation
• Results in cytopenias and a systemic inflammatory response syndrome or cytokine storm
• EBV causes LHH in immunodeficient patients, B-cell lymphomas and posttransplant tymphoproliferative
disorders
• High levels of

Inflammatory mediators - interferon-γ, TNFα, IL-6, and IL-12

Serum ferritin, soluble IL-2 receptor (indicates severe inflammation)

Liver function tests and triglycerides (hepatitis)

Neoplasms of White blood cells

Leukemias Lymphomas
Lymphoid Myeloid Hodgkin's lymphoma Non Hodgkin lymphoma
• ALL • AML • Nodular sclerosis • Follicular lymphoma
• CLL • Myelodysplastic • Mixed cellularity • Burkitt lymphoma
syndromes • Lymphocyte rich • Mantle cell lymphoma
• Myeloproliferative • Lymphocyte depleted • Marginal zone lymphoma
disorders • Lymphocyte predominant • Hairy cell Leukemia

ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA

• ALL is the most common cancer in childhood (2nd most common - brain tumors)
• Neoplasms of immature B (pre-B) and T (pre-T )cells which are referred to as lymphobtasts
• 85% are pre-B cell tumors and present in childhood as leukemias
• Less common pre-T cell tumors present in adolescent males as Thymic lymphomas

Morphology
• Lymphoblasts contain PAS positive material (myelob(asts contain peroxidase positive granules)
• Starry sky pattern of tumor cells

Immunophenotype
• TdT positive (expressed only by pre-B and pre-T cells)
• Pre-B ALL cells - CD19, CD10, CD20, PAX5
• Early pre-B ALL is distinguished from late pre-B ALL by the absence of cytoplasmic IgM heavy(μ) chain
• Pre-T ALL cells - CD1, CD2, CD5, CD7

Cytogenetics: Most common is hyperploidy (>50chromosomes)

Types: L1 ALL, (mc type, best prognosis) L2 ALL, L3 ALL (rare type, worst prognosis)

Clinical features
• Abrupt stormy onset
• B cell lineage: Pancytopenia due to BM depression
• T cell lineage: Mediastinal mass, lymphadenopathy, splenomegaly, testicular enlargement
• CNS - head ache, vomiting nerve palsies
Treatment of ALL
• Combination chemotherapy - daunorubicin, vincristine, prednisone, and asparaginase.
• This produces complete remissions in 90% of patients
• For Philadelphia chromosome-positive ALL - add a tyrosine kinase inhibitor (dasatinib)

Unfavorable prognosis Favourable prognosis

• WBC count >50000/mm3 at diagnosis • Low WBC count
• Age < 1 or > 10 years • Age 2-10 years
• Male • Female
• Hepatomegaly, splenomegaly, lymphadenopathy • No Liver, spleen and node involvement
• Testicular enlargement present • Absent
• CNS leukemia present • Absent
• ALL L2, ALL L3 • ALL L1
• Hypodiploidy • Hyperdiploidy
• t(9;22) t(4;11) t(1;19) • Trisomy 4,10, 17, or t (12;21)
• Pre T cell, pre-B cell, mature B cell phenotype • Early pre-B phenotype
• Peripheral blast count > 100000 • Peripheral blast count < 100000

CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LEUKEMIA

• Small lymphocytes mixed with larger cells called prolymphocytes which gather to form proliferation centers
- pathognomic of CLL/SLL
• Smudge cells or basket cells which are fragile CLL cells disrupted in the process of making slides
• Only mantle cell lymphoma and CLL are positive for both CD5 and CD19
• CLL is distinguished from mantle cell lymphoma by the expression of CDZ3, low expression of surface Ig and
CD20, and the absence of a translocation or overexpression of cyclin D1
• Not associated with radiation exposure

Clinical features
• Usual age of presentation above 60
• Mostly asymptomatic; Fatigue, Generalized lymphadenopathy, hepatosplenomegaly
• Hypogammaglobinemia contributes to increased susceptibility to infections
• Few develop autoimmune hemolytic anemia or thrombocytopenia
• Mostly it transforms into a diffuse large B cell lymphoma (Richter syndrome)
• Isolated Lymphocytosis is the hall mark. Peripheral smear > 5000/mm3, Bone marrow > 30%

Bad prognosis is associated with

• Deletions of 11q and 17p
• Lack of somatic hypermutation
• Expression of ZAP-70, a protein that augments signals produced by the Ig receptor
• Presence of NOTCH1 mutations

Treatment
• Patients < 70 years: fludarabine + rituximab + bendamustine or cyclophosphamide
• Patients > 70 years: chlorambucil + obinutuzumab
• Relapsed/refractory CLL, deletion of 17p: Ibrutinib

ACUTE MYELOID LEUKEMIA

Risk factors
• Myelodysplastic syndromes
• Genetic disorders: Down syndrome, Fanconi anemia, Congenital neutropenia (Kostmann syndrome)
• Chemicals: smoking, ionizing radiation, benzene, ethylene oxide
• Drugs: Alkylating agents (4-6 years after exposure), Topoisomerase II inhibitors (1-3 years after exposure),
chloramphenicol, Phenylbutazone
Morphology
• The diagnosis is based on the presence of at least 20% myeloblasts in the bone marrow
• Myeloblasts are peroxidase positive and have Auer rods
• Monoblasts are non-specific esterase positive and lack Auer rods

Clinical features
• Peak incidence 15-39 years
• Usually present with complaints related to anemia, neutropenia, thrombocytopenia
• Spontaneous mucosal and cutaneous bleeding due to thrombocytopenia
• Signs and symptoms related to infiltration of tissues is less striking in AML than ALL

Treatment
• Induction therapy: cytarabine + daunorubicin
• Post remission therapy: intensive chemotherapy(cytarabine) and Allogenic/autologous HSCT
• Promyelocytic leukemia: All-trans retinoic acid(ATRA) + Arsenic trioxide

Classification Features
AML, minimally Myeloperoxidase negative
differentiated (MO) Auer rods absent
AML without maturation (M1) >3% blasts positive for MPO
t (8;21), CBFa/ETO fusion gene
AML with myelocytic Auer rods present
maturation (M2) Highest incidence of chloroma or granulocytic sarcoma or
(Most common type of AML) Myeloblastoma
Peroxidase positive (myeloblasts present)
t(15;17), RARa/PML fusion gene,
Acute promyelocytic
Cells with numerous auer rods (faggot cells)
leukemia (M3)
High incidence of DIC
AML with myelomonocytic Inversion 16, CBFB/MYH11 fusion gene
maturation (M4)
Infiltration of skin (leukemia cutis) and gum hypertrophy
Meningeal leukemia
AML with monocytic
M5a: Non-specific esterase positive monoblasts and pro-
maturation (M5)
monocytes predominate in blood Et marrow
M5b: Mature monocytes predominate in blood
AML with erythroid M6a: >50% dysplastic erythroid precursors; >20% myeloblasts
maturation (M6) M6b: >80% erythroid precursors without myeloblasts
AML with megakaryocytic Often associated with marrow fibrosis
maturation (M7) Most common AML in Down syndrome

Good prognosis Poor prognosis

• Young age at diagnosis • Old age at diagnosis
• M2, M3, M4 • MO, M6, M7
• t(15;17) - very good prognosis • T (6;9), inv 3 and 7 deletion
• t(8;21) or inversion 16 - good prognosis • Prior myelodysplastic syndrome, AML following
• Presence of auer rods indicate better prognosis anticancer therapy have poor prognosis
• Molecular markers: NPMI and CEBPA mutation • WT1, FLT3-ITD & KIT mutations
• Overexpression of BAALC, ERG, MN1, EVI1

• Chromosomal findings at diagnosis are the most important independent prognostic factor

HODGKIN'S LYMPHOMA
• First human cancer to be successfully treated with radiotheraw and chemothera

HL NHL
More often localized to a single group of nodes (cervical, More frequent involvement of multiple
mediastinal, para-aortic) peripheral nodes
Orderly spread by contiguity Noncontiguous spread
Mesenteric nodes and Waldeyer s ring rarely involved Commonly involved
Extranodal involvement rare Common

Clinical course
• Bimodal age distribution, with one peak in the 20s and a second over age 50 years.
• Most common presentation - painless lymphadenopathy (neck, supraclavicular area and axilla)
• Paraneoplastic symptom specific to HL is pain in the involved node on consumption of alcohol
• Spread: first nodal, then splenic, then hepatic and finally marrow and other tissues
• Cyclical high grade fever - afebrile period - recurrence of fever (Pel-Epstein fever)
• Tumor stage is the most important prognostic factor

Morphology
• Diagnostic feature: Reed Stenberg's cells in the background of non-neoplastic inflammatory cells
• RS cells in the lymphocyte predominant HL have a characteristic B-cell immune phenotype
• RS cells in the other types (Classical HL)

Express CD15 and CD30

Positive for PAX 5

Negative for other B-cell. markers, T-cell markers, and CD45
• RS cells have owl-eye appearance
• Activation of the transcription factor NF-KB is a common event in classical HL

RS cells are also seen in

• Infectious mononucleosis
• Solid tissue cancers
• Large cell NHLs

Type/Immunophenotype Morphology Clinical features

Nodular sclerosis Frequent lacunar cells (RS variant) Most common type worldwide
EBV- Background rich in inflammatory cells Frequent involve lower cervical,
Deposition of collagen in bands - divide supraclavicular & mediastinal
lymph nodes into circumscribed nodules involvement
M = F; mostly in young adults
Excellent prognosis
Mixed cellularity Maximum number of R-S cells, Most common type in India
EBV+ Background rich inflammatory cells M >F, Biphasic incidence, more
associated with systemic
symptoms (FUO) Good prognosis
Lymphocyte rich Least number of R-S cells, Uncommon
40% EBV + Background rich in T cells M > F; Older adults
Very Good prognosis
Lymphocyte depletion Reticular variant: frequent R-S cell Least common type;
EBV + Paucity of background reactive cells Seen in HIV+ and in developing
countries. Worst prognosis
Lymphocyte predominance Frequent L & H (popcorn) cell in a Young males with cervical or axillary
R-S cells: CD15- CD30- Background of follicular dendritic cells lymphadenopathy
CD20+ BCL6+ EBV- and reactive B cells Excellent prognosis

Ann Arbor classification of Hodgkin lymphoma and NHL

Stage I Involvement of a single lymph node region (I) or
A single extralymphatic organ or site (IE)
Stage II Involvement of 2 of more lymph node regions on same side of diaphragm alone (II) or
 Localized involvement of an extralymphatic organ or site (IIE)
Stage III Involvement of lymph node regions on both sides of the diaphragm without (III) or
With localized involvement of an extra-lymphatic organ or site (IIIE)
Stage IV Diffuse involvement of one or more extralymphatic organs or sites with or without lymphatic
involvement
All stages are further divided into A (absence) and B (presence) of the following symptoms -unexplained fever,
drenching night sweats, and/or unexplained weight loss of > 10 % of normal body weight over 6 months

Treatment of HL
• Standard first line regimen: ABVD (adriamycin, bleomycin, vinblastine, dacarbazine)
• MOPP regimen - mechlorethamine, vincristine(oncovin), procarbazine, prednisone

NON -HODGKIN LYMPHOMAS

Indolent lymphomas Aggressive lymphomas
• Follicular Lymphoma • Diffuse large B-cell lymphoma
• Marginal zone lymphoma • Mantle cell lymphoma
• Small lymphocytic lymphoma • Primary CNS lymphoma
• Hairy cell leukemia • Burkitt Lymphoma
• Peripheral T cell lymphoma

FOLLICULAR LYMPHOMA
• Express CD19, CD20, CD10, BCL2, BCL6; CD5 negative
• Hall mark translocation (14;18) leads to over expression of BCL2 - antagonist of apoptosis
• Painless generalized lymphadenopathy - me presentation; Extranodal involvement uncommon
• Usually follows an indolent waxing and waning course
• 2 types of cells seen - centrocytes and centroblasts
• Bone marrow - paratrabecular lymphoid aggregates
• Incurable, survival not increased by aggressive therapy (ROBBINS)
• Most responsive to chemotherapy and radiotherapy(HARRISON)
• Histotogical transformation occurs in 50% patients to diffuse large B cell

DIFFUSE LARGE B-CELL LYMPHOMA

• Most common form of NHL
• Median age 60 years
• Dysregulation of BCL6, t(14;18) resulting in overexpression of BCL2
• Waldeyer ring is involved commonly
• Extranodal sites are also involved
• Bone-marrow involvement is uncommon and occurs late
• Treatment: R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone) + Radiation

BURKITT LYMPHOMA
• Clinically most aggressive lymphoid leukemia - Burkitt's leukemia
• Responds well to Chemotherapy

Endemic (African type) Sporadic HIV associated

• All associated with EBV infection • 20% Latent EBV infection • Aggressive form
• Mass involving mandible • Abdominal mass involving • 25% latent EBV
• Predilection for abdominal viscera - ileocaecum and peritoneum infection
kidneys, ovaries and adrenal glands
• Involvement of Bone marrow and
peripheral blood - uncommon

Morphology Cytogenetics
 • High mitotic index • Translocation t(8;14) of c-MYC gene is most
• Starry sky pattern common
• Tingible body macrophages • Others - t(2;8), t(8;22)
• Royal blue cytoplasm with clear cytoplasmic • Express IgM, CD19, CD20, CD10,
vacuoles • BCL6

MANTLE CELL LYMPHOMA

• Usually presents in 5th and 6th decade
• Proliferation consists of a homogenous population of small lymphocytes with irregular to occasionally deeply
clefted (cleaved) nuclear contours
• Most common presentation - painless lymphadenopathy
• Muttifocat mucosal involvement of the small bowel and colon produces "Iymphomatoid polyposis'
• Express CD19, CD20, CD5 and Cyclin D1(BCL-1) which is characteristic; 0023 -ve
• Most characteristic translocation (11;14)
• Prognosis poor

MARGINAL ZONE LYMPHOMAS

• Often referred to as MALTomas
• Often arise within tissues involved by chronic inflammatory disorders of autoimmune or infectious etiology
(salivary gland in SjOgren disease, thyroid gland in Hashimoto thyroiditis, and stomach in H pylori gastritis)
• Remain localized for prolonged periods, spreading systemically only late in their course.
• They may regress if the inciting agent (e.g., Helicobacter pylori) is eradicated

HAIRY CELL LEUKEMIA

• Leukemic Express CD19, CD20, CD22, surface Ig which are B cell markers
• CD11c, CD25, CD103 (diagnostic), CD123 are typical for hairy cell leukemia
• Tartrate resistant acid phosphatase positivity (TRAP) of cytoplasm
• Soluble CD25 level in serum is an excellent tumor marker for disease activity
• Identification cells have fine hair like projections recognized by phase contrast microscope
• of BRAF V600E mutation by sequencing hairy cells - new diagnostic tool

Clinical features
• Old age (median-55 years); Male to female - 4:1
• Massive splenomegaly followed by infections - most common presentation
• Increased incidence of atypical mycobacterial infections due to profound monocytopenia
• Pancytopenia hallmark of hairy cell leukemia
• Hepatomegaly less common; Lymphadenopathy rare
• Bone marrow cannot be aspirated easily (dry tap)
• Splenic red pulp is infiltrated preferentially (beefy red appearance) and obliteration of white pulp
• Excellent prognosis

Treatment: DOC: Cladirabine; 2nd Pentostatin; Residual disease - Rituximab; Splenectomy

ANAPLASTIC LARGE T CELL or NULL CELL LYMPHOMA

• t(2;5) resulting in overexpression of ALK protein
• CD30 (Ki-1) positive
• Large anaplastic cells, containing horseshoe-shaped or embryoid or flower shaped nuclei and voluminous
cytoplasm (hallmark cells)
• ALK positive tumors

Frequent in children or young adults

Involve soft tissues

Carry a very good prognosis
• ALK negative tumors

Occur in older adults

Worse prognosis

ADULT T CELL LEUKEMIA/LYMPHOMA

• Neoplasm of CD4+ T cells
• Only in adults infected by human T-cell leukemia retrovirus type 1 (HTLV-1)
• Skin lesions, generalized lymphadenopathy, hepatosplenomegaly, peripheral lymphocytosis, hypercatcemia.
• Cells with multilobated nuclei (cloverleaf or flower cells)

MYCOSIS FUNGOIDES/SEZARY SYNDROME

• Tumor of CD4 T cells of skin
• Mycosis fungoides

Epidermis and upper dermis are infiltrated by neoplastic T cells

Cerebriform appearance of nucleus due to marked infolding of the nuclear membrane

Later - extracutaneous spread, most commonly to lymph nodes and bone marrow
• Sezary syndrome

Skin involvement manifests as generalized exfoliative erythroderma.

Skin lesions rarely proceed to tumefaction

Leukemia of "Sezary" cells with characteristic cerebriform nuclei.

EXTRANODAL NKJT-CELL LYMPHOMA

• Presents most commonly as a destructive nasopharyngeal mass
• Tumor cell infiltrate typically surrounds and invades small vessels, leading to extensive ischemic necrosis
• Highly associated with EBV

Lymphoma Immunophenotype + ve Immunophenotype - ve

CLL/SLL CD19, CD20, CD5, CD23 CD10
Follicular lymphoma CD10, CD19, CD20, CD43, BCL-2 CD5
Mantle cell lymphoma CD5, CD20, CD43, CYCLIN D1 CD23
Burkitt lymphoma CD19, CD20, CD10, BCL-6 CD3, CD5
Hairy cell leukemia CD19, CD20, CD11c, CD25, CD103 CD5
Classical HL CD15, CD30 CD20
Lymphocyte predominant HL CD 20, BCL-6 CD15, CD30

MYELODYSPLASTIC SYNDROMES
• Maturation defects with ineffective hematoopoiesis + high risk of transformation to AML
• Secondary or Therapy related MDS (t-MDS)

2 to 8 years after drug or radiation exposure

Poor prognosis

Frequent and rapid transformation to AML
• Bone marrow

Hypercellular

Ringed sideroblasts

Nuclear budding abmormalities

Pawn ball megakaryocytes (multiple separate nuclei)

Dwarf megakaryocytes with a uni lobed nucleus

Dohle bodies (toxic granules in neutrophils)

Pseudo-Pelger-Heut cells (neutrophils with 2 nuclear lobes)
• Peripheral smear: Giant platelets
• Decreased neutrophil alkaline phosphatase score
WHO CLASSIFICATION OF MYELODYSPLASTIC SYNDROMES

Name Peripheral blood Bone marrow

Refractory cytopenias with unilineage < 1 % blasts < 5% blasts
dysplasia
• Refractory anemia
• Refractory neutropenia
• Refractory thrombocytopenia
Refractory anemia with ringed No blasts < 5% blasts
sideroblasts
Refractory cytopenias with <1% blasts Multilineage dysplasia ± ringed
multi lineage dysplasia No Auer rods sideroblasts
<5% blasts; No Auer rods
Refractory anemia with excess <5% blasts Unilineage or multilineage dysplasia
blasts, No Auer rods
type 1 (most common type)
Refractory anemia with excess 5-19% blasts Unilineage or multilineage
blasts, + Auer rods dysplasia
type 2 10-19% blasts
+ Auer rods
MDS associated with isolated del(5q) Anemia Hypolobated megakaryocytes
Normal or high platelet count <5% blasts
<1% blasts
Childhood MDS, including refractory Pancytopenia <5% marrow blasts
cytopenia of childhood

CHRONIC MYELOPROLFERATIVE DISORDERS

Disorder Mutation
CML BCR-ABL fusion gene
Polycythemia vera JAK 2 point mutations
Essential thrombocytosis JAK 2 point mutations
MPL point mutations
Primary myelofibrosis JAK 2 point mutations
MPL point mutations
Systemic mastocytosis c-KIT point mutations
Chronic eosinophilic leukemia FIP1L1-PDGFRα fusion gene
Stem cell leukemia FGFR1 fusion genes

CHRONIC MYELOID LEUKEMIA

• Results from a balanced reciprocal translocation between the long arms of chromosomes 9 and 22
(Philadelphia chromosome) - is present in more than 90% of classical CML
• Philadelphia chromosome was discovered by Nowell & Hungerford in 1960
• ABL gene (9q) are translocated next to the major breakpoint cluster region (BCR) gene on chromosome 22
• The fusion gene bcrlabl possesses tyrosine kinase activity
• Peak incidence in 5th - 6th ecades
• Exposure to ionizing radiation has increased the risk of CML, which peaks at 5-10 years after exposure
• Insidious onset, massive splenomegaly, hepatomegaly
• Lymphadenopathy rare (indicates blast crisis)
• Priapism due to leukocytosis

Chronic phase
• Normally bone marrow is 50% fat and 50% cellular; In CML 100% cellular
 • M:E ratio is 20: 1
• Blasts 2-5%; basophilia, eosinophilia, monocytosis, thrombocytosis, anemia
• Large histiocytes (pseudo-Gaucher cells) with blue granules (sea blue histiocytes)
• Decreased neutrophil alkaline phosphatase
• Serum levels of vitamin B12 and B12 binding proteins are elevated

Accelerated phase
• On an average after 3 years patients enter accelerated phase
• Fever, night sweats, weight loss
• Increased basophils >20%
• Peripheral and marrow Blasts 10-20%
• Thrombocytopenia, increasing anemia, Increased neutrophil alkaline phosphatase
• Trisomy 8, isochromosome 17q, or duplication of the Ph chromosome, often appear

Blast crisis
• Within 6 - 12 months, accelerated phase terminates in blast crisis
• Lymphadenopathy, chloromas
• Peripheral and marrow blasts >20%
• Hyposegmented neutrophils appear(Pelger-Huet anomaly)
• Increased neutrophil alkaline phosphatase

Puvenile CML
• Skin rashes
• Philadelphia chromosome absent/BCR-ABL fusion negative
• HbF raised
• Poor prognosis

Treatment
• Imatinib mesylate (Gleevac) a tyrosine kinase inhibitor is the first line treatment
• Dasatinib and nilotinib are other frontline drugs
• Bosutinib - dual bcr/abl tyrosine kinase inhibitor, for refractory cases
• Omacetaxine mepesuccinate - failure of > tyrosine kinase inhibitors
• Curative therapy: allogenic bone marrow transplantation

IPOLYCYTHEMIA VER
• Increased marrow production of phenotypically normal erythrocytes, granulocytic and megakaryocytic
elements in the absence of physiologic stimulus
• Mutations in tyrosine kinase JAK2

Clinical features
• Clinical manifestations are due to erythrocytosis, granulocytosis and thrombocytosis
• Normal arterial oxygen saturation
• Hyperuricaemia due to high cell turnover
• Abnormal blood flow and abnormal platelet function lead to an increased risk of both major bleeding and
thrombotic episodes (DVT, MI, Stroke)
• Thrombosis - most common complication
• Spent phase - features of myelofibrosis develop
• Transforms to Myelofibrosis, CML or AML

ERYTHROCYTOSIS GRANULOCYTOSIS THROMBOCYTOSIS

 • Responsible for most of the • Increased histamine • Budd Chiari syndrome
symptoms secretion • Digital ischemia, easy
• Aquagenic pruritis • (↑ basophils)  Intense bruising
• Plethoric and cyanotic pruritis, Peptic ulcer • Epistaxis
• Headache, dizziness, dimness of • ↑transcobalamine I & III  • Erythromelalgia –
vision increase B12 binding Erythema + burning
• Systolic hypertension capacity sensation + pain in the
• Splenomegaly • Lab features extremities, due to platelet
Lab features • Leukocytosis stickiness
• Red cell morphology normal • ↑ neutrophil alkaline • Lab features
• ↑RBC count (>6million/mm3) phosphatase • Platelet function
• ↑Hb (>18mg%); abnormalities
↑hematocrit(>60%)
• MCV, MCH, MCHC are N or ↓
• Blood viscosity increased
• ESR ↓; Erythropoietin ↓

Treatment
• Treatment of choice - Phlebotomy (500 ml of blood are removed by venesection every week)
• Maintaining hematocrit < 45% decreases the risk of thrombosis
• For myelosuppression - Hydroxyurea with or without Anagrelide
• Pegylated IFN-a2 - is giving promising results
• Treatment with alkylating agents increases the risk of transformation to acute leukemia
• Radioactive phosphorus - for elder patients as it ↑ risk of transformation to acute leukemia

Only 3 conditions with microcytic erythrocytosis

• B-thalassemia trait(RDW is normal)
• Hypoxic erythrocytosis(↑ RDW)
• Polycythemia vera(↑ RDW)

ESSENTIAL THROMBOCYTOSIS
• More common in women
• Activating mutation in JAK2 gene or MPL
• High blood platelet count (> 6 lakhs/mm3)
• Abnormally large platelets
• Absence of polycythemia and marrow fibrosis
• Non-functioning platelets - bleeding
• Occlusion by platelets - thrombosis (both arterial and venous)
• Erythromelalgia - throbbing pain and burning of hands and feet due to occlusion of small arterioles by
platelet aggregates
• The treatment of choice is oral hydroxyurea; Anagrelide if hydroxyurea is not tolerated

PRIMARY MYELOFIBROSIS
• Activating mutation in JAK2 gene or MPL
• Neoplastic megakaryocytes release fibrogenic factors like PDGF and TGF-B
• Replacement of normal marrow by fibrous tissue (extensive collagen deposition by non-
• neoplastic fibroblasts)
• Extramedullary hematopoiesis - massive splenomegaly
• Peripheral smear

Pancytopenia

Leucoerythroblastosis (erythroid and granulocytic precursors in peripheral blood)

Dacrocytes (tear drop erythrocytes) in peripheral blood

Abnormally large platelets
• Bone marrow aspiration

Dry tap

Initially hypercellular, later hypocellular

Abnormal megakaryocytes (cloud like nucleus)

Dilated marrow sinusoids
• Treatment

First choice - Hydroxyurea

Newer agents - lenalidomide, pomalidomide, Ruxolitinib (JAK2 inhibitor)

Medication refractory cases - splenomegaly

PLASMA CELL DYSCRASIAS

ULTIPLE MYELOMA
• Neoplastic proliferation of plasma cells derived from single clone of lymphocytes (monoclonal proliferation)
and secrete homogenous Ig (monoclonal gammopathy)
• The monoclonal Ig present in blood is M component
• The proliferation and survival of myeloma cells are dependent on IL-6
• High levels of IL-6 are associated with poor prognosis
• Myeloma derived MIP1α increased NE-KB ligand (RANKL) expression by bone marrow stromal cells 
activates osteoclasts  lytic bone lesions

Clinical features
• Peak age of incidence 65-70 years
• Most often present as multifocal destructive bone tumors composed of plasma cells (plasmacytomas)
throughout the skeleton.
• Vertebral column is most commonly involved followed by ribs, skull, pelvis.
• Bone pain is the most common symptom - precipitated by movement
• The bone lesions appear radiographically as punched out defects
• Bone resorption leads to pathological fractures - most common in femoral neck and vertebrae
• Pancytopenia due to replacement of normal marrow elements by plasma cells
• Hypercalcemia - confusion, lethargy, constipation, polyuria and renal failure
• Bence Jones proteinuria (K & ƛ light chains) may lead to renal failure and amyloidosis (AL)
• Hypogammaglobulinemia, low CD4 count, decreased neutrophil migration - Frequent infections (MCC of
death)
• Cryoglobulinemia

Lab features
• Classic triad - marrow plasmacytosis (>30%), lytic bone lesions, and serum and/or urine M component
• Plasma cells are positive for CD138+ (syndecan-1) and CD56
• Plasma blasts or its variants - Flame cells, Mott cells with fibrils, crystalline rods, and globules
• Russel bodies (intracytoplasmic) & Dutcher bodies (intranuclear) in plasma cells
• The most common monoclonal Ig (M protein) is IgG (55%) followed by IgA (25%)
• High level of serum M protein cause rouleaux formation of RBCs
• Alkaline phosphatase level not increased (bone resorption without osteoblastic activity)
• Serum β2-microglobulin is the single most powerful predictor of survival
• Radionuclide bone scan is not useful in detecting bone lesions in myeloma, since there is usually no
osteoblastic component

Prognosis
• Translocations involving cyclin 01 - good outcome
• Deletions of 13q, 17p, and t(4;14) - aggressive course.

Treatment
• Transplant candidates: Lenalidomide + Bortezomib (Proteasome inhibitor) + dexamethasone
• Non transplant candidates: Alkylating agent (melphalan)+ prednisolone
• For hyperviscosity syndrome plasmapheresis

IgM myeloma
 • Lytic bone lesions
• Predominant infiltration with CD138+ plasma cells in the bone marrow

WALDENSTROM'S MACROGLOBINEMIA or LYMPHOPLASMACYTIC LYMPHOMA

• B-cell neoplasm presenting in 6th or 7th decades
• The tumor cells undergo terminal differentiation to plasma cells
• Patients present with weakness, fatigue, and recurrent infections similar to myeloma
• Lymphadenopathy, hepatomegaly, splenomegaly and normocytic normochromic anemia
• 10% patients have autoimmune hemolysis caused by cold agglutinins
• No bone destructions; no hypercalcemia
• Plasma cells secrete monoclonal IgM, producing a hyperviscosity syndrome
• Hyperviscosity syndrome: visual impairment, neurologic problems, bleeding, cryoglobulinemia
• PAS +ve inclusions containing Ig seen in cytoplasm(Russel bodies) or nucleus(Dutcher bodies) of plasma cells
• All patients have mutations in MYD88
• M component is present in the serum in excess of 30 g/L (3 g/dL)
• But only 20% excrete light chains - complications due to free light chains (amyloidosis, renal failure) rare
• The light chain isotype is kappa in 80% cases
• Bone marrow shows >10% infiltration with lymphoplasmacytic cells
• Malignant lymphocytes are usually present in the peripheral blood
• Treatment: Plasmapheresis, anti-CD20 antibody(rituximab), fludarabine, Cladirabine

MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE

• MGUS is the most common plasma cell dyscrasia
• M proteins identified in serum of 3% asymptomatic patients >50 years and 5% > 70 years
• 1% progress to an overt plasma cell dyscrasia (usually Multiple Myeloma) per year
• No evidence of other B cell proliferative disorders

Feature Multiple myeloma Smouldering myeloma MGUS

End organ damage Present Absent Absent
Marrow plasma cells > 30% 10 - 30% < 10%
Serum M protein > 3g/dL > 3g/dL < 3 g/dL
Bence-Jones proteinuna > 6mg/dL Absent

POEMS SYNDROME
• Polyneuropathy: severe progressive sensorimotor
• Organomegaly: hepatomegaly, splenomegaly, lymphadenopathy
• Endocrinopathy: amenorrhea, impotence, gynacomastia, Hyperprotactinemia, type 2 DM, hypothyroidism
• Multiple myeloma
• Skin changes: hyperpigmentation, hypertrichosis, skin thickening, digital clubbing

LANGERHANS CELL HISTIOCYTOSIS or HISTIOCYTOSIS X

• Proliferation of a special type of immature dendritic cells called Langerhans cell
• Cytoplasm contains Birbeck granules (tubules with dilated terminal end producing a tennis racket like
appearance)
• Tumor cells express HLA-DR, S-100, CD1a
• Normal epidermal Langerhans cells express CCR6; Neoplastic cells express CCR6 and CCR7
• Increased risk of ALL

Letterer Siwe disease (multifocal multisystem LCH) Eosinophilic granuloma (Unifocal and Multifocal
uniisystem LCH)
• Mostly < 2 years of age • Eosinophils are usually prominent
• Cutaneous lesions, Pulmonary lesions • Usually arise in the medullary cavities of bone
• Hepatosplenomegaly, Lymphadenopathy • Most common in calvarium, ribs and femur
• Destructive osteolytic bone lesions • Posterior pituitary stalk involvement leads to DI
• Bad prognosis
Pulmonary LCH Hand Schuller-Christian triad
• Calvarial bone defects
• Mostly in adult (20-40 years) smokers
• Diabetes Insipidus
• Regress spontaneously after smoking cessation
• Exophthalmos
• Most prominent in upper and middle lung zones
• X-ray: Bilateral, symmetric ill-defined nodules

HEMATOPOIETIC STEM CELL (HSC)

• All of the cell types in the peripheral blood and some cells in every tissue of the body are derived from HSC
• Transplantation of a small percentage of a donor's bone marrow volume results in complete and sustained
replacement of the recipient's entire lymphohematopoietic system (red cells, granulocytes, B and T
lymphocytes, platelets) as well as cells comprising the fixed macrophage population (Kupffer cells of the
liver, pulmonary alveolar macrophages, osteoclasts, Langerhans cells of the skin, brain microglial cells)
• Hematopoietic stem cells circulate in the peripheral blood but in very low concentrations
• Under conditions of marked stress, such as severe anemia or acute inflammation, HSCs are mobilized from
the bone marrow and appear in the peripheral blood
• G-CSF & Plerixafor (blocks CXCR4) used clinically to mobilize marrow hematopoietic stem cells for transplant.
• Hematopoietic stem cells resemble small lymphocytes morphologically

AUTOLOGOUS STEM CELL TRANSPLANTATION

• Hematopoietic stern cells are collected from the patient and then re-infused after chemotherapy
• G-CSF & Plerixafor (blocks CXCR4) - used to mobilize marrow HSCs into the blood
• Stem cells collected from peripheral blood
• Administration of high-dose chemotherapy (preparative regimen) to the patient
• Wait for clearance of the chemotherapy out of the patient's system
• Intravenous re-infusion of the thawed autologous hematopoietic stem cells
• There is a period of severe pancytopenia during the gap between myelosuppression caused by the
chemotherapy and the recovery produced from the new bone marrow derived from the infused HSCs
• Pancytopenia typically lasts 7-10 days and requires support with transfusions of red blood cells and platelets
as well as antibiotics
• Treatment of choice for lymphomas that have recurred after initial chemotherapy but are still responsive
to chemotherapy

Diffuse large B cell lymphomas

Hodgkin lymphoma

Testicular germ cell cancers
• Used as frontline therapy (curative)

Peripheral T cell lymphoma

AML
• Not curative, but prolongs remission and overall survival:

Mantle cell lymphoma

Multiple myeloma

ALLOGENIC STEM CELL TRANSPLANTATION

• Hematopoietic stem cells are collected from a donor
• Effector mechanism - alloimmune graft-versus-malignancy (GVM) effect derived from the donor immune
system.
• Donor matched with the patient (recipient) at the HLA loci (HLA A, B, C, DR) that specify major
histocompatibility antigens
• Preparative regimen is given to the patient
• Intravenous infusion of hematopoietic stem cells either fresh or after cryopreservation et thawing
 • There is a period of pancytopenia, usually 10-14 days
• Graft versus Host reaction (GVH) - major cause of morbidity and mortality during an allogeneic stem cell
transplantation
• The most common regimen used for GVH prophylaxis - cyclosporine or tacrolimus plus methotrexate
• In most cases immunosuppression can be tapered and discontinued 6 or more months after transplantation
• Treatment of choice for high risk acute leukemias
• Only curative treatement for

Myelodysplasia

CML
• Only definitive treatment for Aplastic anemia
• Plays a major role in the treatment of AML

LEUKOCYTE ALKALINE PHOSPHATASE (LAP) SCORE

• Scores range from Zero to 400
• Normal levels: 15 - 130

Low LAP High LAP

• Chronic myeloid leukemia (0 - 13) • Infections, Inflammations
• Myelodyspiastic syndrome • Growth factor therapy
• Aplastic anemia • Myeloproliferative disorders (except CML)
• Pernicious anemia • Leukemoid reactions
• Pregnancy, Oral contraceptives, Stress
• Drugs (Lithium, Corticosteroids, Estrogen)

SPLEEN
Spleniculi - accessory spleens; 20 - 35% in post mortem examinations

Massive splenomegaly (Spleen extends > 8 cm below left costal margin and/or weighs > 1000 g)
• CML, CLL • Sarcoidosis
• Lymphomas • Chronic malaria
• Myelofibrosis with myeloid metaplasia • Kala azar
• Hairy cell leukemia • Autoimmune hemolytic anemia
• Polycythemia vera • Diffuse splenic hemangiomatosis
• Gaucher's disease • Niemann Pick's disease

PLENECTOMY
• Only contraindication: Bone marrow failure
• Most important complication after splenectomy: Increased susceptibility to sepsis/meningitis caused by
encapsulated bacteria - Strep pneumoniae, N meningitidis and H influenzae

Indications
• Splenic rupture (traumatic or iatrogenic) - most common indication
• Hypersplenism
• Hereditary spherocytosis
• Immune thrombocytopenic purpura
• Hairy cell leukemia
• Prolympriocytic leukemia
Manifestations after splenectomy
Acute: Leukocytosis, Thrombocytosis
• Chronic
• Anisocytosis and poikilocytosis
• Howell-Jolly bodies (also in megaloblastic anemia and hemolytic anemia)
• Heinz bodies
• Pappenheimer bodies
 • Basophilic stippling
• Nucleated erythrocytes
• Target cells

Cells and Cluster differentiation (CD)

T cells CD1, CD3 (pan T cell marker), CD4, CD5, CD7, CD8
B cells CD10 (CALLA) CD19 (pan B cell marker), CD20, CD21, CD23, CD79a
Monocyte/Macrophage CD11c, CD13, CD14, CD15, CD33, CD64
NK cell CD16, CD56
Stem cell and progenitor CD34
cell
Activation marker CD30
All leukocytes CD45(leukocyte common antigen,LCA)
Endothelium CD31
Langerhans cell CD1a
histiocytosis
Tumor metastasis CD44
Apoptosis CD95
T-B interaction CD40
Plasma cell CD38
Myelomonocytes CD33
Memory T cell CD 45 RO
Membrane inhibitor of reactive CD 59
lysis
Cajal cells(GIST) CD117(c-KIT)

CD as host receptor for Microorganisms

CD4 - HIV
CD11b/CD18, CD14 - Candida albicans, Blastomyces dermatitidis
CD21 - EBV
CD44 - Streptococcus pyogenes
CD46 - Measles (vaccine strain), Human herpes virus 6, Neisseria

DD for dry tap - inability to aspirate bone marrow (4%)

• Metastatic carcinoma infiltration -most common
• Chronic myeloid leukemia
• Myelofibrosis
• Hairy cell leukemia
• Acute leukemias
• Lymphomas; Hodgkins disease
• Aplastic anemia

Leukoeryth roblastosis
• Abnormal release of immature precursors into the peripheral blood
• Due to processes that distort the marrow architecture due to infiltration
• Seen in

Metastatic cancer

Myelophthistic anemia

Primary myelofibrosis

CLL

Granulomatous disorders

Severe infection/inflammation
 X. BLOOD VESSELS & HEARTS
• Arterioles - resistance vessels
• Capillaries

Maximum cross sectional area

No media

Pericytes - deep to endothelium
• Vein - maximum blood volume
• Elastic recoil property of blood vessels (particularly arteries) - Windkessel effect
• Stereotypical response of the vessel wall to any insult - intimal thickening
• Heart failure cells/Siderophages/Hemosiderin laden macrophages that denote previous pulmonary edema

ARTERIOSCLEROSIS
• Affects small arteries and arterioles

Hyaline Arteriosclerosis
• Benign hypertension, elderly persons (normo and hypertensive)
• Diabetic microangiopathy
• Benign nephrosclerosis

Hyperplastic Arteriosclerosis
• Characteristic of malignant hypertension
• Onion skin lesions (concentric, laminated thickening of arteriolar walls)
• Accompanied by fibrinoid deposits and vessel wall necrosis (necrotizing arterioliitis) particularly in kidney

Monkeberg Medial Sclerosis

• Calcification of the walls of muscular arteries, typically involving the internal elastic membrane
• Persons older than age 50 are most commonly affected
• Calcifications do not encroach on the vessel lumen and are usually not clinically significant

THEROSCLEROSIS
Major risk factors
Non modifiable (Constitutional) Modifiable
• Increasing age • Hyperlipidemia
• Male gender • Hypertension
• Family history (most important • Cigarette smoking
• independent risk factor) • Diabetes
• Genetic abnormalities • Inflammation (CRP)
Additional nsk factors
• Lipoprotein (a) • Lack of exercise
• Hyperhomocystinemia • Obesity
• Metabolic syndrome • Diet: deficiency of fresh fruits,
• Antiphospholipid antibodies • PUFA
• Type A personality • Infections
• Impaired fasting glucose

Microorganisms associated
• Chlamydia pneumonia • Enterovirus • Influenza A virus
• CMV • Porphyromonas gingivalis • Hepatitis C virus
• Herpes simplex virus • Helicobacter pylori • HIV

• CRP - elevated levels can strongly and independently predict the risk of MI, stroke, peripheral arterial
disease and sudden cardiac death
• Foam cells - lipid laden macrophages and smooth muscle cells
 • Fatty streaks - Earliest lesions of atherosclerosis

Atherosclerotic plaques
• Encroach the lumen
• Parts
o Superficial fibrous cap - smooth muscle cells, collagen
o Shoulder region - smooth muscle cells, macrophages, T cells
o Necrotic core - lipid (cholesterol and cholesterol esters), debris from dead cells, foam cells
• Neovascularization - seen at the periphery

Most extensively involved vessels in atherosclerosis (in descending order)

• Lower abdominal aorta
• Coronary artery
• Popliteal artery
• Internal carotid artery
• Vessels of the Circle of Willis
Vessels of the upper extremities, mesenteric and renal arteries are usually spared, except at their ostia.

NEURYSMS
• True aneurysm
• Involves all three layers of the vessel wall
• Intact arterial wall or thinned ventricular wall
• Causes : atherosclerosis, syphilis, post MI ventricular aneurysms
• Pseudoaneurysm
• Intimal and medial layers are disrupted and the dilated segment lined by adventitia only
• Causes: pot MI rupture, leakage at vascular anastamosis
• A fusiform aneurysm affects the entire circumference of a segment of the vessel.
• A saccular aneurysm involves only a portion of the circumference

Causes
• Atherosclerosis - most common cause of true aneurysm in aorta
• Marfan syndrome: defective synthesis of fibrillin leads to weakening of elastic tissue
• Loeys-Dietz syndrome: mutations in TGF-B receptors — abnormal elastin, collagen I Et Ill. Aneurysms in such
individuals rupture fairly easily (even at small size)
• Ehlers-Dan los syndrome: defective type III collagen synthesis
• Vitamin C deficiency: altered collagen cross-linking
• Rasmussen's aneurysm - involves pulmonary artery in a tuberculous cavity

THORACIC AORTIC ANEURYSMS

• Most thoracic aortic aneurysms are due to atherosclerosis
• Hypertension is the most common etiology associated with ascending aortic aneurysms
• Atherosclerosis - most frequently associated with aortic arch and descending thoracic aortic
• Traumatic aneurysms most commonly affect the descending thoracic aorta just beyond the site of insertion
of the tigamentum arteriosum
• Investigation of choice - CT scan
• Aneurysms measuring 6 cm or larger may be considered for repair
• Aneurysms of the descending thoracic aorta - endovascular grafting
• Aneurysms of the proximal aortic arch or ascending aorta - open surgery
• Most devastating surgical complication - Paraplegia

ABDOMINAL AORTIC ANEURYSMS (AAAs)

• Aneurysms due to atherosclerosis form most commonly in the abdominal aorta and common iliac arteries.
• MC site - Abdominal aorta (below renal artery and above aortic bifurcation)
• AAAs more frequently occur in men and smokers
• The most important clinical factor affecting aneurysm growth is Blood pressure
 • Mostly asymptomatic
• Risk of rupture: < 4cm diameter: Nil ; > 6cm: 25% per year
• Investigation of choice for initial screening - Abdominal USG
• When an aneurysm measures approximately 5 cm - CT-Angiography with contrast done to accurately assess
the size and define the anatomy
• Treatment: elective repair aneurysms > 5.5 cm in diameter or rapid expansion 0.5 cm in 6 months)
• Pain or tenderness indicate impending rupture and require urgent repair regardless of the aneurysm's
diameter
• Myocardial infarction - most common complication following open aneurysm repair (low incidence in
envdoascular repair)

SYPHILITIC (LEUTIC) ANEURYSMS

• Obliterative endarteritis is characteristic of tertiary syphilis
• Contraction of fibrous scars leads to wrinkling of intervening segments of intima - tree barking
• Ascending aorta is the most common site of syphilitic aneurysms

Variants of AAA
Inflammatory AAAs IgG4 related disease Mycotic AAAs
• Typically in young patients • High plasma levels of IgG4 Tissue • Bacteremia from a
• Elevated inflammatory markers fibrosis primary
• (CRP) • Infiltration of IgG4-expressing • Salmonella
• Dense periaortic scarring with plasma cells. gastroenteritis
abundant lymphoplasmacytic • Aortitis and periaortitis weaken
infiltration the wall to give rise to aneurysms.
• Most cases are not associated • Responds well to steroid therapy
with inflammation of other
arteries

AORTIC DISSECTION
• Hypertension is the most common predisposing factor
• In pregnancy - aortic dissection typically occurs during or after the third trimester
• Dissection is unusual in the presence of substantial atherosclerosis or syphilis (medial scarring}
• Most serious complications - if the dissection involves the aorta from the aortic valve to the arch
• Most frequent preexisting histologically detectable lesion - cystic medial degeneration
• Type A
o Most common and most dangerous
o Proximal lesions involving both the ascending and descending aorta (type I DeBakey) or
o Ascending aorta only (type II DeBakey)
• Type B or type III DeBakey:
o D Distal lesions not involving the ascending part
o Usually beginning distal to subclavian artery
• Sudden onset, persistent, tearing chest pain, radiating to the back between the scapulae, moving downward
as the dissection progresses

Investigations
• X-ray: widening of upper mediastinum, distortion of aortic knuckle, left sided pleural effusion
• Multiplanar CT scan - immediate diagnostic imaging modality of choice
• Transesophageal ECHO - excellent diagnostic imaging method but not readily available
• Ttransthoracic ECHO can image only the first 3-4crns of ascending aorta

Treatment
• Beta blockers (Labetaiol) - first line drugs to achieve rapid BP control
• Alt type A dissections Urgent surgical intervention
 VASCULAR TUMORS
Vascular ectasias
Nevus flarnrneus (birthmark) Port wine stain Spider telangiectasia
• Most common form • Special form of nevus • Blanch with pressure
• Regress spontaneously flammeus. • Most frequently associated
• Grow during childhood with hyperestrogenic states,
• Do not fade with time such as pregnancy or liver
• Lesions in the distribution of cirrhosis.
trigeminal nerve - associated
with Sturge-Weber
syndrome

Benign tumors
Capillary hemangioma Cavernous hemangioma
• Most common vascular tumor Strawberry • Usually in children
hemangioma • Involve deeper structures
• Not present at birth in 90% cases • Does not regress spontaneously
• Rapid growth in the first few months • Surgical removal needed
• Regresses spontaneously by 7 years of age

Borderline tumors
KAPOSI SARCOMA (KS)
• Caused by Human Herpes virus 8 (HHV-8) or KS associated herpesvirus (KSHV)
• Lesions most commonly present as raised macules on the skin
• Lesions are characterized by the proliferation of spindle cells
• KS is rare in paediatric AIDS
• Incidence is more when AIDS is acquired by sexual route

Chronic, Classic or European Lymphadenopathic / Transplant associated KS AIDS associated (epidemic) KS

KS African/Endemic KS
Not associated with HIV Not associated with HIV Not associated with MC HIV related malignancy
↑. risk in homosexuals Age < 40 years HIV Male homosexuals
Skin lesions in extremities Lymphadenopathy Aggressive - nodal, With the use of HAART
Locally persistent, remain Visceral involvement mucosal and visceral incidence decreased
localized and asymptomatic Extremely aggressive involvement Gut involvement and early
Sparse skin lesions No cutaneous lesions dissemination

Treatment
Single/limited number of lesions Extensive lesions
• Radiation Initial therapy: IFNα (if CD4+ Tcetls > 150/μL) & Liposomal daunorubicin
• Intralesional vinblastine Subsequent therapy: liposomal doxorubicin and pactitaxel
• Cryotherapy Radiotherapy

Malignant tumors
Hemangiopericytoma
• Most commonly in pelvic retroperitoneum and thighs
• Capillaries are arranged in Fish-hook pattern
• Silver stain used for diagnosis

Angiosarcoma (Hemangiosarcoma or Malignant Hemangioendothelioma)

• Most often involves skin, soft tissue, breast, and liver
• Hepatic angiosarcoma is associated with carcinogenic exposures (arsenic, Thorotrast, polyvinyl chloride)
• Angiosarcomas are locally invasive and can readily metastasize to lungs
 HEART

Aging changes in heart

Chambers Valves Aorta
• Increased LA cavity size • Calcification of MV and AV • Dilated ascending aorta with
• Decreased LV cavity size • Buckling of mitral leaflets rightward shift
• Sigmoid-shaped ventricular toward the left atrium • Elongated (tortuous) thoracic
septum • Lambl excrescences – small aorta
filiform processes • Sinotubular junction calcific
(organization of small deposits
thrombi) form on the closure • Elastic fragmentation and
tines of AV and MV collagen accumulation

MYOCARDIAL INFARCTION
• Subendocardial MI: ischemic necrosis limited to 1 /3rd of ventricular wall thickness due to incomplete
coronary occlusion
• Transmural MI: ischemic necrosis of full thickness of ventricular wall in complete coronary occlusion
• Earliest changes seen in electron microscopy (1/2 - 4 hours): Sarcolemmal disruption; mitochondrial
amorphous densities
• In infarcts < 12 hours old, the area of necrosis can be diagnosed by immersion of tissue slices in a solution of
tri-phenyltetrazolium chloride (infarcted area - unstained pale zone)
• If infarction is modified by reperfusion, the characteristic microscopic feature - necrosis with contraction
band

Frequency of occlusion of coronary arteries

• Left anterior descending artery (40-50%)
• Right coronary artery (30-40%)
• Left circumflex coronary artery (15-20%)

Time of onset of key events in ischemic cardiac myocytes

Feature Time
Onset of ATP depletion Seconds
Loss of contractility < 2 min
ATP reduced To 50% of normal 10 min
To 10% of normal 40 min
Irreversible cell injury 20 - 40 min
Microvascular injury > 1 hour

Evolution of morphological changes in MI

Time Light microscopic change
1/2 - 4 hr Waviness of fibers at border (earliest change)
4 - 12 hrs Beginning coagulation necrosis
Myocyte vacuolization or myocytolysis
12 - 24 hrs Ongoing coagulation necrosis
Marginal contraction band necrosis
Beginning neutrophilic infiltrate
1 - 3 days Coagulation necrosis
Interstitial neutrophilic infiltrate
3 - 7 days Beginning disintegration of dead myofibers
Dying neutrophils
Beginning of phagocytosis of dead cells at infarct border by macrophages
7 - 10 days Ongoing phagocytosis
Granulation tissue at margins
 10 - 14 days Well established granulation tissue with
New blood vessels and collagen deposition
2 - 8 weeks Increased collaged deposition
Decreased cellularity
> 2 months Dense collagenous scar

Morphology in Rheumatic Heart Disease

• Aschoff bodies are the most distinctive lesion in acute RF
• Consists of eosinophitic collagen surrounded by T cells, plasma cells and plump macrophages called
Anitschkow cells or caterpillar cells (pathognomonic for RF)
• Aschoff bodies may be found in pericardium, myocardium or endocardium
• Bread and butter pericarditis
• MacCallum plaques are sub endocardial lesions usually seen in left atrium
• The cardinal changes in the mitral valve - leaflet thickening, commissural fusion and shortening, thickening
and fusion of tendinous cords
• Fibrous thickening across the valvular commisures and calcification causes fish-mouth or buttonhole stenosis
• Small vegetations (1-2mm) along the lines of closure - verrucae

Salient features of different types of endocarditis

Rheumatic fever NBTE (Marantic) Libman Sacks' (SLE) IE
• Small warty • Small masses of • Small warty vegetations • Large, bulky
vegetations fibrin & platelets • Embolization uncommon vegetations
• Friable (< NBTE) • Friable • Undersurfaces of AV valves, • Most friable (max
• Along the line of • Along the lines of valvular endocardium, chords chance to
closure closure or cusps or mural endocardium of atria embolize)
• Sterile • Sterile or ventricles • Valve cusps; can
• Non-destructive • Non destructive • Sterile extend to chordate
• Destructive tendinae
• Not sterile
• Destructive

 IE: vegetations can erode into the underlying myocardium and produce ring abscess
 NBTE is seen in: Hypercoagulable states like cancer (mucinous adeno carcinoma of pancreas, AML M3, burns,
hyperestrogenic states, sepsis), endocardial trauma (due to indwelling catheter)

Carcinoid heart disease

• Cardiac lesions do not typically occur until there is a massive hepatic metastatic burden
• Endocardium and valves of the right heart are primarily affected

Cardiac tumors
• Most common - metastatic tumors
• Most common metastatic tumors involving heart - carcinomas of lung and breast, melanomas, leukemias,
lymphomas

CARDIAC MYXOMAS
• Most common primary tumor of heart in adult (in children - Rhabdomyoma)
• Most commonly seen in left atrium
• More common in females
• Fossa ovalis in the atrial septum is the most favored site of origin
• Histology - lepidic cells
• Clinical feature: ball valve obstruction, embolization

Sporadic myxomas Familial myxomas

• >90% myxomas • Younger age
 • Old age • Bilateral and multiple
• Solitary • Carney syndrome: myxoma, spotty pigmentation, endocrinopathy

Rhabdomyoma
• Most common primary tumor of pediatric heart
• Histology: spider cells

 Bioptome - device used to obtain endomyocardial biopsy

 XI. GASTROINTESTINAL TRACT & LIVER
NON NEOPLASTIC POLYPS
Hyperplastic polyps Inflammatory polyps Hamartomatous polyps
• MC in the left colon • A part of the solitary rectal • Juvenile polyps
• Discovered in 6th and 7th • ulcer syndrome • Peutz-Jeghers syndrome
decades • Cowden syndrome
• No malignant potential • Cronkhite-Canada syndrome

NEOPLASTIC POLYPS
Tubular adenomas Villous adenomas
• 90% in colon • Rectum and rectosigmoid
• Lesions have dysplastic epithelium • Sessile, cauliflower-like masses
• Cancer is rare in tubular adenomas < 1cm • Cancer risk high in sessile villous adenomas > 4cm
• Cancer risk 1-3% • Cancer risk 40%

HAMARTOMATOUS POLYPOSIS SYNDROME

Cowden syndrome (AD) Peutz-Jeghers syndrome
• Mutation of PTEN gene • Autosomal dominant
• Multiple hamartomas (not pr emalignant) of organs • Median age of presentation - 11 years
derived from all the 3 germinal layers • STK11 mutations
• Lipomas, leiomyomas, hema giomas • Polyps throughout GIT (mc in SI)
• Benign skin tumors (trichilem mamas, papillomatous • Mucocutaneous hyperpigmentation -
plaques, acral keratoses, pigm ented macules on glans lips, nostrils, buccal mucosa, palmar
penis) surfaces of the hands, genitalia, and
• Macrocephaly perianal region
• No increased risk of GI malign ancy • GI adenocarcinoma
• Risk of breast ca, follicular th yroid ca and endometrial ca • Risk of intussusception
• CNS: Dysplastic cerebellar ga gliocytoma (Lhermitte- • Risk of Ca colon, pancreas, breast, lung,
• Duclos disease), meningioma, astrocytoma, ovary, uterus, testes, thyroid
ganglioneuromas

 Bannayan-Ruvalcaba-Riley syndrome: similar to Cowden; addl features - mental deficiency, developmental

delays, less incidence of neoplasia
Juvenile polyps Cronkhite-Canada syndrome
• Mostly in children < 5 years • Non hereditary disorder
• Most common site - Rectum • > 50 years
• Sporadic cases - solitary polyps • GI hamartomas
• Autosomal dominant syndrome: 3-10 polyps • Ectodermal anomalies like nail atrophy,
• Can undergo malignant transformation skin pigmentation and alopecia
• Most common mutation - SMAD4

FAMILIAL POLYPOSIS SYNDROMES

FAMILIAL ADENOMATOIJS POLYPOSIS(FAP) SYNDROME - 4 types
• Mutations in APC gene on chromosome 5
• Autosomal dominant
• 100% risk of cancer
• 50% have congenital hypertrophy of Retinal pigment epithelium
Classic FAP syndrome Gardner syndrome
• Typically 500-2500 colonic adenomas • Intestinal polyps
• Minimum100 needed for diagnosis • Multiple osteomas(mandible, skull, long bones)
• Colonic cancer before 30 years • Epidermal cysts, Retroperitoneal fibrosis,
 • Cancer prevention: early detection and Desmoid tumor
prophylactic colectomy in siblings & first degree • Risk of duodenal, thyroid and Ampullary cancer
relatives at risk • Dental abnormalities
• CNS: Medulloblastoma, glioblastoma,
Attenuated FAP syndrome craniopharyngioma
• Fewer polyps
• Mostly located in proximal colon Turcot syndrome
• Cancer develops > 50 years • Colonic polyps
• Risk of cancer 50% • CNS tumors (APC mutation - medulloblastomas

Screening policy
• Polyps are generally visible on sigmoidoscopy by the age of 15 years and always visible by 30 years
• At risk members of the family should be examined by the age of 10-12 years, repeated every year
• If there are no polyps at 20 years, the 5 yearly examination till 50 years

HEREDITARY NON POLYPOSIS COLORECTAL CANCER (HNPCC) (LYNCH SYNDROME)

• Increased risk of colorectal cancer at younger age and often located in the right colon
• Extraintestinal cancer, particularly endometrial cancer
• The hallmark of HNPCC is mutations in DNA repair genes leading to microsatellite instability
• Mutations in MSH2, MLI-11. genes
• Patients with HNPCC are subjected to regular (every one to two years) colonoscopic surveillance

Amsterdam II criteria for HNPCC diagnosis

• Three or more family members with an HNPCC-related cancer (colorectal, endometrial, small bowel, ureter,
renal pelvis), one of whom is a first-degree relative of the other two
• Two successive affected generations
• At least one colorectal cancer diagnosed before the age of 50 years
• FAP excluded
• Tumours verified by pathological examination

LIVER
Acute liver failure: Acute liver illness associated with encephalopathy and coagulopathy that occurs within 26 weeks
of the initial liver injury in the absence of pre-existing liver disease.

Acute viral hepatitis Chronic viral hepatitis

• Portal inflammation • Defining histologic feature - mononuclear portal infiltration
minimal or absent • Interface hepatitis
• Spotty necrosis or • Chronic hepatitis B - ground glass hepatitis
lobular hepatitis • Fibrosis after many years of slowly accumulating parenchymal injury

AUTOIMMUNE HEPATITIS
• Female predominance
• Associated with HLA-DRB1

Morphology
• Scarring occurs early
• Severe necroinflammatory activity - extensive interface hepatitis or foci of confluent (perivenular or bridging
necrosis) or parenchymal collapse
• Plasma cell predominance in the mononuclear inflammatory infiltrates
• Hepatocyte "rosettes" in areas of marked activity

Type 1 Type 2
 • Middle aged to older individuals • Children and teens
• Antinuclear (ANA) antibodies • Anti-liver kidney microsome-1 (anti-LKM-1)
• Anti-smooth muscle actin (SMA) antibodies antibodies (directed against CYP2D6)
• Anti soluble liver antigen/liver-pancreas • Anti-liver cytosol-1 (ACL-1) antibodies
antigen (anti-SLA/LP) antibodies
• Anti-mitochondrial (AMA) antibodies

Intrahepatic biliary tract disease

Primary biliary cirrhosis Primary Sclerosing cholangitis
Median age 50 years Median age 30 years
90% female 70% male
Associated conditions
• Inflammatory bowel disease (UC)
• Autoimmune: Sjogren syndrome (mc), Scleroderma,
• Pancreatitis
• Thyroid disease, celiac disease
• Retroperitoneal fibrosis
• Infection: Novosphingobium aromaticivorans,
• Pseudotumor of orbit
• Chiamydophila pneumoniae
• HLA-B8, HLA-DR3 or HLA-DR4
• HLA DRB1 08 and DQB1.
• Fatigue - most prominent symptom
• Pruritis - most common initial complaint;
• Fatigue, pruritus, steatorrhea, fat-
• Jaundice (late sign), hepatomegaly, splenomegaly, ascites
soluble vitamin 1,
and edema
• Severity of pruritus does not correlate
• Hyperpigmentation, xanthomas, xanthelasmas,
with the severity of the disease
arthropathy
• Risk factor for Cholangiocarcinoma
• Orthostatic hypotension, cognitive dysfunction
• ↑ risk of developing hepatocellular carcinoma
• ↑ Y-glutamyl transpeptidase and ALP
• ↑ Serum cholesterol • Elevated ALP
• IgM - typically increased • p-ANCA is positive in about 65%
• Anti-mitochondrial antibodies positive - 90% • Hypergammaglobulinemia
• ANA and ANCA positive
Radiology: Normal • Strictures and beading of large bile
ducts
• Pruning of smaller ducts
• Chronic non suppurative, inflammatory destruction of
small and medium sized intrahepatic bile ducts
• Inflammatory destruction of
• Mallory-Denk bodies
extrahepatic and large intrahepatic
Histologic staging:
ducts
I. Portal inflammation with non caseating granulomas
• Periductal portal tract fibrosis (onion
II. Bile duct proliferation (Florid duct lesions - diagnostic) and
skin fibrosis)
periportal inflammation
• Segmental destruction of portal tracts
III. Interlobular fibrous septa
IV. Cirrhosis
Treatment • For pruritis - cholestyramine, opioids,
• For pruritis - cholestyramine, opioids, Ondansetron Ondansetron
• Ursodeoxycholic acid • Ursodeoxycholic acid not effective
Definitive treatment: Liver transplantation

Focal nodular hyperplasia

• Young adult females
• Long term use of anabolic hormones/contraceptives
• Central gray white, depressed stellate scar from which fibrous septa radiate to the periphery

Nodular regenerative hyperplasia

 • Affects entire liver, with roughly spherical nodules but no fibrosis
• Development of portal hypertension
• Most common association - rheumatoid arthritis

DRUG or TOXIN INDUCED HEPATIC INJURY

Cholestasis without Cholestatic hepatitis Hepatocellular necrosis Granulomas
inflammation
• Contraceptives • Cotrimoxaole • Methyl dopa • Sulphonamides
• Anabolic steroids • Amoxy-clav • Phenytoin • Amiodarone
• Erythromycin • Clindamycin • Acetaminophen • lsoniazid
• Ezetemibe • Phenothiazines • Halothane • Allopurinol
• HAART • Statins • Isoniazid • Quinidine
• Clopidrogel • Azathioprine • Diltiazem
• Carbamazine
• Phenylbutazone

Centrilobular necrosis Diffuse necrosis Acute & chronic hepatitis

• Bromobenzene • Halothane • Halothane • Carbamazine
• CCI4, chloroform • Isoniazid • Flutamide • Valproic acid
• Acetaminphen • Acetaminophen • Methyl dopa • Phenytoin
• Halothane • Methyldopa • Isoniazid • Ibuprofen
• Rifampicin • Amantia phalloides • Rifampicin • Diclofenac
• Shock, CCF • Typhoid, brucellosis • Nitrofurantoin • Nifedipine
• Ischemic injury • Herpes, Tularemia • Azoles • Atomoxetine

Microvesicular fatty change Macrovesicular fatty change Periportal fibrosis

• Valproate, Tetracyclines • Ethanol • Methotrexate
• Ethanol, HAART • Methotrexate • Cystic fibrosis
• Aspirin (Reye's syndrome) • Amiodarone • Hereditary
• Acute fatty liver of • Diabetes hemochromatosis
pregnancy • Dysbetalipoproteinemia • Allograft rejection
• Yellow phosphorous • Inflammatory bowel
• Wolman's disease disease
• Chronic viral hepatitis • PEM, starvation

• The most common hepatotoxin causing acute liver failure - acetaminophen

• The most common hepatotoxin causing chronic liver disease - alcohol
• Periportal necrosis is seen in eclampsia, PEM, phosphorus
• Perivenular fibrosis - alcohol
• Midzonal necrosis - viral hepatitis, yellow fever
• Steatohepatitis with Mallory-Denk bodies - Ethanol, Amiodarone

Alcoholic liver disease

Hepatic steatosis Alcoholic Alcoholic cirrhosis
• Moderate intake - • Ballooning of hepatocytes • Hobnail appearance of
microvesicular fatty change • Mallory denk bodies surface of liver
• Chronic intake - (accumulation of cytokeratin • Laennec cirrhosis
macrovesicular fatty change intermediate filaments)
• Reversible if there is Alcoholic steatofibrosis -
abstinence from alcohol at chicken wire fence pattern
this stage
ACUTE HEPATITIS CHRONIC HEPATITIS
• Ballooning degeneration of hepatocytes • Interface hepatitis, Bridging necrosis
• Cholestasis • Steatosis
• Bridging necrosis of hepatocytes • Periportal fibrosis and bridging fibrosis) - hallmark of
• Kupffer cell hypertrophy & hyperplasia irreversible damage
• Interface hepatitis • Cirrhosis
• Councilman or apoptotic bodies • Ground glass appearance of hepatocytes

NON-ALCOHOLIC FATTY LIVER DISEASE

• In persons who are not heavy alcoholics
• Associated with Obesity, Dyslipidemia, Hyperinsulinemia, Insulin resistance
• Most common cause of Cryptogenic cirrhosis
• Diagnosed by liver biopsy

CIRRHOSIS
• Central pathogenic processes

Death of hepatocytes

ECM deposition

Vascular reorganization
• Bridging fibrous septa (fibrosis is the key feature of progressive liver damage)
• Mechanism of fibrosis: proliferation of stellate cells and their activation into highly fibrogenic cells -
myofibroblasts, fibrocytes
• Parenchymal nodules (hepatocyte regeneration and scarring)
• Disruption of architecture of entire liver
• Type I and III collagen in the space of Disse (In normal liver Type I and III collagen - portal tracts; Type IV
collagen - space of Disse)
• Capillarization of sinusoids

NON CIRRHOTIC PORTAL FIBROSIS/ IDIOPATHIC PORTAL HYPERTENSION

Morphology
• Moderate portal fibrosis without cirrhosis
• Intimal fibroelastosis of medium sized portal veins (Obliterative portovenopathy of liver)
• Portal fibrosis (Not bridging fibrosis)
• Lymphocytic infiltration

Clinical features
• Male preponderance; 3rd or 4th decade
• MC symptom - GI bleeding
• Massive splenomegaly
• LFT - normal

Macronodular (< 0.3 cm) cirrhosis Macronodular (> 0.3 cm) cirrhosis Both
• Secondary biliary cirrhosis • Post necrotic • Alcoholism
• Hemochromatosis • Post viral • Tyrosinemia
• Laennec cirrhosis(alcoholism) • Wilson's disease • α1antitrypsin
• Indian childhood cirrhosis • Alcoholic liver disease- late stages deficiency

• Budd-Chiari syndrome

BENIGN TUMORS
• Hemangioma - MC liver tumor
• Cavernous hemangioma - MC benign lesion of liver

Hepatic adenomas
HNF1-α Inactivated hepatocellular β-Catenin Activated Hepatocellular Inflammatory hepatocellular
adenomas Adenomas adenomas
• No risk of malignant • High risk of malignant • Activating mutations in
transformation transformation gp130
• Heterozygous germ line • Resection even when • Found in both men and
mutations - MODY-3 asymptomatic women
(maturity onset diabetes of • Associated with OCP and • Associated with nonalcoholic
young) anabolic steroid fatty liver disease
• Mostly in women • Found in men and women • Small but definite risk of
• OCPs are implicated malignant transformation
• Liver fatty acid binding • Resected even when
protein (LFABP)- absent asymptomatic

MALIGNANT TUMORS
• Hepatoblastoma

MC liver tumor of young childhood

Types: epithelial type, mixed epithelial and mesenchymal type

Originate from immature liver precursor cells

Morphology - proliferating hepatoblasts (not hepatocytes)

Activation of WNT/B-catenin signaling pathway

Associated with FAP syndrome and Beckwith-Wiedmann syndrome

Not associated with cirrhosis

Treatment: chemotherapy and complete surgical excision D Fatal within few years if not treated
• Angiosarcoma - previous exposure to vinyl chloride or Thorotrast

Alagille syndrome
• Liver normal
• Portal and bile ducts completely absent
• Mutations in Jagged 1 gene on chromosome 20

Banti syndrome
• Subclinical obstruction of portal vein (neonatal umbilical sepsis or umbilical vein catheterization)
• Presents as variceal bleeding and ascites years later

Stellate cells
• Under normal conditions stores vitamin A
• During inflammation transformed into myofibroblasts and are the major sources of collagen
• Principal cell type involved in scar deposition

Extrahepatic manifestations of Hepatitis B virus

• Nephrotic syndrome
• PAN
• Essential mixed cryoglobulinemia
• Lichen planus
• Sjogren syndrome

Mallory-Denk bodies Ballooning degeneration Piecemeal necrosis

Characteristically seen in: Alcoholic liver disease
• 1° biliary cirrhosis • Focal nodular • Acute viral • α-1antitrypsin ↓
• Wilson disease hyperplasia hepatitis • 1o biliary cirrhosis
• Hepatocellular • Indian childhood • Alcoholic hepatitis • Chronic hepatitis
tumors cirrhosis • Drug induced
• Non-alcoholic fatty • Chronic cholestatic
liver disease syndromes
• Bileduct obstruction
• Von Meyenburg complexes - bite duct micro-hamartomas
• Caroli disease - biliary cysts + ascending cholangitis
• Nut meg liver - CVC liver
• Infarct of Zahn - acute thrombosis of intrahepatic portal vein radical
• Vanishing bile duct syndrome - Chronic rejection of transplanted liver
• Fatty change is not seen in Indian childhood cirrhosis
• Jaundice is not seen in Reye's syndrome and hepatocellular carcinoma
 XII. KIDNEY & URINARY BLADDER
NEPHROTIC SYNDROME NEPHRITIC SYNDROME
• Proteinuria (>3.5g/day) • Hematuria with RBC casts (dysmorphic RBCs)
• Hypoalbuminemia ft Hypoproteinemia • Proteinuria (1-2g/day, nonselective)
• Peripheral edema - most likely due to sodium • Hypertension (sodium retention resulting from acute
retention decrease in GFR)
• Generalized edema • Oliguria
• Hyperlipidemia and lipiduria • Edema
• Hypertension/hypotension • Azotemia (Rise in serum creatinine, BUN, low GFR)
• Hypercoagulability
• Microscopic hematuria
Morphology Morphology
• Injury to podocytes • Inflammation of the glomeruli
• Changed architecture - scarring, deposition of • Reactive cell proliferation
matrix or other elements • Breaks in GBM
• Crescent formation

Predominant nephrotic syndrome Predominant nephritic syndrome

• Minimal change disease • Post streptococcal glomerulonephritis
• Focal segmental glomerulosclerosis • Subacute bacterial endocarditis
• Membranous nephropathy • Membrano proliferative GN
• Amyloidosis(AL and AA) • Mesangioproliferative GN
• Diabetic nephropathy • ANCA-Small vessel vasculitis
• Fabry's disease • Anti-GBM disease
• Fibrillary immunotactoid disease • IgA nephropathy
• Light chain deposition disease • Henoch Schonlein purpura
• Cryoglobulinemia
• Lupus nephritis

Antibody mediated glomerular injury - in-situ immune complex deposition

Fixed intrinsic tissue antigens Extrinsic planted antigens
• NC1 domain of type IV collagen antigen (anti- • Exogenous (infectious agents, drugs)
GBM nephritis) • Endogenous (DNA, nuclear proteins,
• M-type phospholipase A2 receptor - PLA2R immunoglobulins, immune complexes, IgA)
antigen (membranous glomerulopathy)
• Mesangial antigens

NEPHRITIC SPECTRUM GLOMERULAR DISEASES

ACUTE PROLIFERATIVE (POST STREPTOCOCCAL) GLOMERULONEPHRITIS
• Usually appears 1 - 4 weeks after Group A B-hemolytic Streptococcal pharyngitis (90% caused by M types 1,
4, 12) or
• 2 - 6 weeks following impetigo (M types 2, 47, 49. 55, 57, 60)
• Caused by immune complexes containing streptococcal antigens and antibodies - formed in situ
• Occurs commonly in children between 6-10 years of age, but adults can also be affected
• Streptococcal pyogenic exotoxin B (SpeB) - principal antigenic determinant

Morphology
• The classic diagnostic picture - enlarged, hypercellular glomeruli
• Influx (exudation) of leukocytes
• Electron microscopic findings are discrete, amorphous, electron dense deposits on the epithelial side of the
membrane (granular subepithelia! humps)

Clinical features
 • Hematuria (smoky or cocoa-colored urine), pyuria, RBC casts, oliguria
• Mild proteinuria (< 1gm/day) but 5% children and 20% adults have nephrotic range proteinuria
• Mild to moderate hypertension
• Periorbital edema
• Fever, malaise, anorexia ,flank pain (due to swelling of the renal capsule)

Lab features
• Elevation of ASO titers, anti-DNAse, anti-hyaluronidase antibodies
• Decrease in serum C3 concentration, normal C4
• Cryoglobulins in serum, Rheumatoid factor, p-ANCA are positive in a few

Treatment
• 95% children recover renal function with conservative therapy
• Fewer than 1% become severely oliguric, and develop a rapidly progressive form of glomerulonephritis
• Only 60% adults recover promptly

IgA NEPHROPATHY (BERGER DISEASE)

• Most common primary glomerular disease in the world
• Secondary - hepatic cirrhosis, celiac disease, and infections- HIV and cytomegalovirus
• Males, 2nd or 3rd decade
• Episodic gross hematuria 2-4 days following respiratory infection -mc presenting symptom
• Proteinuria (minimal to nephrotic range)
• Few cases present as persistent microscopic hematuria
• IgA(IgA1) deposition in mesangial region along with C3 and properdin
• Serum IgA elevated
• IgA deposition is seen in skin biopsies
• ACE inhibitors can be used in patients with proteinuria or declining renal function Small studies suggest that
tonsillectomy, steroid therapy, and fish oil are beneficial in few patients

RAPIDLY PROGRESSIVE (CRESCENTIC) GLOMERULONEPHRITIS

Type I (anti-GBM antibody) Type II (immune complex) Type III (pauci immune)
Idiopathic Post infectious ANCA associated Wegener
Good pasture syndrome SLE, HSP granulomatosis Microscopic
IgA nephropathy polyangitis
Immunofluorescence: Linear Granular pattern of staining No Ig or complement deposits
deposits of IgG and C3 along GBM

Morphology
• Distinct crescents (characteristic of RPGN)
• Crescents are composed of proliferating parietal epithelial cells and infiltrating leukocytes
• Fibrin strands are prominent between the cellular layers in crescents
• Subepithelial deposits
• Ruptures in GBM

Clinical course
• Hematuria with red cell casts in urine, moderate proteinuria, hypertension, edema

GOOD PASTURE SYNDROME

• Age group - teens and 20s
• Male preponderance (in contrast to other autoimmune diseases)
• Antibodies against non collagenous domain (NCI) of a3 chain of type IV collagen (basement
• membrane)
• Lungs

Necrotizing hemorrhagic interstitial pneumonitis

Necrosis of alveolar walls with intraalveolar hemorrhages

Hypertrophy of type II pneumocytes
• Kidney

Rapidly progressive glomerulonephritis

Crescents

Fibrin strands prominent between the cellular layers in the crescent

Linear deposition of Ig and complement

Ruptures in the glomerular basement membrane
• Plasmapheresis with steroids and cytotoxic drugs is the treatment of choice

NEPHROTIC SYNDROME
Causes of childhood Nephrotic syndrome
Idiopathic Secondary causes
• Minimal change disease • Drugs (nonsteroidal anti-inflammatory, penicillamine,
• Membranous nephropathy • heroin)
• Focal segmental glomerulosclerosis • Infections (malaria, syphilis, hepatitis B and C, HIV)
• Membranoproliferative • Malignant disease (carcinoma, lymphoma)
• glomerulonephritis • Immunologic: vasculitis syndrome, Castleman disease
• Crescentic glomerulonephritis
• IgA nephropathy

The most frequent systemic causes in all age groups

• Diabetes
• Amyloidosis
• SLE.

MEMBRANOUS NEPHROPATH
• MCC of nephrotic syndrome in adults

Causes
• Idiopathic
• Secondary

Drugs-penicillamine, captopril, gold, NSAIDs

Ca breast, lung, colon, melanoma

SLE, RA

Hepatitis B, C, syphilis, shistosomiasis, malaria

HLA DQA1

Morphology
• Diffuse thickening of glomerular capillary wall
• Electron dense subepithelial Ig deposits, appears as irregular spikes protruding from GBM
• Effacement of foot processes

Clinical features
• Non selective proteinuria
• Highest incidence of renal vein thrombosis, pulmonary embolism and DVT
• Bad prognosis - Male gender, older age, hypertension, persistent proteinuria
• Does not respond to corticosteroid therapy
• When immunosuppressive therapy fails - rituximab or a synthetic ACTH can be used

Loss of foot processes also seen in

• Membranous nephropathy
• Diabetic nephropathy

MINIMAL CHANGE DISEASE (LIPOID NEPHROSIS)

• Most common cause of nephrotic syndrome in children
 • Associated with Atopy (eczema, rhinitis),
• Increased incidence in Hodgkin disease
• Light microscopy - Glomeruli appear normal
• Electron microscopy - Diffuse effacement/loss of foot process of visceral epithelial cells (podocytes) -
reversible after steroid therapy
• Highly selective proteinuria
• Massive proteinuria
• Severe hypoalbuminemia
• Dramatic response to steroids
• Rare - hypertension, microscopic hematuria, atopy
• 95% children and 85% adult have complete remission following prednisone - first line therapy

FOCAL SEGMENTAL GLOMERULOSCLEROSIS

Causes
• Primary FSGS
• Associated diseases/conditions: HIV, heroin addiction, sickle cell disease, morbid obesity
• Secondary to IgA nephropathy, Hypertensive nephropathy, Reflux nephropathy
• Mutations in genes encoding - nephrin, podocin, α-actinin 4, and TRPC6 (transient receptor
• potential calcium channel-6)

Morphology
• Focal epithelial damage is the hallmark of FSGS
• Changes most prominent in the glomeruli at corticomedullary junction
• Sclerosis of some glomeruli (Focal)
• Electron microscopy - diffuse effacement of foot processes
• IgM, C3 deposition in mesangium and sclerotic areas

Clinical features
• Higher incidence of hematuria, reduced GFR and hypertension
• Non selective proteinuria
• Poor response to steroids
• Lipid droplets and foam cells in urine
• Primary FSGS - steroids or cyclosporine
• Secondary FSGS - no role for steroids

Variants of FSGS
• Cellular lesions with endocapillary hypercellularity and heavy proteinuria;
• Collapsingg glomerulopathy

D Global glomerular collapse

May be idiopathic or drug toxicities (e.g. pamidronate)

Most characteristic lesion of HIV-associated nephropathy

Proliferation and hypertrophy of glomerular visceral epithelial cells

Prominent tubular injury with formation of microcysts

Rapid decline in renal function

Poor prognosis
• Hilar stalk lesion
• Glomerular tip lesion - better prognosis.

HIV associated FSGS

• High frequency of collapsing variant (collapse and sclerosis of entire glomerular tuft)
• Striking focal cystic dilation of tubules
• Large no. of tubuloreticular inclusions in endothelial cells (not present in idiopathic FSGS)
• Poor prognosis

MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS
 • Mesangiocapillary or lobar glomerulonephritis
• Present with proteinuria, hematuria, pyuria
• Lobular appearance of glomeruli - proliferating mesangial cells and increased mesangial matrix
• Mesangial interposition of cellular elements - Double contour or tram track or split basement membrane
appearance
• Low serum C3

Type I (Most common) Type II (Dense deposit disease)

• Idiopathic • Idiopathic
• Subacute bacterial endocarditis • C3 nephritic factor associated
• SLE, Hepatitis C, Hepatitis B, HIV • Partial lipodystrophy
• Cancer: Lung, breast, ovary (germinal) • A part of C3 glomerulopathies
Subendothelial deposits Dense thickening of the GBM (intramembranous
deposits)
Immunofluorescence: deposits of C3, IgG, C1, C4 Deposits of C3 - mesangial rings, IgG absent Decreased
serum C3 but normal C1 and C4

Glomerular deposits
Subepithelial Sub endothelial Basement membrane Mesangium
Acute glomerulonephritis MPGN type I MPGN type II IgA nephropathy
Membranous GN SLE Membranous nephropathy HSP
Heyman nephritis Acute GN Good pasture
RPGN syndrome

C3 level in glomerulonephritis
Low C3 Normal C3
• Postinfectious GN • IgA nephropathy
• Lupus nephritis • HSP
• Cryoglobulinemia • Good Pasture syndrome
• MPGN type II • Wegener's granulomatosis
• Microscopic polyangitis -

ALPORT SYNDROME
• X-linked dominant
• Mutations of alpha 5 chain of collagen type IV (COL4A5)
• Organs involved: Kidney, Ear, Eye
• Hematuria with progression to renal failure
• Mild proteinuria
• Sensorineural deafness
• Lenticonus, dot and fleck retinopathy, Posterior cataracts
• Electron microscopy:

Thinning and splitting of GBM

Jo Basket weave appearance

Thin membrane disease

• Benign familial hematuria
• Thin BM (150 - 250 nm; Normal thickness: 300 - 400m)
• Defect in alpha-3 and alpha-4 chains of collagen type IV
• Excellent prognosis

DIABETIC NEPHROPATHY
• Single most common cause of chronic renal failure
• Gross: small shrunken kidneys
• Capillary basement membrane thickening - earliest abnormality
 • Diffuse mesangial sclerosis
• Nodular or intercapillary glomerulosclerosis or Kimmelstiel-Wilson nodules
• Hyalinizing arteriolar sclerosis affecting both afferent and efferent arterioles

LIGHT CHAIN CAST NEPHROPATHY

• Myeloma kidney
• Bence-Jones (light chain proteinuria) - is directly toxic to epithelial cells
• Bence-Jones proteins (K and A) combine with urinary glycoprotein (Tamm-Horsfall protein) to form large
casts that obstruct tubular lumens - Light chain cast nephropathy
• Amyloidosis of AL type - free light chains (usually A type) deposition in mesangium
• Light-chain deposition disease - (usually K type) deposition in mesangium

NEPHROSCLEROSIS
Benign nephrosclerosis Malignant nephrosclerosis
Benign hypertension Malignant hypertension
Diabetes mellitus
Old age -
Leather grain appearance of kidney Flea bitten appearance
Hyaline arteriosclerosis Hyperplastic arteriolitis (onion skinning)
Fibroelastic hyperplasia of arterioles Necrotizing glomerulitis
Fibrinoid necrosis of arterioles
Mild proteinuria Heavy proteinuria

PAPILLARY NECROSIS
Diabetes mellitus Renal vein thrombosis Papillary necrosis in DM: all papillae at same stage of
NSAIDs Pyelonephritis injury
Sickle cell disease Obstructive uropathy Papillary necrosis in NSAID: various stages of necrosis,
Chronic alcoholism Cirrhosis calcification, fragmentation and sloughing

Contracted kidney Kidney size increased

• Chronic glomerulonephritis(bilateral) • Amyloidosis
• Benign nephrosclerosis(bilateral) • Polycystic kidney disease
• Chronic pyelonephritis • Diabetic nephropathy
• Renal artery stenosis • Acute Glomerulonephritis
• Radiation nephritis • Scleroderma

ANGIOMYOLIPOMA
• A benign neoplasm consisting of vessels, smooth muscle, and fat originating from perivascular epithelioid
cells.
• Angiomyolipomas are present in 25% to 50% of patients with tuberous sclerosis, a disease caused by loss-of-
function mutations in the TSCI or TSC2 tumor suppressor genes
• Susceptibility to spontaneous hemorrhage

RENAL CELL CARCINOMA

• More common in males
• Also called as Hypernephroma/ Grawitz tumor

Sporadic renal cancer - risk factors

• Smoking • Hypertension
• Acquired cystic kidney disease with • Unopposed estrogen therapy
• ESRD • Asbestos, petroleum products and heavy metals
• Tuberous sclerosis • VHL gene mutation
• Obesity
 Autosomal dominant familial cancers
Von Hippel-Lindau syndrome Hereditary leiomyomatosis & renal cell cancer syndrome
• VHL gene mutation • Mutations in FH gene
• Renal cysts • Cutaneous leiomyomata
• Bilateral or multiple renal cell • Uterine leiomyomata,
carcinomas • Aggressive papillary carcinoma
Hereditary papillary carcinoma Birt-Hogg-Dubt. syndrome
• Mutations in MET protooncogene • Mutations in BHD gene (expresses folliculin)
• Multiple bilateral tumors • Skin - fibrofolliculomas„ trichodiscomas, acrochordons
• Pulmonary - cysts or blebs
• Renal tumors - wide range of histologic subtypes.

CLEAR CELL CARCINOMA PAPILLARY CARCINOMA

• Most common type • Familial - trisomy 7
• Deletion in 3p (VHL gene) • Sporadic - trisomy 7, 16, 17, loss of Y, t (x;1) in children
• Both familial a sporadic (95%) • MET protooncogene
• Arise from proximal tubules • Arise from distal tubules
• Solitary, Unilateral • Multifocal and Bilateral
• Sharply defined margins • Psammoma bodies
• Within renal capsule • In dialysis associated cystic disease
• Invades renal vein

Chromophobe renal cancer Collecting (Betlini) duct cancer Xp11 translocation carcinoma
• Arise from I cells (intercalated ) • Highly atypical epithelium with • Young patients
• Multiple chromosome losses & hobnail pattern • Translocations of TFE3 gene
extreme hypodiploidy • Prominent fibrotic stroma

Clinical features
• Classic triad of RCC:

Flank pain

Palpable mass

Hematuria
• Characteristic - metastasize widely before giving rise to any local symptoms
• Most common site of metastasis is lungs followed by bones

Treatment
• < 4cm - partial nephrectomy
• > 4cm - radical nephrectomy

URINARY BLADDER
Malakoplakia
• MC bacterial infection E.coli
• Increased incidence in immunosuppressed and transplant recipients
• Michaelis-Gutmann bodies - deposition of Calcium in enlarged lysosomes present in macrophages
• Abundant epitheliod histiocytes (Von Hansenman histiocytes)

Hunner ulcer
• Hemorrhagic inflammation and fibrosis of the bladder wall
• Associated with SLE
• Mast cells are present

BLADDER CANCER
• Urothelial/Transitional cell cancer - most common type
• Squamous cell carcinoma (most prevalent form in Schistosomiasis endemic areas)
 • Adenocarcinoma (usually arise in the fundus of the bladder at the site of urachal remnant)

Risk factors
Transitional cell cancer Squamous cell cancer
• Smoking • Schistosomiasis (Bilharziasis)
• Chemical carcinogens: naphthylamine, • Chronic bladder infection
• benzidine, aniline • Irradiation
• Schistosomiasis (Bilharziasis) • Bladder diverticula
• Long term use of analgesics
• Long time Cyclophosphamide exposure
• Pelvic irradiation

Carcinoma in situ or Flat urothelial carcinoma - Pagetoid spread

Staging and treatment

• Superficial bladder cancers(does not invade the detrusor muscle)

pTa - no lamina propria invasion

pT1 - lamina propria invasion
• The most common site of superficial tumors are the trigone and the lateral walls of bladder

Clinical features
• Painless gross hematuria is the most common symptom
• Frequency, urgency and dysuria are common symptoms

Metastasis: Most common primary to metastasize to penis - bladder cancer

Investigations
• New tests: detection of antigens such as nuclear matrix proteins(NMP22) or mini-chromosome
maintenance (MCM) in urine, which may be able to detect new or recurrent tumors
• The most common radiological sign is a filling defect
• For staging contrast-CT
• MRI can demonstrate LN metastases and muscle invasion
• Cystourethroscopy is the mainstay of diagnosis

Treatment
• Superficial bladder cancers

Solitary papillary lesions, no CIS: endoscopic transurethral resection(TURT)

CIS, recurrent disease, T1 disease, > 40% bladder surface involvement: TURT followed by intravesical
therapy

Standard intravesical therapy: Bacille-Calmette-Guerin(BCG) 6 weekly instillations; followed by monthly
instillations for 1 year

Jo Other agents: mitomycin C, interferon, gemcitabine

For persistent disease after BCG, immediate cystectomy
• Muscle invasive cancers(pT2-pT3): radical cystectomy with pelvic lymphadenectomy; neoadjuvant
chemotherapy (M-VAC: cisplatin, methotrexate, doxorubicin and vinblastine or GC: gemcitabine and
cisplatin)

 Beaded appearance of renal artery - fibromuscular hyperplasia

 Uraplakins - proteins present in umbrella cells on the surface of transitional epithelium
 Brunn nests - transitional cell nests that grows down the mucosa and lamina propria of bladder
 Hunner's ulcer - interstitial cystitis
 Verruca plana - HPV
 Verruca peronee Bartonella bacilliformis
 Glitter cell - pyelonephritis (Gitter cell - CNS microglial cell)
 Thyroidization of tubules - chronic pyelonephritis
 XIII. HEAD & NECK, SOFT TISSUES, SKELETAL MUSCLES, CNS
ODONTOGENIC CYSTS
Inflammatory Developmental
• Periapical cyst • Dentigerous cyst
• Residual cyst • Odontogenic keratocyst
• Paradental cyst • Gingival cyst of new born and adult
• Eruption cyst
• Lateral periodontal cyst
• Glandular odontogenic cyst
• Gorlin cyst (calcifying epithelial odontogenic cyst)

Dentigerous cyst
• Originates around the crown of an unerupted tooth
• Most often associated with impacted third molar (wisdom) teeth
• Histologically lined by a thin layer of stratified squamous epithelium
• Dense chronic inflammatory infiltrate in the stroma
• Treatment: complete removal
• Rarely neoplastic transformation into Ameloblastoma or squamous cell carcinoma

Odontogenic keratocyst (OKC)

• Locally aggressive
• Mostly between 10 - 40 years
• Most common in males
• Most common site - posterior mandible
• Lined by parakeratinized or orthokeratinized stratified squamous epithelium with a prominent basal cell
layer and a corrugated appearance of the epithelial surface
• Treatment: complete removal
• Multiple OKCs occur in Nevoid basal cell carcinoma syndrome (Gorlin syndrome)

MacCune Albright syndrome

• Monoostotic or Polyostotic fibrous dysplasia (maxilla most commonly involved)
• Cafe au lait pigmentation with rough border (coast line of Maine)
• Precocious puberty (most common presentation)
• Involvement of facial bones usually presents as radiodense lesions, which may create a leonine appearance
(leontiasis osea)

Deep seated Fibromatosis (Desmoid tumors)

• Large infiltrating masses that recur after incomplete excision
• Rarely metastasize
• Histology: plump banal fibroblasts

Extra-abdominal Fibromatosis Abdominal Fibromatosis Intra-abdominal Fibromatosis

• Equal in men and women • Women • In Gardner syndrome
• Muscles of shoulder, chest • During or after pregnancy • Mesentery or pelvic walls
• wall, back and thigh • Anterior abdominal wall

SOFT TISSUE SARCOMAS

• The most common presentation is an asymptomatic mass
• Lymph node metastases more common (17%) in

Synovial sarcoma

Epithelioid sarcomas

Clear-cell sarcoma (melanoma of the soft parts)

Angiosarcoma

Rhabdomyosarcoma.
• Lymph node metastases in other cases - 5%
• Lungs - most common site of metastases; Exceptions

GIST - liver

Myxoid Liposarcoma - fatty tissues

Clear cell sarcoma - bones
• CNS metastases rare; except in alveolar soft part sarcoma
• Herring bone pattern - Fibrosarcoma
• Dirty finger pattern benign fibrous histiocytoma (dermatofibroma)
• Chicken wire pattern - chondroblastoma
• Cart-wheel or Pin-wheel or Storiform pattern

Malignant fibrous histiocytoma

Dermatofibrosarcoma protruberans

Fibrous cortical defect
• Palisaded pattern - Schwannomas
• Lipoblasts - Pleomorphic liposarcoma

 Lipoma - Most common benign soft tissue tumor

 Malignant fibrous histiocytoma - Most common soft tissue sarcoma
 Malignant fibrous histiocytoma - Most frequent soft tissue sarcoma following radiotherapy
 Embryonal rhabdomyosarcoma - Most common sarcoma in children
 Leiomyoma - Most common benign tumor in gastrointestinal tract (MC site of leiomyoma - Uterus)
 Leiomyosarcoma - Most common sarcoma of gastrointestinal tract and uterus

RHABDOMYOSARCOMA
• MC soft tissue sarcoma below 15 years
• MC non ocular orbital tumor in children
• Most often found in the head and neck (40%)
• Older children - lesions in extremity, alveolar type
• Associated with Li Fraumeni syndrome, neurofibromatosis and fetal alcohol syndrome R9
• Metastasize commonly to lung, bone marrow and bone
• Treatment: chemotherapy + radiotherapy + surgery

Embryonal Alveolar Sarcoma Botryoides

• Most common type • Early to middle • Variant of embryonal
• Children < 10 years adolescence rhabdomyosarcoma
• Genitourinary tract • Extremities, sinuses • Nasopharynx, Common bile
• Intermediate prognosis • Poorest prognosis duct, bladder, vagina
• Primitive spindle cells, strap • Chromosomal • Form cambium layer
cells, tennis racket cells translocations • Best prognosis
• (2;13 or 1;13)

Rhabdomyoma of heart
• Associated with tuberous sclerosis
• Most common site Left ventricle
• Histopathology - spider cells

SYNOVIAL SARCOMA
• < 10% are intra-articular
• Age group: 20 - 40
• Most common site - lower extremity (around knee and thigh)
• Characteristic translocation t(X;18)
• Common sites of metastases - lung, skeleton

Morphology
 • Keratin positive (usually keratin is positive in carcinomas)
• Epithelial membrane antigen positive
• Calcified concretions

LEIOMYOSARCOMA
• 10% to 20% of soft tissue sarcomas.
• Occur in adults
• Women more frequently affected than men
• Most common site - Uterus
• Most common non-uterine site: Retroperitoneum
• A particularly deadly form arises from the great vessels, especially the inferior vena cava.
• Leiomyosarcomas present as painless firm masses

Bone/Soft tissue tumor Translocation

Alveolar rhabdomyosarcoma t(2;13) t(1;13)
Alveolar soft part sarcoma t(X;17)
Clear cell sarcoma t(12;22)
Liposarcoma t(12;16)
Dermatofibrosarcoma protuberans t(17;22)
Desmoplastic small round cell tumor t(11;22)
Ewing's sarcoma t(11;22)
Synovial Sarcoma t(21;22)
t(X;18)
Nodular fascitis t(22;17)

FGFR-3 mutation FGFR-2 mutation

• Achondroplasia • Crouzon syndrome
• Hyperchondroplasia
• Thanatophoric dwarfism

SKELETAL MUSCLE
Type I fiber atrophy Type II fiber atrophy Atrophy of both
• Myotonic dystrophy • Disuse atrophy • Duchene muscular
• Congenital myopathies • Drug induced myopathies • dystrophy
• Myasthenia gravis

• Spinal muscular atrophy (Infantile motor neuron disease) - panfascicular atrophy

Mitochondria' myopathies
• Ragged red fibres
• Parking lot inclusions
• Gomori trichrome staining

Inflammatory myopathies
Dermatomyositis
Damage to small blood vessels contributes to muscle injury
• Anti-Mi2 antibodies - strong association with Gottron papules and heliotrope rash
• Anti-Jol antibodies - interstitial lung disease, nonerosive arthritis, and skin rash - mechanic's hands
• Anti-P155/P140 antibodies - paraneoplastic and juvenile dermatomyositis
• Grotton lesion (scaling erythematous eruptions over knuckles, elbows, knees)
• Heliotrope rash (discoloration of upper eyelids associated with periorbital edema)
• Proximal muscles involved first
• Dysphagia - involvement of oropharyngeal and esophageal muscles
• Perifascicular atrophy
• Infiltrate rich in CD4+ T-helper cells and deposition of C5b-9 in capillary vessels
Polymyositis Inclusion body myositis
• No cutaneous involvement • Typically affects patients older than 50 years
• Symmetric proximal muscle involvement • First involves distal muscles
• CD8+ T cells - prominent part of the inflammatory • Rimmed vacuoles
infiltrate

Patterns of muscle weakness

Proximal > distal Ptosis, Extraocular muscles Dropped head
• Polymyositis • Oculo-pharyngeat muscular • Myasthenia gravis
• Dermatomyositis dystrophy • Polymyositis
• Muscular dystrophies • Mitochondrial myopathy • Amyotrophic lateral sclerosis
• Mitochondrial myopathies • Myotubular myopathy • Hyperparathyroidism
• Metabolic myopathies
• Toxic myopathies
• Endocrine myopathies

• Facial and scapular winging: Facioscapulohumeral dystrophy

• Facial, distal, quadriceps; handgrip Myotonia: Myotonic muscular dystrophy
• Proximal, distal & quadriceps: Inclusion body myositis

CONGENITAL MYOPATHIES
Disease & Gene Clinical & Pathologic findings
Central core disease Early-onset hypotonia and weakness; "floppy infant"; scoliosis, hip
Mutation: Ryanodine receptor-1 dislocation, or foot deformities; Malignant hyperthermia
Nemaline myopathy Hypotonia at birth ("floppy infant")
Aggregates of spindle-shaped particles (nemaline rods);
Centronuclear myopathy Floppy infant
Poor prognosis in X-linked form ("myotubular myopathy")
Congenital fibre type disproportion Hypotonia, weakness, failure to thrive, facial and resp. weakness,
contractures

DUCHENNE (DMD) AND BECKER MUSCULAR DYSTROPHY (BMD)

• DMD is the most common hereditary neuromuscular disease
• BMD is a milder form of the same disease with Eater onset and slower progression

Genetics
• X-linked recessive(Xp21)
• The gene responsibie(DMD gene) produces a high molecular weight protein - Dystrophin
• Dystrophin is represented in skeletal and smooth muscles, brain, peripheral nerves

Morphology
• Segmental myofiber degeneration and regeneration associated with admixture of atrophic myofibers
• Muscle tissue is replaced by collagen and fat cells fatty replacement
 • Immunohistochemistry for dystrophin - absence of normal sarcolemmal staining pattern in DMD and
reduced staining in BMD

Clinical features
• Perinatal history and early developmental history are normal
• Early gross motor skills(rolling over, sitting and standing) are usually achieved at the appropriate ages
• Poor head control in infancy may be the first sign
• Weakness begins in the pelvic girdle muscles and then extends to the shoulder girdle
• Pseudohypertrophy(fatty infiltration) of calf muscles and wasting of thigh muscles is a classic feature, noted
around 5-6 years
• The next most common site of muscular hypertrophy is the tongue followed by forearm muscles
• Scoliosis is common
• Wheel chair dependency occurs before 12 years
• The function of distal muscles and extraocular muscles - usually well preserved
• Death occurs by 20 years most commonly due to pulmonary insufficiency and respiratory infections
• Gower sign - indicates weakness of pelvic girdle muscles
• Cardiomyopathy is a constant feature
• Intellectual impairment occurs in all patients, although only 20-30% have an IQ less than 70
• Acute gastric ditation(intestinal pseudo-obstruction)
• BMD - late onset, more slowly progressive, near normal life expectancy

Diagnosis
• Elevated CPK - 15000 to 35000 U/L or higher(normal < 160 IU/L); may ↓ in very advanced disease
• Muscle biopsy(vastus lateralis or gastronemius) is diagnostic
Treatment: Only drug useful in DMD- Prednisolone; But not useful in BMD

Myotonic Dystrophy
• Autosomal dominant
• Skeletal muscle weakness, cataract, endocrinopathy, cardiomyopathy

Emery-Dreifuss Muscular Dystrophy

• Mutations in genes that encode nuclear lamina proteins
• Triad of slowly progressive humeroperoneal weakness, cardiomyopathy with conduction defects, and early
contractures of the Achilles tendon, spine, and elbows

NEUROFIBROMATOSIS
Type 1(Von Recklinghausen disease) Type 2 (Acoustic neurofibromatosis)
• 50% have family history • NF 2 gene in Chr 22 that encodes Merlin
• NF 1 gene in Chr 17 that encodes Neurofibromin • Café-au-lait spots
• Café-au-lait spots • Lisch nodules not seen
• Lisch nodules(lris hamartoma) • Increased risk of
• Cutaneous, subcutaneous and plexiform • Bilateral acoustic schwannornas(most common)
(premalignant) neurofibromas • Meningioma, Astrocytoma, Ependymoma
• Pseudoarthrosis of the tibia • Nodular ingrowth of Schwann cells into the
• Increased risk of spinal cord (Schwannosis)
• Meningioma, Schwannoma, Astrocytoma • Proliferation of meningeal cells and blood vessels
• Optic nerve glioma that grows into the brain(Meningioangiomatosis)
• Pheochromocytoma • Microscopic collections of glial cells at abnormal
locations (glial harnartia) often in the cerebral
cortex

CNS
MACROGLIA (derived from neuroectoderm)
ASTROCYTES OLIGODENDROCYTES EPENDYMAL CELLS
 • Fibrous astrocytes in white mater • Myelin synthesis in CNS • Line the ventricular system
• Protoplasmic astrocytes in grey • Injured in acute • CMV produces extensive
mater demyetinating disorders ependymat injuries
• Contain Ghat fibrillary acidic protein (multiple sclerosis) and • Viral inclusions may be
(GFAP) • leukodystrophies seen
• Metabolic buffers, nutrient • Viral inclusions in PMLE
suppliers, electrical insulators, blood
brain barrier, repair & scaring

MICROGLIA
• Derived from bone marrow
• Scavenger cells of CNS
• Macrophage (Gitter cells)
• Respond to injury by proliferation, developing elongated nuctei(rod cells) in neurosyphilis

Alzheimer type II astrocyte (Grey matter astrocyte)

• Chronic liver disease
• Wilson disease
• Urea cycle disease
• Canavan disease
• Hyperammonemia
• ' Not seen in Atzheimer's disease

Bergmann gliosis
• Proliferation of astrocytes of cerebellum
• Seen in anoxic injury and conditions associated with death of Purkinje cells

Picks disease
• Wall nut brain
• Knife edge appearance of brain

Pelizaccus Merzbacher disease

• Tigroid appearance of cerebral hemisphere

Corticobasal degeneration
• Ballooned neurons (neuronal achromasia)
• Tufted astrocytes
• Coiled bodies

CNS TUMORS
Tumors of Neuroglia (Glioma) Tumors of neurons Primary intraparenchymal tumors
• Astrocytoma • Neuroblastoma • Hemangioblastoma
• Oligodendroglioma • Ganglioneuroblastoma • Primary CNS lymphoma
• Ependymoma • Ganglioneuroma • Germ cell tumors
• Choroid plexus papilloma
Tumors of meninges Nerve sheath tumors Poorly differentiated & Embryonal tumors
• Meningioma • Schwannoma • Medutloblastoma
• Meningeal sarcoma • Neurofibroma • PNET

Gliomas
• Most common primary brain tumors
• Tumors arising from neuroglia (more precisely neuroectodermal epithelial tissue)

Risk factors
 • Exposure to ionizing radiation (meningiomas, gliomas, and schwannomas)
• Immunosuppression (primary CNS lymphoma)

ASTROCYTOMA
Infiltrating astrocytoma
• 80% of adult primary brain tumors

LOW GRADE ASTROCYTOMA

Pilocytic astrocytoma (Grade I)
• Most common primary brain tumor in children
• Most common tumor of childhood
• Located in cerebellum
• Cerebellar astrocytoma is the MC brain tumor in children
• Hair like processes (GFAP positive); Rosenthal fibres; microcysts
• Complete excision is curative

Subependymal Giant cell astrocytoma

• Usually found in the ventricular wall of patients with tuberous sclerosis
• Often do not require intervention
• Can be treated with inhibitors of the mammalian target of rapamycin (mTOR).

Diffuse Astrocytoma (Grade II)

• Infiltrative tumors that usually present with seizures in young adults
• Temozolomide, an oral alkylating agent, can be helpful
• Transforms to a malignant astrocytoma in the majority of patients,

HIGH GRADE ASTROCYTOMA

Anaplastic Astrocytoma (Grade III)
• Present in the fourth and fifth decades of life

Glioblastoma/Glioblastoma multiforme (Grade IV)

• Most common cause of malignant primary brain tumors
• Patients usually present in the sixth and seventh decades of life
• Appear as ring-enhancing masses with central necrosis and surrounding edema
• Serpentine pattern necrosis
• Endothelial cell proliferation
• Pseudopalisading
• Glomeruloid body
• Treatment: Surgical excision + Radiotherapy + Temozolomide
• Bevacizumab, a VEGF monoclonal antibody, has activity in recurrent glioblastoma
• Poor prognosis

OLIGODENDROGLIONA
• Cerebral hemispheres
• Calcification seen in 90% tumors
• Microgemistocytes
• Better prognosis than astrocytomas
• Perinuclear clearing -giving rise to Fried-egg appearance
• Peri-neuronal satellitosis

EPENDYMOMA
• First two decades - arise from fourth ventricle
• Adults - spinal cord is the most common location
• Myxopapillary ependymomas - arise from filum terminale
 • Perivascular pseudorosettes
• Poor prognosis
• Spreads via CSF

Pleomorphic Xanthoastrocytoma
• Most often in the temporal lobe in children and young adults

MEDULLOBLASTOMA
• Most common primitive neuroectodermal tumor
• Most common malignant brain tumor of childhood
• Predominantly in children
• Exclusively in cerebellum
• Express Homer Wright rosettes and GFAP phenotypes
• Dissemination through CSF - common complication forming nodular masses at some distance from the
primary tumor e.g: cauda equina (drop metastases)
• Extremely radiosensitive tumor
• Poor prognosis

MENINGIOMA
• Most common primary brain tumor, accounting for approximately 35% of the total
• Most commonly located over the cerebral convexities, especially adjacent to the sagittal sinus
• Prior radiation therapy to the head and neck, typically decades earlier, is a risk factor
• The most common cytogenetic abnormality is loss of chromosome 22q
• Encapsulated tumor with a bosselated or polypoid appearance
• En plaque growth pattern tumor spreads in a sheetlike fashion along the dural surface
• Meningiomas have a relatively low risk of recurrence or aggressive growth(WHO grade 1/IV) - syncitiat,
fibroblastic, transitional, psammomatous, secretory, microcystic meningiomas
• WHO grade II/IV: Atypical, clear cell. and chordoid meningiomas
• WHO grade III/IV: Anaplastic, Papillary and Rhabdoid meningiomas
• Psammoma bodies seen
• Female predominance 3:2 in general; 10:1 for spinal meningiomas
• Tumors express progesterone receptors and rapidly grow during pregnancy

CRANIOPHARYNGIOMA
Adamantinomatous craniopharyngioma Papillary craniopharyngioma
• Children • Adults
• Lamellar keratin formation(wet keratin) • No keratin formation
• Cyst contain cholesterol rich, thick brownish • No cysts
• yellow fluid (like machinery oil) • No calcification
• Dystrophic calcification present • No peripheral palisading
• Peripheral palisading + • No spongy reticulum
• Generate spongy reticulum
• Brain invasion

• Suprasellar tumors derived from vestigial remnants of Rathke's pouch

• Bimodal age distribution: 5-15 years and after 65 years
• Children present with growth retardation, adults with visual disturbances
• Hypopituitarism and diabetes insipidus are other common features
• Encapsulated tumors
• Transsphenoidal surgical resection is the treatment of choice
• Good prognosis. Recurrence is rare. Tumors >5cm diameter have higher recurrence rate
• Malignant transformation is very rare and usually occurs postradiation

Genetic syndromes associated with primary brain tumors

Syndrome/ Inheritance Gene/Protein Associated Tumors
Mutation
Cowden's syndrome PTEN Dyspiastic cerebellar gangliocytoma (Lhermitte-
AD (ch10p23) Duclos disease), meningioma, astrocytoma
Breast, endometrial, thyroid cancer, trichilemmomas
Familial schwannomatosis INI1/SNF5 Schwannomas, gliomas
Sporadic/Hereditary (ch22q11)
Gardner's syndrome APC(ch5q21) Medultoblastoma, glioblastoma, craniopharyngioma
AD Familial polyposis, multiple osteomas, skin and soft
tissue tumors
Gorlin syndrome (Basal cell Patched 1 gene Medulloblastomas
nevus syndrome) AD (ch9q22.3) Basal cell carcinoma
Li-Fraumeni syndrome p53 Gliomas, medullobtastomas
AD (chi 7p13.1) Sarcomas, breast cancer, leukemias, others
Multiple Endocrine Neoplasia Menin Pituitary adenoma, malignant schwannomas
1 (Werner's syndrome) (ch11q13) Parathyroid and pancreatic islet cell tumors
AD
Neurofibromatosistype 1 (NF1) NF1/ Schwannomas, astrocytomas, optic nerve gliomas,
AD Neurofibromin meningiomas
(chl7q12-22) Neurofibromas, neurofibrosarcomas, others
Neurofibromatosis type 2 NF2/Merlin Bilateral vestibular schwannomas, astrocytomas, multiple
(NF2)AD (ch22q12) meningiomas, ependymomas
Tuberous sclerosis (TSC) TSC1 /TSC2 Subependymal giant cell astrocytoma,
(Bourneville's disease) AD (ch9q34/16) ependymomas, glioma, ganglioneuroma, hamartoma
Turcat's syndrome AD - APCa (ch5) Gliomas, medullobtastomas
AD/AR AR - hMLH1 Adenomatous colon polyps, adenocarcinoma
(ch3p21)
Von Hippel-Lindau (VHL) VHL gene Hemangiobtastomas
AD (ch3p25) Retinal angiomas, renal cell carcinoma,
pheochromocytoma, pancreatic tumors and cysts,
endolymphatic sac tumors of the middle ear

Metastatic tumors
• Brain metastases are three times more common than all primary brain tumors
• Five common primary sites are: Lung, Breast, Skin (melanoma), Kidney, GIT
• Lung cancer. - most common primary causing metastases in brain
• Breast cancer - most common primary causing metastases in leptomeninges
• Breast cancer - most common to cause epidural spinal cord compression
• Melanoma has the greatest propensity to metastasize to the brain
• Ovarian and Esophageal cancer - rarely metastasize to brain (HARRISON)
• Prostate carcinoma - rarely metastasize to brain (ROBBINS)
• Most metastases develop at the gray matter-white matter junction in the watershed distribution of the brain
• 85% of all metastases are supratentorial
• Prostate and breast cancer also have a propensity to metastasize to the dura
• Leptomeningeal metastases are common from hematologic malignancies. breast and lung cancers
• Spinal cord compression - in patients with prostate and breast cancer, tumors with a strong propensity to
metastasize to the axial skeleton
• Brain metastases are best visualized on MRl

SCHWANNOMA
• Well-circumscribed, encapsulated masses that abut the associated nerve without invading it
• Microscopy: Areas of dense and compact celtularity (Antoni A) alternating with loose acellular areas (Antoni
B)
• Antoni A areas shows palisaded nuclei - Verocoy bodies
• Schwann cells express 5-100 protein

 Agenesis of corpus callosum - bat wing deformity

 Joubert syndrome (hypoplasia of the cerebellar vermis with apparent elongation of the superior cerebellar
peduncles and an altered shape of the brainstem) - molar tooth sign
 Plaque jaune - Old traumatic lesions on the surface of the brain
 Syphilis - ghost vessels in cornea
 Hirano bodies - Alzheimer's disease
 Amphicytes - ataxia telangiectasia
 Lafora bodies - myoclonic epilepsy
 Lewy body in substantia nigra - Parkinson's disease
 Rosenthal fibres - long standing gliosis, Cerebellar pilocytic astrocytoma, Syringomylia, Craniopharyngioma
 Neuroborreliosis (Lyme disease) - organisms stained by Dieterle stain
 HSV 1 encephalitis - temporal lobe involvement
 Soap bubble appearance of brain - Cryotococcal infection
 Candle guttering appearance - Tuberous sclerosis
 Dandy-Walker malformation: hypoplasia/aplasia of cerebellar vermis, agenesis of corpus callosum
 Charcot-Bouchard aneurysms: weakening of the wall of cerebral artery due to lypohyalinosis caused by
hypertension