MECHANISM OF DISEASE

REVISION SESSION
Ashwin Santosh Kumar -
[email protected]
Cell Injury and Free Radicals

■ Cells can become injured in a ■ Free Radicals

numerous ways – Normally present in low concentration
– Hypoxia – Required for killing bacteria and cell
– Chemical agents and drugs signalling
– Infections – Cause damage when in abundance
– Immune-mediated processes ■ Types of Free Radicals
– Nutritional imbalance – OH- (hydroxyl ions) – most dangerous
– Genetic derangement – O2- (superoxide anion radical)
– Physical agents – H2O2 (hydrogen peroxide)
■ Depending on the severity and type – Reactive Oxygen Species (ROS)
of insults cells undergo, reversible or – Nitric Oxide (NO) – made my microphages,
irreversible injury can occur endothelia and neurones
Cell Injury – Light Microscopic Changes

■ Reversible Injury ■ Irreversible Changes

– Cell Swelling – Increased
eosinophilia
– Vascular Changes
– Cytoplasm has
– Fatty Changes ‘moth eaten
– Surface Blebs appearance’
– Nuclear dissolution
Main Ultrastructural
Change in
Irreversible Injury

■ Pyknosis
– Nuclear shrinkage
■ Karyorrhexis
– Nuclear fragmentation
■ Karyolysis
– Nuclear fading
■ ALL LEAD TO NUCLEAR
DISSOLUTION, RESULTING
IN AN ANUCLEAR NECROTIC
CELL
 Apoptosis and Necrosis – The Basics
■ Apoptosis – cell death with shrinkage, induced by a regulated intracellular program
■ Necrosis – morphological changes that occurs after a cell has been dead for a period of time.
■ Oncosis – cell death with swelling
■ Gangrene – visible necrosis
■ *Necrosis is not a type of cell death, it is describes the morphological changes (it describes the appearance, not
the process of cell death)

Apoptosis Necrosis
- Single cell affected - A cluster of cells
- Shrinkage affected
- Intact plasma - Swelling
membrane - Permeable plasma
- Pathological and membrane
physiological - Pathological
 Types of Necrosis
■ Coagulative Necrosis (most common)
– Caused by protein degradation
Coagulative Necrosis
– Microscopy – ghost cells outline (due to pressured cellular
architecture)
– Affects most organs, especially the heart and muscles
■ Liquefactive Necrosis
– Caused by degradation of tissue by enzymes
– Necrotic material is creamy/yellow due to presence of dead
neutrophils Liquefactive Necrosis
– Affects the brain mainly (during an infection)
■ Caseous Necrosis
– Cheese-like gross appearance
– Amorphous debris surrounded by histiocytes
– Present in gramulamatous inflammation (usually in TB)
– Affects the lungs mainly, due to chronic infection
Caseous Necrosis
Types of Necrosis Cont
■ Fat Necrosis
– Caused by destruction of adipocytes
– Primary: trauma
– Secondary: pancreatitis and release of lipase
– White deposits – fatty acids + calcium
– In breast tissue, biopsy needed to exclude breast
cancer Fat Necrosis
– Histology – histiocytes (purple dots) and loss of
nuclei in these cells
– Affects the pancreas and breast
■ Fibrinoid Necrosis
– Caused by an immune reaction involving blood
vessels
■ Fibrin and immune complexes leak from vessels
– Histology – bright pink amorphous fibrinoid deposits
– Affects blood vessels
Fibrinoid Necrosis
 Types of Infarcts
■ Red Infarcts
– Haemorrhagic —> dual blood supply
with numerous anastomoses between
capillary beds
– E.g. in the lungs
■ White Infarcts
Red Infarct
– Robust stromal support —> arterial
insufficiency —> end artery
– E.g. in the heart, spleen and kidneys

White Infarct
Acute Inflammation – The Basics

CARDINAL SIGNS OF Systemic Effects of Acute

ACUTE INFLAMMATION Inflammation
■ RUBOR (REDNESS) ■ Pyrexia
■ TUMOR (SWELLING) ■ Leukocytosis
■ CALOR (HEAT) ■ Acute phase response in the
■ DOLOR (PAIN) liver
■ FUNCTIO LAESA (LOSS OF FUNCTION) ■ Shock
Phases of Acute Inflammation
2) Cellular Phase
1) Vascular Phase
■ Neutrophils – main cells involves
■ Transient vasoconstriction of arterioles ■ Phases:
■ Vasodilation of arterioles – Chemotaxis
■ Capillary vasodilation —> increased blood flow – Activation
■ Increased vascular permeability —> exudation of – Margination
protein rich fluid —> slowing circulation – Rolling (selectins)
■ Vascular stasis – Adhesion (integrins)
– Diapedesis
– Recognition attachement
– Phagocytosis
CHEMICAL MEDIATORS INVOLVED IN ACUTE
INFLAMMATION
Chronic Inflammation

■ Macrophages and Lymphocytes

■ 3 causes for chronic inflammation
– 1) ‘Take over’ from acute inflammation – damage to
severe to be fixed within a few days
– 2) De novo – autoimmune conditions (Rheumatoid
arthritis) and chronic infections (Hep B/C, TB)
– 3) Develop alongside with acute inflammation –
severe persistent or repeated irritation
Chronic Inflammation – Macrophages
■ Macrophages – main cells of chronic inflammation
■ Macrophages circulate in the blood stream as monocytes
■ Functions of Macrophages
– Phagocytosis
– Synthesis of cytokines – interleukin (IL), tumour necrosis factor (TNF)
– Control of other cells by the release of growth factors e.g. EGF, PDGF,
FGF
– Present antigens to the immune system
– Stimulate angiogenesis
– Induce fibrosis
 Chronic Inflammation – Other Cells
Involved
■ Lymphocytes
– T and B Cells
■ Plasma Cells
– Presence implies chronic inflammation
■ Eosinophils
– Attack large parasites such as worms
– High numbers in bronchi
■ Fibroblasts
– Recruited by macrophages
– Produce connective tissue substrates such as collagen
– Can differentiate into myofibroblasts for wound healing
Chronic Inflammation – Effects
■ Fibrosis ■ Granulomatous Inflammation
– E.g. liver cirrhosis – Chronic Inflammation with granulomas
■ Impaired function – Granuloma – organised collection of
– Chronic inflammatory bowel epithelioid cells (modified macrophages)
disease (IBD) – 2 types of granulomas
■ Atrophy ■ 1) Foreign body granulomas: foreign
– Autoimmune gastritis material (suture material) or infections
(mycobacterium TB)
■ Inappropriate stimulation of
■ Immune granulomas: cell medicated
immune response
e.g. sarcoidosis Crohn’s disease
– E.g. rheumatoid arthritis
Granulomas vs Granulation Tissue

- Granuloma
- Organised collection of epithelioid cells (modified macrophages) seen in chronic inflammation
- Granulation Tissue
- New connective tissue and microscopic blood vessels that form on the surfaces of wounds during
the healing process
TB vs Sarcoidosis Granulomas
Giant Cells
■ Giant cells develop when macrophages
fail to deal with the particle to be
removed
■ Macrophages fuse together and form
multi—nucleated giant cells
■ Multinucleate
■ Fusion of Macrophages
■ Frustrated phagocytosis

■ 3 types of Giant cells

– 1) Langhans —> TB
– 2) Foreign body —> foreign body
– 3) Touton —> fat
 Wound Healing and Fibrous Repair
Wound Healing
■ Main Processes in Wound Fibrous Healing
Healing
■ Stages of Fibrous Repair
– 1) Haemostasis – Inflammatory cells
– 2) Inflammation ■ Phagocytosis of debris (neutrophils and
– 3) Regeneration macrophages)
■ Scar Formation ■ Production of chemical mediators
(lymphocytes and macrophages)
– 1) Haemostasis – Endothelial Cells
– 2) Acute inflammation ■ Angiogenesis
– 3) Chronic Inflammation – Fibroblasts and Myofibroblasts
– 4) Granulation tissue ■ Produce extracellular matrix (ECM)
– 5) Early scar tissue proteins
■ Wound contractions
– 6) Mature Scare
FIBROUS
REPAIR
Primary and Secondary Intention
Primary Intention Secondary Intention
■ Excisional wound
■ Incised Wound
■ Tissue loss
■ Closed wound ■ Separate edges
■ Non-infected wound ■ Filled with granulation tissue
and grows in from wound
■ Sutured wound margins
■ MINIMAL CLOTS AND ■ Scab contracts, dries and
then shrinks
GRANULATION
■ Myofibroblasts appear and
TISSUE contract – draw margins into
centre
PRIMARY
AND
SECONDARY
INTENTION
Factors that Affect Wound Healing

■ Local Factors ■ Systematic Factors

– Type – Age
– Size – Anaemia
– Location of wound – Obesity
– Mechanical stress – Diabetes
– Blood supply – Malnutrition
– Local infection – Steroids
– Foreign body – Vitamin Deficiency
Complications of Wound Healing
■ Adhesion formation
– e.g. intestinal obstruction following abdominal surgery
■ Loss of function
– E.g. healed myocardial infarction (MI) with non-contracting area of
myocardium
■ Disruption of complex tissue relationships within an organ
– E.g. liver cirrhosis
■ Overproduction of fibrous scar tissue
– E.g. keloid scar
■ Excessive scar contraction
– E.g. abnormal scars following burns
Haemostatsis – The Basics
■ Stages of Haemostasis
– 1) Primary Haemostasis - formation of a platelet plug
– 2) Secondary Haemostasis – Coagulation Cascade
– 3) Dissolution of clot and vessel repair – Fibrinolysis
■ Phases of Haemostasis
– 1) Vascular spasm
– 2) Platelet plug formation
– 3) Coagulation system
– 4) Fibrinolytic system
Primary Haemostasis

■ 1) Platelets adhere to
subendothelial structures via
Von Willebrand Factor
■ 2) Adhere to each other
■ 3) Form a platelet plug held
together by insoluble fibrin
Secondary Haemostasis – Coagulation Cascade
 Secondary Haemostasis – Clotting
Cascade
■ How the body stops the cascade
– 1) Antithrombin III
■ Inhibits thrombin and factor Xa
■ Deficiency leads to a prothrombotic state
– 2) Protein C
■ Cleaves co-factor V and VIIIa
■ Deficiency is a prothrombotic state (known as Factor V Liden Deficiency)
■ Factor V Liden Deficiency is the most common inherited thrombophilia
– 3) Protein S
■ Co factor to protein C
■ Deficiency leads to a prothrombotic state
Haemophilias
Types of Haemophilias Symptoms of Haemophilias
■ Haemophilia A ■ Bleeding after a minor
– Inherited deficiency in injuries
clotting factor VIII ■ Bruising
■ Haemophilia B (Christmas ■ Epistaxis (Nose bleeding)
disease)
■ Hamarthrosis
– Inherited deficiency in
clotting factor IX ■ Haematuria and PR
■ BOTH ARE X LINKED bleeding
 Measuring Cascade Functioning and Important
Drugs
How can we measure cascade Important Drugs
functioning clinically? ■ Warfarin
■ Prothrombin Time (PT) – Reduces action of vitamin KO reductase
– Measures extrinsic pathway – Inhibits formation of vitamin K dependent
clotting factors (factor X, IX, VII, II)
■ Activated Partial Thromboplastin Time (APTT)
– Needs regular monitoring with regular INR
– Measures intrinsic pathway blood tests
■ International Normalised Ratio (INR) ■ Heparin
– Compares PT with standard/normal – Enhances the effect of antithrombin III
value as a ration
■ Direct Oral Anticoagulants (DOACS)
– Used to monitor warfarin use and risk of
bleeding – Direct factor Xa inhibitors – apixiban,
riveroxaban
– *different conditions will have different
INR targets – Direct thrombin inhibitors – dabigatram
Fibrinolysis

■ Break down of fibrin clot

■ Activates plasminogen into plasmin
■ Activation of plasminogen is triggered by:
– 1) Tissue plasminogen activator (TPA)
■ Occurs in the body and given as medication
– 2) Urokinase
■ Occurs in the body and given as medication
– 3) Streptokinase
■ Only given as a medication
Thrombosis – The Basics

■ Thrombus – solidification of blood constituents formed within

the vascular system during life
■ Haematoma – solidification of blood constituents formed
outside the vascular system or after death
■ Thrombosis – the process of thrombus formation
■ Embolus – A blood clot (normally) that gets carried in the
bloodstream to lodge in a distant blood vessel
 Thrombosis – VTE
Virchow’s Triad
Venous Thromboembolism
■ Blood clot forms within the circulatory ■ 1) Blood flow: stasis/
system and prevents normal blood flow turbulence
■ Venous Thromboembolism (VTE) ■ 2) Vessel wall: injury to vessel
wall from e.g. atheroma
– Deep Vein Thrombosis (DVT)
■ Thrombus in the deep veins of ■ 3) Blood components: e.g.
the legs factor V Liden deficiency
– Pulmonary Embolisms (PE) ■ * Well’s Score is used for the
■ Embolus in the pulmonary artery diagnosis of DVT and PE
or its branches
 Risk Factors for VTE’s and Outcomes of
a Clot
Risk Factors
■ Age
■ Previous VTE
Outcomes of a Clot
■ Malignancy
■ Pregnancy ■ Propagation
■ Oral contraceptive pill ■ Organisation
■ Immobility/ bed rest ■ Recanalisation
■ Obesity ■ Fibrinolysis
■ Smoking
■ Embolisation
■ Inherited thrmobophilia
■ Post operation
 Treatment for VTEs
Others
Drugs ■ Inferior Vena Cava (IVC)
■ Low molecular weight – Recurrent/ long term
heparin (LMWH) ■ Hydration
– Short term ■ Elastic compression stockings
■ Warfarin ■ Mobilisation
– Intermediate/ long term
■ Treat underlying condition
■ DOAC
■ Stop smoking
– Intermediate/ long term
■ Normalise BMI
■ Medication Review
Atherosclerosis
What is it? Risk Factors
■ Modifiable
■ Thickening and hardening of – Hyperlipidemia
walls of medium and large – Smoking
sized arteries as a result of – Hypertension
an atheroma – Diabetes mellitus and
impaired glucose
■ Atheroma: accumulation of tolerance
intracellular and – Alcohol
extracellular lipids in tunica – Diet
media and intima – Infection
■ DOES NOT AFFECT VEINS ■ Non-modifiable
– Age
– Sex
 Reaction to Injury Theory
■ 1) Chronic Endothelial Injury
– Raised LDLs
– Toxins
– Hypertension
– Haemodynamic stress
■ 2) Endothelial dysfunction
– Platelet adhesion and release of platelet derived growth factor (PDGF)
– Monocyte accumulation within intima with release of growth factors and cytokines
– T lymphocytes attracted to the area
■ 3) Smooth muscle emigration from media to intima
■ 3) Macrophages and smooth muscle cells engulf accumulated, oxidised lipids and form
foam cells
■ 4) Smooth muscle proliferation in response to cytokines and growth factors, collagen and
matrix deposition, neovascularisation
REACTION
TO INJURY
THEORY
 Cell Types
■ Labile Cells
– Stem cells divide persistently
– E.g. enterocytes, epidermis
■ Stable
– Quiescent and proliferate slow
– Do not revenante unless requires
– E.g. hepatocytes of liver
■ Permanent
– Cannot regenerate
– Once damage, cannot regenerate
– E.g. myocardiocytes
Cellular Adaptations

■ Hyperplasia – increase in the number of cells

■ Hypertrophy – increase in the size of the cells
■ Regeneration – cells multiply to replace losses
■ Atrophy – shrinkage of tissue or organs due to decrease in size or
number of cells
■ Metaplasia – cells replaced by a different type of cell (BARRET’S
OESOPHAGUS)
■ Dysplasia – abnormal cell development (irreversible in the later stages)
■ Neoplasia – abnormal growth of cells
■ Aphasia – no development of an organ/ tissue
■ Hypoplasia – underdevelopment of an organ
 Examples of Cellular Adaptations
Physiological Pathological
■ Hyperplasia – Breast size
during pregnancy, ■ Hyperplasia – Heart failure
endometrium during menstrual ■ Hypertrophy – excessive
cycle hormones
■ Hypertrophy – pregnancy,
■ Atrophy – ageing, starvation,
endurance training
Cushing’s syndrome
■ Atrophy – not using muscles
enough ■ Metaplasia – squamous
Metaplasia in uterine cervix
■ Metaplasia – lung, oesphagus during the menstrual cycle
5 MINUTE BREAK?
 Neoplasia
The Basics Neoplasia Nomenclature
■ Neoplasm - an abnormal growth of cells ■ Benign – usually end with -oma
that persist after the initial stimulus is
removed ■ Malignant – usually end with
■ Malignant neoplasm – a neoplasm that carcinoma (epithelium
invades to surrounding tissues with the neoplasm -90%) or sarcoma
potential to spread to distant sites (stromal neoplasm)
■ Tumour – any clinically detectable lump or ■ In-situ carcinoma - no invasion
swelling of epithelial membrane
■ Metastasis – malignant neoplasm that has ■ Invasive carcinoma – neoplasm
spread from its original site to a new non- has penetrated through
contiguous site basement member
■ Dysplasia - pre-neoplastic alteration in
■ Glandular carcinoma –
which cells show distorted tissue
adenocarcinoma
organisation
Causes of Cancer
Intrinsic and Extrinsic Factors Behavioural Factors
■ Intrinsic Factors ■ High BMI
– Age
– Sex
■ Low fruit and
– Hereditary vegetable intake
■ Extrinsic Factors ■ Lack of physical
– Environmental factors exercise
– Chemicals
■ Tobacco use
– Radiations
– Infections ■ Alcohol use
(direct/indirect)
 Carcinogens
Carcinogens Carcinogenesis
■ Carcinogen – an agent with the capacity to
cause cancer in humans ■ Carcinogenesis – formation of cancer, whereby
normal cells are transformed into cancer cells
■ Work by interacting with a cell’s DNA and
inducing genetic mutation ■ There are 3 stages
■ Can be direct or indirect – 1) Initiation – carcinogen works as a
– Indirect – chronic tissue injury —> mutagen (cells known as initiated cells)
regeneration —> mutation – 2) Promotion: promoter stimulates the
■ There’s a long delay between chemical proliferation of imitated cells —> being
carcinogen exposure and onset on malignant tumours
neoplasms
– 3) Progression: further genetic changes that
■ Risk of cancer depends on total carcinogen lead to the progression of a malignancy
dose
■ There is latency between the exposure to the initiator
■ There is organ specificity for particular and the growth of a detectable neoplasm
carcinogens
■ Germline mutation: neoplastic cells get a ‘head
■ Complete carcinogen – Initiators + Promotor start;
(e.g. cigarette smoke)
 Direct vs Indirect Carcinogenesis
Direct Indirect
■ Human Papilloma Virus (HPV) ■ 1) Chronic tissue damage —>
– Expresses the E6 and E7 proteins, which regeneration occurs and acts
inhibit tumour suppressor genes (TSG) as a promotor or initiator —>
– p53 (Guardian of the genome) - recognises neoplasms develop.
any replication errors in the cell cycle
– E.g Hep B and Hep C
– pRB – major G1 checkpoint, blocking S-phase
entry and cell growth ■ 2) HIV —> lowers immunity,
– E6 inhibits p53 allowing other potential
– E7 inhibits pRB carcinogenic infections to
■ HPV causes cervical, anal, penile, oral, vaginal
occur
and valvular caner – E.g. HHV8 causes
Kaposi sacroma
Oncogenes, TSGs and 2 Hit Hypothesis

Oncogenes and TSGs 2 Hit Hypothesis

■ TSG: Normal genes that ■ 2 Hit Hypothesis
slow down cell division, – Most tumour suppressor genes
repair DNA mistake or (TSGs) require both alleles to
be inactivated either through
cause apoptosis
mutation or epigenetic
■ Proto-oncogenes – a silencing to cause phenotypic
gene involved in normal changes
cell growth ■ These mutations can be germline
mutations (inherited) or sporadic.
Important Steps in Neoplastic
Transformation
■ Telomerase expression
– Prevents telomeric shortening – cell immortality
■ Inactivation of TSG function in the immortalised cells
– Inhibits growth control
– TSGs – p53, pRB
■ Oncogene activation (e.g. RAS)
– Sets up autocrine growth stimulation
– The cell shows neoplastic transformation
Development of Large Bowel Adenocarcinoma
■ 1) A single epithelial cell with the mucosal gland becomes transformed into
a tumour cell
■ 2) Tumour cell proliferates to produce a clone of cells (monocryptal
ademona)
■ 3) Further proliferation (adenomatous polyp)
■ 4) Becomes an invasive carcinoma due to further genetic mutations
(malignant)
■ 5) Carcinoma invasion of blood vessels and lymph nodes, which spreads to
liver and lymph nodes
■ 6) Metastases occurs
 THE 6
HALLMARKS
OF CANCER
Skin carcinomas
 Metastasis and Invasion
Basic Steps Steps of ECM Invasion
■ Primary site —> spread ■ 1) Altered adhesion —> detachment of
to secondary site tumour cells from each other by unzipping
– 1) Grow and invade at E-Cadherin
the primary site ■ 2) Stromal Proteolysis —> Degradation of
the ECM by colleganases that attack
– 2) Enter a transport collage in the basement membrane (BM)
system
■ 3) Loss of adhesion of cells from integrins
– 3) Grow at the
secondary site to form ■ 4) Migration of tumour cells through ECM
a new tumour
Metastasis and Secondary Tumours
Steps of Metastasis Site of Secondary Tumour
■ Travel through regional drainage of blood, lymph
■ 1) Primary tumour
or coelomic fluid
■ 2) Proliferation ■ ‘seed and soil’ phenomenon: cancer likely to
■ 3) Angiogenesis metastasise to a site where the
microenvrionement is favourable.
■ 4) Local invasion, detachment
and intravasation ■ Carcinomas usually spread via lymphatics

■ 5) Embolisation and survival ■ Sarcomas usually spread via the blood stream
■ Common sites of blood bourne metastasis: lung,
■ 6) Arrest and extravasation at bone, liver, brain
target organs
■ Neoplasms that most frequently spread to
■ 7) Micro-metastasis bone: bronchus, breast, kidney, thyroid and
■ 8) Metastasis prostate
Neoplasia
Factors that Affect Cancer Microscopic Characteristics
Outcome of Malignancy
■ Age and general health ■ Pleomorphism – increasing in the
variation in the size and shape of
■ Tumour site
cells and nuclei
■ Tumour type
■ Increasing nuclear size and
■ Grade (differentiation) nuclear cytoplasmic ration
■ Tumour stage (spread) ■ Clumping of chromatin occurs in
nuclei
■ Availability of effective
treatments ■ Increase in mitotic figures
(including abnormal mitosis)
Tumour Grading and Staging

Tumour Grading Tumour Staging

■ Represents how much the
■ Measures how far the tumour has
tumour resembles its parent
spread
tissue
■ Ann arbor – Lymphomas
■ Usually a 4 tier system
– G1: well differentiated ■ Dukes Staging - colorectal cancer
– G2: Moderately ■ TNM Staging
differentiated – T status: extent of tumour at the
– G3: Poorly differentiated primary site
– G4: Anaplastic carcinoma – N status: Regional metastasis
(lymph nodes)
– M status: Distant metasis
 Local and Systemic Effects of Neoplasms
Local Effects of Systemic Effects of
Neoplasms Neoplasms
■ Direct invasion and destruction ■ Cachexia – reduced appetite and weight loss
of normal tissue ■ Immunosuppression
■ Ulceration at the surface leading ■ Malaise
to bleeding
■ Fever
■ Compression of adjacent
■ Myosotis
structures
■ Benign endocrine tumours are well differentiated
■ Blocking tubes and orifices so typically produce hormones
– E.g. thyroid adenomas produce thyroxine
■ Skin problems (pruritus and pigmentation)
■ Neuropathies affecting the brain and peripheral
nerves
 Tumour Markers
■ Tumour markers
– anything present in or produced
by cancer cells or other cells of
the body in response to cancer or
certain benign (non-cancerous
conditions)
■ Provides information about the cancer
such as:
– How aggressive it is
– Whether it can be treated with
targeted therapy
– Whether it is responding to
treatment
 Cancer Treatments and Screening
Programs
Types of Cancer Cancer Screening
Treatments Programs
■ Surgery ■ Cervical cancer (pap smear):
■ Radiation therapy – 25-50 y/o – every 3 years
– 50 – 65 y/o – every 5 years
■ Chemo therapy
■ Immunotherapy ■ Breast cancer (mammography):
– 50-70 y/o – every 3 years
■ Hormone therapy
■ Bowel Cancer (FIT):
■ Targeted therapy
– 60 -74 y/o +56 y/o – every 2 years
■ Stem cell therapy
THANK YOU
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