USMLE Path Review

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USMLE Path Review

• 2004 pgs 231-235
• 2005 pgs 225-228

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Tumor grade (character)

• Histological appearance
• I-IV based on
• degree of differentiation
• number of mitoses

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Tumor Stage (spread)

• Site Size of 1 lesion
• Regional lymph node spread
• Mets
• T tumor size
• N node involvement
• M metastasis

Prognostic value Stage gt Grade
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Tumor nomenclature
Epithelium

• Benign
• Adenoma, Papilloma
• Hemangioma
• Leiomyoma
• Rhabdomyoma
• Osteoma
• Lipoma
• Mature teratoma

• Malignant
• Adenocarcinoma, Papillary Carcinoma
• Leukemia, Lymphoma
• Angiosarcoma
• Leiomyosarcoma
• Rhabomyosarcoma
• Osteosarcoma
• Liposarcoma
• Immature teratoma

Blood cells
Blood vessels
Mesenchyme
Smooth muscle
Skeletal muscle
Bone
Fat
gt1 cell type
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Diseases neoplasms

• Down syndrome
• Xeroderma pigmentosum

• ALL, AML
• Melanoma
• Basal squamous cell carcinomas of the skin

we ALL fall Down
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• Chronic atrophic gastritis
• Pernicious anemia
• Postsurgical gastric remnants
• Tuberous sclerosis (facial angiofibroma,
  seizures, MR)

• Gastric carcinomas
• Astocytoma
• Cardiac rhabdomyoma

Chris
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• Actinic keratosis
• Barretts esophagus
• Plummer-Vinson synd.
• (atrophic glossitis, esophageal webs, anemia)

• Squamous cell carcinoma or the skin
• Esophageal adenocarcinoma
• Squamous cell
• carcinoma of
• esophagus

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• Cirrhosis
• Ulcerative colitis
• Pagets dis. of bone
• Immunodef. States
• AIDs

• Hepatocellular carcinoma
• Colonic adenocarcinoma
• 2 osteosarcoma fibrosarcoma
• Malignant lymphomas
• Aggressive malignant lymphomas (nonHodgkins)
  Kaposis sarcoma

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• Autoimmune dis.
• Acanthosis nigricans
• Dysplastic nevus

• Benign malignant thyomas
• Visceral malignancy (stomach, lung, breast,
  uterus)
• Malignant melanoma

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Oncogenes (turn on)
All the guys!

• C-myc ----------------------Burkitts lymphoma
• Christinas MycDreamy Dr. Burk
• bcl-2 --------------Folicular undifferentiated
  lymphomas
• erb-B2--------------breast, ovarian gastric
  carcinomas

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• ras (ras)-------------colon carcinoma
• L-myc -----------------Lung cancer
• N-myc -----------------Neuroblastoma
• ret--------------multiple endocrine neoplasia
• (MEN) types II III
• retirement

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Tumor Suppressor genes (suppress fxn)

• Rb -------------------- Retinoblastoma,
  osteosarcoma
• BRCA 12 ---------- Breast ovarian
  cancer
• p53 ----------------- most human CA,
• Li-Fraumeni syndrome
• APC -------------------Colorectal cancer

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• WT1 ------------------ Wilms tumor
• NF1 ---------------- Neurofibromatosis type 1
• NF2 ---------------- Neurofibromatosis type 2
• DPC ------------------- Pancreatic Cancer
• DCC ---------------------- Colon Cancer
• Must loose both alleles,
• all are in Caps (except Rb p53)

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Tumor Markers
Confirm/monitor NOT Dx !!

• PSA -------- Prostatic carcinoma (screening)
• CEA ------ 70 colorectal pancreatic CA
• also gastric breast CA
• a fetoprotein ------ norm. made by fetus
• hepatocellular carcinomas
• nonseminomatous grem cell
• tumors of testes

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• ß hCG --------Hydratidiform moles
• Choriocarcinomas
• Gestational trophoblastic tumors
• CA 125 ------ ovarian, malignant epi tumors
• S 100 ------ melanoma, neural tumors,
  astrocytomas
• Alkaline phosphatase ------ met to bone
• obstructive biliary dis.
• Pagets dis. of bone

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• Bombesin -------- neuroblastoma, lung
  gastric CA
• TRAP (tartrate resistand acid phosphatase)---
• Hairy call leukemia (B call)

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Oncogenic Viruses

• HTLV1 ----------------- Adult T cell Leukemia
• HBV, HCV ------- Hepatocellular carcinoma
• EBV ----------------Burkitts lymphoma
• nasopharyngeal carcinoma
• HPV ------------ Cervical carcinoma (16,18)
• penile/anal carcinoma
• HHV8 ------------- Karposis sarcoma, body cavity
  fluid B cell lymphoma

HHV HIV Karposis
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Chemical Carcinogens

• Aflatoxins ----------------- Liver
• (hepatocellular carcinoma)
• Vinyl chloride ----------------- Liver
  (angiosarcoma)
• Nitrosamines --------------- Esophagus, Stomach
• Asbestos ---------------------- Lung
  (mesothelioma bronchogenic carcinoma)
• Arsenic ----------------------- Skin (squamous
  cell carcinoma)
• CCl4 ----------------- Liver (centrilobular
  necrosis, fatty change)
• Naphthalene (aniline) dyes ----------- Bladder
• (transitional cell carcinoma)

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Local Effects of Tumors

• Mass -------tissue lump/tumor
• Non healing ulcer ----- destruction of epi
  surface
• Hemorrhage ----- ulcerated area/eroded vessel
• Pain ------ sites with n. endings (brain
  painless)
• Seizures ------ mass in brain
• Obstruction ---------- bronchus ? pneumonia
• biliary tree ? jaundice
• left colon ? constipation
• Perforation ------- ulcer in vicera ?
  peritonitis/free air
• Bone destruction -------- path fracture, collapse
  of bone
• Inflammation -------- serosal surface ? pleural
  effusion, pericardial effusion, ascites
• Space occupying lesion ----- raised intracranial
  pressure with brain neoplasms. Anemia due to
  BM replacement
• Localized loss of sensory/motor fxn
  -----compression/destruction of n.
• Edema ------ venous/lymphatic obstruction

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Skin Cancer

• Squamous cell carcinoma
• ? sunlight arsenic exposure, hands face,
• locally invasive, rare mets

Squamous cell carcinoma Insitu
Keratin pearls
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• Basal cell carcinoma
• ? sunlight, locally invasive, never mets
• pearly papules
• Melanoma
• common mets, ? sunlight, ? fair skin
• depth correlates with met risk
• precursor dysplastic nevus

Palisading nuclei
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Primary Bone Tumors - Benign

• Osteochondroma
• most common benign, ? lt 25yo.
• originates from long metaphysis
• malignant transformation rare
• Giant Cell Tumor
• epiphyseal end of long bones
• peak 20-40yo, locally aggressive
• distal femur, proximal tibial region
• doubld bubble/soap bubble Xray
• spindle shaped cells with multi nuc. Giant
  cells.
• Enchondroma
• cartilagenous, intramedullary bone,
  distal extremities

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Primary Bone Tumors - Malignant

• Osteosarcoma
• most common 1 bone tumor
• peak ? 10-20yo.
• metaphysis of long bones
• predisposing Pagets dis., bone infarcts,
• radiation, retinoblastoma

Codmans triangle (periosteum elevation)
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• Ewings sarcoma
• anaplastic small blue cell. ?lt 15yo
• aggressive, early mets, responsive to chemo
• onion skin in bone
• diaphysis of long bones, pelvis, scapula, ribs
• 1122 translocation
• Chondrosarcoma
• chartilagenous, ? 30-60yo.
• pelvis, spine, scapula, humerus, tibia, femur
• primary of from osteochondroma

Go out for Ewings onion rings
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