In help of understanding difficult pathology terms

Differentiation
"Differentiation,” a term used to describe the appearance of malignant tumors. It
refers to the extent to which a tumor resembles its tissue of origin. Well-differentiated
tumors resemble closely their tissue of origin, whereas poorly-differentiated tumors
barely resemble their tissue of origin.

The well-differentiated squamous cell carcinoma cells (top image, right side) look a
lot like the adjacent benign squamous epithelium. They are large, eosinophilic, and
polygonal, and they are layered in an architectural pattern that looks like squamous
cell epithelium. Sometimes, well-differentiated squamous cell carcinomas will even
produce keratin, which usually it appears in the center of a group of epithelial cells
with a whorled appearance (there are a couple such groups on the far right side of
this image, but without keratin). This type of keratin is called a “keratin pearl”
because it looks like a little pink pearl surrounded by a nice group of epithelial cells.

The moderately-differenatiated squamous cell carcinoma looks less like normal

squamous epithelium. The tumor cells are still in nests, and there are some larger,
eosinophilic, polygonal cells that are trying to layer themselves in a squamousy way,
but the overal resemblence to normal squamous epithelium is less striking. The
poorly-differentiated squamous cell carcinoma has lost most of its squamous
epithelial characteristics and architecture, although if you were able to look closely,
you might still be able to see some intracellular bridging like you do between normal
squamous cells.

The concept of differentiation is not just some arcane exercise in morphologic skills.
There is a clinical correlation between the degree of differentiation of a tumor and its
clinical behavior; well-differentiated tumors tend to act nicer and be less aggressive
than poorly-differentiated ones.

Well-differentiated squamous cell carcinoma

Moderately-differentiated squamous cell carcinoma

 Poorly-differentiated squamous cell carcinoma
Anaplasia
Anaplasia refers to a lack of differentiation in neoplastic cells. Well-differentiated
tumors resemble their tissue of origin, whereas poorly-differentiated or
undifferentiated (anaplastic) tumor cells appear primitive and lack specialization
along any particular cell line. In general, benign tumors tend to be well-differentiated.
Malignant tumors run the gamut from well-differentiated to undifferentiated.

Anaplasia is not the best choice of words. Anaplasia means “to form backward,”
which implies that the anaplastic cells are formed from well-differentiated cells that
degenerate into an undifferentiated state. This is misleading. Cancers do not arise
from reverse differentiation of normal cells, but from stem cells present in all tissues.
So the term anaplasia is really a misnomer. I’m just saying.

Anaplastic cells have certain characteristics:

1. pleomorphism (variation in size and shape).
2. abnormal nuclear morphology, such as hyperchromatism (very dark nuclei),
irregular nuclear contours, an increased nuclear:cytoplasmic ratio, coarse chromatin,
and nucleoli.
3. Mitoses (tons of them – or, more importantly, abnormal ones, like the ones at the
tips of the arrows above).
4. Loss of polarity (disrupted orientation of cells; loss of architecture and
organization)
5. Other things: tumor giant cells, ischemic necrosis (from tumor cells outgrowing
their blood supply)

Can you find these characteristics in the image?

Poorly-differentiated tumors:
So when you have a poorly-differentiated squamous cell carcinoma, how do you
know it’s a squamous cell carcinoma (as opposed to an adenocarcinoma, for
example)? If the tumor is poorly-differentiated, that means there are still some
morphologic features (albeit few) that reveal the squamous nature of the tumor. If you
look carefully, you should be able to find some of these features, which would then
point you towards the diagnosis of squamous cell carcinoma.

Two clear-cut features of squamous cell carcinoma are intercellular bridging and
keratin pearls (there are other, “softer” features indicating a squamous cell origin, but
we’ll focus on the more definitive features). Intercellular bridging is a term describing
the special connection between the epithelial cells of squamous epithelium (it’s not
present in glandular epithelium). By light microscopy, you can see little horizontal
hair-like connections between the epithelial cells in both normal squamous epithelium
and in malignant squamous epithelium. Look closely between the epithelial cells in
the image to the left of a squamous cell carcinoma. See the little connections
between the cells (they look like little zippers connecting the cells)? Those are
intercellular bridges.

Keratin pearls are whorl-shaped accumulations of keratin made by malignant

squamous cells. In normal squamous epithelium, keratin lies in a nice flat layer on
the epithelial surface. In malignant squamous epithelium, the tumor cells can grow in
any direction they want, and so the keratin they produce often gets trapped inside the
tumor, forming pink, glassy, spherical masses. There’s a nice keratin pearl at about 2
o’clock in the image at left.

So, if you have a tumor that you think might be a squamous cell carcinoma, but the
cells aren’t showing clear squamous cell differentiation, look closely for epithelial
bridging and keratin pearls. If you find either of these, it’s a good bet that you’re
dealing with a squamous cell carcinoma. There are other little clues that point
towards other types of tumors too (like adenocarcinoma, or melanoma, or sarcoma).

Sometimes, you’ll get a tumor that shows no defining morphologic features

whatsoever – no interepithelial bridging, no keratin pearls, no signs of differentiation
along any other cell line. In these tumors (which would be described as “anaplastic”),
you need to use a secret weapon to figure out what the cells are:
immunohistochemistry. In this technique, you use a reagent consisting of antibodies
against specific components of cells (there are lots of these specific components:
squamous cells have cytokeratin in them, muscle cells have actin in them, etc.).
These antibodies are bound to a substance that appears brown under the
microscope. The concept is simple: you apply the reagent to the tissue in question,
allow it to bind to the cells, then wash off the excess reagent and look at it under the
microscope. If the tumor cells appear brown, that means they possess whatever
antigen the antibodies in your reagent are directed against, and that information can
help you figure out what type of cells your tumor contains.

So, if you have an anaplastic tumor, you might choose to apply immunohistochemical
stains for cytokeratin, actin, and CD45 (an antigen present on lymphoid cells). If the
cytokeratin stain comes back positive (brown), and the actin and CD45 stains come
back negative, the tumor is most likely a squamous cell carcinoma. There are tons of
immunohistochemical stains for all different types of cells. Generally, these stains are
pretty specific for one cell line, but it’s not always totally straightforward. Some
tumors stain positive for markers from cell lines other than their cell of origin, and
some tumors show only weak staining with the stains that are supposed to be nice
and positive. So you really need to use a panel of a bunch of different stains to make
the best diagnosis.

The bottom line, then, if you have an undifferentiated appearing tumor: look for little
morphologic clues (like keratin pearls) first. If you see few or no clues, then your next
step is immunohistochemical staining, which will almost always reveal the origin of
the tumor. If that doesn’t work, there are still other tests you can do – like
cytogenetics or molecular diagnostics – and we’ll talk about those in future posts.

Photo credit: AFIP

Curious substances in relation to tumor prevention

Curcumin (in turmeric) – inhibits inflammation, inhibits angiogenesis, promotes

apoptosis in tumor cells

Ellagic acid (in berries) – inhibits angiogenesis, blocks transformation of

environmental carcinogens into toxic substances

Anthocyanidins (in blueberries, cranberries, cinnamon, dark chocolate) – promote

apoptosis in tumor cells

Terpenes (in mint, thyme, marjoram, oregano, basil, rosemary) – inhibit tumor cell
invasion, promote apoptosis in tumor cells, inhibit angiogenesis

Gingerol (in ginger) – inhibits inflammation and angiogenesis

Sulforaphane, indole-3-carbinol (in cruciform veggies) – prevent precancerous cells

from becoming malignant; promote apoptosis of tumor cells, inhibit angiogenesis

Sulfur compounds (in garlic and onions) – reduce carcinogenic effects of

nitrosamines (created in overgrilled meat and present in tobacco); promote apoptosis
in tumor cells; help regulate blood sugar levels.

Lycopene (in carrots, yams, other bright colored veggies and fruits) – stimulates NK
cells to become more aggressive; inhibits tumor cell growth
Long-chain omega-3 fatty acids (in fatty fish) – reduce cancer cell growth, prevent
metastasis

Vitamin D (sun, cod liver oil, milk (tiny amount), vitamins) – dramatically reduces risk
of several cancers

Polyphenols (red wine, chocolate) – block NF-kappa B (important in all three stages
of cancer development: initiation, promotion, progression), limit angiogenesis