AssessmentsNecrosis and apoptosis
Necrosis and apoptosis
USMLE® Step 1 style questions USMLE
A 52-year-old woman comes to the clinic due to a new painless lump in her left breast that she noticed yesterday. She has no other symptoms. Her past medical history includes a recent left breast biopsy for a lesion found on screening mammography, which turned out to be benign. Her sister was diagnosed with invasive ductal carcinoma two years ago. She takes no medications. Her temperature is 37°C (98.6°F), pulse is 72/min, respirations are 12/min, and blood pressure is 148/72 mm Hg. Examination shows a painless irregularly-shaped fluctuant mass, with mild erythema and bruising of the overlying skin. The mammogram is shown below:
Case courtesy of Dr Chris O'Donnell at Radiopaedia
Which of the following pathological features is expected to be present?
Generally speaking, cells have two ways to die. One way is by apoptosis, which is a form of programmed cell death - a bit like cellular suicide.
The second way is by necrosis, which is when cells die due to injury or disease.
Overall, apoptosis occurs much more often than necrosis.
One example is when old skin cells undergo apoptosis, and get replaced by new skin cells.
Another example is in our hands and feet during fetal development.
Initially, human hands and feet look like duck’s feet, with webs of skin connecting the fingers.
But the cells in the webbing undergo apoptosis and that allows us to form individual digits that allow us to pick our nose and play the piano.
In contrast, necrosis occurs less frequently, and an example of that is when a blood vessel that goes to your big toe gets clogged causing ischemia, which is where oxygen and nutrients can’t reach the cells.
As a result, those cells begin to die, turning your big toe a nasty shade of black.
In apoptosis, there are two activating mechanisms - the intrinsic pathway, also called the mitochondrial pathway, and the extrinsic pathway, also called the death receptor pathway.
The intrinsic pathway occurs when a cell is exposed to stress like radiation, hypoxia, or low oxygen, a high intracellular concentration of calcium ions, or oxidative stress, which is where reactive molecules with unpaired electrons called free radicals steal electrons from nearby molecules.
These stressors cause two intracellular proteins, Bax and Bak, to move from the cytosol to the mitochondria.
Once in the mitochondria, Bax and Bak pierce the outer mitochondrial membrane making it porous and leaky.
This allows two additional proteins, called SMACS and cytochrome C, to spill into the cytosol.
SMACS binds to proteins that normally inhibit apoptosis and deactivates them.
Meanwhile, cytochrome C binds to both ATP - the main form of intracellular energy - as well an enzyme called Apaf-1.
Together, cytochrome C and Apaf-1 combine to form a large protein complex called an apoptosome.
The Apaf-1 portion of the apoptosome then cleaves an enzyme called pro-caspase 9 into its active form, caspase-9.
Caspase 9 then goes on to activate caspase-3, and caspase-3 goes on to activate other caspases - like a chain event.
Eventually this caspase cascade leads a cell to commit apoptosis.
That’s because these caspases cleave the proteins that make up the cell’s nucleus, organelles, and cytoskeleton - a bit like a ninja sabotaging a bridge by removing its nuts and bolts.
This destroys the cytoskeleton, as well as the proteins that anchor the cytoskeleton to the cell membrane.
As a result, the cell membrane starts to develop blebs - or bulges in the cell membrane.
The blebs are structurally weak, so they start to break off from the cell membrane, and this attracts nearby macrophages, which begin to clean up the mess by eating up the cell fragments.
So apoptosis is a neat process that conveniently recycles the organic contents of the dead cell.
Now, when the signals from apoptosis come from outside the cell - it’s called the extrinsic pathway.
One example is when a nearby macrophage recognizes an old cell, a pathogenic cell, or a cell that has completed its task.
In these situations, a macrophage can initiate apoptosis by releasing tumor necrosis factor alpha or TNF-alpha, a cell signaling protein, that binds to very appropriately named death receptors on the target cell membrane, one example being tumor necrosis factor receptor 1.
The cytosolic end of this receptor, dives deep inside the cell, and it’s called the death domain.
When the TNF-alpha binds to the tumor necrosis factor receptor 1, the death domain changes its shape and is able to bind to two proteins.
One is called Fas-associated protein with death domain or FADD and the other is called take a deep breath here Tumor necrosis factor receptor type 1-associated DEATH domain protein or TRADD.
So the death receptor, FADD, and TRADD come together to form a multi-complex protein called... wait for it... the death-inducing signaling complex or DISC.
Once everything is together, DISC cleaves pro-caspase-8 into caspase-8, which in turn activates caspase-3, and caspase-3 goes on to activate other caspases.
This initiates the caspase cascade that commits the cell to apoptosis.
After that, the process of apoptosis unfolds just like in the intrinsic pathway.
Now in addition to macrophages, if a cytotoxic T cell detects that a cell is expressing foreign antigens, the T cell will express a protein on its membrane called Fas ligand which binds to a death receptor on the target cell called the first apoptosis signal receptor - or Fas receptor.
Similar to the death domain of tumor necrosis factor receptor 1, the Fas receptor protein also has its very own death domain that can bind to FADD to form DISC.
As before, DISC activates pro-caspase-8 into caspase-8 and that triggers the caspase cascade which leads to apoptosis.
Now let’s switch gears and look at necrosis - which can be triggered by external factors like an infection or extremely hot or cold temperatures, as well as internal factors like tissue ischemia.
Necrosis can start one of two ways. The first is a form is called oncosis, which starts when toxins or ischemia damage the mitochondria.