PREVENZIONE PRIMARIA DEI TUMORI DI ORIGINE AMBIENTALE

PREVENZIONE PRIMARIA DEI TUMORI

UOMO: epidemiologia analitica, epidemiologia molecolare,biomonitoraggio, trials clinici

METODI

ANIMALI DA LABORATORIO: valutazione di biomarcatori intermedi, studi di cancerogenicit SISTEMI IN VITRO: tests a breve termine

TEST DI AMES
Ceppi di Salmonella typhimurium Istidina-richiedenti + frazioni post-mitocondriali (S9) di fegato di ratto

Controlli

Fumo

Fumo + S9

Controlli

Fumo + S9

Fumo + S9 + inibitore

PREVENZIONE PRIMARIA DEI TUMORI

REGOLAMENTI
Controllo dei fattori di rischio ambientali

EDUCAZIONE SANITARIA
Fattori di rischio legati allo stile di vita

DIETA
Popolazione generale

FARMACI
Individui ad alto rischio

CONTROLLO DEL RISCHIO

CHEMIOPREVENZIONE

VALUTAZIONE DEL RISCHIO GENOTOSSICO E CANCEROGENO

VALUTAZIONE DEGLI EFFETTI E MECCANISMI PROTETTIVI

UOMO: epidemiologia analitica, epidemiologia molecolare, biomonitoraggio, trials clinici

METODI

ANIMALI DA LABORATORIO: valutazione di biomarcatori intermedi, studi di cancerogenicit SISTEMI IN VITRO: tests a breve termine MODELLI STRUTTURA ATTIVITA (SAR)

A C F

VITAMIN A SOURCE VITAMIN C SOURCE FIBER SOURCE CRUCIFEROUS VEGETABLE

NCI/NIH

PIANO DI SVILUPPO PER GLI AGENTI CHEMIOPREVENTIVI DEL CANCRO

Ibuprofene Oltipraz Piroxicam Proscar Sulindac Tamoxifene Vitamina D3 e analoghi Vitamina E

N-Acetil-L-cisteina (NAC) 18- Acido glicirretinico Aspirina Calcio -Carotene e altri carotenoidi DHEA Analogo 8354 2-Difluorometilornitina (DFMO) N-(4-Idrossifenil)retinamide (4-HPR)

G J. Kelloff and C.W. Boone (Eds.), J. Cell. Biochem. Suppl. 20, 1-303, 1994

PREVENTION OF LUNG TUMORS IN MICE

NUMBER OF TUMORS/MOUSE
0.35 11.06 1.95

CONTROLS (STANDARD DIET)

URETHANE (STANDARD DIET)

URETHANE (DIET WITH NAC 0.2%)

S. De Flora et al., Cancer Lett. 32, 235-241,1986

DNA ADDUCTS IN THE LUNGS OF RATS RECEIVING INTRA-TRACHEAL INSTILLATIONS OF

POLLUTED AIR PARTICULATE EXTRACTS

A. Izzotti, A. Camoirano, F. DAgostini, S. Sciacca, F. De Naro Papa, C.F. Cesarone, S. De Flora Cancer Res. 56, 1533-1538, 1996

URINARY MUTAGENICITY IN A SMOKER AS RELATED TO NAC ADMINISTRATION

35

Revertants/24 h x 103

30 25 20 15 10 5 0
NAC NAC NAC

Time (days)
S. De Flora et al., J. Cell. Biochem. 58 (Suppl. 22), 33-41,1995

MECHANISMS OF CANCER CHEMOPREVENTIVE AGENTS

S. De Flora and C. Ramel, Mutat. Res., 202, 285306, 1988 S. De Flora and L.R. Ferguson, Mutat. Res., 591, 815, 2005
3. Inhibition of tumor promotion
3.1. Inhibition of genotoxic effects (see 1 and 2) 3.2. Antioxidant activity and scavenging of free radicals 3.3. Antiinflammatory activity 3.3.1. Cyclooxygenase inhibition 3.3.2. Lipooxygenase inhibition 3.3.3. Inhibition of inducible nitric oxide synthase 3.3.4. Leukotriene receptor antagonism 3.4. Inhibition of proteases 3.5. Inhibition of cell proliferation 3.5.1. Inhibition of ornithine decarboxylase 3.5.2. Promoting proteasomal degradation of cyclins 3.5.3. Interference with multiple signaling pathways 3.6. Induction of cell differentiation 3.7. Modulation of cell apoptosis 3.8. Signal transduction modulation 3.9. Protection of intercellular communications

1. Inhibition of mutation and cancer initiation in the extracellular environment or in nontarget cells
1.1. Inhibition of uptake of mutagens/carcinogens 1.1.1. Inhibition of penetration 1.1.2. Removal from the organism 1.2. Inhibition of the endogenous formation of mutagens and carcinogens 1.2.1. Inhibition of the nitrosation reaction 1.2.2. Modification of the intestinal microbial flora 1.3. Complexation, dilution and/or deactivation of mutagens/carcinogens outside cells 1.3.1. By physical or mechanical means 1.3.2. By chemical reaction 1.3.3. By enzymecatalyzed reaction 1.4. Favoring absorption of protective agents 1.5. Stimulation of trapping and detoxification in nontarget cells

2. Inhibition of mutation and cancer initiation in target cells

2.1. Modification of transmembrane transport 2.1.1. Inhibition of cellular uptake 2.1.2. Stimulation of extrusion outside cells 2.2. Modulation of metabolism 2.2.1. Inhibition of activation of promutagens/ procarcinogens by Phase I enzymes 2.2.2. Induction of Phase I detoxification and Phase II conjugation pathways, or acceleration of decomposition of reactive metabolites 2.2.3. Stimulation of activation, coordinated with detoxification and blocking of reactive metabolites 2.3. Blocking or competition 2.3.1. Trapping of electrophiles by either chemical reaction or enzyme catalyzed conjugation 2.3.2. Antioxidant activity and scavenging of reactive species 2.3.3. Protection of DNA nucleophilic sites 2.4. Inhibition of cell replication 2.5. Maintenance of DNA structure and modulation of DNA metabolism and repair 2.5.1. Increase of fidelity of DNA replication and repair 2.5.2. Stimulation of repair and/or reversion of DNA damage 2.5.3. Inhibition of error-prone repair pathways 2.5.4. Correction of hypomethylation 2.5.5. Inhibition of histone deacetylation 2.5.6. Blocking of telomerases or inhibition of their activity 2.6. Control of gene expression 2.6.1. Targeted inactivation of oncogenes 2.6.2. Inhibitionofoncogene expression 2.6.3. Inhibition of oncogene sequences or activity 2.6.3.1. Inhibition of translation targeted to oncogene mRNA 2.6.3.2. Inhibition of transcription of specific DNA sequences 2.6.3.3. Blocking of target genes 2.6.2.4. Farnesyltransferase inhibition 2.6.4. Neutralization or posttranslational modification of oncogene products 2.6.5. Replacement of deleted tumor suppressor genes 2.6.6. Mimicking the DNA binding of tumor suppressor genes by antiidiotypic antibodies 2.6.7. Killing of cells lacking tumor suppressor genes

4. Inhibition of tumor progression

4.1. Inhibition of genotoxic effects (see 1 and 2) 4.2. Antioxidant activity and scavenging of free radicals 4.3. Inhibition of proteases 4.4. Signal transduction modulation 4.5. Effects on the hormonal status 4.5.1. Selective estrogen receptor modulation 4.5.2. Aromatase inhibition 4.5.3. Selective blocking of prostaglandin E2 receptors 4.5.4. Decrease in ovarian hormones by dietary isoflavones 4.5.5. Inhibiting the pituitary secretion of luteinizing hormone 4.5.6. Preventing conversion of testosterone into dehydrotestosterone by 5areductase 4.5.7. Selective androgen receptor antagonism 4.6. Effects on the immune system 4.7. Inhibition of angiogenesis 4.8. Antineoplastic activity by either mechanical, physical, chemical, or biological means

5. Inhibition of invasion and metastasis

5.1. Antioxidant activity and scavenging of free radicals 5.2. Signal transduction modulation 5.3. Inhibition of cell proliferation (see 3.4) 5.4. Modulation of cell apoptosis 5.5. Induction of cell differentiation 5.6. Inhibition of angiogenesis 5.7. Effect on cell-adhesion molecules 5.8. Inhibition of proteases involved in basement membrane degradation and modulation of the interaction with the extracellular matrix 5.9. Activation of antimetastasis genes

Angioprevention in multistage tumorigenesis

Normal Dysplasia (In situ) Neoplasia (invasion) Neoplasia (metastatic)

Epithelium Basement Membrane

Dermis

Angiogenesis

Angiogenesis

Angiogenesis
Metastatic Dissemination/ Extravasation

Antiangiogenic agents

F. Tosetti et al., FASEB J. 16, 2-14, 2002

LA NAC INIBISCE LESPRESSIONE DEL VEGF IN CELLULE DI SARCOMA DI KAPOSI

VASCOLARIZZAZIONE DI SPUGNE DI MATRIGEL

NAC

NAC +

T. Cai et al., Lab. Invest. 79, 1151-1159, 1999

CRESCITA DI SARCOMA DI KAPOSI UMANO IN TOPI NUDI

CONTROLLI
1.5 1.0

NAC
F E M M I N E F E M M I N E

3
Volume del tumore (cm )

0.5 0 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 5 10 15 20 25 )3

M A S C H I

M A S C H I

30 5 10 Tempo (giorni)

15

20

25

30

A. Albini et al., Cancer Res. 61, 8171-8178, 2001

Treatment group

Tumor weight after 60 days

mean SE Statistical significance

A Controls

3.09 0.14

INHIBITION OF LOCAL TUMORS (MELANOMA) IN BLACK MICE

P < 0.0001 Vs. A

B NAC p.o. ( + 16 h ) 12.25 mmol/Kg b.w. 1.77 0.18

C DOX i.v. ( + 24 h ) 2 mol/Kg b.w. 1.45 0.12 P < 0.001 Vs. A

D NAC ( + 16 h ) DOX ( + 24 h ) 1.11 0.11

P < 0.0001 P = 0.009 P = 0.07

Vs. A Vs. B Vs. C

E NAC ( 72 h ) DOX ( + 24 h ) 0.73 0.08

P < 0.0001 P < 0.0001 P < 0.0001

Vs. A Vs. B Vs. C

F. DAgostini et al., Int. J. Oncol. 13, 217-224, 1998

CHEMOPREVENTION OF CIGARETTE SMOKEINDUCED TUMORS

R. Balansky et al., Int. J. Cancer 126, 1046-54, 2010

Sham

M F M+F M F M+F M F M+F M F M+F M F M+F M F M+F M F M+F

MCS

MCS + NAC (current smokers) MCS + Budesonide (current smokers) MCS + PEITC (current smokers) MCS + Budesonide (exsmokers) MCS + PEITC (exsmokers)

P < 0.1 P < 0.05 P < 0.01 P < 0.001

10

20

30

40

50

60

70

Incidence (%)

Multiplicity (mean SE)

CHEMOPREVENTION OF CIGARETTE SMOKEINDUCED LUNG ADENOMAS BY NATURAL PRODUCTS

BCB = black chokeberry SB = strawberry

Sham

M F M+F

MCS

M F M+F

MCS + BCB

M F M+F

** **

** *

MCS + SB

M F M+F

* *

10

15

20

25

30

35

0.25

0.50

0.75

Incidence (%)

Multiplicity (mean SE)

GENOMIC CHANGES IN MOUSE LUNG AT BIRTH

A. Izzotti et al., Mutat. Res. (Rev. Genetic Toxicol.), 544, 441-449, 2003

Lung of newborn mice / fetuses

8-oxo-dGuo DNA adducts Expression of 746 genes

UNTREATED PREGNANT MICE

1.9
P < 0.05

5.0
P < 0.001

NACTREATED PREGNANT MICE

0.9
NS

2.0
NS

MICE EXPOSED TO SMOKE AFTER BIRTH

LUNG TUMORS LUNG EMPHYSEMA HYPERPLASIA OF BLADDER EPITHELIUM

UNTREATED PREGNANT MICE

61.1 % 16.7 % 20.4 %

NACTREATED PREGNANT MICE

17.0 %

6.4 %

2.1 %

R. Balansky et al., Carcinogenesis 30, 1398-1401, 2009

EXPRESSION OF 4858 GENES IN RAT LUNG

A. Izzotti et al., Mutat. Res. 591, 212223, 2005

SMOKE-FREE MICE

SMOKE-EXPOSED MICE

SHAM

NAC

OPZ

OPZ 5,6-BF + NAC

PEITC

I3C

PEITC + I3C

ECS

OPZ

NAC

5,6-BF

OPZ + NAC

I3C

PEITC + I3C

PEITC

EFFECT OF CIGARETTE SMOKE (ECS) AND CHEMOPREVENTIVE AGENTS ON miRNA EXPRESSION IN RAT LUNG
0.6 0.5

PCA component 2

ECS + PEITC + I3C ECS + OPZ + NAC ECS + PEITC ECS + NAC ECS + I3C ECS + OPZ ECS + BF NAC BF

0.4 0.3 0.2 0.1 0 -0.1 -0.2

ECS

SHAM
NAC + OPZ PEITC

OPZ -0.4 -0.3 -0.2

PEITC + I3C -0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

PCA component 1
A. Izzotti et al, Cancer Prev. Res. 3, 6272, 2010

REQUISITI EFFICACIA

INTERVENTI (Bersagli)
TERAPIA (malati di cancro) PREVENZIONE TERZIARIA (malati di cancro curati) INTERVENTO PRECOCE (malati di cancro in fase preclinica o precoce) PREVENZIONE DELLA PROGRESSIONE (individui affetti da lesioni precancerose)

BASSO COSTO PRATICITA TOLLERABILITA

CHEMIOPREVENZIONE MIRATA (individui ad alto rischio) INTERVENTO DI SANITA PUBBLICA (soggetti sani nella popolazione)

S. De Flora et al., IARC Sci. Publ. No. 139, 1996, pp. 291-301

PHASE II CHEMOPREVENTION TRIAL WITH NAC IN DUTCH SMOKERS

DNA adducts/ 108 nucleotides in BAL cells 8oxodGuo/ 105 nucleotides in BAL cells Micronuclei in mouth cells ()

Placebo

T0 T6

6.0 0.7 5.9 0.7

4.8 0.5 3.2 0.8

1.2 0.3 1.0 0.2

NAC

T0 T6

6.0 0.9 4.3 0.8

4.9 0.7 1.8 0.3

1.3 0.3 0.9 0.3

Statistically significant as compared to T0

F.J. van Schooten et al., Cancer Epidem. Biomarkers Prev. 11, 167-175, 2002

PHARMACOGENOMICS / NUTRIGENOMICS OF CHEMOPREVENTIVE AGENTS

2.4 before NAC 6 months after NAC 1.6

2.0

MN ()

1.2

0.8

**

**

0.4

All subjects

Fast

Slow

Null

NAT2

GSTM1

Anticancer drugs

Mechanisms of cardiotoxicity

Protective agents

Anthracyclines and anthraquinolones Capecitabine, Cytarabine, 5Fluorouracil Paclitaxel, Vinca alkaloids Cyclophosphamide TK Inhibitors (Trastuzumab, Imatinib, Bevacizumab, Sorafenib, Sunitinib, etc) COX2 inhibitors Estrogen receptor modulators Irradiation to the thorax

Mitochondrial dysfunction Apoptosis of cardiomyocytes ROS generation DNA damage Endothelial cell damage Antibody directed cellular cytotoxicity ATP block Cell signaling, survival block Fibrosis Hypertension Sinus bradicardia Atrium-ventricular block Ventricular tachycardia Arrhythmias Thromboembolism

ACE inhibitors Betablockers Statins Dexrazoxane LCarnitine Coenzyme Q10 NAcetylLCysteine Glutathione Erdosteine Selenium Zinc Melatonin Flavonoids and polyphenols Platelet antiaggregants

DECLINO DELLA MORTALIT PER MALATTIE CRONICO-DEGENERATIVE NEL XX SECOLO IN ITALIA

MORTALIT PER 100.000 (st. per et) MALATTIE GENERE M F CARDIOVASCOLARI M F TUMORI M F MAX (ANNO) 152,4 (1928) 123,2 (1940) 273,5 (1963) 233,5 (190156) 196,2 (1987) 100,0 (195689) 2000 DIMINUZIONE 42,0 31,5 131,6 74,9 160,2 87,1 72,4% 74,4% 51,9% 67,9% 18,3% 12,9%

CEREBROVASCOLARI

THE EPIDEMIOLOGICAL REVOLUTION OF THE 20th CENTURY

S. De Flora, A. Quaglia, C. Bennicelli & M. Vercelli, FASEB J. 19, 892897, 2005

ITALY, GENERAL MORTALITY DATA, 19012000

35 30
Rates per 100.000

25 20 15 10 5 0 1900 1910 1920 1930 1940 1950 1960

ITALY, 2000 Population: 58 million Deaths: 1,276,000 Mortality rate: 22 ITALY, 2000 Population: 58 million Deaths: 560,000 Mortality rate: 9.7 ITALY, 1901 Population: 33 million Deaths: 726,000 Mortality rate: 22
1970 1980 1990 2000