Med 6.

1a February 13, 2013

Cancer Biology Dr. Gracieux Fernando

OUTLINE  MARIE AND PIERRE CURIE

I. History o Discovered radium (Note: developed and used today as basis for
II. Cancer Characteristics
radiation therapy)
III. Clonality
IV. Autonomy  EMIL GRUBBE
V. Anaplasia o First person to use radiation treatment on a cancer patient.
VI. Metastasis  Began daily 1-hour treatments on patients with advanced
VII. Phenotypic Characteristic of Malignant Cells
VIII. History- Environment and Cancer breast carcinoma.
IX. Carcinogenesis  Involved placing x-ray tube against the lesion/tumor
X. Carcinogens  Continued for as long as it was comfortable to the patient.
 Marked regression of tumor was reported.
I. HISTORY  ALFRED GILMAN AND LOUIS S. GOODMAN
 HIPPOCRATES o Hired by U.S. Department of Defense during the World War II to
o Father of Medicine conduct research on the use of nitrogen mustard as a
o First person to clearly recognize the difference between benign therapeutic agent.
and malignant tumors.  Found to be an effective agent in treating lymphoma.
o His writings include description of cancers involving various  Served as the model for alkylating agents (more effective
body sites. than nitrogen mustard. Kills rapidly growing cancer cells by
o Karkinos damaging their DNA)
 Greek name for crab
 Term he used to describe the blood vessels around a
II. CANCER CHARACTERISTICS
malignant tumor (looked like claws of crabs).
 Today/English: Carcinos or Carcinoma  Clonality
 GALEN  Autonomy
o Believed that the body consisted of four “humors”. Any  Anaplasia
imbalance of the system of humors caused sickness or death.  Metastasis
 Red = blood  White = phlegm
 Yellow = yellow bile  Black = black bile  HALLMARKS OF CANCER
o He believed excess in black bile (called “melanchole”) causes o All these 6 characteristics need to be present, in any order, for a
Cancer. cell to become malignant:
 Based on appearance of untreated breast tumor = black and  Self-sufficiency in growth signals
hard, eventually erupting through skin with black fluids.  Insensitivity in anti-growth signals
o Believed that breast cancer was a systemic disease, not just a  Tissue invasion and metastasis
localized part, because black bile coursed throughout the entire  Limitless replicative potential
body, so even if the tumor was removed, the bile would still  Sustained angiogenesis
remain in the body, ready to create more tumors. (Notes: early  Evading apoptosis
belief of the principle of metastasis)
 Surgery to remove tumor was not considered as a cure
because of this belief.
 ANDREAS VESALIUS (1500s)
o Began to perform human dissections and document anatomy
o Challenged the theory of black bile as a cause of cancer (his
dissections did not find evidence of black bile)
o Surgery as a treatment modality for malignancy started.
 THEODORE BILLROTH
o Insisted on sterility in the operating room to decrease post-
operative infection.
o Instituted daily charting of body temperature in the post-
operative period (remains as standard of care today)
o Performed the first known partial esophagectomy
o Also began excising rectal cancers and anastomosing sigmoid
colon to remaining rectum or anus.
 RUDOLF VIRCHOW Figure 1. Hallmarks of Cancer
- The beginnings or sometimes the initial onset of malignancy is from genetic
o Cellular Theory
mechanisms and it can be through the activation of an oncogene, which
 Human body is composed of cells represents your self-sustained capacity for proliferation.
 All cells come from cells (“omnis cellula e cellula”) - If you recall, the oncogene is activated by a single mutation and there are
- 2 mechanisms for cells to grow: several ways by which oncogenes can be activated ranging from point
1. Hypertrophy – increase in size mutations, translocations, DNA amplification. The end result of this is you
2. Hyperplasia – increase in number have a gene that codes for continuous proliferation (which is explained by
the Oncogene-Car Analogy discussed later).

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 III. CLONALITY
 Genetic disease at the cellular level
 Mutations play a critical role in its pathogenesis
 Consequences of genetic instability:
o Phenotypic Heterogeneity
 Mutated parent genes proliferate → different expression of
the mutation in offspring
 Note: 5 patients with same malignancy, same age, same
stage of disease, but some may survive while some won’t.
(Individuality of patients!)
o Tumor Progression
 A proliferating mass of cells → tumor formation
 TYPES OF CANCER GENES
1. Oncogenes
2. Tumor Suppressor Genes
3. DNA Repair Genes
A. ONCOGENES
 Promote/Accelerate cell proliferation (normal cells: regulate cell
growth)
 Represent the abnormal stimulation of a particular gene.
 Dominant and highly conserved
o When activated, their expression is dominant = only 1 of a pair
of oncogenes needed to be activated for it to express
malignancy potential
 “Off” state of oncogene = proto-oncogene
o Proto-onc → mutation → oncogene
 Types:
o Viral Oncogenes (v-oncs)
o Cellular Oncogenes (c-oncs)
 Classification:
A. Secreted Growth factors – c-sis, hst
B. Cell Surface Receptors – erb B, fms, ret, trk, fes, fms
C. Intracellular Transducers – c-srs, c-abl, mst, ras
D. DNA-binding Nuclear Proteins – myc, jun, fos
E. Regulators of the Cell cycle – bcl, bax, bad
 A, B, C, D are components of Signal Transduction Pathways
Figure 2. (From National Cancer Institute) Oncogene-Car Analogy.
Think that the oncogene is the gas pedal of the car.
a) Normal genes regulate cell growth; the brakes of the car work, so cell
growth and division can be controlled.
b) When oncogenes are activated, and suppressor genes are inactive, the gas
pedal is pushed to the floor, and the brakes don’t work → uncontrolled cell
proliferation.
- An activated oncogene does not mean that the cell would go into actual
proliferation because in a normal setting, we know that the cell is actually
in an inhibited state because proliferation is tightly controlled by a set of
genes called tumor suppressor genes.
- So in order for proliferation to go ahead, there must be a loss of function of
tumor suppressor genes representing what we now call a loss of growth
inhibitory signals.
- TS genes represent the brake of the car. And because there is a tight
control of TS genes then it requires damage to both pair of TS genes as
dictated by the two-hit hypothesis of Kundson.
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HARRISON’S PRINCIPLE OF MEDICINE
ONCOGENES
 positively influence tumor formation
 acquire mutations in cancer cells, and the mutations typically
relieve this control and lead to increased activity of the gene
products. This mutational event typically occurs in a single allele
of the oncogene and acts in a dominant fashion.
MECHANISMS OF ONCOGENE ACTIVATION
1. Point Mutation
 common mechanism of oncogene activation.
 For example, mutations in one of the RAS genes (HRAS, KRAS, or
NRAS) are present in up to 85% of pancreatic cancers and 45% of
colon cancers. Most of the activated RAS genes contain point
mutations in codons 12, 13, or 61 (these mutations reduce RAS
GTPase activity, leading to constitutive activation of the mutant
RAS protein).
 The restricted pattern of mutations observed in oncogenes
compared to that of tumor-suppressor genes reflects the gain-
of-function mutations are less likely to occur than mutations
that simply lead to loss of activity.
 Inactivation of a gene can be accomplished through the
introduction of a stop codon anywhere in the coding sequence,
whereas activations require precise substitutions at residues
that can somehow lead to an increase in the activity of the
encoded protein.
2. DNA Amplification
 It leads to overexpression of the gene product.
 This increase in DNA copy number may cause cytologically
recognizable chromosome alterations referred to as
homogeneous staining regions (HSRs) if integrated within
chromosomes, or double minutes (dmins) if extrachromosomal.
3. Chromosomal Rearrangement
 Chromosomal alterations in human solid tumors such as
carcinomas are heterogeneous and complex and occur as a
result of the frequent chromosomal instability (CIN) observed in
these tumors.
 In contrast, the chromosome alterations in myeloid and
lymphoid tumors are often simple translocations, i.e., reciprocal
transfers of chromosome arms from one chromosome to
another.
 Translocations are particularly common in lymphoid tumors,
probably because these cell types have the capability to
rearrange their DNA to generate antigen receptors.
 Antigen receptor genes are commonly involved in the
translocations, implying that an imperfect regulation of receptor
gene rearrangement may be involved in the pathogenesis.
B. TUMOR SUPPRESSOR (TS) GENES
 Inhibit growth and multiplication of mutated cells
 Prevent neoplastic transformation
 Recessive and highly conserved
o Always on the “on” state.
o Recessive – need to destroy both/pair of TS gene to lose
function. (will still somewhat function even if only 1
chromosome of the pair is working)
 CLASSIFICATION OF TS
o Cell Adhesion Molecule – APC, DCC
o Regulators of the Cell Cycle – RB1, Tp53
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 KNUDSON’S TWO-HIT HYPOTHESIS Oncogene = gas pedal; TS genes = 2 brakes: foot brake & hand brake
st
st a) If 1 TS gene is mutated (1 hit), you lose the function of 1 brake, but you
o 1 hit: TS mutation or inherited mutation
nd still have another one left → oncogene is still suppressed, whether
o 2 hit: gross chromosomal loss
activated or not
nd
b) If 2 TS genes mutate (2 hit), no more brakes left → oncogene
 TYPES OF TS GENE DEFECTS unsuppressed → uncontrolled cell proliferation → malignancy
o Wild-type TS gene - However, growth needs to be overcome by a balance of loss of cells. And if
 Occurs in the natural state there is an equal number of cells that are lost with the number of cells that
 Sporadic mutation are growing, then you have a net growth rate of zero.
 1st hit: new TS gene mutation in 1 of the Chr pair - So for a cell to continuously proliferate, for some population to increase in
nd size, then you must overcome the death signal and this involves the
 2 hit: damage/deletion of normal TS gene in the other pair
phenomenon of apoptosis. So if apoptosis is overcome, then there is
nothing that stops the proliferative potential of a cancer cell. Apoptosis can
be overcome by several ways but the key factor played here is by your TS
genes called p53.

HARRISON’S PRINCIPLE OF MEDICINE

Figure 3. Wild-type TS gene
o Heritable cancer syndromes
 Familial type
 1st hit: inherited mutation
nd
 2 hit: damage/deletion of normal TS gene in the other pair
 Tendency to develop malignancy at an earlier age compared to
wild-type mutations because 1st hit is already present at birth
(so only 1 more hit needed to express malignancy phenotype)
 Heterozygous TS gene at birth (1 normal, 1 mutated TS gene)
→ the remaining normal gene becomes damaged/deleted →
“loss of heterozygosity” (malignant phenotype)
TUMOR-SUPPRESSOR GENES
 negatively impact tumor growth
 restrain cell growth, and this function is lost in cancer.
 Because of the diploid nature of mammalian cells, both alleles
must be inactivated for a cell to completely lose the function of a
tumor-suppressor gene, leading to a recessive mechanism at the
cellular level.
 Knudson Two-Hit Hypothesis states that both copies of a tumor-
suppressor gene must be inactivated in cancer.
 Subset of tumor-suppressor genes,
o Caretaker genes
 Do not affect cell growth directly, but control the ability of the
cell to maintain the integrity of its genome.
 Cells with a deficiency in these genes have an increased rate of
mutations throughout their genomes, including in oncogenes
and tumor-suppressor genes.
 Two major types of somatic lesions observed in tumor-suppressor
genes during tumor development
o Point mutations in the coding region of tumor-suppressor genes
will frequently lead to truncated protein products or otherwise
nonfunctional proteins.
o Deletions lead to the loss of a functional product and sometimes
encompass the entire gene or even the entire chromosome arm,
leading to loss of heterozygosity (LOH) in the tumor DNA
compared to the corresponding normal tissue DNA.

Figure 4. Heritable cancer syndrome C. DNA REPAIR GENES

 Ensures fidelity of replication
 Checks and corrects mismatched pairs
 If non-functional:
o Mutation → inefficient repair and replication → increased
propensity of oncogenes and TS genes to undergo mutation
(Microsatellite Instability/MIN)
o MIN – areas of unstable DNA because mutations are already
present there.
o Example of DNA repair gene failure: Hereditary Non-polyposis
Colon Cancer (HNPCC)
 Apoptosis – programmed cell death; as cells grow older, their
tendency to develop mutations gets higher, thus apoptosis is
necessary to prevent continuous proliferation of cells.

Figure 5. (From National Cancer Institute) Oncogene-TS gene-car analogy.

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Figure 6. When cells age, they develop DNA damage. So before they undergo
mutation, they commit suicide (apoptosis) so no mutations will be passed on
to the next generation.
D. CYCLIN REGULATORS
 The mechanism of apoptosis is mediated by 2 important TS genes:
o p21 – inhibits cell cycle progression & permits DNA repair to take
place
o p53 – “guardian of the genome”
 most common genetic alteration found in human cancer
 in the presence of DNA damage:
- halts cell cycle progression to facilitate DNA repair, if
damage is repairable (reactivation of capping of the DNA)
- activates apoptosis in cases of severe DNA damage
(apoptotic pathway)
 In the presence of mutated DNA, it stops proliferation, allows
DNA to be proofread, repaired and if repair is impossible then
it is moved to level of apoptosis.
E. COMPONENTS OF APOPTOTIC PATHWAY
 BCL-2 family of proteins
o Pivotal decisional checkpoint
 Anti-apoptotic:
- BCL-2
- BCL-xL
 Pro-apoptotic:
- BAX
- BAD
- BAK
- BID
o i.e. main mechanism of lymphoid tumors is overexpression of
BCL-2 (anti-apoptotic = favors continuous proliferation of tumor
cells)
o possible target cell for future drug development against cancer.
 Cytochrome C
o Component of mitochondria released in response to apoptotic
signals.
o Apoptotic signals → Cytochrome C stimulated → activates cells
that destroy the cell
 Caspases (Cysteine-containing ASPartate-specific ProteASES)
o Initiator Caspases
 activated in response to apoptotic signal
o Executioner/Effector Caspases
 activates cascade resulting in DNA fragmentation and
apoptosis.
 Once apoptosis is evaded, the cells are able to proliferate.
Unfortunately, there comes a time in proliferation when cell hits a
wall called “replicative senescence” and the reason is because of a
loss and shortening of your telomeres, which is your cell’s biologic
clock.
 Once that biologic clock expires then that cell, although it can still
replicate, actually stops and goes into replicative arrest or
replicative senescence. So if a cell with continuous replicative
potential needs to continue replication in order to give rise to a
Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao
malignancy, then it must have the capacity to regenerate its
telomere. And it does that by reexpressing an enzyme called
telomerase.
 Once telomerase is expressed, then your cell now goes into a
condition called unsustained replication and that ends up to the
formation of a malignancy.
 Unsustained replication can never occur unless you have fuel for
that particular activity. Fuel for that activity arises when blood
vessel network disforms and connects to the main tumor mass
fueling that mass into continuous growth. The number one factor
that stimulates formation of a new blood vessel network is the
occurrence of tissue hypoxia in the tumor bed. When the tumor
cells get to the point that they start to override or overwhelm the
local blood supply, it will lead a blood supply of its own. Once that
blood supply is formed, secondary to substances secreted by the
tumor to form these new blood vessels, then that tumor goes into
and able to sustain continuous proliferation. The formation of this
blood vessel network is a two-way street because, not only does it
bring nutrients to your tumor bed, it is also highway by which your
tumor cells can invade into your blood vessels and eventually
spread to other parts of the body. This leads to the sixth and
defining characteristic of malignancy which is the capacity to
invade and metastasize.
F. TELOMERES AND TELOMERASE
 Telomeres
o Prevent recombination and shortening of the lagging strand
o Repeats of 6 nucleotide sequences
 Humans: TTAGGG
o Biologic/Reproductive clock of a cell – the more times a cell
replicates, the higher the chance for it to develop a mutation.
Therefore, cells have telomeres (biologic/repro clock) to regulate
amount of replications that can occur. (When their time is up –
bio/repro clock -- cells commit suicide)
o Replicative Senescence:
 Telomeres become shorter in every replication → very short →
sensed by p53 as damaged DNA → apoptosis
o Can be regenerated by Telomerase. (expressed in cancer cells)
 Telomerase
o Adds 6 nucleotide repeats to 3’-OH end of DNA
 RNA serves as template
 Reverse transcriptase
o Enzyme that maintains telomeres
o Expressed in normal cells during embryologic development d/t
the need for continuous reproduction to form the entire human
body. Switched “off” afterwards except for stem cells.
o possible target cell for future drug development against cancer.
REVIEW:
Oncogene TS Gene DNA Repair
Gain of function→ Loss of function→ Loss of function→
cancer cancer cancer
Promote cell Inhibit growth and Checks and corrects
proliferation multiplication of mismatched pairs
mutated cells
Ex: Her2-neu, Ras, Ex: p53, Rb, APC Ex: BRCA1, BRCA2
Myc
*** Multiple/accumulated mutations are needed in development of cancer.
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G. NOWELL’S HYPOTHESIS
Figure 7. Nowell’s hypothesis.
N: normal cell; T: tumor cell; shaded circles: TS genes.
- Accumulation of mutation is different for each cancer and for each
individual with cancer.
- The accumulation of mutation is actually a Darwinian phenomenon
brought about by pressure from the environment itself and from the
genetic defect in these affected cells. This evolution or accumulation of
mutations is expressed in Nowell’s hypothesis, which states that there is a
number of mutations required before a cancer cell develops. Hence, one
mutation is not enough.
- Multistep clonal development of malignancy. In this diagram a series of
five cumulative mutations (T1, T2, T4, T5, T6), each with a modest growth
advantage acting alone, eventually results in a malignant tumor. Note that
not all such alterations result in progression; for example, the T3 clone is a
dead end. The actual number of cumulative mutations necessary to
transform from the normal to the malignant state is unknown in most
tumors. (After P Nowell: Science 194:23, 1976, with permission.)
 Accumulation of mutations eventually gives rise to a malignant cell
 Linear event – survival of the fittest
o The cell line that gives the best survival advantage will
eventually end up being the malignant cell.
 A mutation DOES NOT confirm malignancy! It is an evolution that
involves several mutations and lack of several genes.
o TS genes or oncogenes or both may be involved.
Figure 8. Example: Colon Cancer development. A person has to have 5
mutations to develop a normal colon epithelium to a malignant one.
Progressive somatic mutational steps in the development of colon
carcinoma. The accumulation of alterations in a number of different genes
results in the progression from normal epithelium through adenoma to full-
blown carcinoma. Genetic instability (microsatellite or chromosomal)
accelerates the progression by increasing the likelihood of mutation at each
step. Patients with familial polyposis are already one step into this pathway,
since they inherit a germline alteration of the APC gene. TGF, transforming
growth factor.
H. MUTATIONS
 Change in the normal base-pair sequence
 Commonly used to define DNA sequence changes that alter
protein function.
Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao
 May affect 2 types of cells leading to 2 types of mutations:
1. SOMATIC MUTATIONS
o Occur in non-germline tissues
o Non-inheritable - damage to mature cells that do not
participate in the reproductive process.
o Most cases of cancer
o Several genes are involved and accumulated mutations
needed to develop malignancy since there were no
st
mutations present at birth (no 1 hit yet. See Knudson’s 2-hit
hypothesis)
o Sporadic malignancies
o Overall rate increases with age (more common in the
elderly)
o Because they do not replicate, it is not passed to the next
generation.
o Tend to accumulate over time and begin when an individual
is at an older age compared from germline mutations so
OLDER AGE when they manifest malignancy. Majority of
patients we encounter in the wards who are 50, 60, 70 years
old tend to have somatic malignancy.
2. GERMLINE MUTATIONS
o Heritable – causes cancer family syndrome and Mendelian
cancer syndrome
o Important to detect! Patients at risk for these mutations
would have other family members that are similarly at risk.
(widened scope of responsibility)
o All cells affected in offspring; risk is present at birth
o Damage to cells involved in the reproductive process (Ovum
in females and/or sperm in males)
o Average age at onset of malignancy: young (usually 30s or
40s, sometimes even 20s), earlier onset of disease.
o If we can recognize these individuals, then we can do
screening to catch the malignancy early or have lifestyle
changes in order to prevent/diminish exposure to certain
substances that can promote mutations that give rise to
malignancy.
I. HEREDITARY CANCER
 Approximately 5-10% of breast, ovarian, and colon cancers are
linked to hereditary risks.
 Clinical Importance:
o Identified high risk individuals may be motivated to change
behavior/lifestyle
o Early recognition of people at risk results in changes in
management
o Studies of high risk families may contributes greatly to
understanding cancer in the general population
 Clinical features of Hereditary Cancer Syndrome:
o 2 or more relatives in a family have been diagnosed with cancer
o >1 generation is affected
o Cancer has been diagnosed in a family member <50 years old
o Same type of cancer has occurred in several members of the
family
o >1 type of cancer has occurred in 1 person or a clustering of
specific tumor types is present
o A rare cancer has occurred in one or more members of the
family.
o Certain ethnic groups (Ashkenazi Jews)
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 IV. AUTONOMOUS GROWTH B. CELL REGENERATION CYCLE
 Consequence of germline or somatic mutations.
 Common in tissues with rapid turnover
1. Tissues exposed to environmental agents
 Epidermal or lining epithelial tissues (majority of
malignancies encountered now are termed CARCINOMA –
malignancy of epithelial tissue)
2. Tissues whose proliferation is hormone dependent
 i.e. breast, prostate
 The growth of cancer is expressed in doubling time
1. mean length of time for division of all tumor cells present
2. directly proportional to rate of progression and aggressiveness
of tumor
Figure 10. As cells enter the S-phase (Synthesis phase), they rapidly
A. GOMPERTZIAN TUMOR GROWTH proliferate. Thus, high S-phase fraction → aggressive tumor → poor
prognosis
 Tumor cell growth is Gompertzian (s-shaped, see Fig 9), with 3
phases:  S-phase – only phase of the cell cycle that is susceptible to
1. LAG phase manipulation by external agents (i.e. drugs, radiation)
o Initial; slow growth phase. LOW number of cells, circulating  Cyclins, CDKs, and CDKis
factors, and nutrients in the tumor bed.
o Cyclin and CDK – promote cell cycle
o Most susceptible portion – no blood supply yet, less
o CDKi – inhibits cell cycle (cyclin regulator)
nutrition to fuel growth, no metastasis
 Induced by growth inhibitors
2. LOG phase
 Inhibited by positive growth factors
o Rapid proliferation phase. ANGIOGENESIS; energy, nutrient,
 Genetic alterations occur with high frequency in some cancers
and O2 requirements increase → hypoxia of tumor cell →
stimulus for new blood vessel proliferation
o phenomenon of antigens fuels growth in the log phase
o Sensitivity to chemotherapy is highest when the cells are
proliferating. Hence, cancer cells in the log phase tend to be
most sensitive to the effects of chemotherapy.
3. PLATEAU phase
o Terminal growth phase. Net growth is usually flat or zero.
MIX of proliferating, resting, and dying cells (in order to
conserve nutrients)
o Tumors in the plateau phase tend to be resistant to
chemotherapy and radiotherapy.
o Need to debulk the tumor to allow it to go back to the log
phase → then, institute chemotherapy Figure 11. Important gate points:
1. Junction between G2 and M– if promoted by cyclin → cell goes into mitosis
2. Junction between G1 and S – MORE IMPORTANT; commonly affected in
many malignancies.

 G2/M checkpoint
o Regulated by cyclin B/cdc2 (mitosis promoting factor or MPF)
o Activity of cyclin with its substrate results in:
 Chromosome condensation
 Nuclear membrane breakdown
 Spindle formation
o Therapeutic goal in this phase: prevention of mitosis in the
presence of damaged DNA
 G1/S checkpoint
o Area most often involved in cancer
o Complex mechanism of regulation; involves phosphorylation of
Rb gene, which results in:
Figure 9. Gompertzian growth of tumor cell  Activation of several genes needed for S phase progression
 Promotes differentiation through association with
 Junction between lag and log phases – cells slowly grow and transcription factors
proliferate - earliest time for cancer to be clinically detected.

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 V. ANAPLASIA

A. CONSEQUENCES OF AUTONOMY
 continued proliferation results in mass formation
 Unregulated growth results in architectural disorganization
(ANAPLASIA) → histologic abnormalities
 Loss of normal differentiation and function
o The more poorly differentiated the tumor is, the more anaplastic
it tends to be, the more aggressive the behavior of the tumor is.
 MICROSCOPIC APPEARANCE OF CANCER CELLS
Figure 12. Rb gene activation
 Rb gene – “gate keeper”
- Keeps the entire replication process in check
- Conjoined with protein E2F (when non-phosphorylated) – no
replication can occur
- Phosphorylated → detaches from protein E2F → E2F sends
signals to copy DNA
 i.e. Retinoblastoma – caused by Rb gene mutation; very
malignant and very rapid progression of tumor because there
is no gatekeeper to stop E2F from sending signals to copy the
mutated DNA of the cell → continuous replication of mutated
gene

HARRISON’S PRINCIPLE OF MEDICINE

CELL CYCLE CHECKPOINTS
1. G1 phase
 Cell stops before entering the DNA synthesis phase or S phase
to take inventory.
 The main brake on the process is the retinoblastoma protein,
Rb. When the cell determines that it is prepared to move
ahead, sequential activation of cyclin-dependent kinases
(CDKs) results in the inactivation of the brake, Rb, by
phosphorylation.
 Phosphorylated Rb releases the S-phase-regulating
transcription factor, E2F/DP1, and genes required for S phase
progression are expressed.
 If the cell determines that it is unready to move ahead with
DNA replication, a number of inhibitors are capable of blocking
the action of the CDKs
 Nearly every cancer has one or more genetic lesions in the G 1
checkpoint that permits progression to S phase.
2. S phase
 At the end of S phase, when the cell has exactly duplicated its
DNA content, a second inventory is taken at the S checkpoint.
 Have all of the chromosomes been fully duplicated? Were any
segments of DNA copied more than once? Do we have the
right number of chromosomes and the right amount of DNA?
If so, the cell proceeds to G2
3.G2 phase
 Cell prepares for division by synthesizing mitotic spindle and
other proteins needed to produce two daughter cells.
 When DNA damage is detected, the p53 pathway is normally
activated.
 Normally p53 is bound to mdm2, which transports p53 out of
the nucleus for degradation in the proteosome.
 When damage is sensed, the ATM (ataxia-telangiectasia
mutated) pathway is activated; ATM phosphorylates mdm2,
which no longer binds to p53, and p53 then stops cell cycle
progression, directs the synthesis of repair enzymes, or if the
damage is too great, initiates apoptosis of the cell to prevent
the propagation of a damaged cell
VI. METASTASIS
A. ANGIOGENESIS IN TUMOR GROWTH AND METASTASIS
Figure 13. Angiogenesis
ANGIOGENESIS
 Clinical importance:
o Tumor vessel number correlates with risk and degree of
dissemination
o Cytokines that stimulate endothelial cell proliferation also
stimulate proliferation of malignant cells
 In order for a cancer cell to sustain its growth, it needs to create
blood supply.
 As it gets bigger, passive diffusion of nutrients becomes an
inefficient method for which to create more growth.
 As it continues to grow → area of the tumor becomes hypoxic →
that’s the signal for the cell to secrete factors→ stimulate the
formation new blood vessels (VEGF, TGF, PDGF, etc).
 One of the strongest families of these factors is a group of proteins
called vascular endothelial growth factors. By expressing these, the
tumor is able to create its own blood supply and that blood supply
will stimulate the growth of the tumor.
 This has 2 important consequences to tumor growth because the
more growth factors released
o more new blood vessels are formed and those substances that
stimulate blood vessels to form can also stimulate the tumor to
grow so the tumor grows faster as a result of this.

Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao 7 of 11
 o more extensive a blood vessel network a tumor tends to have,
the more aggressive a tumor tends to be. There is an early
chance to metastasize because these blood vessels are not just
highways of nutrients that gets into the cell, they are also escape
route of the cell to go to other parts of the body.
 Metastasis cannot occur without angiogenesis. **Can be a
hallmark of tumor cell aggressiveness: more vascular = more
aggressive because the substances secreted by the tumor to create
new blood vessels are also GROWTH FACTORS so it helps the tumor
to grow.
 **Very large tumors = very vascular. This poses as a barrier in
cases where the tumors are extremely large and the slightest
manipulation would cause them to bleed due to their excessive
vascular nature. Example: Breast CA patient, stage 4, had a gauze
on her tumor to avoid soiling her clothes. Mere removal of the tape
caused the tumor to bleed.
HARRISON’S PRINCIPLES OF MEDICINE
TUMOR ANGIOGENESIS
 The diffusion limit for oxygen in tissues is 100 mm.
 A critical element in the growth of primary tumors and
formation of metastatic sites is the angiogenic switch: the ability
of the tumor to promote the formation of new capillaries from
preexisting host vessels.
o angiogenic switch- a phase in tumor development when the
dynamic balance of pro- and antiangiogenic factors is tipped in
favor of vessel formation by the effects of the tumor on its
immediate environment.
 Stimuli for tumor angiogenesis include hypoxemia,
inflammation, and genetic lesions in oncogenes or tumor
suppressors that alter tumor cell gene expression.
 Angiogenesis consists of several steps
o stimulation of endothelial cells (ECs) by growth factors
o degradation of the ECM by proteases
o proliferation of ECs and migration into the tumor
o eventual formation of new capillary tubes
 Tumor blood vessels
o Are not normal; they have chaotic architecture and blood flow.
o Due to an imbalance of angiogenic regulators such as VEGF
and angiopoietins, they are tortuous and dilated with an
uneven diameter, excessive branching, and shunting.
o Tumor blood flow is variable, with areas of hypoxemia and
acidosis leading to the selection of variants that are resistant
to hypoxemia-induced apoptosis (often due to the loss of p53
expression).
o Vessel walls have numerous openings, widened
interendothelial junctions, and discontinuous or absent
basement membrane; this contributes to the high vascular
permeability of these vessels and, together with lack of
functional intratumoral lymphatics, causes increased
interstitial pressure within the tumor (which also interferes
with the delivery of therapeutics to the tumor)
o Lack perivascular cells such as pericytes and smooth-muscle
cells that normally regulate flow in response to tissue
metabolic needs.
 Unlike normal blood vessels, the vascular lining of tumor vessels
is not a homogeneous layer of ECs but often consists of a mosaic
of ECs and tumor cells;
 the concept of cancer cell–derived vascular channels, which may
be lined by ECM secreted by the tumor cells, is referred to as
vascular mimicry.
Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao
 During tumor angiogenesis, ECs are highly proliferative and
express a number of plasma membrane proteins that are
characteristic of activated endothelium, including growth factor
receptors and adhesion molecules such as integrins.
B. GROWTH FACTOR AND ONCOGENES
Figure 14.
C. INVASION AND METASTASIS
Cancer cells invade surrounding tissues and blood vessels
Cancer cells are transported by the circulatory system to distant sites
Cancer cells reinvade and grow at new location system to distant sites
 The defining characteristic
 Least understood
 Events involved:
o Loss of cell-to-cell adhesion
 This is necessary because all normal cells can’t exist as a single
cell when removed from a tissue because they are dependent
on support from their adjoining cells. But the tumor cells, once
they lose the need for cell to cell adhesion, can now exist as a
single cell and can now achieve the capacity to become
motile. By becoming motile, it can now go from its primary site
to other parts of the body.
o Elaboration of proteases
 For cells to get into the other parts of the body, the malignant
cells need to break through barriers and the limiting barrier to
break through is always going to be the basement membrane.
To get through this, a tumor needs proteases to destroy the
membrane. Once this happens the tumor can seed to any part
of the body and create metastatic lesions.
 These events may occur before clinical detection
 Tumor spread:
o Direct invasion or contiguous spread
o Lymphatic invasion
o Hematologic invasion
o The more aggressive a malignancy tends to be, the higher the
chance that it is going to spread by hematogenous route.
 Clinical consequences:
o Treatment failure after local control
o Main cause of death in majority of cases
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 VII. PHENOTYPIC CHARACTERISTIC OF MALIGNANT CELLS
 Genetic instability to mutation
o Defects in DNA repair pathways leading to either single or oligo-
nucleotide mutations (as in microsatellite instability, MIN) or
more commonly chromosomal instability (CIN) leading to
aneuploidy.
o Caused by loss of function of p53, BRCA1/2, mismatch repair
genes, DNA repair enzymes, and the spindle checkpoint.
 Deregulated cell proliferation
o Loss of function of negative growth regulators (suppressor
oncogenes, i.e., Rb, p53), and increased action of positive
growth regulators (oncogenes, i.e., Ras, Myc).
o Leads to aberrant cell cycle control and includes loss of normal
checkpoint responses.
 Failure to differentiate
o Arrest at a stage before terminal differentiation.
o May retain stem cell properties.
o Frequently observed in leukemias due to transcriptional
repression of developmental programs by the gene products of
chromosomal translocations.
 Loss of normal apoptotic pathways
o Inactivation of p53, increases in Bcl-2 family members.
o This defect enhances the survival of cells with oncogenic
mutations and genetic instability and allows clonal expansion
and diversification within the tumor without activation of
physiologic cell death pathways.
 Loss of replicative senescence
o Normal cells stop dividing in vitro after 25–50 population
INK4a
doublings. Arrest is mediated by the Rb, p16 , and p53
pathways. Further replication leads to telomere loss, with crisis.
Surviving cells often harbor gross chromosomal abnormalities.
Relevance to human in vivo cancer remains uncertain. Many
human cancers express telomerase.
 Increased angiogenesis
o Due to increased gene expression of proangiogenic factors
(VEGF, FGF, IL-8) by tumor or stromal cells, or loss of negative
regulators (endostatin, tumstatin, thrombospondin).
 Invasion
o Loss of cell-cell contacts (gap junctions, cadherins) and increased
production of matrix metalloproteinases (MMPs).
o Often takes the form of epithelial-to-mesenchymal transition
(EMT), with anchored epithelial cells becoming more like motile
fibroblasts.
 Metastasis
o Spread of tumor cells to lymph nodes or distant tissue sites.
o Limited by the ability of tumor cells to survive in a foreign
environment.
 Evasion of the immune system
o Downregulation of MHC class I and II molecules; induction of T
cell tolerance; inhibition of normal dendritic cell and/or T cell
function; antigenic loss variants and clonal heterogeneity;
increase in regulatory T cells.
Abbreviations: FGF, fibroblast growth factor; IL, interleukin; MHC,
major histocompatibility complex; VEGF, vascular endothelial
growth factor. *From Harrison’s
VIII. HISTORY- ENVIRONMENT AND CANCER
 Bernardino Ramazzini o
o His attention was drawn to diseases suffered by workers.
o Ramazzini systematized the existing knowledge and made a
large personal contribution to the field by collecting his
observations in De Morbis Artificum Diatriba [Diseases of
Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao
Workers]. Each chapter of the De Morbis Artificum Diatriba
contains a description of the disease associated with a particular
work activity.
 John Hill
o Warned of the overuse of snuff or chewing tobacco because he
found out that it causes vulnerability to nasal and oral cancers
 Percival Pott
o He is the first one to describe squamous cell carcinoma of the
scrotum and noticed that it is only limited to children who are
chimney sweepers/cleaners.
IX. CARCINOGENESIS
A. INITIATION
 rapid, genotoxic, irreversible
 results in the formation of mutant DNA
 requires at least one round of cell division
 normal cells are exposed to a carcinogen
1.Direct-acting carcinogens
2.Indirect-acting carcinogens or procarcinogens
Procarcinogen
Cytochrome p450
Ultimate carcinogen
 If that exposure is stopped at the initial point, then the initiated
cell can be destroyed by the body’s immune system. Although this
produces an irreversible damage, as long as the damage is limited,
then there should be no progression to malignancy.
 When repeated exposures occur, then the phase of initiation
moves into the phase of promotion.
B. PROMOTION
 chronic, epigenetic, potentially reversible
 initiated cells are exposed to promoters
 promoters are not carcinogens
 properties of promoters
o reversible
o dose-dependent
o time-dependent
 slower mechanism;
 damage is at higher levels of DNA in cytoplasmic granules;
 potentially reversible if stopped at earliest possible time
 For you who are smoking (YES, YOU!) and you want to reverse the
effect of smoking, the minimum amount of time you need to stop
smoking to get back to the risk of a nonsmoker is 16 years! !
 The lesson here is if you really want to stop, stop NOW! Because if
you stop at 40 or 50 how many years do you have left for you to
get 16? Stop early because it’s the easiest.
 Hence, CARCINOGENESIS teaches us that the formation of a
malignant cell from an environmental factor can be stopped if
defect is recognized as early as possible. Those are principles that
will underlie the management of cancer patients in the preventive
setting.
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 X. CARCINOGENS  Vinyl chloride
 Occupation related causes o used in production of plastics once exposed the individual has
 Lifestyle related causes – biggest problem as far as malignancy is high risk of developing angiosarcoma and it involves the liver and
concerned can involve the brain
o Tobacco, Diet , Sexual practices  Benzidine
 Multifactorial causes o tumors of the bladder as well as lymphoproliferative tissues
 Viral carcinogens  Barrier protection is very important to prevent these types of
 Chemical carcinogens cancers as well as to recognize that an substance that an employee
is dealing with is carcinogenic
 Ionizing radiation
 LAG TIME Table 1. Summary of Occupational Carcinogens
Carcinogen Occupation Type of Cancer
Arsenic Mining, pesticide workers Lung, skin, liver
Asbestos Construction workers Lung, mesothelioma
Benzene Petroleum, rubber, chemical Leukemia
workers
Chromium Metal workers, electoplaters Lung
Leather dust Shoe manufacturing Nasal, bladder
Naphthylamine Chemical, dye, rubber workers Bladder
Radon Underground mining Lung
Soots, tars, oils Coal, gas, petroleum workers Lung, Skin, Liver
Figure 15. 20-year lag time between smoking and lung cancer. The lag time Vinyl chloride Rubber workers, polyvinyl Liver
between the exposure and the manifestation of malignancy is due to chloride
PROMOTION stage – it takes periods of time: if you start smoking now, the Wood dust Furniture manufacturing Nasal
effects will manifest 20 years later. Why is there a lag period? Nowell’s
hypothesis. The accumulation of mutations over time
B. LIFESTYLE-RELATED
A. OCCUPATION RELATED TOBACCO
METALS:  Amount of smoking is directly proportional to the development of
HUMAN cancer: the more one smokes, the higher the risk of developing
METAL CANCERS PRESENT IN malignancy.
CARCINOGEN?
Skin, lung, o The most carcinogenic substance ever produced by human
Wood preservatives
Arsenic bladder, Yes beings for commercial consumption
Glass, Pesticides
kidney, liver o It contains substances that contains thousands and thousands of
Nuclear weapons, substances that are carcinogenic
rocket fuel, ceramics,
Beryllium Lung Yes o The cancer plague of our generation
glass, plastic,
fiberoptic products o Many of the substances that are associated with occupational
Metal coatings, plastic carcinogens are contained in a single cigarette. That is how much
Cadmium Lung products, batteries, Yes carcinogenic tobacco is.
fungicides o Non smokers are still at risk due to secondhand smoke.
Automotive parts,  Tobacco-Related Malignancies
floor covering, paper, o Lung cancer
cement
Chromium Lung Yes o Pancreatic cancer
asphalt roofing,
anti-corrosive metal
o Bladder cancer
plating o Renal cancer
Cotton dyes, metal o Cervical cancer
coating, drier in paints
Kidney Probable
Lead varnishes and pigment ALCOHOL
brain carcinogen
inks, certain plastics  2nd most common carcinogenic substance produced by human
specialty glass beings for commercial consumption
Steel, dental fillings Nickel metal:
 Associated with liver cirrhosis and potential liver cancer
copper and brass Probable
Nasal cavity
Nickel permanent magnets carcinogen
lung DIET- RELATED RISK FACTORS
storage batteries, Nickel
glazes compounds: Yes RISK FACTORS TYPE OF CANCER
 Solvents Nitrates Gastric
Salt Esophageal
o Carbon tetrachloride and Chloroethylene solvents →
Low Vitamins A, C, E
malignancies of the blood and lymphoproliferative tissues. Low consumption of yellow- green veggies
 Pesticides High fat Low calcium Colon Breast
o very notorious for creating lymphomas and leukemias Low fiber Broiled or fried food Pancreatic Uterine
 Fibers Prostate
o Asbestos- notorious for mesothelioma Mycotoxins Liver
o Fibers of grains where the farmers are exposed to give rise to **If you eat grain, beans, legumes that are poorly stored and are infested
carcinomas of the lungs and nasal passages with certain fungi → AFLATOXINS

Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao 10 of 11
 Japanese = high rate of gastric CA due to high intake of pickles and
preserved food.
 The higher the caloric intake, the higher intake of red meat = the
higher the chance of developing colon cancer.
 People in New Zealand who have nothing there but cows and
sheep have increased risk of colonic CA while people in Nigeria who
have nothing to eat have low risk for developing colonic CA.
OVERWEIGHT and EXERCISE
 WEIGHT – not an actual risk factor per se, but once present, can
aggravate any other risk factor present.
 Recommended: BMI = 25 or less and to exercise at least 3 times a
week for at least 30 minutes.
SEXUAL PRACTICES RISK FACTORS
RISK FACTOR TYPE OF CANCER
Sexual promiscuity Cervical
Multiple partners ** Notice that it is only Cervical CA → because the
Unsafe se length of the urethra of men protect htem from HPV
HPV infection- men are the ones that are most affected
Higher prevalence of cervical CA to those women infected with HPV
(vs. those who are not). Vaccine is available that can prevent the
onset. Advise vaccination BEFORE sexual contact because it is
theorized that once you have sexual contact, you have been exposed
to HPV.
C. MULTIFACTORIAL FACTORS
 Tobacco + Alcohol → Oral Cavity Cancer
 Tobacco + Asbestos
Respiratory Tract
 Tobacco + Mining Cancer, Lung Cancer
 Tobacco + uranium + radium
 Combination of cigarettes with alcohol potentiates the
carcinogenic property of both substances. This is because the
carcinogenic substances in smoke become soluble in the presence
of alcohol therefore it is easily absorbed by mucosal surfaces.
 Effect is synergistic: Smoking alone = 7-8% risk of developing
cancer, Drinking more than 4 bottles alone = 7-8% risk of
developing cancer, Smoking + Drinking more than 4 bottles = 40
times more risk of a non smoker
EFFECTS OF ALCOHOL AND TOBACCO:
Figure 16. Combination of Alcohol and Cigarettes increases risk for Cancer of
the Esophagus
D. MEDICATIONS AS CARCINOGENS
 Anti-CA Treatment
o Anti-CA treatment can damage DNA. Their potential to develop
malignancies exists. Therefore it is not unusual for those who
have been on therapy for malignancies when they were younger
develop secondary malignancies 10, 15, 20 years after.
 Aromatase Inhibitors
Group # 14| Khey Domingo, Chari Doria, Judge Du, Geli Eamilao
E. SYNTHETIC HORMONES
 The use of estrogens in post-menopausal women to alleviate the
post-menopausal symptoms can increase the development of
breast cancer
 And in women given diethylstilbestrol to alleviate the symptoms of
pregnancy like nausea. The problem is that is passed on to the
female fetus and that fetus can be at risk for developing
endometrial malignancy later on
F. IONIZING RADIATION
 Includes electromagnetic rays & particulate matter
 Mechanism: ↑ free radicals & mutations
 Pathology: leukemias > thyroid ca > lung & breast ca
 Radio Resistant tissues: bone, skin and the GIT
 Radiation because it produces free radicals
 The most sensitive is the bone marrow, followed by the thyroid
gland, followed by the breast and the lungs
G. SOURCES OF POTENTIALLY CARCINOGENIC RADIATION
 Sunlight
o Most common source
o High risk for skin cancer and melanoma
o Use a skin protective factor of 15 or higher during dangerous
times of the day
 Artificial sources of UV light
 X-rays (radiotherapy)
o Generates peroxidases (free radicals) which damage the DNA.
 Radio-chemicals
 Nuclear fission
H. VIRAL CARCINOGENESIS
 Viral carcinogens are classified into RNA and DNA viruses.
 Most RNA oncogenic viruses belong to the family of retroviruses
that contain reverse transcriptase → mediates transfer of viral
RNA into virus specific DNA.
I. VIRUSES ASSOCIATED WITH HUMAN NEOPLASIA DEVELOPMENT
Remember: HPV – Cervical Cancer, EBV – Nasopharyngeal
Carcinomas and Hepatitis B virus – Hepatocellular Carcinomas.
J. BACTERIAL: Helicobacter pylori
 creates ulcers in GIT-ulcerated areas are areas of continuous
proliferation and repair
 chronic repair/proliferation process can eventually get out of
hand and give rise to malignancy
 many patients with gastric cancers have history of chronic peptic
ulcer disease
 common ulcer sites: esophagus, stomach, small intestine, large
intestine
 the only bacteria associated with risk for developing cancer
 Infectious carcinogens --- Viral and lone bacterial cause of
malignancy which is H. Pylori
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