‘Another example is the deletion of asparagine synthetase in attain lymphomas. Why Cancer Cells are Immortal? (One reason is that cancer cells have increased and persistent aclvity of telomerase, the enzyme that maintains the length of telomeres (end region of chromosomes). See Fig. 40.19. Apoptosis Programmed cell death is called apoptosis (see Chapter 42), itis a Greek word, meaning “falling of leaves". In normal ‘organs, the number of cells newly produced will be equal to the number of cells dead. In those cells which are progressing to apoptosis, there will be condensation of chromatin, shrinking of cells, DNA fragmentation and finally integration of the cell. Examples of apoptosis mediating genes (suicidal genes) are c-fos, p53, Rb; and so they in {urn are oncosuppressor genes. By the same argument, apoptosis protecting genes are cancer producing genes, e.g bbck2 and other oncogenes. Tumor Immunology All forms of treatment of cancer (surgery, radiotherapy and chemotherapy) leave some residual cancer cells in the body. ‘These are annihilated by the body's immune mechanism. All the effector arms of immunological mechanisms described in Chapter 49 are active against cancer cells. These are (a) T cells, (b) NK cells, (c) antibody dependent complement mediated lysis, (d) antibody dependent cell mediated cytolysis {ADCC), and (e) macrophages. Bumet (Nobel prize, 1960) had postulated that the major purpose of immunological system is the surveillance against spontaneously occurring ‘cancer cells. In the tumor bearing host, appreciable level of immunological reaction against the cancer is detected. This is because of the presence of tumor associated antigens (TAA) on the surface of cancer cells. Virally induced tumors show virus-specific antigens. The ‘same virus may produce tumors in different species; but all of them carry same antigen. This is because the virus is integrated at specific regions of the DNA, causing the same alterations in all the instances. Chapter 51; Biochemistry of Cancer ™ 575 Chemically induced cancers show individually specific antigens. The same carcinogen injected at two diferent sites of the same animal may produce two tumors, with distinct antigens. This is because chemicals react with DNA at random sites, causing mutations at different loci. Most of the human cancers show the emergence of oncofetal antigens. Oncofetal Antigens During the fetal life, a particular gene is active, and the product, a protein is therefore produced in the cell (Fig. 51.8). During the differentiation process, this gene is suppressed and therefore the protein is not present in adult cells. However, along with the malignant transformation, de-differentiation ‘occurs, the gene is derepressed and the protein is again available in the cell, Such products are classified as oncofetal proteins. The best examples are the appearance of alpha- fetoprotein (AFP) in hepatomas and carcinoembryonic antigen (CEA) in colon cancers. They generally serve as tumor markers, TUMOR MARKERS They are also called as tumor index substances. They are factors released from the tumor cells, which could be detected in blood and therefore indicate the presence of the tumor in the body. They are useful for the following purposes. a. For follow-up of cancer and to monitor the effectiveness of the therapy and also to detect the recurrence of the tumor (Fig. 51.8). b. To facilitate detection of cancer. The presence of tumor marker suggests the diagnosis, but caution is to be taken to rule out other non- malignant conditions. ¢. For prognosis. Serum level of the marker may indicate roughly the tumor load, which in turn indicates whether the disease is curable or not. d. For localisation. Experimentally it is shown that radiolabeled antibodies against the marker will be fixed on the tissues producing the marker. Embryonic antigens expressed f Embryonic call, ‘Antigen is not expressed [Normal adult colt Embryonal antigen re-expressed (tumor e repressed "900 ———_>. Gene is de-ropressed Malignant cell Fig. 51.8. Oncofetal antigen576 ™ Textbook of Biochemistry; Section G: Advanced Biochemistry Table 51.8. Common tumor markers Name ‘Serum level increased in Carcino embryo- cnie antigen (CEA) Colorectal, gastrointestinal, land lung cancer Tissue Antigens Tissue polypeptide antigen General cancer load Placental type ALP (Regan) Lung, seminoma Prostate Specific Antigen (PSA) Hormones and their Metabolites Prostate cancer Beta-HCG Choriocarcinoma Big ACTH ‘Lung oat cell cancer Vanilyl mandelic acid Pheochromocytoma (vMA) and neuroblastoma Tissue Catabolic Product Hydroxy proline Bone metastasis Bence-Jones proteins Multiple myeloma (in urine) e. Precautions: Tumor markers are sometimes elevated in nonmalignant conditions. Not every tumor will cause a rise in the level of its associated marker, especially in the early stages of some cancers. When a marker is used for cancer screening or diagnosis, the physician must confirm a positive test result by using imaging studies, tissue biopsies, and other procedures. Clinically Important Tumor Markers 1. Alpha Fetoprotein (AFP) In 1963, Abelev demonstrated AFP. Its molecular weight is 70,000 D . It is fetal albumin and has sir fies with adult albumin. It is increased in the circulation of patients with hepatocellular carcinoma, germ cell tumors, teratocarcinoma of | ovary and in pregnancy with fetal malforniations of neural tube (Table 51.8). In adult males and nonpregnant females, normal value is less than 15 ng/L. A value of AFP above 300 ng/L is often associated with cancer, although levels in this range may be seen in nonmalignant liver diseases. Levels above 1000 ng/L are almost always associated with cancer (except in pregnancy). The gene for AFP is, located in chromosome No. 4. 2. Carcinoembryonic Antigen (CEA) CEA level is markedly increased in colorectal cancers. Its molecular weight is 1,85 kD (Tabie 51.8). In 1965, Gold and Freedman identified the CEA. Over 50% of persons with breast, colon, lung, gastric, ovarian, pancreatic, and uterine cancer have elevated levels of CEA. CEA levels may also be elevated in inflammatory bowel disease (IBD), Pancreatitis, and liver disease. Heavy smokers and about 5% of healthy persons have elevated plasma levels of CEA. 3. Beta Chain of Chorionic Gonadotropin Beta-HCG is synthesised by normal syncytio trophoblasts (cells of placental villi). Its molecular weight is 45 kD. HCG is a glycoprotein; it has alpha and beta subunits. The alpha subunit is identical with those of FSH, TSH and LH. The beta subunit is specific for HCG. It is increased in hydatidiform mole, choriocarcinoma and germ cell tumors (Fig. 51.9.). About 60% of testicular cancers secrete hCG. Normal value is less than 20 IU/L for males and non-pregnant females. Greater than 100,00 IU! L indicates trophoblastic tumor. 4. Cancer Antigen 125 (CA-125) CA-125 is a tumor maker for ovarian cancers. Itis a glycoprotein with a molecular weight of 10 milion; one of the biggest molecules identified. The name is so given because it reacted with a monoclonal antibody, originally termed as OC-125 (Bast, 1981). Approximately 75% of persons with ovarian cancer will have elevated serum levels. (50% of persons with stage | disease and 90% with stage Il). Elevated levels of CA-125 are also found in approximately 20% of persons with pancreatic and digestive tractcancers. CA-125 levels correlat consequently, this testis used recurrence of the cancer ha: chemotherapy. Normal blood than 35 U/mL. te with tumor mass; to determine whether S Occurted following level of CA125 is less 5, Tissue Polypeptide Antigen (TPA) Itwas isolated by Bjorklund in 1957. Itis a common human carcinoma antigen, produced during G2 phase and released into surrounding fluids during mitosis. It is not specific for cancer of a particular site; but itis useful to assess the activity of the tumor. Itis seen in blood as long as the tumor cells proliferate. The TPA blood test is sometimes used along with other tumor markers to help follow Patients being treated for lung, bladder, and many other cancers. 6. Prostate Specific Antigen (PSA) Chu isolated it in 1980. It is produced by secretory epithelium of prostate gland. Itis normally secreted into seminal fluid, where it is necessary for the liquefaction of seminal coagulum. It is a 32 kD glycoprotein. It is a protease, and in serum it is ‘seen complexed with alpha-1-antitrypsin. The PSA level, especially the complexed form, is increased in prostate cancers. PSA has been found to be elevated in 60-70% patients with cancer of the Prostate. Most PSA is bound to antitrypsins in plasma but some PSA circulates unbound to protein (free PSA). Normal blood level of total PSA is less than 4 ng/L. Persons with a borderline total PSA (between 4-10 ng/L), but who have a low free PSA are more likely to have malignant prostate disease. Other Tumor Markers used occasionally Estrogen Receptor (ER) ER is a protein found in the nucleus of breast and uteri {ssues. The level of ER in the tissue is used o determine ‘whether a person with breast cancer Is likely to respon therapy with tamoxifen, which binds to the receptors blocking the action of estrogen. Women who are ER-negative have a ‘eater risk of recurrence than women who are ER-postive Less than 6 fertomol/mg protein is negative; greater than 10 fmolimg protein is positive. ey Faeroe ees, nich ar lean the nul of both breast and uterine tissues. PR has the same prognostic at nn moocured by simlar maode Tissue Wave CS xyes to Pt rocoto les aly Dd Catogen andope used o oa te moe Pron ho at “eee Chapter 51; Biochemistry of Cancer = 577 Concentration in agi! ; Months after teament iia treatment Fig. 51.9. Monitoring of serum level of beta-HCG in chorionic carcinoma (The level is decreased after treatment and goes up when the recurs) negative for both ER and PR have less than a 6% chance of responding to endocrine therapy. Those who test positive for both markers have greater than a 60% chance’ of tumor shrinkage when treated with hormone therapy. Normal value is less than 6 femtomol/mg protein. Greater than 10 fmolmg protein is positive, Nuclear Matrix Protein (NMP22) NMP22 is a structural nuclear protein that is released into the urine when bladder carcinoma cells die. Approximately 70% of bladder carcinomas are positive for NMP22. Bladder Tumor-assoclated Analytes (BTA) BTA is comprised of type IV collagen, fibronectin, laminin, and proteoglycan, which are components of the basement ‘membrane that are released into the urine when bladder tumor cells attach to the basement membrane of the bladder wall ‘These products can be detected in urine using a mixture of antibodies to the four components. BTA is elevated in about 30% of persons with low-grade bladder tumors and over 60%, of persons with high-grade tumors. ‘Beta-2-Microglobulin (82M) 'B2M blood levels are elevated in multiple myeloma, chronic lymphooytic leukemia (CLL), and some lymphomas. Levels may also be higher in some non-cancerous kidney disease. Normal levels are usually below 2.5 mg/L. : B2M is useful to help predict the long-term prognosis n these cancers. Patients with higher levels of B2M usually have a poorer prognosis. ‘B2Mis also checked during treatment of multiple myeloma to see how well the treatment is working, Bladder Tumor Antigen (BTA) BTA is found in the urine of many patients with bladder ‘cancer. It may be seen in some non-cancerous conditions such as kidney stones.or urinary tract infections. It Is sometimes used along with NMP22 to test patients for the recurrence of bladder cancer. This test is not often used.(a RN SR TT 578 m@ Textbook of Biochemistry; Section G: Advanced Biochemistry Calcitonin Itis a hormone produced by cells called perafollicular C cells the thyroid gland (see Chapter 35). Itnormally helps regulate blood calcium levels. Normal calcitonin levels are below 5 to 12 pgimi (picograms per milliliter) (A picogram is 10-"2of a gram.) In medullary thyroid carcinoma (MTC), a cancer of Parafollicular C cells, blood levels of calcitonin are often greater than 100 pg/ml. This is one of the rare tumor markers that can be used to help detect early cancer. Because MTC is often inherited, blood calcitonin can be measured to detect the cancer in its very earliest stages in family members who are known to be at risk HER2Ineu (or erbB-2, or EGFR2) HERZ is a protein that stimulates breast cancer cells to grow. Higher than normal levels can be found in some other cancers, too. The HERZ level is usually found by testing a sample of the cancer tissue itself, not in blood, HER2 testis positive in about 1 in 5 breast cancers. These cancers tend to grow and Spread more aggressively than other breast cancers. Allnewly lagnosed breast cancers should be tested for HER2. HER2- Positive cancers are more likely to respond to certain treatments such as trastuzumab (Herceptin) and lapatinio (Tykerb), which work against the HER2 receptor on breast cancer cells. Nouron Specific Enolase (NSE) NSE is a marker for neuroendocrine tumors such as small cell lung cancer, neuroblastoma, and carcinoid tumors. It is most useful in the follow-up of patients with small cell lung cancer or neuroblastoma, Elevated levels of NSE may also be found in some non-neuroendocrine cancers. Abnormal levels are usually higher than 9 ug/ml (micrograms per milter) Table 51. Mercaptopurine Purine analog Thyroglobutin Thyroglobulin is a protein synthesised by the thyroid gland, Thyroglobulin levels are elevated in many thyroid diseases, including some common forms of thyroid cancer. Treatment for thyroid cancer often involves removal of the entire thyroid gland. Thyroglobulin levels in the blood should fall to undetectable levels after treatment. A rise in the thyroglobulin level may indicate the recurrence of cancer. In some persons, antithyrogiobulin antibodies may be present in circulation, which can affect test results. This is why levels of anti. thyroglobulin antibodies are often measured at the same time. Paraproteinemias and multiple myeloma are described in Chapter 49. Oncofetal proteins and tumor markers are listed in Table 51.8. ANTICANCER DRUGS Surgery and radiotherapy are most effective to reduce the initial tumor load. These are the prime Modalities of treatment in solid tumors. Chemo- therapy is the sheet anchor of therapy in leukemias, advanced lymphomas, choriocarcinoma and other widely disseminated malignancies. The effectiveness Of cytotoxic drugs is directly proportional to the doubling time of the tumors, and is inversely Proportional to the number of cancer cells. Cytotoxic drugs affect all the cells which are in the dividing phase. Rapidly dividing normal cells (gastrointestinal tract, hematopoietic system, hair follicles, gonads) are also affected by chemotherapeutic drugs, leading to toxicity. In fact, pharmacological dose and tox: dose usually overlap in the case of these drugs. Common anticancer drugs Mode of action Inhibits the conversion of IMP to AMP ‘Stthioguanine | Purine/analog. Inhibits synthesis of purine nucieatides”""" Alkylating ager nt Adriamycin Etopos c S Camptothecin Cross linking of bases of DNA; inhibition of strand separation ‘bridges are formed between DNA|base i Intercalates with guanine bases of DNA; prevents transcription novem Leica mara me sis (i dim wn Ree aS Topo-isomerase mediated breaks in DNA 2s topo-somaraJLONA cleavage complexes Modifies function of topo-isomerase-| to DNA breaking agent cisplatin “Platinum compound Forms intrastrand DNA adducts) ee Imatinib Monoclonal antibody Tyrosine kinase inhibitor pe Ee