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CANCER&Genetics,Cell Biology,
ANN MEREDITH U. GARCIA, MD, FPCP, DPSMO, MCMMOInternal Medicine – Medical Oncology
Angiogenesis
Harrison’s Principles of Internal Medicine 19E
Characteristics & types of cancer
Tissue invasion
Avoidance of cell death Ability to metastasize
Unregulated cell division
CANCER TYPE TISSUE OF ORIGINCarcinomas Epithelial tissueSarcomas Mesenchymal tissuesLeukemiasLymphomasPlasma cell dyscrasias
Hematopoietic tissue
CANCER
Cancer is a genetic disease…
http://web2.uconn.edu/http://www.bu.edu/
…with a clonal origin
http://www.nature.com/
Critical discriminating feature between neoplasia and hyperplasia
The multistep nature of cancer
Multiple cumulative mutational events
http://img2.tfd.com/
Types of cancer genes
ONCOGENES+ (+) = +
– Positive influence on tumor formation– Tightly regulated in normal cells, but acquire activating mutations in cancer cells– Mutations typically occur in a single allele (dominant)
TUMOR-SUPPRESSOR GENES
- (-) = +
– Negative impact on tumor growth– Loss of function in cancer cells– Knudson’s two-hit hypothesis: Both alleles must be inactivated for a cell to completely lose function (recessive)
Gatekeeper genes – Directly regulate tumor growthCaretaker genes (i.e., DNA mismatch repair genes)
– Affect cell growth indirectly, but control the ability of the cell to maintain the integrity of its genome– “Mutator” phenotype
Exert their effects on tumor growth through their ability to control cell division (cell birth) or cell death (apoptosis)
Oncogenesvs. tumor-suppressor genes
http://cisncancer.org/
The bad guys, turn abnormal cell growth on (go/gas pedal)
The good guys, turn cell growth off(stop/brake pedal)
Oncogene activation
http://23pairsofchromosomes.com/
• KRAS• Melanoma• Colorectal CA• Acute myeloid
leukemia (AML)• BRAF
• Melanoma• Lung CA• Colorectal CA
• ERBB2 (HER2)• Breast CA• Ovarian CA• Gastric CA• Neuroblastoma
• N-MYC• Neuroblastoma• Lung CA
• t(9;22) or BCR-ABL (Philadelphia chromosome)• Chronic myeloid
leukemia (CML)• t(8;14)
• Burkitt’s lymphoma
Oncogene activation
http://www.cubocube.com/
Oncogene products have been found to function at critical stepsin growth factor pathways.
Oncogene activation
Tumor-suppressor gene inactivation
http://slideplayer.com/
Loss of heterozygosity (LOH) in tumor DNA is considered a hallmark for the presence of a tumor-suppressor gene at a particular tumor location.
• Two major types of somatic lesions• Point mutations• Large deletions
Tumor-suppressor gene inactivation
Ahmed H. Biomarkers in Cancer. 2010;2:17–33
Gene silencing is an epigenetic change that leads to the loss of gene expression and occurs in conjunction with promoter hypermethylation and histone deacetylation.A general decrease in the level of DNA methylation is a common change in cancer.
Viruses* in human cancer
VIRUS ASSOCIATED CANCERSEpstein-Barr virus (EBV) Burkitt’s lymphoma
Hepatitis B virus (HBV) Hepatocellular CA
Human papillomavirus (HPV)
Cervical CA, anal CA, oropharyngeal CA
Human T-cell lymphotropic virus (HTLV)
T cell leukemia
Human herpesvirus 8 (HHV-8)
Kaposi sarcoma
http://medchrome.com/
Activation of growth-promoting pathways or inhibition of tumor-suppressor products in the infected cells*Not sufficient for cancer development
The hallmarks of cancer
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
Signal transduction pathways
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
An elaborate integrated circuit operates within normal cells and is reprogrammed to regulate hallmark capabilities within cancer cells.
The hallmarks of cancer
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
Hallmark #1
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Loss of function of negative growth regulators & increased action of positive growth regulators
• Aberrant cell cycle control & loss of normal checkpoint responses
Cell cycle checkpoints
Rb
p53
Chromosomal instability
van Jaarsveld RH & Kops GJPL. Trends in Cancer. 2016;2(10):561-571
A number of mitotic checkpoint genes are found mutated or abnormally expressed in various tumors.
Solid tumors are generally highly aneuploid, containing an abnormal number of chromosomes.
Hallmark #2
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Inactivation of p53 & increases in Bcl-2 family members
• Enhanced survival of cells with oncogenic mutations & genetic instability
• Clonal expansion & diversification within the tumor without activation of apoptotic pathways
Inhibition of apoptosis
Petronelli A, et al. Drugs Fut. 2005;30(7):707
The evolution of tumor cells to a more malignant phenotype requires the acquisition of genetic changes that inhibit apoptotic pathways and promote cancer cell survival and resistance to anticancer therapies.
EXTRINSIC PATHWAY INTRINSIC PATHWAY
Hallmark #3
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Loss of Rb, p16, & p53 pathways
• Telomerase expression
Telomere shortening & senescence
Resonance Research Foundation, Inc.
DNA polymerase is unable to replicate the tips of chromosomes
Loss of telomeric repeats & gradual telomere shortening
p53-regulated DNA-damage checkpoint response
Senescence or growth arrest
Reactivation of telomerase expression
in cancer cells
Nonfunctional pRB & p53
Hallmark #4
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Nonresponsiveness to external growth-inhibiting signals
Gompertzian tumor kinetics
http://highered.mheducation.com/
The growth fraction of a tumor declines exponentially with time.Not every daughter cell produced by a cell division is itself capable of dividing.
Hallmark #5
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Increased gene expression of proangiogenic factors by tumor or stromal cells
• Loss of negative regulators
Angiogenic switch
Markkanen JE, et al. Cardiovasc Res. 2005;65(3):656-664
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
SPROUTING
Angiogenic switch
Koch AE & Distler O. Arthritis Res Ther. 2007;9(Suppl 2):S3
Abnormal tumor vasculature
Cao Y. Front Biosci. 2009;14:3962-3973
Hallmark #5
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Epithelial-mesenchymal transition (EMT): Loss of cell-cell contacts & increased production of matrix metalloproteinases
Epithelial-mesenchymal transition (EMT)
Angadi PV & Kale AD. Indian J Health Sci Biomed Res. 2015;8:77-84
Malignant cells that metastasize undergo EMT as an important step in that process but retain the capacity for unregulated proliferation.
Metastasis
Emerging hallmarks &enabling characteristics
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
Enabling characteristic #1
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Defects in DNA repair pathways
• Accumulation of a variety of mutations & heterogeneity
Enabling characteristic #2
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Production of tumor-promoting bioactive molecules to the tumor microenvironment
• Release of chemicals, notably reactive oxygen species, that are actively mutagenic
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
Both the parenchyma and stroma of tumors contain distinct cell types and subtypes that collectively enable tumor growth and progression.The immune inflammatory cells present in tumors can include both tumor-promoting as well as tumor-killing subclasses.
The dynamic tumor microenvironment
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
The dynamic tumor microenvironment
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
The dynamic tumor microenvironment
Emerging hallmark #1
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Downregulation of MHC class I & II molecules
• Induction of T cell tolerance• Inhibition of normal
dendritic cell &/or T cell function
• Antigenic loss variants & clonal heterogeneity
• Increase in regulatory T cells
Tumor-host interactions that suppress the immune response to the tumor
Immune checkpointsT-cell activation is kept under check through inhibitory signals from the interaction of CTLA-4 and its ligands, CD86 or CD80.The interaction between the PD-L1 and PD-1 receptors also leads to inhibition of T-cell activation and effector function.
Emerging hallmark #2
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
• Shift to aerobic glycolysis
Warburg effectProliferative tumor tissues, especially in the setting of hypoxia, use aerobic glycolysis to generate energy for cell survival and generation of building blocks for new cells.
CLINICALImplications
Familial cancer syndromes
Ambry Genetics
The affected individuals have a predisposing loss-of-function mutation in one allele of a tumor-suppressor gene.
Familial cancer syndromes
Ambry Genetics
Autosomal dominant – majorityAutosomal recessive – DNA repair abnormalities (xeroderma pigmentosum, Fanconi’s anemia)
Familial cancer syndromesSYNDROME GENE ASSOCIATED TUMORS
Familial adenomatous polyposis (FAP)
APC Intestinal adenoma, colorectal
Hereditary breast/ovarian cancer (HBOC)
BRCA1BRCA2
Breast, ovarian, colon, prostate
Hereditary nonpolyposis colon cancer (HNPCC) or Lynch syndrome
MSH2MLH1MSH6PMS2
Colon, endometrial, ovarian, stomach, small bowel, ureter
Li-Fraumeni syndrome TP53 Sarcoma, breastMultiple endocrine neoplasia (MEN)
Type 1Type 2a
MEN1RET
Parathyroid, endocrine, pancreas, pituitaryMedullary thyroid carcinoma, pheochromocytoma
von Hippel-Lindau syndrome
VHL Kidney, cerebellum, pheochromocytoma
Risk factors for hereditary cancer
Family history of cancerHaving 3 or more relatives on the same side of
the family with the same or related forms of cancer
Cancer at an early ageHaving 2 or more relatives diagnosed with
cancer at an early age, which may be different depending on the type of cancer
Multiple cancersHaving 2 or more types of cancer occurring in
the same relative
American Society of Clinical Oncology
Genetic testing
Personalized cancer treatmentbased on molecular profiles(precision medicine/targeted therapy)Dependent on the identification of sufficient actionable changes (mutations or pathways that can be targeted with a specific drug)
MUTATION TARGETED DRUG INDICATIONS
ALK Crizotinib Non-small cell lung CA (NSCLC)BCR-ABL Imatinib Chronic myeloid leukemia (CML)
Acute lymphoblastic leukemia (ALL)Gastrointestinal stromal tumors (GISTs)
BRAF Vemurafenib Malignant melanomaEGFR Erlotinib Non-small cell lung CA (NSCLC)
Pancreatic CA
Therapeutic targeting of the hallmarks of cancer
Hanahan D & Weinberg RA. Cell. 2011;144:646-674
Thank you!