CANCER

Cancer is a group of diseases characterized by uncontrolled

growth and spread of abnormal cells. If the spread is not
controlled, it can result in death.
(American Cancer Society)
 INCIDENCE of CANCER

- is a common disease
- 1 person in 3 can expect to contract cancer at some
stage in their life
-1 person in 5 can expect to die from it

-worldwide, 100-350 of every 100,000 people will die of

cancer each year
- given a global population of about 6.4x109, this implies
6.4 t0 22.4 million people will die this year
 TUMOUR CLASSIFICATION

BENIGN TUMOURS

Develop in any tissue

• grow locally

• May cause problems by pressure (brain) or obstruction ( colon)

• Histologically resemble the tissue of origin

• Covering or lining tissues of skin, intestine, bladder etc may produce

wart-like outgrowths containing all cell types

• In other situations only one cell type may be present- may produce an
excess of particular hormone

• Benign does not mean ‘completely harmless’

• Do not spread to distant sites

 TUMOUR CLASSIFICATION

IN SITU TUMOURS

Usually develop in the epithelium

Usually small
• Have altered histological appearance
• Loss of normal arrangement of cells
• Variations in cell size and shape, increase in nucleus size and
staining ( increased DNA ), presence of abnormal chromosomes
• Do not invade basement membrane and supporting mesenchyme
 TUMOUR CLASSIFICATION

CANCERS

Fully developed malignant tumours with the specific capacity

to invade and destroy the underlying mesenchyme.
• Metastasise
• Stimulate angiogenesis and development of blood
supply
• difficult to treat.
Two Broad Classes of Genes are Involved in the Onset of Cancer

1). Proto-oncogenes
activated by mutation to become oncogenes,- excessively
active in growth promotion.

2). Tumour Suppressor genes

normally restrain cell growth- damage to these genes allows
inappropriate growth

Many of the genes in both classes code for proteins involved in

• entry into, and passage through, the cell cycle
• cell death by apoptosis
• repair of damaged DNA
Chemical Carcinogens

-Earliest example 1775 coal tar and skin cancer

-Later, 2 – naphthylamine as a bladder carcinogen

-Wide chemical diversity and many ( eg polycyclic aromatic

hydrocarbons) show great chemical stability.

- Now known to be converted to highly reactive compounds

by detoxification enzymes in the liver.

-Guanine is often converted to methyl guanine, acts like

adenine and pairs with thymidine in the copied strand-
hence G-C pair is converted to A-T pair as point mutation.
3 ways in which cancer cells become growth signal autonomous.

- modulation of growth factor provision

- modulation of growth factor receptor activity

- modulation of intracellular signalling pathways

 Self Sufficiency in Growth Signals

ii). Modulation of growth factor receptor activity

Many growth factor receptors are protein tyrosine kinases

Overexpression allows tumours to respond to low levels of growth
factor that would not normally produce a growth response.

EGF-R ( the receptor for EGF) and Erb-B ( the receptor for hereglulin )
are upregulated in stomach, brain and breast tumours.

HER2/neu is overexpressed in stomach and breast tumours

Overexpression of GF receptors may result in ligand –independent

signalling.
 Self Sufficiency in Growth Signals

ii). Modulation of growth factor receptor activity

(cont)

Receptors may become structurally altered- ligand independent as a

result.
Truncated versions of the EGF receptor lacking the cytoplasmic
domain are constitutively active

Alteration of integrins expression (ECM receptors) to those favouring

growth.

Ligand activated GF receptors and pro-growth integrins attached to

ECM often activate the SOS-Ras-Raf-MAP Kinase pathway.
 Self Sufficiency in Growth Signals

iii). Modulation of intracellular signalling

pathways

Frequently involves the SOS-Ras –Raf- MAPK cascade

About 25% of human tumours have a mutated Ras protein.
(90% pancreas, 50% colon, 30% lung -- the first oncogene
discovered in human tumours))
--- mitogenic signals are transmitted without any upstream
activation of the pathway

Ras also interacts with PI3 kinase

This enables growth signals to simultaneously generate survival signals
ie. Signals which protect against apoptosis
 Insensitivity to Antigrowth Signals

Tumours have developed several ways to block TGFß action

•Expression of TGFß receptor is down regulated

•The receptor is mutated to a less active form
•Intra-cellular signalling is disrupted by-
•Mutation of Smad
•Loss of p15
•Mutation of CDK4 to be less p15 sensitive
•Mutation of Rb
 Insensitivity to Antigrowth Signals

Tumours have developed several ways to block TGFß acting through Rb

In some DNA – virus induced tumours ( cervical carcinomas) Rb is

inactivated by being complexed with a viral protein .

In human cervical tumours this is the E7 protein of human papilloma virus

 Insensitivity to Antigrowth Signals

Cancer cells can also

•Turn off the expression of cell adhesion molecules that
transmit antigrowth signals
•These probably act through Rb also
 Insensitivity to Antigrowth Signals

Some tumours have developed mechanisms for differentiation

One such mechanism involves the c-myc oncogene

 Evasion of Apoptosis

Hormone dependent tumours undergo massive apoptosis if the

hormones were removed.

Suggested that increased cell growth and apoptosis occurred at

the same time

Apoptosis may be switched on by oncogene overexpression

Elimination of cells with activated oncogenes by apoptosis may
be the primary means by which mutant cells are continually
removed from the body’s tissues.

For a tumour to progress it has to inactivate the apoptopic machinery

 Evasion of Apoptosis

In 50% of lymphomas, there is a mutation in c-myc

and a mutation in bcl-2

Further evidence for a myc-bcl-2 interaction

Fibroblasts overexpressing myc grown in culture

In low serum the c-myc expressing cells show high apoptosis
Increased apoptosis could be abolished by
•Addition of survival factors such as IGF-1 to the medium
•Overexpression of Bcl-2 or Bcl-XL
•Disruption of the FAS pathway
 Evasion of Apoptosis

In transgenic mice,
•Inactivation of Rb ( expected to increase cell proliferation)
produced slow growing microscopic tumours with a high rate of
apoptosis
•Additional inactivation of p53( a key mediator of apoptosis) in the
same cells produced rapidly growing tumours

•Mutation of p53 and the presence of a mutated p53 protein is

extremely common in human tumours ( greater than 50%)

Some lung and colon cancers produce a decoy non-

signalling receptor for the FAS ligand
 Limitless Replicative Potential

Why should tumour cells need to become ‘immortalised’?

Normal human cell types have the capacity for 60–70 doublings.

This should enable clones of tumor cells to expand to numbers

that vastly exceed the number of cells in the human body.

There seems to be no sense in the idea that the tumour cells have
to become immortal in order for malignant tumour growth to occur

But……

During tumour development there is widespread apoptosis along side the

increased cell division.

The number of cells in a tumour greatly under represents the cell

divisions required to produce it.

Thus the generational limit of normal somatic cells may be a barrier to

cancer development.
 Limitless Replicative Potential

Telomeres

Telomeres are simple-sequence DNA repeats found at the end of chromosomes

Human telomeres contain 250-1500 copies (6-12 kb) of the sequence TTAGGG

At each cell division, 50–100 bp of telomeric DNA are lost from the
ends of every chromosome
DNA polymerases are unable to completely replicate the 3′ ends.

Progressive shortening of the telomeres occurs with each division.

Eventually the telomeres lose the ability to protect the ends of the
chromosomes

This results in end to end chromosomal fusion and the death of the
affected cell.
 Limitless Replicative Potential

Telomeres

…………..and Telomerase

Telomere maintenance occurs in just about all malignant cells

The majority (85%–90%) upregulated expression of an enzyme called
telomerase
This adds hexanucleotide repeats onto the ends of telomeric DNA.

The telomeres are thus kept at a length above a critical threshold

which allows for unlimited multiplication of descendant cells.
 Sustained Angiogenesis

Normal Cells and Tissues

Cells in a tissue need to be within 100μ of a capillary blood vessel

This closeness is achieved during organ development and once a tissue is
formed, the growth of new blood vessels—the process of angiogenesis—is
transitory and carefully regulated.

Cancer Cells

Cancer cells initially lack angiogenic capacity

this limits initial expansion of the tumour.
To develop to a clinically detectable size the tumours usually develop
angiogenic ability.
 Sustained Angiogenesis

Cancer Cells

A cancer cell mass of about 2 millimeters emits signals that recruit

surrounding connective tissue and vascular cells to the tumor and
induce them to grow into blood vessels.

The blood supply to the tumour provides nutrients and oxygen,

and provides a route to the rest of the body,
ie. A route to metastasis.
 Sustained Angiogenesis

Angiogenesis is controlled by both positive and negative signals.

Important ones are

• vascular endothelial growth factor (VEGF)

• acidic and basic fibroblast growth factors (FGF1 and FGF2)

• thrombospondin-1
•binds to a transmembrane receptor( CD36) on endothelial cells.
 Sustained Angiogenesis

Tumors activate angiogenesis by changing the balance of inducers and

inhibitors.

Many tumors increase expression of VEGF and/or FGFs.

- activation of ras oncogene may upregulate VEGF expression.

Some down regulate expression of inhibitors such as

thrombospondin-1
-thrombospondin-1 is to positively regulated by the p53.
-Loss of p53 function, which occurs in most human tumors, causes
thrombospondin-1 levels to fall, releasing the endothelial cells from
inhibition.

Some do both.

The mechanisms remain largely incompletely understood.

 Metastasis

An exception to the immobilised format of tissue structure is the white

blood cell.

This can migrate out of the blood stream and enter into other tissues.

For tumour cells to metastasise, they must acquire the migratory

properties usually restricted to white-blood cells.
 Metastasis

Spread may occur via the blood or the lymphatics.

Localised spread to lymph nodes is a sign of poor prognosis.

Certain tumors spread to particular organs.

- prostate cancer to the bones.

- colon cancer to the liver.
-stomach cancer to the ovary.
-occular melanoma to the liver.
 Metastasis
Metastatic cells must become mobile

the cytoskeleton has to be re-configured for motility.

Normal epithelial cells have several shapes—cylindrical, cuboid or
flattened.
Cancer cells are usually star-shaped and elongated.
Similar fibroblastic morphology is also observed in epithelial cells
during development of the embryo.
Many tumour cells resemble cells seen only during the very early
stages of embryonic development.
 Metastasis

Metastatic cells must loose connections with the

other cells and ECM of the primary tumour

Proteases used to degrade the basal membrane

Plasminogen activators ( serine proteases)
- leads to conversion of plasminogen to plasmin

Cathepsin B ( cysteine protease)

Matrix metalloproteinases ( MMPs)

- often converted from a pro- (inactive ) form by
plasmin
 Metastasis
Cancer cells in the blood stream

2 mechanisms for surviving in the bloodstream.

Travel in clusters, increases the possibility that at least one will survive.
Surround themselves with blood cells such as platelets, -- masks the
cancer cells from immune surveillance.
 Metastasis
The secondary site

The secondary site is often specific.

Specific interactions between the cancer-cell surface and the endothelial
cells that line the blood vessels in the new host tissue.
Carbohydrates on the cancer-cell surface bind to a specific receptor on the
endothelial cells called a selectin.
Different selectins recognise different carbohydrates on the cancer cell
surface.
Normally, the carbohydrate-selectin interactions are used by white blood
cells to identify particular tissues to combat local infection.
Each cancer-cell type expresses a different set of carbohydrates on its
surface, attracted to different selectin molecules.
The specificity of these interactions helps account for the differential
homing specificities of different types of cancer cells.
 Metastasis

The secondary site

The cancer cell contacts a surface where the cells express the appropriate
selectins.
More bonds, mediated by integrins, form between the cells.
The cancer cell migrates through the blood-vessel wall, degrading the
connective-tissue matrix with proteases.
The cancer cell is now ready to proliferate and form a new tumor in its new
host tissue
 Cancer Therapy
Current Therapy is fairly crude
Surgery if possible
some cancer cells remain at the original site
others may have already started to metastasise to distant organs
So the patient is given Radiation
eradicates cells by inducing apoptosis
can be directed very specifically to where the primary tumor was
located in order to destroy any remaining cancer cells. However,
undetected metastases elsewhere go untreated
Radiation is often given in conjunction with Chemotherapy
designed to curtail division and proliferation
many normal cells with high turnover rates, such as skin, hair and
blood cells, are affected along with the cancer cells
Sometimes cancer cells develop resistance to chemotherapy
Current therapeutic approaches are thus fairly 'blunderbus-like'
 Cancer Therapy

Potential Improved Therapeutic Approaches

Stimulate the patient's immune system

Boost the patient's immune system, and direct it against molecules expressed on
the cancer cells but not on healthy cells.
Tumor-specific antigens have been hard to identify
Many of the immune agents now in use target healthy cells as well
In the test tube, immune cells are effective in killing the cancer cells.
Unfortunately, in vivo once the immune cells meet the cancer cells, nothing further
seems to happen.
The immune cells fail to mediate any attack.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Stimulate the patient's immune system

Cancer cells ward off possible attack by secreting large amounts of

immunosuppressive messenger molecules, such as interleukin-10
transforming growth factor b
and prostaglandin E2.

They also secrete molecules such as α2-macroglobulin, which inhibit cancer-cell-

destroying proteases.

May travel through the circulation in clusters, (increasing the possibility of

survival) or may surround themselves with platelets to escape immune
surveillance.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Stimulate the patient's immune system

The cancer cells may also attack the immune cells using the Fas/ Fas-L system.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Doxorubicin ( Adriamycin)

Doxorubicin induces the expression of both Fas and FasL on cancer

cells –

- causes cancer cells to kill themselves by inducing apoptosis.

 Cancer Therapy

Potential Improved Therapeutic Approaches

Some modest successes with immunostimulants.

Injecting the bacterial preparation BCG seems to be effective in
early stage bladder tumours.

Interleukin 2 (IL-2) or with alpha-interferon (IFN-α) has been

beneficial in some instances.

Generally attempts to stimulate the host immune system

sufficiently to beat off the cancer have been disappointing.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Monoclonal Antibodies as therapeutic agents

The receptor Her2 is overexpressed in a subset of breast tumours.

Anti-Her2 monoclonal antibody (Herceptin) has proved highly successful.

The antibody combines with the receptor and blocks it so that growth
factors ( EGF) no longer bind.

May also cause the receptor it to be internalised

This leads to the selective death of the cancer cell

 Cancer Therapy

Potential Improved Therapeutic Approaches

Immunotoxins
Monoclonal antibodies coupled to a cytotoxic drug.

Mylotarg.

MAb against a cell-surface molecule (called CD33), found on acute

myelogenous leukemia cells coupled to a complex oligosaccharide called
calicheamicin

Makes double stranded breaks in DNA.

BL22, a MAb against CD22 (found on some leukemias and lymphomas) joined
to a bacterial endotoxin that blocks protein synthesis.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Radioimmunotherapy

Monoclonal antibodies against tumor antigens can also be

coupled to radioactive atoms such as indium -111 , yttrium -90 or
iodine-131.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Allografts of T cells

Treat leukemia with massive doses of chemotherapy and radiation

- the leukemic cells are killed.

- also kills the patient's own bone marrow.

The patient must be then given a transplant of donor bone marrow

containing the stem cells from which all blood cells are derived.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Autografts of T cells: Tumor-Infiltrating Lymphocytes (TIL)

The idea here is that T cells isolated from within solid tumours are
specific for tumour antigens.

T cells are isolated from the solid tumour,

- grown to large numbers outside the body ( in culture)
-activated
- and reintroduced back into the patient.

Has been successful with malignant melanomas of the skin.

Successful in about 77% of patients, and worked against metastases as

well as the primary tumours.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Cancer vaccines

1). Dendritic-cell Vaccines

Dendritic cells are the most potent of the antigen-presenting cells.

-harvest dendritic cells from the patient
-expose these in vitro to antigens associated with the type
of tumour in the patient
-inject the "pulsed" dendritic cells back into the patient
-hope they kick the immune system into action.

So far have shown promise against melanomas, prostate cancer and

lymphoma.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Cancer vaccines

2). Tumour-specific Antigen Vaccines

Tumour cells are removed from the patient,

- treated with heat or chemicals so they are not viable,
- mixed with an adjuvant (such as BCG)
- injected back into the patient,
-hopefully to now stimulate the patient's immune system.

Such vaccines are currently in clinical trials for use against chronic
myelogenous leukemia CML).
 Cancer Therapy

Potential Improved Therapeutic Approaches

Inhibit Tumour Angiogenesis

Two angiogenesis inhibitors with potential clinical applications

1) angiostatin (an amino-terminal fragment of plasminogen)

2) endostatin (a 20 kD protein derived from the carboxyl-terminal

domain of collagen XVIII)

Both inhibit angiogenesis in laboratory animals

 Cancer Therapy

Potential Improved Therapeutic Approaches

Inhibit Tumour Angiogenesis

Much of the research has been centered on VEGF.

Antisense constructs against VEGF inhibit experimental

angiogenesis.

Monoclonal antibodies against VEGF receptors have also been

successful in stopping angiogenesis.

Genetically engineered cells secreting a soluble form of the VEGF

receptor have been shown capable of inhibiting angiogenesis at
distant sites.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Inhibit Tumour Angiogenesis

Small molecule inhibitor of receptor tyrosine phosphorylation

- inhibits the tyrosine phosphorylation of VEGF receptors

- and PDGF receptor and thus inhibits signalling .

Has potent anti-angiogenic effects in pre-clinical models and is

undergoing clinical trial.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Inhibit Tumour Angiogenesis

Various interferons also are reported to inhibit angiogenesis

Interferon alfa-2a given to a 5-year-old girl with a large rapidly

growing tumor of the mandible.

Resulted in dramatic decreases in urinary excretion of FGF,

and complete tumor regression over a three year treatment-free
interval
 Cancer Therapy

Potential Improved Therapeutic Approaches

Correct Mutated Signalling Pathways
Recent experimental strategies attempt to compensate for or
correct defective genes.

Eg with ras

The ras protein has to be post-translationally modified.

This requires that ras has a lipid molecule attached to it.

This is catalyzed by an enzyme called farnesyl transferase.

Inhibitors of farneslyl transferase are being tested in clinical trials

as anti -cancer agents.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Restore Growth Inhibitory Pathways

Another (theoretical) approach is to restore the function of

growth-inhibiting genes inactivated through mutation.

Gene therapy, -- replace the mutated gene with a functioning one.

To date the clinical results have been disappointing.

 Cancer Therapy

Potential Improved Therapeutic Approaches

Halt Metastasis

2 general targets.

Adhesion molecules

Proteases
 Cancer Therapy

Potential Improved Therapeutic Approaches

Halt Metastasis

Restore adhesion-molecule synthesis

Gene-replacement therapy has worked in the

laboratory,

but it is still a long way from being useful clinically.

 Cancer Therapy

Potential Improved Therapeutic Approaches

Halt Metastasis
Other potential targets are the proteases that metastatic cells use.

Marimastat, an inhibitor of matrix metalloproteinases (MMPs) caused

great excitement.

Marimastat is water-soluble.

Marimastat inhibited tumour development and metastasis in animals.

Treated animals showed increased amounts of connective tissue

around the tumors, consistent with the drug inhibiting MMPs.

Early clinical trials were promising.

Unfortunately the early results were not borne out by more extensive
studies.

Despite the initial optimism, the usefulness of marimastat may be

limited to a small subset of patients.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Halt Metastasis

Another approach involves a specific small, water-soluble inhibitor of

cathepsin-B.

- claimed to inhibit only the cathepsin-B on the cell membrane

- not the internal lysosomal enzyme
- and to have minimal effect on normal cells.

Inhibition of extracellular, but not intracellular, activity suggests

therapeutic promise, because it blocks only the pathologically
expressed cathepsin-B and not the physiologically required stores.
 Cancer Therapy

Potential Improved Therapeutic Approaches

Halt Metastasis

Given orally to rats with colon cancer that had metastasized to the liver

the number of tumors was reduced by one-third

and the size of the tumors was reduced by two-thirds.

Strongly suggests that cathepsin-B is involved in colon-cancer

metastasis to the liver.

It has yet to be shown that this drug has any use therapeutically,

but it seems possible.

 Cancer Therapy

Potential Improved Therapeutic Approaches

Induce Apoptosis in the Tumour

Attempts to stimulate apoptosis specifically in tumour cells seem to

work in the laboratory, but have not yet been useful clinically
So-
Overexpression of BAX (apoptosis stimulator) in tumor cells
increases the sensitivity to conventional chemotherapy and to
decrease the growth rate when implanted into mice.
Another approach has been to stimulate apoptosis by transfection of
wild type p53 with the addition of a construct expressing FAS-L.
This approach led to dramatically enhanced apoptosis in transfected
glioma cells in culture
Yet another approach has been to inhibit the activity of bcl-2 by the
use of drugs, which seems to work in cells overexpressing Bcl-2
 Cancer Therapy

Potential Improved Therapeutic Approaches

Telomerase as a Potential Target

A second approach assumes that tumor cells which strongly

express telomerase should drive a telomerase promoter.

Transfection with a cytotoxic transgene in which the telomerase

promoter is attached to the gene for Bax (to promote apoptosis)
should produce tumour-specific killing.

This was found to be so.

Induction of Bax elicited tumor-specific apoptosis in vitro and
suppressed tumor growth in nude mice.
Normal, telomerase negative, cells were not affected
.