Principles of Oncology

1
 CELL NUMBER CONTROL
Cell number is the
balance of:

• cell production (due to proliferation via

the cell cycle)
and
• cell loss via a number of means including
cell death by the process of apoptosis
2
 Small number of stem cells
Hard to identify
Actually slowly turning over
Give rise to other cells which can proliferate
extensively (transit amplifying cells)
Allows amplification and increase in number of cells
Allows for rapid response to changing demands
And creation of cells with different phenotypes
Figure 23-8 Molecular Biology of the Cell (© GarlandScience 2008)
GROWTH DISORDERS
• Hypertrophy
• Hyperplasia
• Atrophy
• Hypoplasia
• Metaplasia
• Dysplasia
• Neoplasia

4
 Perspective
• About 250,000 people every year are
diagnosed with cancer in the UK:
– about 120,000 die every year
– about 1 in 3 of all deaths.

• The annual cost of diagnosing and

treating cancer is about £1.5 billion for
the NHS every year.
5
 Basic definitions
Rupert Willis 1930s A neoplasm

• is an abnormal mass of tissue,

• the growth of which is uncoordinated with that of
normal tissues,
• and that persists in the same excessive manner after
the cessation of the stimulus which evoked the
change“

An important additional component is

• "the presence of genetic alterations that alter cell

growth"
6
 Basic definition
An alternative OPERATIONAL definition
of neoplasia is;
"a growth disorder characterised by
genetic alterations that lead to loss of
the normal control mechanisms that
regulate cell growth, morphogenesis and
differentiation"

7
 DYSPLASIA
• A spectrum of abnormal growth
conditions with many of the
morphological and genetic changes of
neoplasia BUT without any invasion of
spread

• Half way to neoplasia

8
DYSPLASIA IN THE COLON

Associated sometimes with the

formation of polyps

Can be flat

Pre malignant

Associated with some familial

types of colon cancer
FAP or Familial Adenomatous Polyposis

Also associated with inflammatory

bowel disease

9
DYSPLASIA IN THE CERVIX

Abnormal maturation of squamous epithelial cells

Associated with HPV infection
Varying degrees of abnormality . . . . .
. . . . ultimately can become invasive and become a frank
CARCINOMA

10
 The purpose of classification
• is to provide an aid to diagnosis

• to allow the accurate exchange of information

• to define clinical sub-groups who have

different biological or clinical features
– will benefit from particular types of treatment
– have different outcomes (prognosis)
– to facilitate epidemiological analysis

11
Why is classification important?

PRECISE CLASSIFICATION
OF A NEOPLASM FROM A PATIENT
IS ESSENTIAL FOR THE
CORRECT AND APPROPRIATE
PLANNING OF TREATMENT

12
 Two key elements of
classification of a neoplasm

Behavioural Histogenetic
classification classification

• based upon the • based upon the

probable behaviour presumed cell of
of a tumour origin a tumour
– E.g. benign or – E.g. epithelium or
malignant connective tissue

13
 Behavioural classification
• Spectrum of behaviour
e.g. benign or malignant

• Essentially a prediction of likely natural

history

• Pathologists use a range of morphological

features in an attempt to categorise a
tumour as benign or malignant
14
 Benign Malignant
Slow growing Variable and may be rapid

Few mitoses Variable but may be many mitoses

Variable, but may only poorly

Usually resemble tissue of origin
resemble tissue of origin

Nuclear morphology may be variable

and can be very abnormal with
Nuclear morphology is usually normal
hyperchromasia, pleomorphism and
nucleolomegaly

Usually have a well circumscribed or

Often poorly defined or irregular
encapsulated

Necrosis is rare Necrosis is common

Ulceration is rare Ulceration is common

Never invade May invade surrounding tissues

Never metastasise May metastasise

15
 Histogenetic classification
• Histogenesis refers to the presumed cell of origin of
a tumour

• Tumours from a specific histological tissue often

have microscopic features similar too that tissue

• The basis of this aspect of classification is

HISTOLOGY.

• Thus

– tumours arising in squamous epithelia have a squamous pattern

– tumours arising from the glandular epithelium of the gastro-

intestinal tract have a glandular pattern.
16
 Two main histogenetic sub
groups of malignant tumours
CARCINOMA SARCOMA
Derived from epithelium Derived from connective tissue

Always malignant Always malignant

Common Rare

Spread by lymphatics Spread by blood

May have a pre-malignant phase Not believed to have a pre-

(or in situ phase) malignant phase

Older patients Younger patients

17
 PREFIXES
Prefix Tissue of origin
Glandular
Adeno-
epithelium
Non-glandular
Pappilo-
epithelium

Lipo- Fat

Osteo- Bone

Chondro- Cartilage

Angio- Blood vessel

Rhabdo- Skeletal muscle

Leiomyo- Smooth muscle

18
 SUFFIXES
Suffix Meaning

Tumour (benign
-oma
or malignant)

Epithelial
-carcinoma
malignancy

Connective
-sarcoma tissue
malignancy
malignancy of
bone marrow
derived cells
-aemia (exceptions
exist eg.
anaemia)
19
 Grade
• the degree of differentiation of a tumour.

• It is the degree to which a tumour cell resembles its presumed

normal counterpart as assessed by its morphological appearances
by a pathologist.

• In general
– a low grade [or well differentiated] tumour has a less aggressive
course
– than a high grade [or poorly differentiated] tumour.

• ANAPLASTIC –

– This word implies that histological examination shows a very poorly

differentiated neoplasm that does not resemble any normal tissue.
– These tumours are always malignant and usually behave very
aggressively.

20
 Stage
Stage refers to the extent of spread
of a tumour.

Stage is informed by both

• clinical and radiological assessment (clinical
stage)
as well as
• pathological examination of surgical specimens
(pathological stage)
21
Classification of epithelial tumours

• Benign tumours of epithelium

– Adenoma benign tumour of
glandular epithelium
– Papillomas benign tumour of
non-glandular epithelium
• Malignant tumours of epithelium
– These are always carcinomas.
– Qualifying terms needed like
• Adeno-carcinoma
• Transitional cell carcinoma
22
 Classification of connective
tissue tumours
Connective tissue Benign tumour Malignant tumour

Cartilage Chondroma Chondrosarcoma

Bone Osteoma Osteosarcoma

Blood vessel Angioma Angiosarcoma

Skeletal muscle Rhabdomyoma Rhabdomyosarcoma

Smooth muscle Leiomyoma Leiomyosarcoma

Fat Lipoma Liposarcoma

23
THE PROBLEMS OF EXCEPTIONS . . . . . .

• For example

– MELANOMA
– MESOTHELIOMA
– LYMPHOMA

• EPONYMS

– Hodgkin's disease (a kind of lymphoma)

– Ewing's sarcoma (a malignant tumour of bone in children and
young people)
– Burkitt's lymphoma (a kind of lymphoma)

24
 Relevance

• Classification, grade and stage

• are important as they enable the
clinician to make some prediction of the
likely prognosis of a patient

AND

• are essential information for the logical

planning of treatment.
25
 A case history
• A 48 year old man presents with a history of
blood in his stool.

• He has lost weight (2 stone over 8 months).

• His brother had colon cancer a the age of 35.

26
• On examination middle aged man with evidence of weight loss,
pale skin.

• Abdominal examination: ? Irregular liver edge and suggestion of

mass in lower abdomen

• Rectal examination: blood on finger but no mass

• Differential diagnosis:
– Piles
– Inflammatory bowel disease
– Diverticular disease
– Tumour

• Referred to Consultant Surgeon.

• Sigmoidoscopy shows a mass at 20 cm which is biopsied

27
• Flexible sigmoidoscopy:
– mass in colon
– biopsy taken
• Histology of mass
– Glandular neoplasm
– Pleomorphism
– Invasion

• Surgery planned
– Resection of colon

28
29
Evidence of
metastatic
spread
Liver deposits

30
 Why epidemiology is useful

• It allows you to gauge what is common and

what is rare
• It can provide clues to aetiology
• Can guide the provision of scarce resources
• Can facilitate planning of preventative
measures
• It underpins the development of screening
methods for early diagnosis

31
A range of factors can influence the
epidemiology of a disease
• Age variation
• Gender differences
• Historical variation
• Geographic variation
• Social and economic factors
• Occupational factors
• Dietary factors
• Genetic factors
etc . . . . . . . .

32
 EPIDEMIOLOGY examples
• Ultraviolet light and skin cancer
• Asbestos and mesothelioma
• Smoking and lung cancer
• HPV, sexual activity and cervix cancer
• Malaria and Burkitt’s lymphoma
• Meat consumption and colon cancer
• Radiation and thyroid cancer
• Aniline dyes and bladder cancer
• Family history and many cancers
• Alcohol and cancer
• Hepatitis virus, aflatoxins and liver cancer
33
 Colorectal cancer as an example
Age Incidence increases rapidly with increasing age
Gender Affects both men and women
Historical variation Is becoming more common
Associated with developed nations rather than
Geographic variation
developing nations
Social and economic
Can occur in all groups
factors
Occupational factors None known
Associated with a low fibre, high fat, high red meat
Dietary factors
diet
Familial forms well described including:-
1. Familial Adenomatous Polyposis or FAP (APC gene)
2.Hereditary non polyposis cancer (HNPCC) DNA
Genetic factors repair genes
BUT ALSO
3. Genes whose products are involved in metabolism of
carcinogens can increase the risk of neoplasia
34
 MIGRATION STUDIES CAN ILLUMINATE THE
ROLE OF ENVIRONMENTAL AND GENETIC FACTORS

35
 Mortality statistics
the big 5 in men and women

Males Females
Lung Lung

Prostate Breast

Colorectal Colorectal

Stomach Ovary

Oesophagus Pancreas

36
CHANGING PATTERNS OF NEOPLASIA

37
 Why tumours cause problems

• grow
• press on structures
• ulcerate
• bleed
• cause loss of organ function
• invade locally
• spread to distant sites (metastasise)
• produce substances
– appropriate for the site
– inappropriate for the site
38
• It is implicit from our definition of neoplasia
that neoplastic (or tumour) cells have lost
normal regulation of cell number control

• Tumours are usually clonal in origin

• From this single transformed cell tumours

grow

• 1 cm3 of tumour = ~ 1 gram = ~ 109 cells

39
 Clonality
• Tumours are usually clonal in origin (that is they arise
from neoplastic change in a single initial cell),

• But there are exceptions

• BUT NOTE not all cell populations that are clonal are
tumours!

40
Growth of tumours

41
 How tumours present
• A consequence of local disease
– (eg. grow, compression, ulcerate, bleed, destroy adjacent
structures)

• A consequence of distant spread

– (eg. grow, compression, ulcerate, bleed, destroy adjacent
structures)

• A non-metastatic manifestations of malignancy

– (paraneoplastic effects) including anaemia, skin changes,
neurological effects, inappropriate hormone production,
weight loss and fatigue.
- CACHEXIA or severe weight loss and debility.

• An incidental finding
– (eg. on screening or on routine medical examination)
42
 When thinking about a tumour
at a given anatomical site, it might be

A primary tumour that can be either

benign or malignant

or be a
a secondary deposit (a metastasis)
from another site

43
 Spread of tumours
• Metastasis is the process whereby malignant
tumour cells spread from

• their site of origin

– (known as the PRIMARY SITE or PRIMARY
TUMOUR)

• to some other distant site in the body

– (known as the SECONDARY SITE or
SECONDARY TUMOUR or SECONDARY
DEPOSIT or METASTASIS or METASTATIC
DEPOSIT)

44
INVASION and METASTASIS
• The two properties that accounts for
most of the serious (and lethal)
consequences of neoplasia.

• Associated with
– increased cellular motility,
– the production of enzymes with proteolytic
activity and
– alterations in cell adhesion

45
 ROUTES OF METASTASIS
1. BLOOD [ HAEMATOGENOUS] SPREAD

2. LYMPHATIC SPREAD

3. TRANSCOELOMIC SPREAD

4. PERINEURAL SPREAD

5. IMPLANTATION

46
SPREAD OF
TUMOURS

47
The process of metastasis . . . .
• Local growth

• Angiogenesis • THE SPREAD OF

TUMOURS IS NOT
• Further local growth RANDOM

• Alteration in cell-cell and cell-matrix • DEPENDS ON FACTORS

adhesion and altered cell motility RELATING TO BOTH
• Remodelling and alteration of extra-cellular
matrix • SEED
(THE TUMOUR CELLS)
• Leading to invasion and detachment

• Entry into lymphatic and/or blood vessels AND

• Survival in the lymph and/or blood • SOIL

• Arrest at some distant site (THE SITE OF SPREAD)

• Survival at the distant site

48
. . . then repeat the whole sequence
 STAGE
Stage refers to the extent of spread
of a tumour.

TNM System
• T How big the primary tumour is
• N Whether nodes are involved
• M Whether distant sites are involved
(eg. Liver or bone marrow)
49
 WHY IS STAGE SO IMPORTANT?

• Key determinant
of prognosis

• Key factor in determining type of treatment

options available
– Surgery
– Radiotherapy
– Chemotherapy 50
51
52
OVERVIEW OF CARCINOGENESIS
The hallmarks of cancer
Hanahan & Weinberg
Cell 2000; 100: 57-70

54
 Properties of tumour cells
1. Self-sufficiency in growth signals
2. Insensitivity to anti-growth signals
3. Evasion of apoptosis
4. Unrestricted replicative potential
5. Sustained angiogenesis
6. Tissue invasion and metastasis
7. Genetic instability

55
Self-sufficiency in growth signals
• Normal cells depend on exogenous growth factors to
stimulate growth and cell proliferation.

• Tumour cells grow and divide without these signals.

• Why?
– because of mutations in genes that encode components of
the signalling pathways that normally regulate these
processes.
– Such mutations lead to constitutively active signalling

56
Insensitivity to anti-growth signals

• Usually the growth and proliferation of cells is

controlled by a balance of growth promoting signals
and growth inhibitory (or anti-growth) signals.

• The loss of growth inhibitory signals or the loss of

the ability to respond to these signals is typical of
tumour cells.

57
 Evasion of apoptosis
• A critical component of normal cell number control is
apoptosis (programmed cell death).

• Apoptosis is also a mechanisms for the removal of

unwanted cells, for example those with significant
damage, including genetic damage.

• Tumour cells have often developed mutations in key

genes whose products are involved in apoptosis such
that cell death is blocked.

58
 Unrestricted replicative potential

• Normal cells can only divide a finite number of times.

• This was first shown by Hayflick in the 1960s

– normal human fibroblasts will divide about 70 times if taken
from a neonate,
– but 40 times from a middle aged person,
– and barely divide at all from an elderly person.

• Normal cells thus have a restricted replicative potential as a

consequence of a number of mechanisms.

• Tumour cells have an unrestricted replicative potential and just

carry on dividing!

• The role of telomerase

59
60
 Sustained angiogenesis
• Tumours will stop growing when they outgrow their
blood supply - without this they will have insufficient
nutrients and oxygen to sustain themselves – and
undergo ischaemia and infarction.

• Tumours overcome this problem by the production of

various factors that stimulate the formation of new
blood vessels.

61
 Tissue invasion & metastasis
• Normal cells remain where they are supposed to be
and normal tissue boundaries are maintained.

• Tumours are characterised by invasion into nearby

tissues and structures (ie. normal boundaries are not
maintained) and may spread to distant sites
(metastasis).

• These properties are the main reason why tumours

are such a significant clinical problem.

62
 Genetic instability
• Normal cells maintain the integrity of their genomes

• Mutation is a key feature of neoplasia

• Genetic instability is common in neoplasms.

• A characteristic feature of tumours, particularly

aggressive tumours, is the unstable nature of their
genomes.
– They often develop aneuploidy (abnormal DNA content) with
abnormal chromosomes and mutation is also common
– Hyperchromasia (densely staining)
– Pleomorphism (variable size & shape)

63
 Evidence that neoplasia is a genetic disease

1 Nuclear abnormalities are

common in tumours
– Hyperchromasia
– pleomorphism
2 Often see abnormal mitoses
3 Abnormal DNA content is
common in tumours
4 Chromosomal abnormalities are
common in tumours
– Some are specific to particular
tumour types
– Some are non-specific
64
 Evidence that neoplasia is a genetic disease

5 Nearly all carcinogens are

mutagens

6 Specific mutations in
growth control genes are
common in tumours

7 Genetic instability is a
characteristic feature of
tumours

M FISH – GMP lecture 10

8 Tumour cells breed true
65
Evidence that neoplasia is a genetic disease

9 SOME CANCERS RUN IN FAMILIES

There are a number of familial forms of neoplasia.

That is genetic abnormalities in genes that

predispose to neoplasia that can be inherited.

Provide insights into the molecular events in

neoplasia

66
 TUMOUR PROGRESSION
• Clinical and experimental phenomenon
• With time tumours grow and successive
populations become increasingly abnormal,
accumulating more genetic abnormalities
(mutations)
• Associated with increasingly abnormal
appearance and behaviour
• Increasingly insensitive to growth inhibitory
signals, more resistant to apoptosis,
increasingly unstable etc.

67
Tumours: Multiple genetic
events are needed
Evidence: clinical examples eg. colorectal cancer

68
Tumours: Multiple
genetic events
are needed

Evidence: clinical
examples eg. tumour
progression

69
Tumours: Multiple genetic events are needed
Evidence: Experimental skin tumours in mice

70
 Molecular events in neoplasia
Exactly what genes are involved in neoplasia?

several hundred genes mutated in tumours have been identified

usually encode proteins involved in the kinds of process as being typical

of tumours.

• Self-sufficiency in growth signals

• Insensitivity to anti-growth signals
• Evasion of apoptosis
• Unrestricted replicative potential
• Sustained angiogenesis
• Tissue invasion and metastasis

We can call such genes 'CANCER CRITICAL GENES' :

meaning all genes whose mutation contributes to the causation and

progression of cancer. 71
72
 Cancer critical genes
There are two broad
ONCOGENES
categories of cancer
critical gene +
Cell number [or other
• Oncogenes key cellular control]

• Tumour suppressor -
genes TUMOUR SUPPRESSOR
GENES

73
 Cancer critical genes
Cancer critical genes ONCOGENES

generally are involved Stimulate cell division OR inhibit cell death

in cell cycle or cell

+
death processes
Cell number [or other
Key cellular control]

[Some are involved in -

DNA repair] Inhibit cell division or stimulate cell death

TUMOUR SUPPRESSOR GENES

74
 Oncogenes
Involved in cancer by an increased activity of the (proto)oncogene
stimulating an increase in cell number

Genetically dominant
Function like an accelerator

The gain of function of an oncogene product as a consequence

• of more of the gene product being expressed,

• or a mutation in the gene such that the resultant protein has increased
function,
• or expression occurring in the wrong cell type,
• or at the wrong time

leads to the stimulation of a critical cell process (such as the

cell cycle).

Examples include is the ras oncogene, myc oncogene, bcr-abl oncogene 75

 Tumour suppressor genes
Involved in cancer by a decreased activity of the tumour
suppressor gene leading to an increase in cell number

Genetically recessive
Functions like a brake

The loss of function of a tumour suppressor gene product as a consequence

• of less of the gene product being expressed,

• or a mutation in the gene such that the resultant protein has reduced
or loss of function,

• It is a genetically recessive event and requires the loss of both copies

of the tumour suppressor gene (as first proposed by Knudson in his 'two
hit hypothesis').

• Examples include the p53 gene, the APC gene and the Rb gene

76
 Understanding cancer critical genes:
an analogy
A foot on the accelerator can make you
go faster!
Oncogenes encode potential
accelerators of growth.
A single event is enough - it is
genetically dominant –
and involves GAIN OF FUNCTION
One Accelerator
You have two brakes
If one stops working you can use the other.
If both stop working you cannot stop and will
accelerate.
Tumour suppressor genes usually encode the
brakes on cell growth –
loss of their function can lead to accelerated
growth - but it requires 2 events - loss of both
brakes.
You need LOSS OF FUNCTION of both alleles of a
tumour suppressor gene (genetically recessive)!
Two brakes
77
 Oncogene
Pathways

Figure 15-1 Molecular Biology of the Cell (© Garland Science 2008)

 Activating oncogenes

2 1 3

79
 1. GENE AMPLIFICATION
Receptor amplification

Positive growth
signal

erbB2 in breast and

ovarian cancer
HSR=homogeneously staining region (Neoplasia 6) 80
2. POINT MUTATIONS IN CODING SEQUENCE
Receptor mutation

Mutations in oncogenes are

termed ‘gain of function or
activating mutations’

inappropriate expression of the

Positive growth
signal
pathway eg. ras signalling

81
Many signalling proteins are
molecular switches
Mutant ras is always switched on
3. CHROMOSOMAL
REARRANGEMENTS
Altered regulation: myc
gene over-expressed in
lymphoma

New gene formed: bcr-abl

with altered/new
properties

84
 Tumour suppressor genes
The Knudson Hypothesis
Knudson studies children Familial form
with an eye tumour called • present earlier in
retinoblastoma childhood
• often had bilateral
2 groups of patients:- disease
• within an eye could be
multi-focal.
• those with a family
history
Sporadic
• and those without (the • presented later
majority) • only had a single eye
involved.
85
 Tumour suppressor genes
The Knudson Hypothesis
For a tumour to develop Knudson proposed that:-

• a gene was involved

• mutations were needed in this gene (called the retinoblastoma

gene)

• normal people have two copies of this gene

• one inherited from the father and one from the mother

• Needed to have loss of function mutations in BOTH maternal

and paternal copies of the retinoblastoma gene

86
 Knudson’s Two-Hit Hypothesis

Hereditary Sporadic

Multiple tumours, Single tumours,

bilateral, early onset. unilateral, late onset

87
 Tumour suppressor genes
The Knudson Hypothesis
Sporadic form
• a mutation has to occur in both
copies of the retinoblastoma gene.
• If a single mutation could occur in
one in a 106 cells in a given period of
time then the probability of a
mutation occurring in both copies
would be one in 1012.
• ie. very rare.
• the longer the period of time that
elapses the more likely this is, but it
is unlikely to occur more than in one
cells. hence tumours occur late and
are unilateral.
Familial form
• the child inherits from one mutant
copy of the retinoblastoma gene.
• Since it still requires mutations in
both copies for a tumour to develop
then the probability of this is onein
a 106.
• This is a million times more likely
than in the sporadic form.
• the disease occurs earlier and also
there is a high probability of it
occurring in more than one cell, and
thus tumours may be multi-focal and
bilateral.
88
Familial

1 in 106
Overall
1 in 106

Sporadic

1 in 106 1 in 106
Overall
1 in 1012

89
 PEDIGREE OF THE FAMILIAL FORM OF RETINOBLASTOMA

• Disease status of 24 children & grandchildren descended from a

single male with retinoblastoma in childhood
• ~ 50% of his descendants developed disease (red)
• Proband did not develop disease but passed the susceptibility to 2 of
his children
• Proband is one of the small fraction (10%) with incomplete
penetrance
90
91
Ways of inactivating a TSG

92
92
 p53 TSG
• Altered in more than 50% of human
cancers
• Involved in a pathway that responds to
DNA damage and allows repair or
apoptotic cell death:
– if it is not working damage accumulates and
tumours can arise.
• Is a transcription factor: regulates
other genes

93
94
PREVALENCE
OF P53
MUTATIONS
IN HUMAN
CANCERS

95
PEDIGREE OF A FAMILY WITH LI-FRAUMENI
SYNDROME
96
 The component cancers of Li-Fraumeni syndrome tend
to show up at different stages of life:

Type of Cancer
Age of Onset
1. Development of
1. Infancy adrenocortical carcinoma
2. Under 5 years of age 2. Development of soft-
3. Childhood and young tissue sarcomas
adulthood 3. Acute leukaemias and brain
4. Adolescence tumors
5. Twenties to thirties 4. Osteosarcomas
5. Premenopausal breast
cancer is common
Those who survive the first cancer are at higher risk for a second cancer. These
second cancers often occur in areas of the body previously treated with radiation.
97
Tumours: Multiple genetic
events are needed
Evidence: clinical examples eg. colorectal cancer

98
 INNER SURFACE OF THE COLON OF A NORMAL
PATIENT WITH FAMILIAL ADENOMATOUS COLON
POLYPOSIS

99
THE APC GENE- genotype/phenotype correlations
EXON
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
CHRPE rare CHRPE frequent
MUTATION CLUSTER
REGION

LESS PROFUSE
AAPC PROFUSE POLYOSIS
POLYPOSIS
EARLY ONSET

DUODENAL POLYPOSIS,
FAP MULTIPLE
ADENOMAS GASTRIC ADENOMAS, CHRPE

GARDNER’S AS FOR FAP AS FOR FAP + EPIDERMOID

SYNDROME CYSTS, DESMOID TUMOURS

VARIABLE NOS GASTRIC POLYPS OF

AAPC
OF ADENOMAS FUNDAL GLANDS
100
FOUR GENERATION FAMILY PEDIGREE
WITH AN INHERITED PREDISPOSITION
TO BREAST & OVARIAN CANCER 101
 BRCA1 Tumour Suppressor Gene
Isolated by positional cloning as one of the genes
predisposing to early onset breast and ovarian cancer

Germline mutations of BRCA1 found in

50% inherited breast cancers
81% inherited breast-ovarian cancer)

Penetrance varies based on age and population

56-85% by age 70 for inherited breast cancer
16-60% by age 70 for inherited ovarian cancer
Sporadic disease
- BRCA1 mutations detected in 10% of sporadic ovarian
cancer
- Reduced protein expression observed in the majority of
sporadic breast cancers 102
 BRCA1 Function

(1) Regulation of transcription

(2) DNA damage
(3) Cell cycle

22 103
 XERODERMA PIGMENTOSUM
2 mutant copies of the same gene
inherited – one from each parent
Very rare condition
Susceptibility to skin cancer
Inherited defect in DNA repair
(excision repair)
Skin cancer rates 2000-fold > normal
Average age 8yrs cf 60yrs general
population
20-fold > brain, lung, stomach, breast
& leukaemias

Also a cancer critical gene!!

104
 XERODERMA PIGMENTOSUM PEDIGREE
Both parents are ‘carriers’ with no disease symptoms
Child has 50% chance of inheriting mutant allele from each parent
Overall probability of developing XP is 50%x50%=25%
1st generation 2/8 children developed the disease
All of their children inherit a mutant allele so are carriers
Some in the 1st generation may be carriers but not evident from
the pedigree
105
FOUR GENERATION FAMILY PEDIGREE
WITH AN INHERITED PREDISPOSITION
TO BREAST & OVARIAN CANCER 106
 WHY BOTHER TO TEST FOR BRCA1
MUTATIONS?
PROBABILITY OF BREAST OR OVARIAN CANCER(%)

100
With BRCA1
mutation

With family
50
history

Without BRCA1
mutation

30 50 70
107
AGE (YEARS)
 RISKS/BENEFITS OF CANCER
GENETIC TESTING
RISKS BENEFITS

• Ambiguous results • Ends uncertainty

• Results cause • Possible absence of
anxiety mutation
• Lack of prevention • Improved medical
strategies care
• Discrimination • Clarifies risk for
• Strain on family relatives
relationships • Informed
reproductive choices 108
 ETHICAL ISSUES
• Patient confidentiality
- insurance
- employment

• Commercialism – Myriad Genetics

• Prenatal testing

Harris, Winship & Spriggs Lancet Oncology 2005; 6:

301-10 ‘Controversies and ethical issues in cancer-
genetics clinics’.
To be continued PoDT year 2 – clinical genetics 109
A MULTIFACTORIAL DISEASE
• Having these mutant genes inherited
from a parent is not enough: need other
mutations
• Also the other genes in the genome
contribute to overall risk
– The deck of cards!
• Modifying loci
– Penetrance
– The exact mutation

110
 The causes of neoplasia
Carcinogenesis is the process by which a
normal cell is converted into a neoplastic cell

A carcinogen is an agent that can cause neoplasia

• Most neoplasms occur as a consequence of environmental factors

• Epidemiological and experimental studies provide insight into

carcinogens

• It is rare for a carcinogen to act by itself - it usually requires

co-factors

• Genetic variability in the population and other host

factors contributes to carcinogenesis

• Carcinogens are almost invariably mutagens

 The causes of neoplasia
• Toxins such as smoking
• Ionising radiation There is a
• Non-ionising radiation complex interplay
• Viruses between
• Bacteria environmental
• Fungi factors and host
• Parasites factors, including
• Hormones genetics
• Diet susceptibility
• Inherited genes
 How do we find carcinogens?
• Epidemiology
– Geographical risk
– Historical changes
– Occupational risk
– Behavioural risk
• Experimental evidence
– Cell culture
– Animal models
Genetic damage is the key to neoplasia

Chemical carcinogenesis

• History
– Percival Pott 1776
• Identified skin cancer in chimney sweeps as
being due to soot
– Aniline dyes and bladder cancer
Genetic damage is the key to neoplasia

Chemical carcinogenesis
• Diverse compounds
– Direct acting
– Indirect acting: require metabolic
activation
• Examples
– Alkylating agents (direct)
– Polycyclin hyrdocarbons (indirect)
Genetic damage is the key to neoplasia

Chemical Carcinogenesis
– Ames test
• Use bacteria that can only grow on particular
media
– Treat with compound: do they mutate to grow on
other media?
– Pre treat compound with metabolic enzymes (liver
microsaomes) and repeat
– Animal studies
• As good as it gets! . . . . but possibly not always
relevant to man
 THE AMES TEST

Figure 2.24 The Biology of Cancer (© Garland Science 2007)

Genetic damage is the key to neoplasia

Chemical carcinogenesis
– Human studies
– Epidemiology

– Complex and difficult but lots of good

evidence for environmental chemical
carcinogens
• Asbestos
• Aflatoxins
• Aniline dyes
Genetic damage is the key to neoplasia

Chemical carcinogenesis
– Smoking
– Huge number of chemicals involved
– Clear evidence for carcinogenic role of smoking
– “If everyone smoked then lung cancer
would be a genetic disease”
– Emphasises the point that we are all genetically
different
• Xenobiotic metabolism
• DNA repair
• Other
Genetic damage is the key to neoplasia

Radiation carcinogenesis
• Ionising radiation
• Hiroshima, Nagasaki, Chernobyl,
Laboratory accidents
• Environmental radiation
– Aberdeen, Cornwall,
– radon exposure
• Therapeutic & diagnostic radiation
Genetic damage is the key to neoplasia

Radiation carcinogenesis
• Non-ionising radiation
• UV causes skin cancer
– Low risk in Negroes, high risk in Caucasians,
high risk in albinos
– Families with defective DNA repair
(Xeroderma pigmentosa)
Genetic damage is the key to neoplasia
SOME EXCEPTIONS
• Hormones
– Act as promoters, stimulating cell proliferation
– Breast, endometrial and ovarian cancer are
hormone dependent (used in treatment)
• Bacteria, fungi and parasites
– Gastritis caused by Helicobacter pylori
– Aflatoxins (carcinogen) produced by Aspergillus
flavus and liver cancer
– Bladder inflammation caused by Schistosomes
(Eygpt) - bladder cancer
Genetic damage is the key to neoplasia

Viruses and cancer

• Good evidence in experimental models
• Good evidence that viruses cause human
cancer
– HPV and cervical cancer
– HBV and liver cancer
– EBV and lymphoma
• Viral genes functioning in human cells
 Viral carcinogenesis I
• Viral genes can act as dominant
transforming oncogenes like ras

• Viral genes can encode proteins that can

inactivate cellular proteins
– HPV encodes 2 proteins called E6 and E7
that bind to and inactivate p53 and Rb thus
effectively inactivating these tumour
suppressor proteins (genes)
 Human papillomavirus and the pathogenesis of cervical carcinomas

This histological section of a human papillomavirus (HPV)-infected cervical epithelium

reveals, through immunostaining with an anti-HPV antibody stain (brown), clusters of
HPV-infected cells in dysplastic areas of the epithelium, termed high-grade squamous
intraepithelial lesions (HSILs). The dysplastic cells arise, in large part, from the ability
of the HPV E7 oncoprotein to inactivate pRb and thus block entrance into a postmitotic
state, and to suppress apoptosis, the latter being achieved through the
actions of the viral E6 oncoprotein, which targets the host cell’s p53 protein for
destruction. The resulting lesions progress with a low but significant frequency to
cervical carcinomas.
125
 Viral carcinogenesis II
• Viruses can also integrate into the
genome of a cells and do one of two
things

Activate the expression of a cellular gene

(proto-oncogene)
OR
Inactivate a gene by disrupting it
(inactivate a TSG)
 Viral carcinogenesis III
• Viruses can also function in neoplasia by
stimulating proliferation (HBV in liver;
EBV in lymphocytes) and thus acting as
a promoter

• Also some viruses can cause

immunosuppression (EBV and HIV) and
this may be associated with
development of tumours
Genetic damage is the key to neoplasia

Host factors
– Race,
– diet,
– gender,
– inherited factors, etc

• Familial cancers
 Hereditary cancer
• Some tumours run in families
• We know the genes involved in some
cases
– Familial polyposis coli
• (APC)
– Hereditary non polyposis colon cancer
• (DNA repair enzymes)
– Breast cancer (+/- ovarian cancer)
• BRCA1 and BRCA2
– Li Fraumeni syndrome
• p53
 Hereditary cancer
• Having these mutant genes inherited
from a parent is not enough: need other
mutations
• Also the other genes in the genome
contribute to overall risk
– The deck of cards!
• Modifying loci
– Penetrance
– The exact mutation
Genetic damage is the key to neoplasia

• Abnormalities of DNA repair genes are

common in cancer
• Can be inherited or be acquired
– Mismatch repair
– Double strand repair
– Nueclotide excsion repair
Genetic damage is the key to neoplasia

• Familial cancers are relatively rare

• Genes involved in familial forms of

cancer are (usually) also involved in the
sporadic forms of cancer
Overview of treatment options
Accurate clinical diagnosis of patients with neoplastic
disease requires a logical and careful application of

history taking
clinical examination and
appropriate special tests & investigations.

Ultimately the diagnosis of neoplasia requires

histopathological assessment or a tissue diagnosis.

This involves
cytology (eg. fine needle aspiration)
needle or core biopsy
incision biopsy or
excision biopsy
 Multi-disciplinary team approach
The diagnosis and treatment of cancer is increasingly complex

Requires a multi-disciplinary team (MDT) of professionals including

– Surgical oncologists
– Radiation oncologists
– Medical oncologists
– Pathologists
– Radiologists
– Geneticist
– General practitioners
– Palliative care specialists
– Psychologists
– Social workers
– Nurses
– Chaplains etc . . . . . . . . . .
 New information helps diagnosis
• Molecular profiles
• Expression arrays
• Antibodies
• More robust and reproducible diagnoses
and classification
• Identification of subgroups that need
specific therapies
• Tailored treatments
Identifying prognostic factors
Things that predict survival

• Tumour type
• Stage and Grade
• Karnovsky status
• Tumour factors
– Gene expression
– Proliferation
Identifying predictive factors
Things that predict response to therapy

• Sub types of tumour

• Expression of various genes
• Expression of p53
• Expression of other genes
Survival curves (Kaplan-Meier)
100% TUMOUR TYPE

Mesothelioma Seminoma

1 yr 10 yr

Time
Survival curves (Kaplan-Meier)

STAGE
Survival curves (Kaplan-Meier)

GENE
EXPRESSION
 GENE EXPRESSION ARRAYS
Analysis of expression levels of
70 ‘prognosis genes’ in 295
primary breast cancers

Stratification into 2 groups

based on common patterns of
expression

Kaplan-Meier plot following survival

of 151 patients over 10 years shows
they have a dramatically different
clinical course

Figure 16.4a The Biology of Cancer (© Garland Science 2007)

 Treatment goals
The goals of patient management:

• Cure

• Palliation
– with the aim of improving lifespan and
quality of life
 Treatment principles I
Are based upon:

• Biological behaviour of the tumour

• Extent and bulk of disease

• Mortality and morbidity of any therapies

• The efficacy of the therapies

• The general well being of the patient including co-

existent (co-morbid) diseases
 Treatment principles II
• Screening
– Early Diagnosis is preferable (eg. Breast cancer)
– Diagnosis at a pre-malignant stage (eg. Cervical
cytology)

• Prevention
– Behaviour modification (eg. smoking, sun exposure)
– Risk avoidance (eg. occupational risks, dietary
factors)
 Cancer cure: difficult but not hopeless!

• SURGERY is very effective

• For some tumours chemotherapy and radiotherapy

are very effective

• Over the last decade all sorts of new approaches and

new drugs coming into the clinic.

• Lots of hope for the future . . . . . . .

 How do current therapies work?

• Exploit properties of tumour cells

– Proliferation & loss of cell cycle control
– Genetic instability

• Most drugs and radiation cause massive

DNA damage and induce cell cycle
arrest and cell death
 low doses of doxorubicin on
hepatoma cells induce ‘mitotic
catastrophe’ in tumour cells
because they often lack G2/M
checkpoint controls and so
continue into mitosis without
repairing the chromosomal
damage.

Normal cells with intact

checkpoints arrest mitosis until
damage is repaired.

Increasing aneuploidy, polyploidy

and cell death with time

Figure 16.7 The Biology of Cancer (© Garland Science 2007)

 THE CENTRAL ROLE OF P53

IHC of an ovarian
carcinoma stained for
p53 protein.

Various cellular stresses can Intense staining is

upregulate p53 with a variety of that of mutant p53.
downstream effects

Figure 9.8 The Biology of Cancer (© Garland Science 2007)

 Cancers can evolve resistance to
treatment
• Just like bacteria and antibiotics!
• Mutation and natural selection for resistant
clones
• If the apoptotic pathway is not working then
drugs will not work.
– Therefore, Increased resistance when there is
mutant p53
• Increased expression of MDR1 in tumours: an
efflux pump that exports exogenous
compounds out of cells
 Monitoring treatment I
• Clinical examination
• Radiology
• Tumour markers
– Measure something produced by the tumour
cells as an index of tumour burden
• AFP (alpha feto protein in liver cancer)
• AFP & HCG (human chorionic ganadotrophin in
testicular cancer)
Monitoring treatment II
Monitoring treatment IIIa
Clinical examination

Occult disease

Time
Monitoring treatment IIIb
Radiological examination

Occult disease

Time
Monitoring treatment IIIc
Biochemical examination
Level of marker

Occult disease

Time
Monitoring treatment IIIc
Molecular marker
MINIMAL RESIDUAL DISEASE

Time
 New treatments are based on new
understanding of cancer biology: p53
• Drugs that reactivate mutant p53: restoring
sensitivity to current drugs.

• Viruses that will only grow in cells with mutant

p53 as biological therapy

• Side effects of current therapy include cell

death in bone marrow due to p53 function in
normal cells: use drugs that inactivate p53 in
normal cells to reduce side effects of current
therapies and increase therapeutic ratio
 What about blocking blood vessels?

• Angiogenesis is key to tumour growth so

is an obvious target

• Angiogenesis is induced by various

factors such as VEGF: this acts on a
receptor VEGF-R to induce new blood
vessels to grow. Design drugs that
block the receptor so that the tumour
derived VEGF does not work?
 Small molecules can be designed to
target specific oncogenic proteins

• The example of HERCEPTIN

– An antibody that blocks the erbB2
receptor (also called HER2) now used in
breast cancer
• The example of GLEEVEC
– A small molecule that blocks the active site
of the abnormal bcr-abl protein, now used
in CML (chronic myeloid leukaemia)
INTRACELLULAR SIGNALLING VIA THE ERBB2 RECEPTOR

LIGAND

ERBB2 RECEPTOR

INTRACELLULAR
TRANSDUCER

NUCLEUS

RECEPTOR
mRNA
 AMPLIFICATION OF THE ERBB2 PROTO-ONCOGENE

LIGAND

ERB B2
RECEPTOR

INTRACELLULAR
TRANSDUCER

NUCLEUS
THERAPY VIA RECEPTOR BLOCKING BY ANTIBODY

LIGAND

RECEPTOR
ANTIBODY

INTRACELLULAR
TRANSDUCER
NUCLEUS

Herceptin
 Understanding cancer biology leads
to rationale tailored treatments
• Next generation of treatments will be
based on our new understanding
PLUS
• Specific treatments for specific
patients based on genetic and molecular
knowledge . . . . . .

Grounds for optimism