1. Neoplasia lecture 5
Dr Heyam Awad
FRCPath

2. HALLMARKS OF CANCER
Dr Heyam Awad
FRCPath

3. Hallmarks of cancer: changes in cell physiology resulting from genetic changes that result in cancer.
Cancer occurs due to successful breach of anticancer mechanism, i:e of regulatory mechanisms in our cells and tissues that prevent uncontrolled proliferation.

4. HALLMARKS OF CANCER
Douglas Hanahan and Robert A. Weinberg published in 2000 a review article about the expanding knowledge of tumorogenesis. They suggested that ALL tumor cells need to acquire SIX traits in order for the cells to be transformed to malignant cells.
These six traits were called: hallmarks of cancer
The original work was revisited and another article was published in

5. The 2013 article described the 6 characteristics (hallmarks) and emphasized the importance of genomic instability and tumor promoting inflammation as two enablers of malignancy ( they enable and help the development of the 6 hallmarks.
Also two new, emerging hallmarks were discussed: evasion of the immune system and reprogramming of metabolism
Moreover, the stromal, host derived cells are thought to play a major role in carcinogenesis as they provide a suitable microenvironment of the tumor to evolve.

6. FOR CANCER TO DEVELOP: we need the 8 characteristics (hallmarks) plus the 2 enabling characteristics and the correct microenvironment.
All the above are acquired as mutations or epigenetic alterations accumulating overtime
So: no single mutation is enough to cause cancer.

7. Carcinogenesis is a multistep process.
Each step results from a genetic change
Each genetic change results in acquiring a certain phenotype ( one of the hallmarks)
There is no specific sequence of acquiring these phenotypes… the main issue is to acquire them all

8. Tumor clonality
Although tumors start from one clone.. They acquire more mutations .. Some result in invasiveness, others in ability to metastasize and so on
So when discovered clinically the tumor mass is heterogeneous and composed of subclones
This process of acquiring new properties leading to more aggressive behavior is called tumor progression

9. During tumorogenesis and tumor progression some subclones are deleted ( they die)
This is due to selection processes ( immune and nonimmune- selection)
Example: clones that are highly antigenic die whereas less antigenic ones are positively selected ( they are fitter so they survive = survival of the fittest)

10. Genetic evolution and selection of the fittest subclones explains the tendency of tumors to become more aggressive with time
It also explains why tumors become more resistant to therapy overtime

11. Carcinogenesis is a multistep process

12. Subclones develop overtime upon accumulating new mutations

13. Hallmarks of cancer Six original hallmarks
1. self sufficiency in growth signals
2. insensitivity to growth inhibitory signals
3. evasion of cell death
4. limitless replicative potential
5. sustained angiogenesis
6. ability to invade and metastasize

16. hallmarks Two emerging 1. reprogramming of metabolism
2. evasion of the immune system

17. Enablers ( help in the tumorogenesis process and set the right conditions for genetic changes to develop)
1. genomic instability
2. inflammation

19. Tumor microenvironment
Stromal cells, mainly fibroblasts and pericytes

20. The language Gene symbols etalicazed , protein products not
So RAS is the gene and RAS is the protein product of RAS

21. 1. Self sufficiency in growth signals
Tumors need to grow regardless of the normal regulatory mechansms.
This is achieved by mutations in proto-oncogenes
Oncogenes cause increased growth by increasing oncoproteins which act as growth factors, growth factor receptors, transcription factors..etc

22. Physiologic normal cell proliferation
1. growth factor binds to its receptor
2. this causes transient limited activation of the receptor
3. the activated receptor activates signal transducing proteins on the inner leaflet of plasma membrane
4.transduced signal transmitted through cytosol to nucleus
5.activation of nuclear regulatory factors that regulate DNA transcription
6. entry into cell cycle

23. Increased growth can happen if there is interference with any f the 6 steps in the previous slide.

24. Growth factors
Some tumors produce their own growth factors, ie factors they respond to
This creates an autocrine loop
Eg glioblastomas produce PDGF and express its receptor
Many sarcomas produce TGF alpha and its receptor

25. Growth factors
Tumor cells can interact with their stroma to produce growth factor

26. GF receptors
Mutant receptor proteins.. Continuous mitogenic signal even in the absence of GF
OR: Overexpression of the receptor .. So, Receptor is hyper responsive to GF even in levels that don’t normally trigger proliferation

27. Overexpression of GF receptor.. examples
EGF (epidermal growth factor receptor) receptor family
ERBB1 (which is a EGF receptor) overexpressed in > 80% of squamous cell carcinoma of the lung, and % of epithelial head and neck tumors
PLEASE UNDERSTAND THE IDEA< DON’T TRY TO REMEMBER PERCENTAGES!!

28. Amplification of GF receptor
Gene encoding her2/neu= ERBB2 is amplified in 25-30% of breast cancers and adenocarcinoma of lung, ovary and salivary gland
High level of HER2/Neu protein in breast cancer worsens prognosis ( results in more proliferation)
If her2 receptor blocked.. By anti her2 antibodies.. Treatment used ( refer to details in previous lecture about HER2 oncogene)

29. Signal transducing proteins
Main signal transducing proteins involved: RAS and ABL

30. RAS RAS is the most commonly mutated oncogene in humans
30% of human cancers contain RAS mutation
Even higher incidence in colon and pancreatic carcinomas

31. RAS is a small g protein that binds GDP and GTP ( G protein)
Inactive with GDP.. Quiescent
If GF binds to a receptor.. GDP to GTP..
Active RAS
Activation is short lived as GTPase hydrolyses GTP to GDP
GTPase activating proteins GAPs prevent over activation of RAS,, so they act as brakes of RAS activation

32. Activated RAS.. Sends messengers to the nucleus by two pathways
1. RAF.. MAPK
2. PI3K..AKT..mTOR
If 1 or 2 mutated.. Can mimic RAS effect
Eg BRAF mutated in 60% of melanomas

34. How RAS is activated
Point mutation in an amino acid residues within the GTP binding pocket or in the enzymatic region of GTP hydrolysis
Both result in defective hydrolysis.. Leading to trapped RAS in active phosphorylated GTP bound RAS

35. Loss of function mutation in GAPs can mimic this
NF1 ( is a GAP) neurofibromatosis 1 mutation

36. ABL
Proto-oncogene with tyrosine kinase activity regulated by internal negative regulatory domain
ABL-BCR translocation.. Results in a hybrid gene
The hybrid gene produces novel tyrosine kinase which is always active and stimulating proliferation.
ABL-BCR pathway activates all the downstream signals of ras

37. CML: t(9;22). ABL-BCR fusion gene…
CML: t(9;22).. ABL-BCR fusion gene….tyrosine kinase which is always turned on
Kinase inhibitors can be used to treat CML
Imatinab/gleevec .. Inhibits the kinase and treats the leukemia
= targeted therapy

39. Oncogene addiction!
Bcr abl is an example of oncogene addiction.. Tumor depends on a single signaling molecule
Although other mutations have accumulated, the leukemia is addicted to this abl bcr , so if this is inhibited the tumor collapses
Drug resistance happens when there is a subclone with mutation in abl bcr that prevents the drug from binding to abl bcr protein ( the kinase)

40. Nuclear transcription factors
Most commonly involved in human cancers: MYC

41. myc Can activate or repress expression of other genes
Activates cyclins and cyclin dependent kinases CDK ( so cells enter cell cycle and divide)
Myc also inhibits cyclin dependent kinase inhibitors (CDKI)

42. MYC amplified in breast, colon, lung and other carcinomas
t8; 14 in burkitt dysregulattes myc activate
Nmyc amplified in neuroblastoma
Lmyc amplified in small cell carcinoma lung

43. Myc also important in changing metabolism.. To be discussed later