Carcinogeneza

Conf Dr Cainap Calin

Oct 2018
 Carcinogeneza – definiție
• Procesul prin care apar tumorile (maligne)

• Protooncogena activată

• Gena supresoare -inactivată

Creștere anormală

Eșec al supravegherii imune

 Cancerogeneza
• Mecanismul este genetic !
(somatice / germinale)
• 4 categorii de gene implicate
a) Oncogene – proliferare
b) Supresoare
c) Gene implicate în apoptoză
d) Gene implicate în homeostazia ADN

e) .......
 Mecanism genetic al cancerului
Proto-oncogene Gene supresoare
• Implicate in multiplicarea • Implicate in multiplicarea
celulara celulara

• FRANA in calea X necontrolate

• Stimuleaza X celulara
• Gene recesive
• Gena dominanta
• Predispozitie familiala
– RET (germinala)
– MEN2 – BRCA1
– FAP

2-5%
 Mecanism genetic al cancerului
Gena reparatorie a ADN
• Implicate in repararea ADN

• X celulara= acumulare de
erori in materialul genetic

• Cumulativ apare cancerul

– Xeroderma pigmentosum
– Sdr Lynch – CRC, endometru

2-5%
 Cancerogeneza
• Proces complex

• Multistadial, multifactorial

• Modificari genetice
– Deletii
– Mutatii
– Translocatii
 Gene implicate în cancerogeneză
• Gatekeepers (creștere și X celulară)
– CDH1 (ECadherin)
– TP53 (Tumor Protein 53)
– pRB (Retinoblastoma protein)
– VHL (von Hippel Lindau)
– APC (Adenomatous polyposis coli)

• Caretakers (integritatea și stabilitatea genomului)

– ATM (Ataxia telangiectasia mutated),
– MLH1 (MutL homolog 1)
– MSH2 (human homologues of bacterial mutS and mutL),
– BRCA1 (Breast cancer gene 1) & BRCA2

• Landscapers (micromediu tumoral)

– PTEN (Phosphatase and tensin homolog)
– matrix metalloproteases (MMPs) -MMP7,
– Membrane-type Matrix metalloproteinase 1 (MT1-MMP), MMP11 & MMP3
 Vocabular
• Hiperplazie = cresterea numarului de celule
• Hipertrofie = cresterea dimensiunii celulare
• Displazie= multiplicare dezordonata
• Neoplazie = crestere anormala
• Anaplazie = lipsa de diferentiere

• Tumora = benigna sau maligna

• Metastaza= crestere tumorala la distanta
Teorii ale cancerogenezei
 Teorii ale carcinogenezei
• Antice
– Hippocrate – bila (umoarea) neagră

• Iritației cronice

• Origine embriologică (teratoame)

• Infecțioasă (parazit, virus, bacterie)

 Teorii noi ale carcinogenezei
• Carcinogeneza chimică
– Peste 900 de carcinogenetici

• Teoria virală

• Teoria ‘hit and run’

– 2 etape: inițiere & promoție și progresie
(reversibile) (ireversibilă)
 Teorii ale carcinogenezei
2 pași 5 pași sau >
• I • Fiecare leziune determină p
– Inițiere modificare a genomului
care este transmisă clonei
• II descendente
– Promoție
 A Timeline of Pioneering Cancer Treatments
1970’s:
Less extensive
1930’s-1940’s: surgery was shown to
1939: Charles Huggins be equally as
discovered that effective. Also, 3D Late 1990’s to early
3000 BC: hormones were radiation delivery 2000’s:
Eight cases of Late 1800’s: important for the was developed with Monoclonal
tumors or ulcers Surgeons perfected 1893: growth of certain CT, allowing for more antibodies against
were described 168 BC: procedures to remove Coley’s Toxins cancers, further accurate radiation tumor antigens
in ancient Galen, a Roman parts of affected were administered paving the way for dosing. 1980’s: were approved by
Egyptian text on physician, tissues, such as as a vaccine to hormone therapies. Scientists identified a Biological therapy the FDA to treat
trauma surgery. believed mastectomies cancer patients. 1941: mutation in the and certain cancers.
Tumors were advanced tumors (removal of the entire The idea that the Diethylstilbestrol, a Philadelphia immunotherapy 2001: The first
treated by should be breast and lymphatic immune system synthetic estrogen, chromosome as the expanded, as targeted anti-
cauterization operated on by system of the breast) could be used to was found to be genetic cause of interferon was cancer therapy,
with a “fire cutting around to prevent outward help fight cancer effective in treating chronic myelogenous found to be able to against CML, was
drill.” the affected area. invasion. was pioneered. prostate cancer. leukemia (CML). treat cancer. approved.

3000 BC 400 BC 168 BC 1846 AD Late 1800s 1870-1890 1893 1895-1899 1930-1940 1946 1970’s 1976 1980’s 1995 1997-2006 2010

400 BC: 1846 AD: 1870-1890: 1890’s: 1946: 1976: 1995: 2010:
Hippocrates proposed Anesthesia Thomas Beatson 1895: Wilhelm The first chemotherapy was The first DNA microarrays were Sipuleucel-T (a
the Humoral Theory of becomes discovered that Rontgen discovered x- discovered by Louis Goodman. oncogene was developed to measure cancer vaccine that
Medicine and attributed available and estrogen stimulates rays, which helped in Nitrogen mustards, used in discovered by gene expression. This boosts the immune
cancer to an excess of surgery becomes breast cancer, the detection of WWII chemical warfare, were Harold E. Varmus led to the possibility of system) was
black bile. He believed more prominent. providing a tumors. found to be useful as and J. Michael targeted therapy, or approved to treat
the cancer should be foundation for 1899: The first chemotherapeutic agents Bishop. targeting genes and prostate cancer.
left alone, because hormone therapy. successful treatment against cancer. processes directly
those who got of cancer with involved in cancer
treatment did not live as radiation from x-rays. initiation and
long as those who were Radiation therapy metastases.
untreated. begins.
 SCT (Stem Cells Theory)

 sugereaza o ierarhie clara cresterea tu e un proces

a celulelor in tu aleator la care poate
contribui orice celula
Mecanismul carcinogenezei
Epigenetic - exozomii
Epigenetic - exozomii
Epigenetic - exozomii
https://doi.org/10.3892/ol.2017.6002
 Consecința unei alterări genetice
1. Reparația

2. Apoptoza

3. Supraviețuirea – cu modificare la nivel de:

 Celulă
 Țesut
 Organism
 Specie
 Comparație
CELULA NORMALĂ CELULA MALIGNĂ
• Membrană – netedă • Neregulată
• Nucleu – proporționat • Mare (erori ADN)
• Citoplasmă – mare
• Mică

• Ciclu celular- control

• Imunogenicitate – normală
• Necontrolat
• Suport hematologic- da • Mică
• Angiogeneză
• Energie – ƞ- f bun • ƞ- f mic (glucoză)

• pH- alcalin • pH- acid

https://fineartamerica.com/art/cancer+cells
 Dependență de substrat

T 2X 200 zile= 20 ani = 1 cm tu

100 zile= 10 ani= 1 cm
20 zile= 2 ani= 1 cm
Inhibiție de contact
Metastazele au T 2X mai mic ca si tu primara

Inhibiție dependentă de densitate

20 m 20 m
(a) Celule normale (b) Celule canceroase
Bull Acad Natl Med. 2014 Apr-May;198(4-5):867-79.
[Risks associated with unrestricted consumption of alkaline-reduced water].
[Article in French]
Henry M, Chambron J.
Abstract

Consumption of alkaline reduced water produced by domestic electrolysis devices was

approved in Japan in 1965 by the Minister of Health, Work and Wellbeing, for the treatment
of gastrointestinal disorders. Today, these devices are also freely available in France. The
commercial information provided with the devices recommends the consumption of 1 to 1.5
liters per day, not only for gastrointestinal disorders but also for numerous other illnesses such
as diabetes, cancer and inflammation. Academic research on this subject has been undergoing
in Japan since 1990, and has established that the active ingredient is dissolved dihydrogen,
which eliminates the free radical HO· in vivo. It has also been shown that electrode
degradation during use of the devices releases highly reactive platinum nanoparticles, the
toxicity of which is unknown. The authors of this report recommend alerting the French
health authorities to the uncontrolled availability of these devices that generate drug
substances and should therefore be subject to regulatory requirements.

PMID:
26753412
 Caracteristicile celulei canceroase
• Creștere necontrolată(GF autocrini)
- deficit de apoptoză
- nediferențiere
- erori genetice

• Invazia de vecinătate
(dispare inhibiția de vecinătate)

• Metastazarea
–Limfatică
–Hematogenă
–Transdiafragmatică https://qph.fs.quoracdn.net
http://telomerance.com/images/
https://www.123rf.com/photo_63431794_stock-illustration-dividing-cancer-cells-
multiplication-of-tumor-cells-3d-illustration.html
Potentialul replicativ al celulelor normale

• Maximum = 60-70 X.
• Se instaleaza apoi senescența.
• Responsabili de acest lucru = telomerii.

• Scurtarea telomeri = oprire ciclu celular –

deces celular
 Mecanism
• Reparare ineficienta = cromozomi dicentrici
• Apar noi rupturi in ADN
• Instabilitate genetică

• catastrofă mitotică

• Apariția cancerului
 Comparații
ȚESUT MALIGN ȚESUT BENIGN
• CAPSULĂ ++ • CAPSULĂ +/-
• INVAZIV • NON INVAZIV
• NEDIFERENȚIAT • BINE DIFERENȚIAT
• MITOZE FRECVENTE • MITOZE RARE

• RATA DE CREȘTERE MARE • RATA DE MULTIPLICARE

(ki67) MICĂ
• METASTAZE • METASTAZE +/-
• Lez preneoplazice & in situ • Lez displazice
+/-
http://www.primadonastems.com/cancer/how-do-healthy-cells-
transforming-into-cancer-cells-cancerous/attachment/8045471_orig/
Nature volume 513, pages 202–209 (11 September 2014)
 Laboratory Medicine 41:364-372 · May 2010
Mutation and Copy Number Discordance in Primary vs. Metastatic Colorectal Cancer (mCRC)<br />

Presented By Scott Kopetz at 2014 ASCO Annual Meeting

 Enrolled population

115 patients with mCRC with metastasectomy + resection of

primary tumor

Variable>

- Administrated chemotherapy regimen

- Timing of resections
- Primary tumors and metastasis localizations
- Type of confirmation and genetic analysis on primary tumors
and metastasis
Presented By Scott Kopetz at 2014 ASCO Annual Meeting
 Low Concordance Between Primary and Metastases for PIK3CA and Minor Genes

Presented By Scott Kopetz at 2014 ASCO Annual Meeting

 DISCREPANT

1. Genetic modifications are more frequent for metastasis

which are resected metacrone for 3.4 X more

2. Chemotherapy could increase by 2.7 times between

primary tumors and metastasis

Presented By Scott Kopetz at 2014 ASCO Annual Meeting

 DISCREPANT
3. The highest genetic discrepancies:

 Metastatic sites>

• Lung
• Peritoneum
• Bone
• Brain
 Primary tumors

• Rectum < left or right colon

Presented By Scott Kopetz at 2014 ASCO Annual Meeting
 Enzalutamide: Phase 3 (AFFIRM) Study

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Resistance to Enzalutamide

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Resistance to Abiraterone

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 AR Splice Variants (AR-Vs)

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 AR-V7: Most Important AR Variant

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Best PSA Response (Enzalutamide)

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 PSA Progression-Free Survival (Enzalutamide)

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Progression-Free Survival (Enzalutamide)

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Outcomes: AR-V7 “conversions”

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

 Prevalence of AR-V7 in CRPC (n=62)

Presented By Emmanuel Antonarakis at 2014 ASCO Annual Meeting

Biopsii lichide
 Stadii ale Carcinogenezei
Initiere
Initiere Proliferare
Evenimen celulară
t
(expansiuneț ie
t a
mu )
clonală
2 Promotie
A

Proliferare
celulară
a ție Progresie
ut
N "M
"
Proliferare
celulară
Malignitat
e
 1.Inițiere
• Necesită agent carcinogenic = inițiator
• Cocarcinogenic = poate interacționa &
determinant
• Lez ADN permanentă + promotor
• Doar celulele inițiate care se divid vor putea
determina cancer (modificarea se fixează &
trasmite la cel fiice)

Lez ireversibilă
 Inițiatori
• Radiații ionizante
– Radicali liberi de oxigen – afectare ADN (rupturi crom, del, transloc)

• UV
– Punți de timidină & p53

• Microtraumatisme
– Azbest
– Corpi străini

• Agenți biologici
– Virusuri- HTLV1, HBV, HCV, EBV, HS, HPV
– Bacterii- H pylori
– Paraziți - schistosoma
 Carcinogenic
• Complet (hidrocarburi, tutun, cărbune)

– Are inițiator & promotor

– Doze mici= inițiator doze mari= promotor

• Incomplet

– Necesită promotor
Mecanism – ag biologici
68
 Helicobacter pylori
• G neg
• Cel mai puternic factor de risc pt cc gastric
• Tipuri tumori:
– ADK gastric
– LNH MALT
• Mecanism: prot CagA care determina secretie de IL
6+8+ TNF alfa= inflamație(ROS, RNOS) (proliferare
celulară)+ angiogeneză
• Acț în std incipiente ale carcinogenezei, eliminarea
scade risc de cancer dacă nu avem leziuni preneoplazice
 Fusobacterium
• G neg
• Risc de cancer colorectal

• Mecanism : aderă de E Cadherin (lipici

intercelular), stim sinteza de beta catenin
(interacțiunea celulă-celulă, transcripția
genelor)
• Inflamație (proliferare celulară)+ angiogeneză
 2.Promoție
• Stimulează proferarea celulară = mitogeni

• Nu determină afectare ADN

• Prima celulă tumorală
• Dose-dependentă
– Mici – favorizează apariția de lez ‘preneoplazice’
– Mari – poate inhiba carcinogeneza prin selecție
negativă la clonele sensibile

Lez reversibilă
 3.Progresie
• Clonă care supraviețuiește
• Creștere adaptativă – depinde de factori de
mediu (fact de creștere, nutriționali, hormoni,
imunologici etc)
• Necesită suport angiogenic

• Va determina tumori care vor fi clinic &

imagistic evidențiabile
 Progresie
• Poate explica progresia în timp a tumorii spre
a variantă mai agresivă

• Nu obligatoriu se modifică dimensiunea

CA 125?
PET/CT?
LNH
Invazivitatea celulelor maligne

1- locală

2- metastatică
 Recruitment of capillaries by an implanted tumor

Figure 13.32a The Biology of Cancer (© Garland Science 2007)

 Chaotic organization of tumor-associated vasculature

Figure 13.34a The Biology of Cancer (© Garland Science 2007)

Istoria naturală a cancerului
 Invazia matricei extracelulare(ECM)

• Corpul omenesc este constituit in

compartimente in care avem componente al
ECM:

• 1- membrane bazale .

• 2- țesut interstițial.
 Invazia celulelor tumorale
• Etape:
• 1- detașarea celulelor maligne unele de altele
(E Cadherin)
• 2- Degradarea ECM .
• 3- Migrarea celulelor tumorale
• 4- Atașarea de un nou ECM.
Metastazarea
Mecanism metastazare
0,1 0/0000
Situri metastatice
 Metastasis

Metastaze

Figure 20-1 Molecular Biology of the Cell (© Garland Science 2008)

Pathology Outlines
Pathology Outlines
Caracteristici ale cancerului
Implicatii terapeutice
 Oncogene
• Forma activată a proto-oncogenelor (gene
esențiale = normale a genomului)
• Rol în :
– Reglarea proliferării celulare (factori de creștere &
receptori)
– Diferențierea celulară
– Transmiterea semnalului intracelular

• DOMINANT (1 suficientă pt cancer)

 Gene supresoare
• RECESIVE
• Ambele trebuie să fie afectate ca să se
producă cancer

• Pot fi promotori

• Indirect prin corectarea leziunilor de ADN

 Gene supresoare
• P53 (17p13.1)
‘gardianul genomului’ (asigură stabilitatea
genomului împiedică tumorigeneza)

• 4 zone:
– Stabilizează structura
– Recunoaște leziuni ADN
– Recunoaște secvențe specifice de ADN
– Zona care activează transcripția
 Rolul p53

http://www.bioinformatics.org/p53/introduction.html
http://p53.fr/tp53-database
 Factori de transcripție nucleari
• Creșterea necontrolată == consecința mut
gene care reglează transcripția ADN

• MYC, MYB, JUN, FOS& REL oncogenes,

expresia CDK.
• Supraexpresie ------ cancer
 Exemple de CDKs implicate în patologia
oncologică
• Del / inact p16(CDKN2A) sunt asociate cu:

• 75% ADK pancreatic

• 40% - 70% din glioblastom
• 50% din cc esofagian
• 20% din non-small-cell lung carcinom, sarcom
de părți moi, cancere de vezică urinară.
Cc mamar
 Factori predispozanți - genetici
• FAP
• Retinoblastoma

• Predispoziție pentru inițiere

• Reparare deficitară

• Imunodeficiență
 Instabilitatea microsateliților
• defective DNA mismatch repair (MMR) system
– Mutație în MLH1 ,MSH2 ,MSH6 ,PMS2 / Deleție EPCAM
(MSH2)
– Hipermetilare MLH1

– MSI H versus MSI L / MSS

• G3 / mucus
• Tu cu infiltrat Ly
• Reacție Crohn like
• Mai puține M+
Blocadă PD-1 la tumori dMMR
From: Immune escape to PD-L1/PD-1 blockade: seven steps to success (or failure)
Ann Oncol. 2016;27(8):1492-1504. doi:10.1093/annonc/mdw217
Ann Oncol | © The Author 2016. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights
reserved. For permissions, please email: journals.permissions@oup.com.
Chen DS et al. Molecular pathways : Next generation immunotherapy- inhibiting programmed death ligand 1 and
programmed death 1. Clin Cancer Res 18(24)dec 2012. 6580-6587
Chen DS et al. Molecular pathways : Next generation immunotherapy- inhibiting programmed death ligand 1 and
programmed death 1. Clin Cancer Res 18(24)dec 2012. 6580-6587
 Factori predispozanți - mediu
• Radiații ionizante , etc

• Nutriție

• Mod de viață

• Nutrienți din mediu

 Carcinogenetici chimici

• Initiator  Natural / Sintetic

• 2 categorii: Direct & Indirect

 Carcinogenetici chimici

• Direct :-
 Nu necesita transformare
– Ag alkilanti: Cyclophosphamide

• Indirect
 Necesita activare
– hidrocarburi– Benzpirene
– amines aromatice, - Benzidine
– Produse naturale: Aflatoxin
 Agenti direct
• Carcinogenici slabi
 Nu necesita transformare
– Ag alkilanti: Cyclophosphamide

– Cyclophosphamide, chlorambucil, nitrosoureas

– Al doilea cancer survine tardiv 10-20 ani

 Agentii electrofilici
• Proteine, ARN & ADN au locusuri care pot
interactiona cu agentii electrofilici

• Pot produce adducti in ADN

 Agentii Indirecti
• Necesita activare metabolica.
– Procarcinogen:- initial chimic
– Ultim carcinogen: produs activ
• Exemple
– hidrocarburi: petrol, epoxid
• Benz[a]anthracene: cancer cutanat
• Benzo[a]pyrene: fumat – cancer pulmonar
 Agentii Indirecti
• Exemple
• Amine aromatice
 Conversie in ficat prin P-450

– Nitrosamine & amide

– ADK gastric
• Aflatoxin B
– Aspergillus flavus
» Hepatocellular carcinoma
Carcinogeneza indusa de radiatii
 Efecte ale radiatiilor ionizante
• Radiatiile electromagnetice (X- & gamma)

• electroni care afecteaza direct ADN

• RLO care interactioneaza cu ADN sau cu enzime

• Efect – pe tesut == cancer

pe tesut de reproducere = transmitere la descendenti
predispozitia
Model oncogenetic al RTE
Relatia doza expunere - cancer
Factori care accelereaza transformarea
maligna in combinatie cu RTE
Protectori
Marie Curie & Irene
Hand of dentist
Importanta varstei de expunere

Children and young adults are much more susceptible to

radiation-induced cancer than the middle- and old-aged.
Incidenta cancer tiroidian
Risk of cancer following iodine-131
therapy
Quantitative risk estimates for
radiation-induced cancer
Radiat Res. 2003 Oct;160(4):381-407.
Studies of mortality of atomic bomb survivors. Report 13: Solid cancer and noncancer disease mortality: 1950-1997.
Preston DL1, Shimizu Y, Pierce DA, Suyama A, Mabuchi K.
Author information
Abstract

This continues the series of general reports on mortality in the cohort of atomic bomb survivors followed up by the
Radiation Effects Research Foundation. This cohort includes 86,572 people with individual dose estimates, 60% of whom
have doses of at least 5 mSv. We consider mortality for solid cancer and for noncancer diseases with 7 additional years of
follow-up. There have been 9,335 deaths from solid cancer and 31,881 deaths from noncancer diseases during the 47-
year follow-up. Of these, 19% of the solid cancer and 15% of the noncancer deaths occurred during the latest 7 years. We
estimate that about 440 (5%) of the solid cancer deaths and 250 (0.8%) of the noncancer deaths were associated with the
radiation exposure. The excess solid cancer risks appear to be linear in dose even for doses in the 0 to 150-mSv range.
While excess rates for radiation-related cancers increase throughout the study period, a new finding is that relative risks
decline with increasing attained age, as well as being highest for those exposed as children as noted previously. A useful
representative value is that for those exposed at age 30 the solid cancer risk is elevated by 47% per sievert at age 70.
There is no significant city difference in either the relative or absolute excess solid cancer risk. Site-specific analyses
highlight the difficulties, and need for caution, in distinguishing between site-specific relative risks. These analyses also
provide insight into the difficulties in interpretation and generalization of LSS estimates of age-at-exposure effects. The
evidence for radiation effects on noncancer mortality remains strong, with risks elevated by about 14% per sievert during
the last 30 years of follow-up. Statistically significant increases are seen for heart disease, stroke, digestive diseases, and
respiratory diseases. The noncancer data are consistent with some non-linearity in the dose response owing to the
substantial uncertainties in the data. There is no direct evidence of radiation effects for doses less than about 0.5 Sv.
While there are no statistically significant variations in noncancer relative risks with age, age at exposure, or sex, the
estimated effects are comparable to those seen for cancer. Lifetime risk summaries are used to examine uncertainties of
the LSS noncancer disease findings.
Quantitative
risk estimates
for radiation-
induced
cancer
Summary of risk estimates

For the population

composed of both
sexes the ICRP
recommends
the following
figures