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Tumor (really GROWTH) suppressor genes TGF- COLON E-cadherin STOMACH NF-1,2 NEURAL TUMORS APC/ -cadherin GI, MELANOMA SMADs GI RB RETINOBLASTOMA P53 EVERYTHING!! WT-1 WILMS TUMOR p16 (INK4a) GI, BREAST BRCA-1,2 BREAST KLF6 PROSTATE

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TRANSFORMATION & PROGRESSION Self-sufficiency in growth signals Insensitivity to growth-inhibiting signals Evasion of apoptosis Limitless replicative potential: Telomerase Angiogenesis Invasive ability Metastatic ability Defects in DNA repair: Spell checker

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Evasion of APOPTOSIS BCL-2 Overexpression Seen in B-cell lymphomas of follicular type t(14;18)(q32;q21),dominant with IgH genes and overexpression of BCL-2 protein P53 (Pro-apoptic gene) - Directly activates Bax (Bcl-2 protein) Reduced levels of CD95/Fas FLIP protein Inhibits Caspase 8 Loss of APAF1(Apoptosis activating factor-1) Increased IAP (inhibitors of apoptosis)

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LIMITLESS REPLICATIVE POTENTIAL TELOMERES determine the limited number of duplications a cell will have! TELOMERASE, present in >90% of human cancers, changes telomeres so they will have UNLIMITED replicative potential

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TUMOR ANGIOGENESIS Q : How close to a blood vessel must a cell be? A: 1-2 mm Activation of VEGF and FGF-b Tumor size is regulated (allowed) by angiogenesis/anti-angiogenesis balance

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Proteases of tumors can induce production of angiogenic factors and inhibitors Proteases act on ECM components (E.g. Collagen) releasing bFGF and VEGF VEGF triggers the NOTCH Pathway

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INVADE & METASTASIS 1. Invasion of Extracellular Matrix 2. Vascular Dissemination Invading the Extracellular matrix requires breaching the basement membrane Intersitial Connective Tissue Vascular Basement Membrane

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Invasion of ECM 1. Detachment ("loosening up") of the tumor cells from each other Down-regulation of E-cadherin and Beta-catenin reducing cells adherance to each other

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Invasion of ECM 2. Degradation of ECM, e.g., collagenase, etc. Break down the basement membrane Proteases MMP (matrix metalloproteinases) Releasing growth factors (e.g. VEGF) and angiogenic, growth promoting effects with cleavage of Type IV collagen for example 3. Attachment to matrix components Breakdown by MMP allows tumor cell receptors to bind ECM proteins and stimulate migration E.g. MMP2 cleaves laminin and MMP9 cleaves collagen IV Change in tumor cell receptor attachment to ECM proteins Stimulates Migration

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Invasion of ECM Migration of tumor cells Cytokines ( autocrine factors) Cleavage of the ECM components (Laminin, collagen) and growth factors (IGF I, II) that have chemotactic activity Stromal cells around tumor also produce hepatocyte growth factor-scatter factor promoting motility

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TRANSFORMATION GROWTH BM INVASION ANGIOGENESIS INTRAVASATION EMBOLIZATION ADHESION EXTRAVASATION METASTATIC GROWTH etc.

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Vascular Dissemination Following intravasation, clumps of platelet-tumor aggregates are formed Extravastion of this tumor emboli at distant sites Attachment to the endothelium Exits through the basement membrane Followed by migration to lymphoid tissue using the CD44 adhesion molecule (expressed on T cells) CD44 binds to hyaluronate allowing migration and towards metastic spread *Most metastases occur in the first capillary bed available to tumor

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Other possible mechanisms explaining metastasis: 1. Tumor cell adhesion molecule ligands are expressed on the endothelial cell of target tissue Target organ variation in endothelial cell expression of adhesion molecule ligands 2. Chemokine receptors are expressed in cancer cells that allowing binding of chemokines expressed at specific tissues E.g. CXCR4 and CCR7 receptors expressed in breast cancer cells 3. Chemoattractants E.g. IGF 1, II, can be expressed at target tissues

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Breast cancer cells, how do they adapt and make their environment habitable? - Osteolytic behavior in bone by osteoclasts Tumor cells PTHRP (parathyroid hormone-related protein) Osteoblasts RANK ligand Osteoclasts Osteoclasts break down the matrix releasing growth factors

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Development of Metastasis One hypothesis suggest why only some tumors metastasize? Metastasis Signature Multiple abnormalities taking place in the early stage of development Intrinsic properties, microenvironment (stroma), angiogenesis, resistance to immune defenders, and local invasiveness Other hypothesis Rare clonal variation that develop metastasis

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DEFECTS IN DNA REPAIR 1. Mismatch Repair 2. Nucleotide Excision Repair 3. Recombination Repair

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DNA REPAIR GENE DEFECTS DNA repair is like a spell checker HNPCC (Hereditary Non-Polyposis Colon Cancer [Lynch]): TGF- , - catenin, BAX Xeroderma Pigmentosum: UV fixing gene Ataxia Telangiectasia: ATM gene Bloom Syndrome: defective helicase Fanconi anemia

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Hereditary Non-Polyposis Colon Cancer Mismatch Repair Proofreaders disabled Microsatellite fragments 1 to 6 nucleotide repeats Creates instability Dna mismatch repair gene affect cell growth indirectly, through mutations in other genes TGF-beta, beta-catenin, Bax

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Xeroderma Pigmentosum UV radiation exposure Pyrimidine dimers DNA damage with defect in nucleotide excision repair

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Autosomal Recessive Disorders Defect in DNA repair by Homologous Recombination Ataxia Telangiactasia neurological degenerative disorder, exposure to Ionizing radiation Defective ATM gene Bloom Syndrome - Ionizing radiation resulting in developmental defects Defect in gene of chromosme 15 encodes helicase dna repair through homologus recombination Fanconi anemia Chemotherapeutic agents causing damage Bone-marrow aplasia BRCA1 and BRCA 2 Proteins take part in homologous recombination repair pathway Mutation of BRCA2 gene chromosomal breaks & aneuploidy

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STROMAL MICROENVIRONMENT Cross-Talk between the tumor cells and ECM E.g. Laminin degradation by MMP2 Stimulates tumor cell motility E.g. Type IV collagen degradation by MMP9 Release of VEGF Storage of inactive growth factors in ECM, proteases release the active form (E.g. PDGF, TGF-beta, bFGF)

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STROMAL MICROENVIRONMENT Inflammatory Cells and fibroblasts Cytokines released during inflammation Induce survival and progression of tumor cells Chemokines Chemotactic properties Fibroblasts Important role in tumor cells Desmoplastic response, highly fibrotic, promoting growth

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Metabolism of Tumors

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WARBURG EFFECT Otto Warburg, Nobel Prize discovery on the metabolism of turmors Cancer cells rely on Aerobic Glycolysis, Warburg Effect, instead of the mitochondrial oxidative phosphorylation Several Hypothesis 1. During angiogenesis, vessels are poorly formed, activation of H1F1alpha due to hypoxia increases expression of enzymes of glycolysis, and vasculature 2. Exposure to state of continous hypoxia and normoxia 3. Mutations in oncogene and tumor supressors (p53, RAS, PTEN) stimulate metabolic changes

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Metabolic Alterations In addition, tumor cells need to build and maintain its membrane, proteins, and organelles --- Anabolic Pathway Lipid, nucleotide, proteins (amino acids), glucose (carbon) Glutamine Both glycolytic and anabolic pathway

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PI3K/AKT/Mtor pathway Important in regulating normal cell functions including amino acid, glucose uptake In tumors, mutation of tumor supressors and oncogenes - -- Abnormality in pathway can occur favoring survival and proliferation of tumor cells E.g. PTEN has a negative regulation of this pathway,

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Other tumor supressors that supress this pathway:- Peutz-Jegher syndrome mutated gene LKB1 ( Liver kinase B1) Limits or regulates cell growth by AMP-dependent protein kinase mechanism Negative regulator of mTOR pathway Supression of LKBI (also called STK11) Increase in anabolic metabolism of cancer cells TuberousSclerosis mutated genes (TSC1 and TSC2) ----- Negative regulation of mTOR

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CHROMOSOME CHANGES in CANCER TRANSLOCATIONS and INVERSIONS Occur in MOST Lymphomas/Leukemias Occur in MANY (and growing numbers) of NON-hematologic malignancies also

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MalignancyTranslocationAffected Genes Chronic myeloid leukemia(9;22)(q34;q11)Ab1 9q34 bcr 22q11 Acute leukemias (AML and ALL)(4;11)(q21;q23)AF4 4q21 MLL 11q23 (6;11)(q27;q23)AF6 6q27 MLL 11q23 Burkitt lymphoma(8;14)(q24;q32)c-myc 8q24 IgH 14q32 Mantle cell lymphoma(11;14)(q13;q32)Cyclin D 11q13 IgH 14q32 Follicular lymphoma(14;18)(q32;q21)IgH 14q32 bcl-2 18q21 T-cell acute lymphoblastic leukemia(8;14)(q24;q11)c-myc 8q24 TCR- 14q11 (10;14)(q24;q11)Hox 11 10q24 TCR- 14q11 Ewing sarcoma(11;22)(q24;q12)Fl-1 11q24 EWS 22q12

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Translocations ------------- Activate Proto-Oncogenes 2 common mechanism of translocation: A) Lymphoid Tumors --- Swapping or movement of segment of chromosome to another chromosome B) Hematopoietic tumors --- Two chromosomes recombine to form hybrid fusion genes for production of chimeric proteins

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Burkitt Lymphoma:- t(8:14) (q24;q32) Translocation at chromosome 8 (c-MYC) and 14 ( IGH gene) MYC containing segment of chromosome 8 movement to to chromosome 14q32 at IGH gene Overexpression of MYC

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Follicular Lymphomas:- t(14:18) (q32:q21) Translocation at chromosome 14 (IGH gene) and 18 (BCL2) Activation of BCL2

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Chronic Myeloid Leukemia (CML):- t(9;22) (q34;q11) Translocation at chromosome 9 (ABL gene) and 22 (BCR gene)

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What is the Philadelphia chromosome? Chromosome 22 that exchanges portion (reciprocal translocation) of the chromosome with Chromosome 9 Fusion of two genes BCR-ABL producing protein with tyrosine kinase activity Found in both CML & ALL (Acute Lymphoblastic Leukemia)

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Ewing Sarcoma Also known as PNET (Primitive neuroectodermal tumor) T(11:22) (q24;q12) FLI 1 gene and EWSR1 gene Chimeric protein EWS-FLI 1 Fusion of most genes encode for transcription factors

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GENE AMPLIFICATION Amplification of particular chromosomal regions that contain the oncogenic sequence Hallmark Features:- Double minutes ---- Small, centric structures or chromatin bodies of extrachromosomal dna Homogenous staining regions Once a gene is amplified, these amplified regions can be inserted into new choromsome Lack a normal banding pattern and appear homogenous (G-banded karyotype)

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Gene Amplification N-MYC ---- Neuroblastoma ERBB2 --- Breast Cancers C-myc, L-myc, N-myc --- Small cell lung cancer **Greater the amplification, poorer the prognosis

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Epigenetic Changes Heritable changes in gene expression without changing the DNA sequences Post-translational modfications of histones + DNA methylation ===== Gene Expression Cancer cells --- Hypermethylation within promoter regions and global DNA Hypomethylation Tumor supressor genes --- hypermethlation --- Silenced E.g. BRCA1, VHL, MLH1

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Epigenetic Changes Genomic Imprinting: Maternal or paternal allele of a gene or chromosome is modified by methylation and inactivated

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miRNAs Non-coding, single stranded RNA RNA-induced silencing complex Post-transcriptional gene silencing Downregulate gene expression by translational repression, and deadnylation In cancer cells, increase oncogene expression or reduce tumor supression gene expression

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miRNAs 1. Reduced miRNA (Inhibitor of oncogene translation) --- ------------ Overproductin of oncogene 2. miRNA reduces tumor supressor gene

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Molecular Basis of Carcinogenesis

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Carcinogenesis is MULTISTEP NO single oncogene causes cancer BOTH several oncogenes AND several tumor suppressor genes must be involved Gatekeeper/Caretaker concept Gatekeepers: ONCOGENES and TUMOR SUPPRESSOR GENES Caretakers: DNA REPAIR GENES Tumor PROGRESSION ANGIOGENESIS HETEROGENEITY from original single cell

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Cancer result from accumulation of multiple mutations

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Chimney Sweeps ---------- Scrotal skin cancer

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Two-stage experimental model (mouse skin) of cancer development (Skin Cancer):- Initiation ---- Exposure of cells to a sufficient dose of a carcinogenic agent (Initiator) Promoter ----- Induce tumors in Initiated cells

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Carcinogenesis: The USUAL (3) Suspects Initiation/Promotion concept: BOTH initiators AND promotors are needed NEITHER can cause cancer by itself INITIATORS (carcinogens) cause MUTATIONS PROMOTORS are NOT carcinogenic by themselves, and MUST take effect AFTER initiation, NOT before PROMOTERS enhance the proliferation of initiated cells Promoters are non-tumorigenic by themselves

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Initiators === Highly reactive electrophiles ( Electron deficient) atoms Bind to nucleophiles ( Electron rich sites) in cell E.g. DNA, RNA, Proteins

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Q: WHO are the usual suspects? Inflammation ? Teratogenesis ? Immune Suppression? Neoplasia? Mutations?

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A: The SAME 3 that are ALWAYS blamed! 1) Chemicals 2) Radiation 3) Infectious Pathogens

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CHEMICAL CARCINOGENS: INITIATORS DIRECT -Propiolactone Dimeth. sulfate Diepoxybutane Anticancer drugs (cyclophosphamide, chlorambucil, nitrosoureas, and others) Acylating Agents 1-Acetyl-imidazole Dimethylcarbamyl chloride PROCARCINOGEN S Polycyclic and Heterocyclic Aromatic Hydrocarbons Aromatic Amines, Amides, Azo Dyes Natural Plant and Microbial Products Aflatoxin B1 Hepatomas Griseofulvin Antifungal Cycasin from cycads Safrole from sassafras Betel nuts Oral SCC

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CHEMICAL CARCINOGENS: INITIATORS OTHERS Nitrosamine and amides (tar, nitrites) Vinyl chloride angiosarcoma in Kentucky Nickel Chromium Insecticides Fungicides PolyChlorinated Biphenyls (PCBs)

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Cytochrome P450-dependent mono-xoygenase ----- Metabolizing most carcinogens (E.g. Benzo [a]pyrene) ** Genes for these CP450 mono-oxygenase enzymes are polymorphic, determining susceptibility to cancer E.g. CYP1A1 gene --- increases lung cancer in smokers Carcinogen Aflatoxin B1 --- Mutation in p53 (transversion in codon 249 G:C T:A) or 249 (ser)

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Nitrosamine in Food --Curing meat as a food preservation Aflatoxin contamination

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CHEMICAL CARCINOGENS: PROMOTORS HORMONES PHORBOL ESTERS (TPA), activate kinase C PHENOLS DRUGS, many Initiated cells respond and proliferate FASTER to promotors than normal cells

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Following initiation, damaged dna template must be replicated for the change to be heritable Promoter induction leads to proliferation and clonal expansion of initiated cells

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RADIATION CARCINOGENS UV: BCC, SCC, MM (i.e., all 3) IONIZING: photons and particulate Hematopoetic and Thyroid (90%/15yrs) tumors in fallout victims AML CML Solid tumors either less susceptible or require a longer latency period than LEUK/LYMPH BCCs in Therapeutic Radiation

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Ultraviolet Rays UVA (320-400nm) UVB (280-320nm) -- Induction of cutaneous cancers Pyrimidine dimers UVC (200-280nm) --- Filtered by Ozone shield

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VIRAL CARCINOGENESIS HPV SCC EBV Burkitt Lymphoma HBV HepatoCellular Carcinoma (Hepatoma) HTLV1 T-Cell Malignancies KSHV Kaposi Sarcoma

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Oncogenic RNA Virus Human T-Cell Leukemia Virus Type 1:- T-cell leukemia / lymphoma Target -- CD4+ Tcells Induction of Leukemogenesis In addition to the genome gag, pol, env, another type tax gene is crucial Tax --- Viral replication, viral mrna transcription, transcription of host cell genes for T-cell differentiation Tax protein inactivation of Inhibitor p16/INK4a, allowing increased cyclin D cell cycle dysregulation Proliferating T Cells --- Mutations and genomic instability

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Oncogenic DNA Virus Human Papilloma Virus DNA Virus ---- 70 different types of HPV Low Risk type (E.g. HPV 6 & 11) Benign squamous papillomas ( Warts) E.g. Genital area Episomal form (non-integrated) High Risk type (E.g. HPV 16, 18, 31) Squamous cell carcinoma of cervix Integrated form Genomic instability

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HPV Viral proteins HPV viral genes ---- E6 & E7 (oncogenic potential) E7 --- Binds to RB---- E2F transcription factors displaced Progress to cell cycle E7 --- Inactivates p21 inhibitor - Increase cyclins E6 --- Binds and Degrades p53 & Bax Also activates Telomerases Effects of E6 & E7 ---- Express oncogenic proteins, inactivate tumor supressors, activate cyclins, inhibit apoptosis, and combat cellular senescence

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Epstein-Barr Virus Commonly found in HIV patients, immunocompromised patients Central Africa B-lymphocyte infection by its CD21 receptor (attachment) Latent infection, no viral replication Hijaciking of normal signal pathways Borrows a normal b- cell activation pathway Latent membane protein (LBP-1) and EBNA-2 --- oncogenic --- B-cell proliferation ---inducing b-cell lymphomas

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Epstein-Barr Virus EBV virus -------------- Burkitt Lymphoma?? Repeated infections such as malaria----small number of EBV infected B cells persist ----- Lymphomas ------ Translocation ===== > c-myc oncogene

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HBV & HCV Integration into host cell explained by immunologic response --- chronic inflammation (proliferation of hepatocytes, growth factors, chemokines, cytokines) Activation of NF-kB, blocks apoptosis Productin of ROS (reactive oxygen species) HBx gene found in HBV ----- activates transcription factors **NO viral oncoproteins

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H. Pylori Carcinogenesis Similar to HBV, HCV, chronic inflammation such as epithelial cell proliferation leads to gastric adenocarcinoma Chronic gastritis Gastric atrophy Intestinal metaplasia Dysplasia Cancer CagA (cytotoxin-associated A) gene Signaling cascade Gastric Lymphoma (B-cell type) 100% of gastric lymphomas (i.e., M.A.L.T.-omas), mucosa- associated-lymphoid-tissue, similar features of normal Peyers patches Gastric CARCINOMAS also!

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HOST DEFENSES IMMUNE SURVEILLENCE CONCEPT CD8+ T-Cells NK cells MACROPHAGES ANTIBODIES

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Escape from Immune Surveillance 1. Selective outgrowth Strong immunogenic subclones are eliminated 2. Loss of expression of MHC molecules 3. Lack of costimulation (modulate immune response by T and B cells) 4. Immunosupression Chemicals, Radiation, tumor products TGF-beta 5. Antigen masking Hidden antigens by glycocalyx molecule 6. Apoptosis of cytotoxic T cells By expressing FasL on T-lymphocytes

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CYTOTOXIC CD8+ T-CELLS are the main eliminators of tumor cells

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How do tumor cells escape immune surveillance? Mutation, like microbes MHC molecules on tumor cell surface Lack of CO-stimulation molecules, e.g., (CD28, ICOS), not just Ag-Ab recognition Immunosuppressive agents Antigen masking Apoptosis of cytotoxic T-Cells (CD8), i.e., the damn tumor cell KILLS the T-cell!

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Clinical Features of Neoplasia

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Effects of TUMOR on the HOST Location anatomic ENCROACHMENT HORMONE production Bleeding, Infection ACUTE symptoms, e.g., rupture, infarction METASTASES

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Local / Hormonal Effects Location E.g. Pituitary Adenoma --- Hypopituitarism Endocrine Gland Neoplasm -- Endocrine Insufficiency GIT Neoplasm --- Obstruction, Intussception or Telescoping, melena, hematuria Hormone Production Mostly benign Eg. Adenoma of pancreatic islets (beta cell) Increased insulin --- Hypoglycemia E.g. Non-endocrine tumors ----- Paraneoplastic syndrome

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CACHEXIA Progressive body fat loss & lean muscle, along with profound weakness, anorexia, and anemia **Food intake reduced, however basal metabolic rate is increased --- Why?? Cytokines:- TNF ( by default) IL-(6) PIF (Proteolysis Inducing Factor)

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Cancer Cachexia Progressive weakness, loss of appetite, anemia and profound weight loss (>20%) Often correlates with tumor mass & spread Etiology includes a generalized increase in metabolism and central effects of tumor on hypothalamus Probably related to macrophage production of TNF-a

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Paraneoplastic Syndromes Group of signs and symptoms as a result of substance produced by a tumor or reaction to a tumor Not related to growth, spread or metastasis of the tumor itself Earliest manifestation or appearance of the paraneoplastic syndrome may precede the diagnosis and give clue to its presence Mimic metastic disease

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Paraneoplastic Syndromes Due to Products released by tumor (Ectopic Hormone production) Cushings Syndrome Adrenal, Small Cell Lung Ca ACTH (Increased Corticotropin and pro-opiomelanocortin, POMC) Hypercalcemia Cancer osteolysis is the common cause either due to primary bone or metastasis Humoral hypercalcemia -- Parathyroid hormone- related protein (PTHRP production) Breast (PTHRP Osteolytic), Squamous cell bronchogenic carcinoma

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Paraneoplastic Syndromes Neuromyopathic paraneoplastic syndromes Myasthenia Gravis --- Bronchogenic, Breast ca (Antibodies against tumor antigens) Inappropriate ADH syndrome (Hyponatremia) Small cell lung ca Acanthosis Nigricans -- Hyperkeratosis of skin Hypertrophic Osteoarthropathy Hypothalamic tumors (vasopressin) Hypoglycemia - insulin or insulin like activities in Fibrosarcoma, Cerebellar hemangioma. Vascular and Hematologic Manifestations -- Migratory thrombophlebitis (Trousseau syndrome) --- Pancreatic Ca

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PARA-Neoplastic Syndromes Nerve/Muscle, e.g., myasthenia w. lung ca. Skin: e.g., acanthosis nigricans, dermatomyositis Bone/Joint/Soft tissue: HPOA (Hypertrophic Pulmonary OsteoArthropathy) Vascular: Trousseau, Endocarditis Hematologic: Anemias Renal: e.g., Nephrotic Syndrome

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ENDOCRINE Cushing syndromeSmall cell carcinoma of lungACTH or ACTH-like substance Pancreatic carcinoma Neural tumors Syndrome of inappropriate antidiuretic hormone secretion Small cell carcinoma of lung; intracranial neoplasms Antidiuretic hormone or atrial natriuretic hormones HypercalcemiaSquamous cell carcinoma of lung Parathyroid hormone-related protein (PTHRP), TGF-, TNF, IL-1 Breast carcinoma Renal carcinoma Adult T-cell leukemia/lymphoma Ovarian carcinoma HypoglycemiaFibrosarcomaInsulin or insulin-like substance Other mesenchymal sarcomas Hepatocellular carcinoma Carcinoid syndromeBronchial adenoma (carcinoid)Serotonin, bradykinin Pancreatic carcinoma Gastric carcinoma PolycythemiaRenal carcinomaErythropoietin Cerebellar hemangioma Hepatocellular carcinoma

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Grading & Staging of Tumors Assess extent and spread of neoplasm Making prognosis, and for treatment

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GRADING/STAGING GRADING: HOW DIFFERENTIATED ARE THE CELLS? STAGING: HOW MUCH ANATOMIC EXTENSION? TNM Which one of the above do you think is more important?

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Grading & Staging of Tumor Grading Cellular Differentiation (Microscopic) Staging Progression or Spread (clinical)

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Grading Degree of differentiation Number of mitoses Architectural features Staging -------- TNM Size of lesion (T) Extent of spread to lymph nodes (N) Presence or absence of Metastases (M)

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TNM : Staging of tumor:

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WELL? (pearls) MODERATE? (intercellular bridges) POOR? (WTF!?!) GRADING for Squamous Cell Carcinoma

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ADENOCARCINOMA GRADING Lets have some FUN!

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LABORATORY DIAGNOSIS 1. Excision / Biopsy 2. Fine needle aspiration 3. Cytologic Smears

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Excision:- Selection of area for excising large mass can be challenging (center can be necrotic, periphery not reliable) Preservation with caution --- Immersion in formalin Fixative for Electron microscopy Refrigeration at optimal temperature for molecular analysis

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Fine needle aspiration:- Aspirating cells with small-bore needle Cytologic examination of the smear Commonly breast, thyroid, and lymph nodes Less Invasive and immediate need biopsies obtained, BUT difficult Cytologic smears (PAP):- Smear, Fix, and Stain Cervix, endometrial, bronchogenic, prostati for tumor cells in abdominal, pleural joint and CSF Provides recognition of differentiation to normal, dysplasia, malignant cells, cellular changes specific to carcinoma in situ

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IMMUNOHISTOCHEMISTRY Categorization of undifferentiated tumors Antibodies specific to intermediate filaments 9E.g. cytokeratins, desmin) Site of origin Organ-specific antigens E.g. PSA Prognostic or therapeutic signficant molecules Receptors, e.g., Estrogen/progesterone receptors Protein products of oncogenes E.g. ERBB2

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Flow Cytometry:- Measure individual cell characteristics E.g. DNA content of tumor cells T and B lymphocytes tumors Molecular Diagnosis:- A) Diagnosis of NeoplasmsPolyclonal and monoclonal proliferations of T or B Cells PCR FISH Hematopoietic neoplasms (e.g. translocations) B) Prognosis of malignant neoplasms C) Diagnosis of hereditary predisposition D) Detection of minimal residual disease

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TUMOR MARKERS CA-125 Ovarian cancer CEA (carcinoembryonic antigen) colon, pancreas, lung, stomach AFP (alpha-fetoprotein) Hepatocellular carcinoma, germ cell tumors, yolk sac tumors Beta-HCG - Chorioncarcinoma

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