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Multistage carcinogenesis 85
Peutz-Jeghers polyp
RER+ cancer
(Replication
Dysplasia in hamartoma air Error Positive)
rep
atch
ism
s of m
Los
Juvenile polyp
Normal Early adenoma Intermediate adenoma Late adenoma Cancer
Fig. 3.3 Histological representation of the pathogenesis of colorectal cancer. Phenotypic changes in the morphology of the colonic mucosa reflect the sequen-
tial acquisition of genetic alterations.
other words, not every tumour will nec- and tumour suppressor genes, p96) have esis are being progressively identified
essarily exhibit all the genetic changes been identified in terms of their biological [11]. As noted earlier, members of some
established for the tumour type in ques- function [9]. Such genes are among those cancer-susceptible families inherit muta-
tion. Moreover, there is often marked that facilitate transmission of growth con- tions in particular genes that contribute to
heterogeneity within an individual trol signals from the cell membrane to the cancer development, and hence to their
tumour: adjacent cells differ. Mapping nucleus (that is, signal transduction), that individual risk of disease. However, with
and identification of genes involved in mediate cell division, differentiation or cell most cancers, the genetic change critical
malignant transformation has been a death and, perhaps most critical of all, to carcinogenesis results from damage to
major component of the study of the that maintain the integrity of genetic infor- DNA by chemicals, radiation and viruses
molecular mechanisms of carcinogene- mation by DNA repair and similar process- (Fig. 3.1). This damage is not entirely and
sis. es (Carcinogen activation and DNA repair, perhaps not predominantly produced by
p89). Since mutations are normally infre- exogenous agents but by natural process-
Multiple genetic changes required quent events, it seems unlikely that in the es, such as the production of reactive oxy-
The emergence of a malignant cell popu- course of a human lifetime a cell would gen species or the spontaneous deamina-
lation is understood to be the cumulative acquire all the mutations necessary for tion of the 5-methylcytosine naturally
effect of multiple (perhaps five, ten or cancer to develop, unless at some point present in DNA [13]. Furthermore, as
more) genetic changes, such changes the developing cell lost its ability to pro- shown as the second step in Fig. 3.2, bio-
being accumulated in the course of the tect itself against mutation and gained logical change that is heritable may result
evolution of the cell from normal to malig- what is called a mutator phenotype [10]. from non-genetic processes including the
nant. The genes designated as oncogenes Thus, alterations in gene structure and modulation of gene expression by hyper-
and tumour suppressor genes (Oncogenes expression which bring about carcinogen- methylation [12].
Ageing also at the cellular level. In humans, as well when further maintained in culture, once-
Apart from multistage development, cer- as in other mammals, the incidence of normal cells acquire the same characteris-
tain other processes are fundamental to cancer rises dramatically with age. An tics as cells cultured from malignant
malignant disease. Principal amongst exponential increase occurs from mid-life tumours. These and various other alter-
these is ageing, which can be considered [14]. Passage of time is also critical to cell ations in growth characteristics are recog-
both in relation to the whole individual, and biology. Normal cells do not divide indefi- nized as the experimental counterpart of
nitely due to senescence (Box: Telomeres multistage carcinogenesis through which
and Telomerase, p108). Senescent cells tumours develop in intact animals or
cannot be stimulated to divide further, humans. The genetic basis for senescence,
become resistant to apoptotic cell death and its relationship to malignancy, is a sub-
and acquire differentiated functions. ject of intense investigation [15].
Senescence may be an anti-cancer mech-
anism that limits accumulation of muta- Preventing cancer
tions. However, when maintained in cul- The significance of multistage carcino-
ture, cells treated with carcinogenic chem- genesis extends beyond facilitating
icals or infected with oncogenic viruses understanding of how a transition from
Fig. 3.4 Severe intraepithelial neoplasia (dyspla-
may avoid senescence and proliferate normal to malignant cell growth occurs.
sia) in the epithelium of an intrahepatic large bile indefinitely. Such cell populations are The fundamental cellular studies outlined
duct, a condition caused by hepatolithiasis. described as being transformed and earlier provide a basis for preventing can-
Multistage carcinogenesis 87
cer (see chapter 4). The fact that partic- mechanisms now known to operate in
ular patterns of cell morphology and the proliferation of cancer cells provide a
growth precede emergence of an basis for the development of new, more
unequivocally malignant cell population efficient therapies without the side-
is the basis of secondary prevention of effects that currently often afflict cancer
cancer. patients [17].
Examples include detection of polyps in
the large bowel (Fig. 3.5) and of morpho-
logical change which is the basis of the
Papanicolaou smear test for early detec-
tion of cervical cancer. Moreover, dietary
or pharmaceutical interventions calculat-
ed to prevent or reverse such lesions are
the basis of chemoprevention [16]. Most
importantly, knowledge of the genetic
basis underlying tumour growth should
provide new criteria for individual deter-
Fig. 3.5 Pedunculated hyperplastic polyp of the mination of diagnosis and prognosis. The
colon.
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Mutat Res, 462 : 209-217. etiology and prevention: a summary and challenge of 20
9. Evan GI, Vousden KH (2001) Proliferation, cell cycle
4. Weinstein IB (1982) Carcinogenesis as a multistage and apoptosis in cancer. Nature, 411: 342-348. years of interdisciplinary research. Mutat Res, 462: 255-
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B, eds, Host Factors in Human Carcinogenesis (IARC 10. Loeb LA (2001) A mutator phenotype in cancer.
17. Kallioniemi OP, Wagner U, Kononen J, Sauter G
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(2001) Tissue microarray technology for high-throughput
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(IARC Scientific Publications No. 116), Lyon, IARCPress. tumour cells with defined genetic elements. Nature, 400:
464-468.
6. Yamasaki H, Ashby J, Bignami M, Jongen W, Linnainmaa
K, Newbold RF, Nguyen-Ba G, Parodi S, Rivedal E, 12. Esteller M, Corn PG, Baylin SB, Herman JG (2001) A
Schiffmann D, Simons JW, Vasseur P (1996) Nongenotoxic gene hypermethylation profile of human cancer. Cancer
carcinogens: development of detection methods based on Res, 61: 3225-3229.
tab le change has the po tential to per- lites arise as by-products of these meta-
turb gro wth control in the affected cell, bolic reactions. The metabolic pathways NORMAL CELLS INITIATED CELLS
and is sometimes referred to as the ini- are well characterized for the major
tiation step of the tumorigenic process classes of chemical carcinogens (Fig. Fig. 3.7 Critical stages in the process of initiation
(Fig. 3.7). 3.8), including polycyclic aromatic hydro- by genotoxic chemicals.
Fig. 3.8 Carcinogen activation by mammalian enzymes: reactions catalysed during metabolism of benzo[a]pyrene and NNK (4-(methylnitrosamino)-1-(3-
pyridyl)-1-butanone), both contained in tobacco, and of aflatoxin B1, produce reactive intermediates (ultimate carcinogens, in box), which bind to DNA. Other
reaction pathways leading to the formation of glucuronides and other esters, which are excreted, are not shown. 1. Benzo{a}pyrene-7, 8-diol-9, 10-epoxide; 2. 4-(methyl-
nitrosamino)-1-(3-pyridyl)-1-butanol; 3. Diazohydroxide; 4. Diazohydroxide; 5. Aflatoxin B1-8,9-oxide; 6. 2,3-Dihydro-2-(N7- guanyl)-3-hydroxyaflatoxin B1.
P OH
Spontaneous hydrolysis
(abasic site) PARP
DNA
glycosylase XRCC1
I
PNK
APE1
II P
III
DNA pol
PCNA
Benzo[a]pyrene Codons 157, 158, 248, 273 G>T transversions Lung, larynx
(tobacco smoke)
Endogenous mechanism Codons 175, 248, 273, 282 C>T transitions Colon, stomach
(enhanced by nitric oxide) at CpG dinucleotides Brain cancers
Table 3.2 Spectra of p53 mutations caused by environmental carcinogens or endogenous mechanisms.
REFERENCES WEBSITES
1. Miller EC, Miller JA (1979) Milestones in chemical car- 8. Friedberg EC, Walker GC, Siede W, eds (1995) DNA A comprehensive listing of human DNA repair genes:
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gens as reactive mutagenic electrophiles. In: Hiatt HH, nesis in human cells by DNA base excision-repair. Mutat DNA Repair Interest Group (NCI):
Watson, JD, Winsten, JA eds, Origins of Human Cancer Res, 462: 129-135. http://www.nih.gov:80/sigs/dna-rep/
(Book B), Cold Spring Harbor, Cold Spring Harbor 10. de Boer J, Hoeijmakers JH (2000) Nucleotide excision
Laboratory, 605-627. repair and human syndromes. Carcinogenesis, 21: 453-
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cinogens. Carcinogenesis, 21: 345-351. 11. Benhamou S, Sarasin A (2000) Variability in
4. Hemminki K, Dipple A, Shuker DEG, Kadlubar FF, nucleotide excision repair and cancer risk: a review. Mutat
Segerbck D, Bartsch H, eds (1994) DNA Adducts. Res, 462: 149-158.
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Publications No. 125), Lyon, IARCPress. D, Romieu A, Ravanat JL (2000) Oxidative base damage to
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Pearce N, eds (1997) Application of Biomarkers in Cancer Res, 462: 121-128.
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IARCPress. transferases. Mutat Res, 462: 83-100.
6. Vineis P, Malats N, Lang M, d'Errico A, Caporaso N, 14. Pedroni M, Sala E, Scarselli A, Borghi F , Menigatti M,
Cuzick J, Boffetta P, eds (1999) Metabolic Polymorphisms Benatti P, Percesepe A, Rossi G, Foroni M, Losi L, Di
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7. McGregor DB, Rice JM, Venitt S, eds (1999) The Use of and mismatch-repair protein expression in hereditary and
Short- and Medium-Term Tests for Carcinogens and Data sporadic colorectal carcinogenesis. Cancer Res, 61: 896-
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mechanisms, including point mutations control the speed or timing of cell division
SUMMARY that constitutively activate an enzyme, but rather its accuracy. Caretaker genes
deletions that remove negative regulatory are usually involved in DNA repair and in
> Human cells become malignant through regions from proteins, or increased the control of genomic stability. Their
the activation of oncogenes and expression resulting from promoter dereg- inactivation does not enhance cell prolif-
inactivation of tumour suppressor
ulation or from multiplication of the num- eration per se but primes the cell for rapid
genes. The pattern of genes involved
varies markedly at different organ sites. ber of copies of the gene (a phenomenon acquisition of further genetic changes [4].
called amplification [3]). Activation of an The combined activation of oncogenes
> Oncogenes stimulate cell proliferation oncogene is a dominant mechanism, since and inactivation of tumour suppressor
and may be overexpressed by gene alteration of a single allele is sufficient to genes drive the progression of cancer. The
amplification (e.g. MYC). In addition, confer a gain of function for cancer onset most evident biological consequences of
oncogenes may be activated by muta- or progression. The non-activated coun- these alterations are autonomous cell pro-
tions (e.g. the RAS gene family). terpart of an oncogene is sometimes liferation, increased ability to acquire
called a proto-oncogene. A proto-onco- genetic alterations due to deregulated
> Tumour suppressor genes are typically gene is in fact a normal gene in all DNA repair, ability to grow in adverse con-
inactivated by gene mutations in one
respects, often with important functions ditions due to decreased apoptosis,
allele (gene copy), followed by loss of
the intact allele during cell replication in the control of the signalling of cell pro- (Apoptosis, p113) capacity to invade tis-
(two-hit mechanism). This leads to loss liferation, differentiation, motility or sur- sues locally and to form distant metas-
of expression and abolition of the sup- vival. tases, and ability to activate the formation
pressor function, which is particularly A tumour suppressor gene is a gene of new blood vessels (a process called
important in cell cycle control. whose alteration during carcinogenesis angiogenesis). Together, these five biolog-
results in the loss of a functional property ical phenomena may be caricatured as
> Mutational inactivation of suppressor essential for the maintenance of normal pieces of the cancer jigsaw [5] (Fig.
genes in germ cells is the underlying cell proliferation. Loss of function of a 3.15). None alone is sufficient in itself, but
cause of most inherited tumour tumour suppressor gene is typically a cancer arises when they interact together
syndromes. The same type of mutation
recessive mechanism. Indeed, in many into a chain of coordinated events that
may arise through mutations occurring
during an individuals lifetime. instances both copies of the gene need to profoundly modifies the normal cellular
be inactivated in order to switch off the pattern of growth and development.
corresponding function. Inactivation of
tumour suppressor genes proceeds by
loss of alleles (most often through the loss
Definitions of entire chromosomal sections encom-
The multi-step nature of carcinogenesis passing several dozen genes), small dele-
has long been recognized (Multistage car- tions or insertions that scramble the read-
Genetic Invasiveness
cinogenesis, p84). Over the past 20 years, ing frame of the gene, transcriptional instability
experimental studies in animals and silencing by alteration of the promoter
molecular pathological studies have con- region, or point mutations that change the
verged to establish the notion that each nature of residues that are crucial for the
step in malignant transformation is deter- activity of the corresponding protein. Autonomous
mined by a limited number of alterations Recently, it has emerged that tumour sup- growth
in a small subset of the several thousands pressor genes can be conveniently sub-
of cellular genes [1]. The terms onco- classified into two major groups. The
gene and tumour suppressor gene are genes of the first group are nicknamed
commonly used to identify the sets of gatekeepers. Their products control the
genes involved in such sequences of gates on the pathways of cell proliferation. Unlimited
Angiogenesis
events [2]. Both groups of genes are Typically, gatekeeper genes are negative replicative potential
extremely diverse in terms of nature and regulators of the cell cycle, acting as
function. An oncogene is a gene whose brakes to control cell division. The genes
function is activated in cancer. This can be of the second group are called caretak- Fig. 3.15 The cancer jigsaw: multiple functions
achieved by a number of simple molecular ers, as their primary function is not to must be altered for tumorigenesis to occur.
ERBB2 A B
In the case of ERBB2, oncogenic activation Fig. 3.17 In cell cultures, activation of a single oncogene may result in a changed morphology from
is almost always the result of amplification normal (A) to transformed (B) and this often corresponds to a change in growth properties. Malignant
of the normal gene [7] (Fig. 3.16). This transformation appears to require the co-operation of at least three genes.
Colorectal cancer
In colorectal cancers, two different famil- Bcl-2
ial cancer syndromes have been found to 14 - 3 -3 p21 p53R2 Bax Unknown
be associated with the constitutive alter- RPA IGF/BP3 proteins?
TFIIH Killer/DR5
ation of two distinct sets of tumour sup- PAG608
pressor genes (Colorectal cancer, p198). PIG3
Patients with familial adenomatous poly- cdc25 Cdk PCNA
posis, a disease that predisposes to the G2 G1 G1/S
Replication/
early occurrence of colon cancer, often Transcription/
Cell cycle arrest Apoptosis
carry alterations in one copy of the ade- Repair
nomatous polyposis coli (APC) gene [17].
This gene plays a central role in a sig-
nalling cascade that couples cell-surface
receptors, calcium-dependent adhesion Fig. 3.21 Multiple response pathways are triggered by the accumulation of p53 in the cell nucleus.
NAMING GENES AND ative of the successful investigator. inhibitor WAF1 is also known as
PROTEINS Identification of a novel gene is often fol- CDKN1A, CAP20, MDA-6, PIC-1 and SDI-
lowed by discovery of structurally related 1. In scientific writing, all such names
Conventionally, a gene (that is, a specif- or homologous genes (and correspon- are given in the first instance, after
ic segment of DNA) is identified by a sin- ding proteins) and these may be given which a single name is used consistent-
gle name, in upper case and italicized names closely related to the first member ly in any one document. The latest esti-
(e.g. the oncogene RAS) that is indica- of the family identified. Such an mates from the Human Genome Project
tive of the character or function of the approach to nomenclature may be inade- suggest that there may be about 30,000
protein encoded, which is designated by quate, for example, in those instances in human genes.
the same name, in lower case (ras in the which a single DNA segment encodes Conventions for the naming of genes
case of the present example). Proteins multiple proteins through alternative and proteins are subject to international
are also named by reference to their splicing of messenger RNA. Multiple agreement and are continuously subject
molecular weight, with the correspon- names for the same gene or protein may to review (HUGO Gene Nomenclature
ding gene in superscript (e.g. p21WAF1 ). arise because of independent discovery Committee, http://www.gene.ucl.ac.uk/
The names of genes are often based on (and hence, naming) by different investi- nomenclature/).
acronyms, and are generally the prerog- gators. Thus, the cyclin-dependent kinase
Lesions in the p16INK4A-cyclin D, CDK4-pRb cancer types have been characterized. cancer process. Moreover, many biolog-
and p14ARF-Mdm2-p53 pathways occur so Most of these have a powerful impact ical alterations leading to cancer may
frequently in cancer, regardless of patient on tumour growth. However, it is very not be detectable at the DNA level.
age or tumour type, that they appear to be likely that many critical genes with less Cancer-causing changes may result
fundamental to malignancy [24]. penetrant phenotypes remain to be from modification of RNA levels or pro-
identified. In particular, the genes cessing, and of protein structure and
Prospects for the molecular analysis of involved in stress reponses, in the con- function through a variety of epigenetic
cancer trol of oxygen metabolism and in the phenomena. The systematic profiling of
More than 200 genes that are altered at detoxification of xenobiotics are all can- gene expression in cancer cells will
variable proportions in different human didates for a role as cofactors in the probably reveal a whole new set of
REFERENCES WEBSITES
1. Fearon ER, Vogelstein B (1990) A genetic model for colo- share the ability to relieve the cell's requirement for cyclin American Tissue Type Collection:
rectal tumorigenesis. Cell, 61: 759-767. D1 function in G1. J Cell Biol, 125: 625-638. http://www.atcc.org/
2. Weinberg RA (1995) The molecular basis of oncogenes 15. Baker SJ, Fearon ER, Nigro JM, Hamilton SR, Centers for Disease Control and Prevention, Atlanta:
and tumor suppressor genes. Ann N Y Acad Sci, 758: 331- Preisinger AC, Jessup JM, vanTuinen P, Ledbetter DH, http://www.cdc.gov/
338. Barker DF, Nakamura Y (1989) Chromosome 17 deletions Cancer Genome Anatomy Project:
3. Savelyeva L, Schwab M (2001) Amplification of onco- and p53 gene mutations in colorectal carcinomas. http://www.ncbi.nlm.nih.gov/ncicgap/
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European Bioinformatics Institute:
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4. Kinzler KW, Vogelstein B (1997) Cancer-susceptibility 30A: 1935-1941.
HotMolecBase (Weizmann Institute, Israel):
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5. Hanahan D, Weinberg RA (2000) The hallmarks of can- dissecting the function of the APC gene. Gastroenterology,
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8. Wiesmuller L, Wittinghofer F (1994) Signal transduction cy, and cancer to cell cycle checkpoints. J Clin Immunol, Protein Data Bank (a protein structure database):
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267.
20. Lane DP (1992) Cancer. p53, guardian of the
9. Henriksson M, Luscher B (1996) Proteins of the Myc genome. Nature, 358: 15-16.
network: essential regulators of cell growth and differenti-
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10. Antonsson B, Martinou JC (2000) The Bcl-2 protein 81-137.
family. Exp Cell Res, 256: 50-57.
22. Momand J, Jung D, Wilczynski S, Niland J (1998) The
11. Knudson AG (1996) Hereditary cancer: two hits revis- MDM2 gene amplification database. Nucleic Acids Res,
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12. Knudson AG, Jr. (1971) Mutation and cancer: statisti- 23. Chin L, Pomerantz J, DePinho RA (1998) The
cal study of retinoblastoma. Proc Natl Acad Sci U S A, 68: INK4a/ARF tumor suppressor: one gene--two products--
820-823. two pathways. Trends Biochem Sci, 23: 291-296.
13. Bartek J, Bartkova J, Lukas J (1997) The retinoblas- 24. Sherr CJ (2000) The Pezcoller lecture: cancer cell
toma protein pathway in cell cycle control and cancer. Exp cycles revisited. Cancer Res, 60: 3689-3695.
Cell Res, 237: 1-6.
14. Lukas J, Muller H, Bartkova J, Spitkovsky D, Kjerulff
AA, Jansen-Durr P, Strauss M, Bartek J (1994) DNA tumor
virus oncoproteins and retinoblastoma gene mutations
tion of cellular materials between the malian cells, these mutations would have
SUMMARY daughter cells. Moreover, immediately been lethal and it would therefore have
> The control of cell division is critical to before or after the cell cycle, various fac- been impossible to characterize them.
normal tissue structure and function. It tors interact to determine whether the cell These mutants were called cdc, for cell
is regulated by a complex interplay of divides again or whether the cell becomes division cycle mutants, and many of them
many genes that control the cell cycle, committed to a programme of differentia- have been accorded wider recognition
with DNA replication (S phase) and tion or of cell death. Therefore, the term through the application of their names to
mitosis as major checkpoints. cell cycle is often used in a broad sense the mammalian homologues correspon-
> The cell cycle is tightly regulated to to refer to, as well as the basic, self-repli- ding to the yeast genes.
minimize transmission of genetic damage cating cellular process, a number of con-
to subsequent cell generations. nected processes which determine pre-
> Progression through the cell cycle is and post-mitotic commitments. These
primarily controlled by cyclins, asso- may include the commitment to stop
ciated kinases and their inhibitors. dividing in order to enter a quiescent
Retinoblastoma (RB) and p53 are major state, to undergo senescence or differen-
suppressor genes involved in the G1/S tiation, or to leave the quiescent state to
checkpoint control. re-enter mitosis.
> Cancer may be perceived as the conse-
quence of loss of cell cycle control and Molecular architecture of the cell cycle
progressive genetic instability. The molecular ordering of the cell cycle is
a complex biological process dependent
upon the sequential activation and inacti-
vation of molecular effectors at specific
points of the cycle. Most current knowl-
Classically, the cell cycle refers to the edge of these processes stems from
set of ordered molecular and cellular experiments carried out in the oocyte of
processes during which genetic material the frog, Xenopus laevis, or in yeast, either Fig. 3.25 Proliferating cells in the basal parts of
is replicated and segregates between two Saccharomyces cerevisiae (budding yeast) the colonic crypts, visualized by immunohisto-
chemistry (stained brown).
newly generated daughter cells via the or Schizosaccharomyces pombe (fission
process of mitosis. The cell cycle can be yeast). The Xenopus oocyte is, by many cri-
divided into two phases of major morpho- teria, one of the easiest cells to manipulate
logical and biochemical change: M phase in the laboratory. Its large size (over a mil-
(mitosis), during which division is evi- limetre in diameter) means that cell cycle
dent morphologically and S phase (syn- progression can be monitored visually in
thesis), during which DNA is replicated. single cells. Microinjections can be per-
These two phases are separated by so- formed for the purpose of interfering with
called G (gap) phases. G1 precedes S specific functions of the biochemical
phase and G2 precedes M phase. machinery of the cell cycle. The Xenopus
During progression through this division oocyte has proven to be an invaluable tool
cycle, the cell has to resolve a number of in the study of the biochemistry of the cell
critical challenges. These include ensuring cycle, allowing, among other findings, the
that sufficient ribonucleotides are avail- elucidation of the composition and regula-
able to complete DNA synthesis, proof- tion of maturation promoting factor (MPF),
reading, editing and correcting the newly- a complex enzyme comprising a kinase
synthesized DNA; that genetic material is (p34cdc2) and a regulatory subunit (cyclin Fig. 3.26 A human osteosarcoma cell nucleus
during mitosis. Cell division proceeds clockwise
not replicated more than once; that the B), which drives progression from G2 to M from upper right through interphase, prophase
spatial organization of the mitotic spindle phase [1]. In contrast, the exceptional (centre), prometaphase, metaphase, anaphase
apparatus is operational; that the packing genetic plasticity of yeast has allowed the and telophase. During the cycle, the chromo-
and the condensation of chromosomes is identification of scores of mutants with somes are replicated, segregated and distributed
optimal; and that there is equal distribu- defects in cell cycle progression; in mam- equally between the two daughter cells.
Gene (chromosome) Product Type of alteration Role in cell cycle Involvement in cancer
p53 (17p13) p53 Mutations, deletions Control of p21, 14-3-3, etc. Altered in over 50% of all
cancers
CDKN2A (9p22) p16 and p19ARF Mutations, deletions, Inhibition of CDK4 and 6 Altered in 30-60% of all
hypermethylation cancers
Table 3.3 Cell cycle regulatory genes commonly altered in human cancers.
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137. Nature Reviews, Focus on cell division:
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mony with normal neighbouring cells, it is tal to the nature of malignancy, it has long
SUMMARY not surprising that the function of genes been postulated that gap junctional inter-
involved in intercellular communication cellular communication is disturbed in
> Cells communicate by means of secret- mechanisms is disrupted in many cancer. The first confirmatory evidence
ed molecules which affect neighbouring
tumours. Thus, several oncogenes (Onco- was the observation that of a reduced
cells carrying appropriate receptors,
and also by direct cell contact, including
genes and tumour suppressor genes, p96) level of gap junctional intercellular com-
specifically includes gap junctions. encode products involved in humoral inter- munication in one tumour type [8]. This
cellular communication: c-erb, c-erbB2 phenomenon has now been observed in
> Cell contact-mediated communication and c-SIS [3]. It has also become clear almost all tumours [4]. Cell lines estab-
through gap junctions is controlled by that cell contact-mediated intercellular lished from tumours, as well as cells
connexin genes and is often disrupted in communication plays a crucial role in cell transformed in vitro, usually exhibit
cancer. This may contribute to uncon- growth control [4] and genes involved are impaired function in respect of gap junc-
trolled and autonomous growth. often classified as tumour suppressor tional intercellular communication. Gap
genes [5]. Cell adhesion molecules are junctional intercellular communication
> Interventions restoring gap junction
communication may provide a basis for
also involved in cell-cell recognition. There between transformed cells and neigh-
therapy. are several lines of evidence which sug- bouring normal counterparts is selective-
gest that aberrant functions of cell adhe- ly defective in murine embryonic
sion may be involved in tumour invasion BALB/c3T3 cells (Fig. 3.31). A lack of het-
and metastasis [6]. erologous gap junctional intercellular
communication between transformed and
Gap junctional intercellular communi- normal cells has been observed using rat
In complex organisms, neighbouring cells cation and cancer liver epithelial cell lines and rat liver
behave and function in harmony for the Gap junctional intercellular communica- tumour in vivo. It appears that reduced
benefit of the whole organism through the tion is the only means by which cells gap junctional intercellular communica-
operation of cell-cell communication. exchange signals directly from the interi- tion is common to many tumour cells.
During evolution, various types of intercel- or of one cell to the interior of surround- Further studies with multistage models of
lular communication have developed, ing cells [7]. Since the extent to which rat liver and mouse skin carcinogenesis
which in mammals take two forms: (1) tumour cells deviate from cells which have revealed that there is, in general, a
humoral communication and (2) cell con- exhibit tissue homeostasis is fundamen- progressive decrease in the level of gap
tact-mediated communication (Fig. 3.30).
Humoral communication is typically medi-
ated by molecules, such as growth factors A. Humoral communication
and hormones, excreted from certain cells
and received by receptors of other cells.
Intercellular communication based on
direct cell-cell contact is mediated by var-
ious junctions, including adherence junc-
tions, desmosomes and gap junctions.
During multistage carcinogenesis, genes
critically involved in cell growth are B. Cell contact-mediated communication
altered [1]. Most such genes are known to 1.Cell adhesion 2. Gap junction
be directly or indirectly involved in the
control of cell replication (The cell cycle,
p104) or in the death of individual cells [2]
(Apoptosis, p113). Genes involved in inter-
cellular communication control cellular
growth at another level. These genes func-
tion to maintain cell growth in harmony
with that of the surrounding tissue. Since Fig. 3.30 Relationships between cells are maintained by different types of intercellular communication,
most cancer cells do not proliferate in har- which may (B) or may not (A) require cell contact.
No bystander
GCV-P effect
Transfected cells
carrying the HSV-tk gene
Ganciclovir
(GCV)
Bystander
GCV-P effect
Movement of GVC-P
from cytoplasm to
cytoplasm in gap
junctions
Fig. 3.32 Role of cell-cell interaction in gene therapy. In a tumour cell population, only a few cells can be reached by vectors carrying the HSV-tk gene.
Expression of the tk gene (orange) makes these cells sensitive to ganciclovir: they produce phosphorylated ganciclovir, which is toxic. As phosphorylated gan-
ciclovir cannot pass through the cell membrane, theoretically only cells expressing the tk gene will die as a result of ganciclovir treatment. Transmembrane dif-
fusion of phosphorylated ganciclovir from cytoplasm to cytoplasm can induce a bystander effect sufficient to eradicate a tumour cell population, even if only a
few cells express the tk gene [13].
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vention of invasiveness. Biochim Biophys Acta, 1198: 11-26. between normal and virus-transformed cells:
engulfing respectively [1]. The regulato- dependent on definition of the ced genes
SUMMARY ry phase includes all the signalling path- in the nematode Caenorhabditis elegans,
ways that culminate in commitment to members of this gene family being vari-
> The term apoptosis refers to a type of cell death. Some of these pathways regu- ously homologous to human BCL2 (which
cell death that occurs both physiologi-
late only cell death, but many of them suppresses apoptosis), APAF-1 (which
cally and in response to external stimuli,
including X-rays and anticancer drugs.
have overlapping roles in the control of mediates caspase activation) and the
cell proliferation, differentiation, respons- caspases themselves (proteases which
> Apoptotic cell death is characterized by es to stress and homeostasis. Critical to mediate cell death). The centrality of
distinctive morphological changes dif- apoptosis signalling are the initiator apoptosis to cancer biology is indicated
ferent from those occurring during caspases (including caspase-8, caspase-9 by excess tumorigenesis in BCL2-trans-
necrosis, which follows ischaemic injury and caspase-10) whose role is to activate genic and p53-deficient mice. An appreci-
or toxic damage. the more abundant effector caspases ation of apoptosis provides a basis for the
(including caspase-3 and caspase-7) further development of novel and conven-
> Apoptosis is regulated by several dis- which, in turn, brings about the morpho- tional cancer therapy
tinct signalling pathways. Dysregulation
logical change indicative of apoptosis.
of apoptosis may result in disordered
cell growth and thereby contribute to
Finally, the engulfing process involves the The role of cell death in tumour
carcinogenesis. recognition of cellular remains and their growth
elimination by the engulfing activity of Apoptosis, or lack of it, may be critical to
> Selective induction of apoptosis in tumour surrounding cells. tumorigenesis [2]. BCL2, a gene mediat-
cells is among current strategies for the Identification of genes mediating apopto- ing resistance to apoptotic stimuli, was
development of novel cancer therapies. sis in human cells has been critically discovered at the t(14:18) chromosomal
APOPTOSIS
Apoptosis is a mode of cell death that
facilitates such fundamental processes as Condensation and
fragmentation of
development (for example, by removal of chromatin
unwanted tissue during embryogenesis)
and the immune response (for example,
by elimination of self-reactive T cells). NECROSIS
This type of cell death is distinguished
from necrosis both morphologically (Fig.
3.33) and functionally. Specifically, apop-
Shrinking/
tosis involves single cells rather than Organelle rounding up,
areas of tissue and does not provoke disruption fragmentation
inflammation. Tissue homeostasis is and break- of cell and
down, nucleus
dependent on controlled elimination of cell swelling
unwanted cells, often in the context of a
continuum in which specialization and
maturation is ultimately succeeded by
cell death in what may be regarded as the
final phase of differentiation. Apart from
elimination in a physiological context, Membrane
cells that have been lethally exposed to blebbing,
cytotoxic drugs or radiation may be sub- residual Engulfing by
ghost cell neighbouring cell
ject to apoptosis. as apoptotic-
The process of apoptosis can be body
described by reference to distinct phases,
termed regulation, effector and Fig. 3.33 Apoptosis and necrosis are distinguished by characteristic morphological changes.
Apoptosis 113
translocation in low grade B cell non-
DNA DAMAGE REPLICATION STRESS
Hodgkin lymphoma. It thus became
apparent that neoplastic cell expansion
could be attributable to decreased cell
death rather than rapid proliferation.
Defects in apoptosis allow neoplastic
cells to survive beyond senescence, Rad17
Rad9, Rad1, Hus1
thereby providing protection from hypoxia ATM + ATR
and oxidative stress as the tumour mass
expands. Growth of tumours, specifically
in response to chemical carcinogens, has Chk1 Chk2 Mdm2 p53 BRCA1 Nbs1 cAbl
been correlated with altered rates of
apoptosis in affected tissues as cell pop-
ulations with altered proliferative activity Cdc25 p21
14-3-3
emerge. Paradoxically, growth of some
cancers, specifically including breast, has
Cdk
been positively correlated with increasing
CELL CYCLE APOPTOSIS TRANSCRIPTION DNA REPAIR
apoptosis [3]. ARREST
Fig. 3.34 Response to DNA damage is mediated by several signalling pathways and may include apoptosis.
Interrelationships between mitogenic
and apoptotic pathways
A dynamic relationship between regula- damage caused by ionizing radiation, con-
tion of growth/mitosis and apoptosis may trolling the initial phosphorylation of pro-
be demonstrated using a variety of rele- teins such as p53, Mdm2, BRCA1, Chk2
vant signalling pathways. Many differing and Nbs1. Other sensors of DNA damage
promoters of cell proliferation have been include mammalian homologues of the
found to possess pro-apoptotic activity PCNA-like yeast proteins Rad1, Rad9 and
[4]. Thus, ectopic expression of the C-MYC Hus1, as well as the yeast homologue of
oncogene (normally associated with prolif- replication factor C, Rad17. Specific mole-
erative activity) causes apoptosis in cul- cules detect nucleotide mismatch or inap-
tured cells subjected to serum deprivation propriate methylation. Following exposure
(which otherwise prevents proliferation). of mammalian cells to DNA-damaging
Fig. 3.35 Apoptotic cell death requires gap junc-
Oncogenes that stimulate mitogenesis agents, p53 is activated and among many tional intercellular communication. Expression
can also activate apoptosis. These include targets consequently upregulated are the and subcellular location of connexin 43 in healthy
oncogenic RAS, MYC and E2F. Mutations cyclin-dependent kinase inhibitor p21 (A) and in apoptotic (B) rat bladder carcinoma
in E2F that prevent its interaction with the (which causes G1 arrest) and Bax (which cells. Arrows indicate location of connexin 43 in
areas of intercellular contact between apoptotic
retinoblastoma protein (pRb) accelerate S induces apoptosis). Thus, the tumour sup- (B) and non-apoptotic (A) cells. Counterstaining of
phase entry and apoptosis. A function of pressor gene p53 mediates two responses DNA with propidium iodide reveals fragmentation
pRb is to suppress apoptosis: pRb-defi- to DNA damage by radiation or cytotoxic of the nucleus typical of apoptosis (B).
cient cells seem to be more susceptible to drugs: cell cycle arrest at the G1 phase of
p53-induced apoptosis. the cell cycle and apoptosis (Oncogenes
Agents such as radiation or cytotoxic drugs and tumour suppressor genes, p96). The
cause cell cycle arrest and/or cell death serine/threonine kinase Chk2 is also able
[5]. The DNA damage caused by radiation to positively interact with p53 and BRCA1.
or drugs is detected by various means (Fig. Chk2 and the functionally related Chk1
3.34). DNA-dependent protein kinase and kinase appear to have a role in the inhibi-
the ataxia-telangiectasia mutated gene tion of entry into mitosis via inhibition of
(ATM) (as well as the related ATR protein) the phosphatase Cdc25 (The cell cycle,
bind to damaged DNA and initiate phos- p104).
phorylation cascades to transmit damage
signals. DNA-dependent protein kinase is The regulatory phase Fig. 3.36 Apoptotic cells in an adenoma, visual-
ized by immunohistochemistry (red). Apoptosis is
believed to play a key role in the response Two major apoptotic signalling pathways restricted to single cells, unlike necrosis, which
to double-stranded DNA breaks. ATM plays have been identified in mammalian cells typically involves groups of cells. Apoptosis does
an important part in the response to DNA (Fig. 3.37). The extrinsic pathway not produce an inflammatory response.
Apoptosis 115
brane. Bcl-2, Bcl-xL and Bax can form ion tion of caspases. However, nitric oxide is sors conserved throughout evolution. The
channels when they are added to synthet- involved in several aspects of apoptosis IAP protein survivin is overexpressed in
ic membranes, and this may be related to and may act both as a promoter and a large proportion of human cancers.
their impact on mitochondrial biology [10]. inhibitor depending on conditions [11]. Little is known about the involvement of
In the cytosol after release from mito- caspase mutations in cancer.
chondria, cytochrome c activates the cas- The effector and engulfing phases
pases through formation of a complex (the In mammals at least 13 proteases which Caspase substrates and late stages of
apoptosome) with Apaf-1 (apoptotic- mediate the breakdown of cell structure apoptosis
protease activating factor-1), procaspase- during apoptosis have been identified and Apoptosis was initially defined by refer-
9 and ATP. It appears that Bcl-2/Bcl-xL are designated caspases-1 through -13 ence to specific morphological change. In
may suppress apoptosis by either prevent- [12]. All possess an active site cysteine fact, both mitosis and apoptosis are char-
ing release of cytochrome c or interfering and cleave substrates after aspartic acid acterized by a loss of substrate attach-
with caspase activation by cytochrome c residues. They exist as inactive zymogens, ment, condensation of chromatin and
and Apaf-1. Sustained production of nitric but are activated by different processes phosphorylation and disassembly of
oxide (NO) may cause the release of mito- which most often involve cleavage of their nuclear lamins. These changes are now
chondrial cytochrome c into the cyto- pro-forms (designated procaspase-8, etc.) attributable to caspase activation and its
plasm and thus contribute to the activa- at particular sites, thereby generating sub- consequences.
units which form active proteases consist- Most of the more than 60 known caspase
ing of two large and two small subunits. substrates are specifically cleaved by cas-
Proteolytic cascades may occur with pase-3 and caspase-3 can process pro-
some caspases operating as upstream ini- caspases-2, -6, -7 and -9 [13]. Despite the
tiators (which have large N-terminal multiplicity of substrates, protease activi-
prodomains and are activated by protein- ty mediated by caspases is specific and
protein interaction) and others being seems likely to account for much of the
downstream effectors (activated by pro- morphological change associated with
tease cleavage). As noted earlier, at least apoptosis. Caspases cleave key compo-
two pathways of caspase activation can nents of the cytoskeleton, including actin
A be discerned: one involving FADD or simi- as well as nuclear lamins and other struc-
lar protein-protein complexes and the tural proteins. Classes of enzymes cleaved
other mediated by release of cytochrome by caspases cover proteins involved in
c. In the former, affinity labelling suggests DNA metabolism and repair exemplified
that caspase-8 activates caspases-3 and by poly(ADP-ribose) polymerase and DNA-
-7 and that caspase-3 in turn may activate dependent protein kinase. Other classes
caspase-6. On the other hand, release of of substrates include various kinases, pro-
cytochrome c into the cytoplasm results in teins in signal transduction pathways and
the activation of caspase-9 which in turn proteins involved in cell cycle control,
activates caspase-3. exemplified by pRb. Cleavage of some
B Though the intrinsic pathway to caspase-3 substrates is cell-type specific. Caspase
activation may be distinguished from the activity accounts for internucleosomal
extrinsic pathway (i.e. that activated by cleavage of DNA, one of the first charac-
Fas, etc.), some interaction is demonstra- terized biochemical indicators of apopto-
ble. Thus, caspase-9 is able to activate sis. ICAD/DFF-45 is a binding partner and
caspase-8. Nonetheless, the pathways are inhibitor of the CAD (caspase-activated
separate to the extent that caspase-8 null DNAase) endonuclease, and cleavage of
animals are resistant to Fas- or TNF- ICAD by caspase-3 relieves the inhibition
induced apoptosis while still susceptible and promotes the endonuclease activity
to chemotherapeutic drugs; cells deficient of CAD.
C in caspase-9 are sensitive to killing by
Fas/TNF but show resistance to drugs Therapeutic implications
Fig. 3.38 Neuroblastoma cells treated with ioni-
zing radiation undergo apoptosis. The TUNEL assay
and dexamethasone. Finally, death of In theory, knowledge of critical signalling
was used to visualize apoptotic cells (green), some cells may occur independently of or effector pathways which bring about
before (A) and 24 hours after (B) treatment with X- caspase-3. Caspases-3, -7 and 9 are apoptosis provides a basis for therapeutic
rays (5 Gray). Close-up shows that the nuclei of the inactivated by proteins of the inhibitor of intervention, including the development of
apoptotic cells are fragmented (C). apoptosis family (IAPs) which are suppres- novel drugs to activate particular path-
Ligand
DRUGS TARGETING SIGNAL
Receptor
TRANSDUCTION PATHWAYS Cell membrane
Apoptosis 117
worthy is the development of caspase 4-hydroxyphenylretinamide. Butyrate, a nase enzyme (COX-2) expression may
inhibitors for the treatment of certain short-chain fatty acid produced by bacter- modulate intestinal apoptosis via changes
degenerative (non-cancerous) diseases ial fermentation of dietary fibre, inhibits in Bcl-2 expression. Aspirin and similar
characterized by excess apoptosis. cell growth in vitro and promotes differen- drugs which inhibit COX-2 may promote
Drugs shown to induce apoptosis specifi- tiation; it also induces apoptosis. Both apoptosis and prevent tumour formation.
cally include chemopreventive agents roles may contribute to its prevention of
(Chemoprevention, p151), exemplified by colorectal cancer. Moreover, cyclo-oxyge-
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tosis in breast cancer. BMJ, 322: 1528-1532. 12. Kumar S (1999) Regulation of caspase activation in
apoptosis: implications in pathogenesis and treatment of
4. Choisy-Rossi C, Yonish-Rouach E (1998) Apoptosis and
disease. Clin Exp Pharmacol Physiol, 26: 295-303.
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5. Rich T, Allen RL, Wyllie AH (2000) Defying death after
DNA damage. Nature, 407: 777-783. 14. Nicholson DW (2000) From bench to clinic with apop-
tosis-based therapeutic agents. Nature, 407: 810-816.
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(APO-1/Fas)-mediated apoptosis. Curr Opin Immunol, 10: 15. Zhou BB, Elledge SJ (2000) The DNA damage
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JC (2000) Changes in intramitochondrial and cytosolic pH:
> The ability of tumour cells to invade and including computed tomography (CT) Growth
colonize distant sites is a major feature scans or magnetic resonance imaging Angiogenic Viable cells
distinguishing benign growths from (MRI), ultrasound, or measurement of cir- factors
malignant cancer. Cytokines Zone of sublethal
culating markers such as carcinoembry- hypoxia
> Most human tumours lead to death through onic antigen (CEA), prostate-specific anti- Growth Necrosis
widespread metastasis rather than the gen (PSA) or cancer antigen 125 (CA125) factors
adverse local effects of the primary neo- are not sufficiently sensitive to detect
plasm. micrometastases. A greater understand- Rapid accumulation
ing of the molecular mechanisms of Inflammatory of genetic damage
> Often, metastatic spread first involves cells in sublethal zone
metastasis is required. It is clear that mediated by oxygen
regional lymph nodes, followed by
haematogenous spread throughout the
metastatic growth may reflect both gain free radicals
(NO= nitric oxide)
body. Metastases may become clinically and loss of function, and indeed the
manifest several years after surgical resec- search for metastasis suppressor genes
Reperfusion of sub-
tion of the primary tumour. has been more fruitful than identification lethal zone containing
of genes which specifically and reliably cells with varying
> Current methods are inadequate for the degrees of genetic
potentiate metastasis [1]. damage. Some have
routine detection of micrometastases and acquired a metastatic
the search for effective, selective phenotype
therapies directed toward metastatic
The genetics of metastasis
growth remains a major challenge. With the publication of the human
genome sequence, and various major ini- Metastasis
tiatives such as the Cancer Genome
Fig. 3.40 The hypoxia hypothesis suggests that
Project in the UK and the Cancer Genome the progression of malignant tumours to a
Anatomy Project in the USA, the search metastatic phenotype is mediated by deficiency of
for genes selectively upregulated, mutat- oxygen and resulting tumour necrosis.
Metastasis (from the Greek meaning
change in location) refers to growth of
secondary tumours at sites distant from a Growth Angiogenesis Decreased cell-cell adhesion
primary neoplasm. Metastasis thus dis- Protease activation Increased protease production
tinguishes benign from malignant lesions Selection Increased cell-matrix adhesion
and is the ultimate step in the multistage 1.Localized tumour 2.Breakthrough 3.Invasion
process of tumour progression.
Metastatic growth is the major cause of
treatment failure and the death of cancer
patients. Although secondary tumours
may arise by shedding of cells within body
cavities, the term metastasis is generally
reserved for the dissemination of tumour 4.Transport
cells via the blood or lymphatics. Spread
in the cerebrospinal fluid and
transcoelomic passage may also occur.
Most (60-70%) cancer patients have overt
or occult metastases at diagnosis, and
the prognosis of the majority of these
5.Lodgement 6.Extravasation 7.Metastasis
patients is poor (Box: TNM Classification
Adhesion Proliferation Angiogenesis
of Malignant Tumours, p124). Protease activation/production
Protease production
There is a critical need to identify reliable Metastasis of metastases
indicators of metastatic potential, since Fig. 3.41 The stages in the metastatic process, illustrated in relation to the spread of a primary tumour
clinical detection of metastatic spread is from a surface epithelium to the liver.
KAI1/CD82/C33 Prostate, stomach, colon, Cell-cell adhesion, motility The biology of metastasis
breast, pancreas, lung Growth of tumours beyond a few millime-
tres in diameter cannot progress without
CAD1/E-cadherin Many adenocarcinomas Cell-cell adhesion,
epithelial organization neovascularization, and there is a growing
appreciation of how this phenomenon is
MKK4/SEK1 Prostate Cellular response to linked to metastasis [3]. Many genetic
stress?
changes associated with malignant pro-
KiSS-1 Melanoma, breast cancer Signal transduction? gression (mutation of HRAS, over-expres-
Regulation of MMP-9? sion of ERBB2 oncogenes, loss of p53)
induce an angiogenic phenotype (devel-
BRMS1 Breast Cell communication,
motility oping blood vessels) via induction of
cytokines, such as vascular endothelial
DPC4 Colon, pancreas ? growth factor (VEGF-A). VEGF-A is also
upregulated by hypoxia in tumours, partly
Table 3.5 Putative metastasis suppressor genes. by host cells such as macrophages. The
presence of hypoxic areas is a character-
ed or lost in metastatic cancers (Table metastasis, although many others so iden- istic of solid tumours and has been relat-
3.5) has gained momentum. It is now pos- tified are also associated with tumour ed to poor response to conventional ther-
sible, using laser capture microdissection growth or developmental processes. apies (Fig. 3.40). In addition, activation of
and serial analysis of gene expression The events which lead to cancer metasta- epithelial growth factor receptor (EGFR)
(SAGE), to isolate invasive cancer cells sis include changes in cell-cell and cell- and other oncogenic signalling pathways
and compare their gene or protein expres- matrix adhesion, alterations in cell shape, can also upregulate VEGF-C, a known
sion with non-invasive or normal cells deformability and motility, invasion of sur- lymphangiogenic cytokine [4]. The recep-
from the same patient [2]. Prior to this, rounding normal tissues, gaining access tors for these cytokines (Flk-1 and Flk-4)
transfection of chromosomes or DNA to lymphatic or vascular channels, dis- are expressed on tumour vasculature,
from metastatic to non-metastatic cells semination via blood or lymph, survival of and both (in addition to acting as potent
(or vice versa), subtractive hybridiza- host defence mechanisms, extravasation mitogens for endothelial cells) also
tion/differential display PCR, cDNA array and colonization of secondary sites (Fig. enhance vessel permeability. Thus activa-
and other strategies resulted in identifica- 3.41). There are now many features of tion of these signalling pathways may
tion of some genes specifically linked to cancer cells recognized to potentiate potentiate both vascular and lymphatic
invasion and tumour spread. Basic fibrob-
last growth factor (bFGF) is often upregu-
lated in cancers, particularly at the inva-
sive edge where tumour cells interact
with host cells [5].
Epithelial cells are normally bounded by
basement membranes which separate
them from the underlying stroma and
mesenchymal compartments. Breaching
this barrier is the first step in the transi-
tion from carcinoma in situ to invasive
and potentially metastatic carcinoma.
Basement membrane is composed of a
Fig. 3.42 Multiple metastatic growths of an intes- Fig. 3.43 Multiple metastases to the brain from a variety of structural proteins including
tinal carcinoma in the liver. lung carcinoma. collagen IV (the major component),
Integrins
Integrins are heterodimeric proteins that
mediate adhesion between cells and the
extracellular matrix or other cellular ele-
ments. Ligand specificity is determined by
the subunit composition; many integrins
bind multiple substrates and others are
more selective. Far from being an inert
glue, they are capable of transmitting
important signals regulating cell survival,
differentiation and migration [7]. Many dif-
ferences in integrin expression between
benign and malignant cells have been doc- Fig. 3.44 MRI scan showing skeletal metastases in a patient with a primary prostatic carcinoma (front
umented, but the patterns are complex. In and back views). Some of the larger metastases are marked by arrows. Note the numerous metastases
addition, their expression and binding in the ribs and in the spine.
Adhesion/attachment RGD-toxin constructs and RGD-targeted Have not reached clinical trials
gene therapy
PDGFR, KDR and EGFR small molecule Active in vitro in animal models; preclinical
inhibitors activity in combinations; phase I trials
completed for several agents, some tumour
stabilization or regression
growth in the liver where there are high transforming growth factor alpha, epider- nating cells. Most metastases occur in
concentrations of its ligands. All of these mal growth factor and platelet-derived the first capillary bed or lymph node
require proteolytic cleavage for activation. growth factor, can induce chemotactic encountered. The number of involved
Other enzymes which have been implicat- responses in tumour cells expressing the nodes is a key prognostic factor for many
ed in metastasis include the cysteine pro- cognate receptors. Scatter factor (also cancers, and this has led to efforts to
teinases, notably cathepsins B and D. For known as hepatocyte growth factor, HGF) identify sentinel lymph nodes in order
most of the enzymes described, there are is a potent host-derived motility factor, to improve predictions of cancer spread.
active research programmes seeking and tumour cells themselves secrete a Lymphatic channels present less of a
selective inhibitors (some of which have variety of autocrine motility factors includ- challenge to tumour cell entry than capil-
reached phase II and III clinical trials) to ing autotaxin and neuroleukin/phospho- laries since they have scanty basement
prevent or treat metastatic disease. hexose isomerase. membrane. Once in the lymphatics,
Motility, coupled with proteolysis, is the tumour cells are carried to the subcapsu-
basis of tumour cell invasion, and is also Organ preference of metastases lar sinus of draining nodes, where they
important during intravasation and The organ distribution of metastases may arrest and grow, succumb to host
extravasation of blood and lymphatic ves- depends on the type and location of the defences, or leave the node via the effer-
sels. Many motility factors have been primary tumour, with 50-60% of the sec- ent lymphatics. The propensity for a
described which may be tumour- or host- ondary sites being dictated by the tumour cell to generate a lymphatic
derived. Many growth factors, such as anatomical route followed by the dissemi- metastasis may depend upon its ability to
adhere to reticular fibres in the subcapsu- there; colon carcinoma cells enter the that specific cancer cells (the seed) had
lar sinus. These fibres contain laminin, portal circulation which delivers cells to an affinity for certain organs (the soil).
fibronectin and collagen IV, and different the liver, and so on (Fig. 3.45). However, a In experimental systems there are many
integrins expressed by different tumour non-random element in metastatic pat- examples showing that primary tumours
cells may be responsible for adhesion to terns has long been recognized (Table are heterogeneous, and that cloned cells
these structures and to the lymphatic 3.6). Stephen Paget developed the seed can vary in their ability to metastasize to
endothelial cells [11]. and soil hypothesis in 1889, based on his different sites. Some of the patterns
Sarcomas tend to metastasize to lungs observations from autopsies of over 700 relate to the ability of malignant cells to
because the venous drainage returns women with breast cancer. He proposed adhere to the endothelial cells in target
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