Lecture 21: End of lecture 20 and Lecture 21:

The Rational Treatment of Cancer

Reading: Chapter 15: 778-795 and first half of
Chapter 16

Immunoevasive strategies believed to used by cancer cells:

1. Hide identity
via repression of tumor antigens or repression of MHC
class I proteins, thus avoiding CTLs
2. Hide stress
stressed cells can attract NK & upregulate MHC-II
3. Avoid apoptosis
acquire resistance to FasL-mediated apoptosis

Induce lymphocyte apoptosis/non-responsiveness

release soluble FasL to kill CTLs
recruit Tregs
Secrete TGFbeta

Table15.3TheBiologyofCancer(GarlandScience2007)

1. Tumors seek to hide from immune response

Down-regulate
antigen expression
or presentation, or
MHC class I protein

Figure15.27TheBiologyofCancer(GarlandScience2007)

 Loss of antigen
expression could
be by loss of
transport of
peptides (loss of
TAP) or 2m which is required
for MHC Class I
shuttling to cell
surface

Figure15.28aTheBiologyofCancer(GarlandScience2007)

Could a tumor cell escape detection by CTL just by shutting

off MHC class I expression completely?
This way it would escape
roving CTL (TC) looking for new
peptides produced in cancer
cells due to:
- Point mutations
- Translocation products
- Expression of proteins
normally ONLY expressed
during embryogenesis
- Antigens produced due
to improper or incomplete
post-translational
modification

But NK cells are pre-programmed to kill tumor cells which

do not express MHC I so cancer cells would need to only
partially affect MHC I expression to escape this

Figure15.12eTheBiologyofCancer(GarlandScience2007)

NK cells
express KIR
receptors
that
suppress
attack if
bound to
MHC class I
- thus MHC
class I
negative
cells are
KIR receptor binds unchanging region of MHC class I
killed
Figure15.29TheBiologyofCancer(GarlandScience2007)

2. Hide stress
NK cells also can be activated by cells
expressing stress-associated cell proteins on
their surfaces

Figure15.30aTheBiologyofCancer(GarlandScience2007)

The NKG2D receptor

recognizes MICA stress
protein --> killing
Tumor cells may
repress ligand -MICA
Tumor cells may
express secreted form of
MICA that acts as an
inhibitor
Evade NK cell death
Figure15.30bTheBiologyofCancer(GarlandScience2007)

3. Tumor cell may also become resistant to CTLs by

becoming resistant to apoptosis - or downregulating
Fas
FasL - mediated cell killing of target cell by CTL
Target cell must express Fas for this work

X
4. Tumors also turn the tables on immunocytes and release
FasL- killing immunocytes that come close to them

4. Tumor cells recruit Tregs

Figure15.14TheBiologyofCancer(GarlandScience2007)

4. Tumor cells recruit Tregs

Tumors
also
secrete
cytokines
that attract
Tregs so that
CTL
response
is blunted

Figure15.34aTheBiologyofCancer(GarlandScience2007)

4. Many tumors release inhibitors of lymphocyte survival e.g. TGF-beta or bias the immune response toward a humoral
repsonse (secrete IL-10 to inhibit TH1)

Figure15.32aTheBiologyofCancer(GarlandScience2007)

What do T cells do endogenously in cancer?

Recognize tumor cells and directly cytolyze them?
Recognize tumor antigens presented by APCs and help CD8 and
B cell responses against the tumor?
How to clinically utilize the T cells?
Blockade Treg function?
Inhibit the inhibitory signals on T cells?
Change the antigen specificity of a T cell?

Do tumors really
actively evade the
immune system?
Rare naturally
occurring tumors
have taken this to the
extreme
Canine transmissible
venereal sarcoma
A transmissible,
parasitic cancer
Eventually often get
regression (immune
system kicks in?)

The tumor cells are themselves the

infectious agents, and the tumors that
form are not genetically related to the
host dog. Although the genome of CTVT
is derived from a canid (probably a dog,
wolf or coyote), it is now essentially
living as a unicellular, asexually
reproducing (but sexually transmitted)
pathogen
Similar case in Tasmanian devils who get Devil
Facial Tumor Disease

Lecture 21: The Rational Treatment of Cancer

Reading: Chapter 15: 778-795 and first half of
Chapter 16

Are we making any progress in treating cancer?

In general:
Incredible leaps in understanding cancer.
With few recent exceptions - no dramatic change in the
longevity of patients with advanced cancer - especially
solid tumors.
Oncologists are frustrated, as many survival times
have not changed
e.g. lung cancer 5 yr. survival was 7% in 1975 - it is 14%
now and this may reflect just an earlier diagnosis of lung
cancer now.
But, more ideas than ever before are in clinical trials --and were seeing the glimmers of hope - dramatic
responses in a subset of patients

This is a biography of cancer

from its first documented
appearances thousands of years
ago through the epic battles in
the twentieth century to cure,
control, and conquer it to a
radical new understanding of its
essence.

Some cancers have proven to be resistant to

traditional therapies - lack of progress

Figure 16.1b The Biology of Cancer ( Garland Science 2007)

Early detection or changes in food storage, less salt

preservation, more fresh fruit and vegetables
available) has made a big difference for some cancers

Early detection has made a big difference for some

cancers but not as much for others e.g. breast cancer
Increased
screening
but
possibly
other
factors

Figure 16.2 The Biology of Cancer ( Garland Science 2007)

More and more sophisticated methods for early

detection may help but increases apparent incidence
A tumor of several mm can be detected

..and progress of therapy followed

Figure 16.3 The Biology of Cancer ( Garland Science 2007)

Early detection of cancer is a good predictor of favorable

outcome.
Percentage of Women Who Survive after Being Diagnosed
with a Breast Tumor at 5 vs 10 years.

5
10

IIA
IIB
III
IV
http://cbcrp.org/publications/papers/BCinCA/page_12.php

Types of screening methods:

Self examination
Breast, testicular, skin cancer
Screens for biomarkers
Viruses as biomarkers high risk Human Pappiloma
Virus detection by PCR
PCR detection of specific, activated oncogenes or
TERT
Secretion or shedding of proteins not expressed or
shed at high levels by normal tissues prostate
specific antigen (PSA) for prostate cancer

Secondary effects of tumor growth

Blood in stools from colon polyps or adenocarcinoma
Direct visualization of stained cells on slides with
abnormal morphology
Pap smear (Papanicolaou)
Imaging techniques
Mammography (low dose x-ray)
Magnetic resonance imaging
Computed tomography (CT or CAT scan)
Colonoscopy (starting age 50)

Once diagnosed, accurate staging of cancer is critical

for successful treatment

http://www.hemonc101.com/What-is-colon-cancer-s/1863.htm

What is staging?
Determination of the local extent of the cancer
Involvement of adjacent structures and lymph nodes
Presence of distant metastasis
Biomarkers of extent of tumor growth
e.g. Prostate specific antigen levels
Measures of biologic potential
S-phase percentage
Nuclear volume
Gene expression profile

Traditional Staging Systems:

Cancer staging usually is described in terms of the TNM
system - a classification system developed and recently
revised by the American Joint Committee on Cancer
(AJCC) and the Union Internationale Contre le Cancer
(UICC; International Union Against Cancer). According to
this system:
T = tumor size
N = node involvement
M = metastasis status
Cancer treatment ultimately depends upon such staging.
In general, the lower the stage, the more favorable is the
individual's prognosis.

The variables

But this is somewhat crude can we use molecular

techniques to get a better idea?

Beyond traditional staging to molecular

staging
Emerging technologies such as gene expression
profiling (microarrays or RNA-seq) promises to
help physicians:
i.determine prognosis (biologic potential)
ii.decide the most effective drug treatments for
individual patients

Microarray hybridization
Microarrays consist of ordered sets of DNA
(representing sequences from genes) fixed to solid
surfaces.
When hybridized with messenger RNA from tumor
samples an expression profile can be obtained

To compare the expression

profile of two different
samples (such as tumor
cell to normal cell):
1. mRNA isolated from both
samples.
2. mRNA reverse transcribed to
cDNA using fluorescently labeled
nucleotides. One sample is
labeled with a red fluorochrome
and the other with a green
fluorochrome
3. The probes are mixed and
hybridized to slide, then washed
and imaged using a scanner.

The scanner detects the red and green signals and the images are
overlayed electronically. Equivalent expression between the two
samples will be displayed as yellow. The ration of red to green shows
the relative level of expression between the two samples

Stratifying breast cancers into subgroups having

distinct biological properties and prognoses, using
functional genomics

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

The two groups have dramatically different clinical courses

Next pick out genes that matter

most for good or poor
prognosis to make diagnostic
assay eg Oncotype DX

Figure 16.4b The Biology of Cancer ( Garland Science 2007)

About Oncotype DX
Oncotype DX is a diagnostic assay that quantifies the
likelihood of breast cancer recurrence in women with newly
diagnosed, early stage breast cancer.
In addition to predicting distant disease recurrence,
Oncotype DX also assesses the benefit from certain types of
chemotherapy.
The assay performed using formalin-fixed, paraffinembedded tumor tissue analyzes the expression of a panel
of 21 genes and the results are provided as a Recurrence
Score (0-100).
The gene panel was selected and the Recurrence Score
calculation was derived through extensive laboratory testing
and multiple independent clinical development studies.
http://www.oncotypedx.com/

Oncotype DX is validated
For women with node-negative, estrogen-receptor-positive
invasive breast cancer
AND
For post-menopausal women with node-positive, hormonereceptor-positive invasive breast cancer

http://www.oncotypedx.com/

ONCOTYPE DX SCORING SYSTEM for BREAST CANCER PROGNOSIS

From L. J. Kleinsmith, Principles of Cancer Biology. Copyright (c) 2006 Pearson Benjamin Cummings.

The quantitative assessment of the likelihood of distant recurrence provided

by Oncotype DX is important in weighing the benefits vs. the risks of adjuvant
chemotherapy in order to determine the most appropriate treatment strategy
increasing confidence that the treatment plan is tailored to the individual
patient.

http://www.oncotypedx.com/

Microarrays/RNA-seq and new therapies

Many drug companies and physicians are
investing in this sort of data
Assume that among the genes that confer
bad prognosis would be new targets for
therapy (e.g. Her-2/Neu story)
Thus, the advent of molecular staging may
involve many measurements of gene
expression levels - rather than just clinical
parameters and a small number of
biomarkers

This paper from Louis Staudt at the National Cancer Institute

revealed the power micro-array data can have for prognosis and
potentially staging cancer - concept is molecular

pathology reveals differences not seen in the

pathologists microscope.

Diffuse Large B Cell Lymphoma (DLBCL)

A cancer arising in lymph nodes (often elderly).
Malignant cells are B cells
Various clinical and histological signs are used to stage
these cancers and determine a prognosis.
This paper posed the question: Although different
cases of DLBCL may look the same under the
microscope are they actually different biologically?
Some patients survive and some have aggressive
disease and do not.

Stratification of DLBCL subtypes via gene expression

analysis

Figure 16.5a The Biology of Cancer ( Garland Science 2007)

KaplanMeier curve illustrates the greatly differing disease

courses that patients with the three subtypes experience.

Figure 16.5b The Biology of Cancer ( Garland Science 2007)

Tumors that are classified through the expression array

analyses exhibit distinct karyotypic and biochemical
alterations

Figure 16.5c The Biology of Cancer ( Garland Science 2007)

The fact that the PMBLs and

the ABCs show high
constitutive levels of NF-kB
activity suggests that they
may be particularly
susceptible to disruption of
this signaling pathway by
inhibition of the upstream
activator of NF-kB, IkB kinase
(IKK)

Figure 6.29a The Biology of Cancer ( Garland Science 2007)

Survival and
proliferation
genes

PMBL and ABC cells particularly susceptible to

inhibition of IkB kinase

Figure 16.5d The Biology of Cancer ( Garland Science 2007)

What happens to most patients after detection

and staging?
Surgical removal of the primary tumor will usually be
accompanied by additional therapy (adjuvant therapy)
Try to prolong relapse-free survival or diseasefree survival period.
The overall survival period is the period between
diagnosis and death.
If disease recurs, it is called relapse or recurrence.
Upon relapse, additional surgery and chemotherapy
are administered.

Time

Main Traditional Therapies

Surgery
Goes back 3000 yrs, first mastectomy in 1890
Radiation
Triggers apoptosis or mitotic cell death (death during
mitosis triggered by DNA damage)
Chemotherapy
Drugs circulate through bloodstream & interfere with
cancer cell proliferation

Emerging Treatments
Immunotherapy
Exploits immune system to recognize and kill tumor cells
Molecular targeting
Drugs designed to target those proteins/pathways known
to be critical to cancerous state

Immunotherapy of tumors
I.

Passive immunization (Supplement immune system)

a. Non-specific
infusion of histocompatible bone marrow (BMT)
b. Specific
antibodies alone or coupled to drugs, pro-drug toxins or
radioisotope

II.

Active immunization
a. Non-specific
BCG, cytokines eg IL2, blocking CTLA-4
b. Specific
killed tumor cells or their extract, recombinant antigens, costimulatory molecule genes

Bone marrow transplantation (BMT)

Used to treat hematopoietic (leukemia, lymphoma) tumor
types
Patients hematopoietic system ablated - drugs or
radiation
Replaced with donor hematopoietic stem cells often in
the form of infusion i.v. of bone marrow cells
Less than perfect MHC match means donor T cells can
recognize recipient cells as foreign
For reasons that are unclear the graft versus tumor
response is stronger than the graft versus host
response and thus the new immune system
specifically targets the tumor

Immunotherapy of tumors
I.

Passive immunization (Supplement immune system)

a. Non-specific
infusion of histocompatible bone marrow (BMT)
b. Specific
antibodies alone or coupled to drugs, pro-drug toxins or
radioisotope

II.

Active immunization (mobilizing and enhancing endogenous

immune defenses)
a. Non-specific
BCG, cytokines eg IL2, blocking CTLA-4
b. Specific
killed tumor cells or their extract, recombinant antigens, costimulatory molecule genes

Specific passive immunization

- need to use humanized monoclonal antibodies

- antibodies alone or coupled to drugs, pro-drug toxins

or radioisotope

Herceptin for breast

cancer
A monoclonal
antibody that binds
HER2/NEU (growth
factor receptor - RTK)
works best with
operable early-stage
HER2 over-expressing
breast tumors
Works in multiple
ways
i. Reduce level by
receptor internalization
Figure 15.35b The Biology of Cancer ( Garland Science 2007)

ii. Antibody-dependent cell-mediated

cytotoxicity (ADCC) NK cells kills

Herceptin

HER2

iii.Herceptin inhibits cell signaling and thus the antiapoptotic benefits of HER2 signaling

= Herceptin

iv. Herceptin synergy with irradiation - presumably due to

lost protection against apoptosis

Other monoclonal antibodies targeting HER family

receptors are in use or clinical trials
Colorectal cancer

Blocks ligand binding

Figure 15.38b The Biology of Cancer ( Garland Science 2007)

Interferes with
signaling

Blocks
heterodimerization

Antibody coated cells are killed by natural killer

(NK) cells

Kill all cells, including cancer cells, with a particular

cell surface protein

Figure 15.3b The Biology of Cancer ( Garland Science 2007)

Anti-CD20 (Rituxan) monoclonal antibody is

widely used for B cell malignancy

Combined with standard chemotherapy

40-70% reduction in risk of disease progression and death
Eventually normal B cells repopulate from stem cells
Figure 15.40 The Biology of Cancer ( Garland Science 2007)

Immunotherapy of tumors
I.

Passive immunization (Supplement immune system)

a. Non-specific
infusion of histocompatible bone marrow
b. Specific
antibodies alone or coupled to drugs, pro-drug toxins or
radioisotope

II.

Active immunization (mobilizing and enhancing endogenous

immune defenses)
a. Non-specific
BCG, cytokines eg IL2, blocking CTLA-4
b. Specific
killed tumor cells or their extract, recombinant antigens, costimulatory molecule genes

William Coley - Coley Fluid for cancer therapy

Used heat killed bacteria to
treat cancer

The first patient to receive Coley Fluid

was a sixteen-year-old boy with a
massive abdominal tumor.
Every few days, Coley injected his fluid
directly into the tumor mass and
produced the symptoms of an infectious
disease.
On each injection, there was a
dramatic rise in body temperature and
chills.
Tumor gradually diminished in size.
After several months, the remains of
the growth were barely perceptible.
The boy received no further anticancer
treatment and remained in good health
until he died of a heart attack 26 years
later.

These days a bacteria (BCG) is used to treat early stage

bladder cancer
Attenuated weak
strain of
mycobacterium
Immunostimulant
Injected into bladder
Attracts T cells,
macrophage, NK cells
giving localized
inflamatory response
Standard of care for
non metastatic tumors

Figure 15.42 The Biology of Cancer ( Garland Science 2007)