Genetics, Reproduction & Female

Healthcare

Cancer Genetics
Dr Tan Eng Lai
 Cancer

“Cancer is, in essence, a genetic disease. Although

cancer is complex, and environmental and other
nongenetic factors clearly play a role in many
stages of the neoplastic process, the tremendous
progress made in understanding tumorigenesis in
large part is owing to the discovery of the genes,
that when mutated, lead to cancer.”

Bert Vogelstein (1988)

NEJM 1988; 319:525-532.
 Cancer
What causes cancer?

Is there a cure for cancer?

Cancer is a collection of different diseases collective known

as cancers.

Can be defined as a set of diseases characterised by

unregulated (uncontrolled) cell growth leading to invasion of
surrounding tissues and metastasis.
 Unregulated Proliferation
Unregulated or uncontrolled growth may NOT necessarily
mean faster growth. > Hyperplastic conditions of normal
cells vs. slow growth rate of breast cancer.

Unregulated refers to the ‘antisocial’ nature of cancer cells,

i.e. the degree of autonomy and independence from the
‘society’ of normal cells.

Cancer cells are not subjected to internal and external

regulatory signal (They are rebels!)
 Cancer Cells as ‘Rebels’
Cancer cells are concerned only with dividing themselves.
They are only interested in increasing their number thus
accumulating greater mass.

They refuse to ‘die’ when they

needed to (apoptosis) and they
do not differentiate.

They increase in size but refuse

to ‘grow up’.

‘Antisocial’ nature of cancer cells

The Normal Cell Cycle
 Cell Cycle Control
Intricately regulated by 2 checkpoints:
1. G1/S transition
2. G2/M transition

Progression through the cycle is controlled

by protein kinases known as cyclin-
dependent kinases (CDKs) and cyclins.
 Deregulation of Cell Cycle
Control
• Any genes (e.g. CDK and cyclins) that control
the progression in the cell cycle can be
subjected to mutations.

• Typically 2 to 20 mutations are required for a

single cell to initiate the development of cancer.

• Agents that cause mutations leading to

carcinogenesis is known as carcinogens.
 3 Main Types of Carcinogen
1. Chemical
2. Radiation
3. Viruses
International Agency for Research on Cancer, World Health Organization
(IARC-WHO) system for classifying carcinogens.
Group 1: Carcinogenic to humans
Group 2A: Probably carcinogenic to humans
Group 2B: Possibly carcinogenic to humans
Group 3: Unclassifiable as to carcinogenicity in humans
Group 4: Probably not carcinogenic to humans
 Chemical Carcinogenesis
Genotoxic carcinogens: damage DNA by direct interaction or after
metabolic activation.
Non-genotoxic carcinogens: do not damage DNA but act as
mitogens encouraging cell proliferation upon binding to their
receptors. E.g. hormones, phorbol ester.
Carcinogenesis: initiation and promotion.
Initiation: the process whereby a chemical or other agent damages
the DNA of the cell.
Promotion: the subsequent progression and proliferation of the
"transformed" cell through a variety of pathological states (e.g.,
hyperplasia, neoplasia) leading eventually to a malignant tumour.
Initiation and promotion each consist of several stages involving
distinct mechanisms; some are reversible and some are not.
Radiation Carcinogenesis
1. Ionising Radiation

Causes breakage in DNA bonds

damage. Either single or double
stand break.

X-rays and gamma rays:

electromagnetic radiation.

Alpha particles: two protons and

two neutrons.

Beta particles: electrons ejected

from the nuclei of atoms.

2. Ultraviolet Ray: Formation of

covalent bonds between adjacent
pyrimidines – dimers.
 Viral Carcinogenesis
• Francis Peyton Rous (1910) inferred the from his study of sarcoma in chicken,
the presence of transforming ‘genes’.

• The causative agent was Rous Sarcoma Virus (RSV), a retrovirus.

• In the nucleus, the RNA is converted into dsDNA and integrated into the host
genome forming the provirus.

• The virus then subvert the host transcription and translation machinery into the
production of viral products which give rise to new RSV particles.

• RSV infection causes tumour formation because one of the viral gene
integrated into the host genome is an oncogene known as the src gene.

• Retroviruses that carry oncogenes are known as acute transforming

viruses.
Viral Carcinogenesis
 Oncogenes and Proto-oncogene
• An oncogene carried by acute transforming retrovirus was not originally viral
genes but a proto-oncogene that was acquired from the host genome
during infection.

• Proto-oncogene is the normal counterpart of an oncogene.

• Proto-oncogenes are involved in the regulation of normal biological

functions such as cell division and programmed cell death (apoptosis).

• A proto-oncogene is converted into an oncogene through point mutations,

translocation and gene amplification which can be mediated by viruses or
arise spontaneously.

• Currently, there are more than 100 known proto-oncogenes which can be
broadly classified into 5 different classes: Growth factors, Growth factor
receptors, Signal transducers, Transcription factors, Negative
regulators of apoptosis.
 Proto-oncogene to Oncogene

*Translocation may be facilitated illegitimate V(D)J recombination,

class switch recombination, homologous recombination, non-
homologous end joining and mutations in DNA repair pathways.
 Ras Oncogene
• The Ras proto-oncogene regulates a signaling pathway for cell growth and
differentiation.
• To turn "on" the pathway, the Ras protein, a GTPase, binds to a GTP.
• To turn the pathway "off" the Ras protein hydrolyse the bound GTP to
GDP.
• Point mutation in Ras proto-oncogene destroys its GTPase function and is
converted to an oncogene.
• The Ras oncogene (or mutant Ras) is permanently turned “on” when bound
to GTP because is unable to be turned “off” after losing its GTPase function.
• The effect of Ras oncogene is dominant – a change in one of the two gene
copies is sufficient to transform a cell.
• Mutant Ras has been identified in cancers of many different origins,
including: pancreas (90%), colon (50%), lung (30%), thyroid (50%), bladder
(6%), ovary (15%).
 Tumour Suppressor Genes
• Tumour suppressor (TS) genes are genes that slow down cell
division, repair DNA mistakes, and regulate apoptosis.

• Inactivation of TS genes enables cells to grow without control, which

can lead to cancer.

• About 30 TS genes have been identified, including p53, BRCA1,

BRCA2, APC, and Rb1.

• Normal functions include: Genes that control cell division (Rb1),

DNA repair genes and positive regulators of apoptosis.
 Oncogenes and Tumour
Suppressor Genes
• A proto-oncogene normally functions in a way that is similar to a
gas pedal – it helps the cell to proliferate. An oncogene could be
compared to a car accelerator which causes the cell to divide out of
control.
• A tumour suppressor gene is like the brake pedal on a car – it
normally keeps the cell from dividing too quickly just as a brake
keeps a car from going too fast. A mutation can result in
uncontrolled cell division.
• Important differences between oncogenes and tumour suppressor
genes are:
1. Oncogenes result from the activation (gain of function) of proto-
oncogenes, but tumour suppressor genes cause cancer when they
are inactivated (loss of function).
2. Most oncogenes develop from mutations in normal genes (proto-
oncogenes) during the life of the individual (acquired mutations),
but abnormalities of tumour suppressor genes can be inherited as
well as acquired.
 Inherited Abnormalities of
Tumour Suppressor Genes
Abnormal Other non-inherited cancers seen with
Inherited cancer
gene this gene

Retinoblastoma RBI Many different cancers

Li-Fraumeni Syndrome (sarcomas, brain tumors,

P53 Many different cancers
leukemia)

Melanoma INK4a Many different cancers

Colorectal cancer (due to familial polyposis) APC Most colorectal cancers

MLH1, MSH2, or
Colorectal cancer (without polyposis) Colorectal, gastric, endometrial cancers
MSH6

Breast and/or ovarian BRCA1, BRCA2 Only rare ovarian cancers

Wilms Tumor WTI Wilms tumors

Small numbers of colon cancers, melanomas,

Nerve tumors, including brain NF1, NF2
neuroblastoma

Kidney cancer VHL Certain types of kidney cancers

 Can Cancer be Inherited? -
Retinoblastoma
• Cancer is a multi-step process resulting from mutations in specific
genes.
• The number of genes that needs to be mutated before a normal cell
becomes cancerous vary between different cancers.
• Depend largely on inherited abnormal tumour suppressor genes.
• The genetic basis of cancer began with the studies on a rare type of
human cancer, retinoblastoma.
• Retinoblastoma arises from the retinal cells after undergoing only a
few mutations.
• Hereditary form usually affect both eyes and affected individuals
and have increased risk developing other cancers.
• Non-hereditary form affects only one eye > Very rare.
 Retinoblastoma
• Mutations in the Rb1 gene (located in 13q14) are
inherited in an autosomal dominant pattern.

• Autosomal: the gene carrying a mutation is located on

one of the autosomes (chromosome pairs 1 through 22).
 Males and females are equally likely to inherit the
mutated gene.

• Dominant: having a mutation in just one of the two

copies of a particular gene is sufficient for a person to
have a trait, such as an increased risk of developing
cancer.
 Retinoblastoma
• An Individual who has a deletion or loss-of-function of mutation
present in one copy of the Rb1 gene is predisposed to or has
increased risk of developing retinoblastoma.

• A second mutation in the other copy of the Rb1 gene will result in
retinoblastoma.

• A person with inherited form of retinoblastoma has Rb1 mutation all

cells, including sperm or egg cells and there is a risk of passing on the
mutated Rb1 gene to the next generation.

• In individuals with heritable retinoblastoma, one copy defective RB1

gene is detected in ALL normal cells. Both copies of RB1 genes are
defective in cancerous cells.

• In individuals with non-heritable retinoblastoma, normal cells of the

body possess the normal RB1. Cancerous cells have both defective
copies of RB1 arising from somatic mutation.
Knudson’s Two-hit Hypothesis
a) Normal individuals
have two normal
copies of Rb1. Two
independent ‘hits’
(mutations) are
required in the
same cell to initiate
retinoblastoma.
b) Individuals who
inherit one copy of
defective Rb1
already have a first
‘hit’ in every cell and
require only one
subsequent ‘hit’ in a
cell to initiate a
retinoblastoma.
Colon Cancer as a Genetic Model
of Cancer
• Colorectal tumours represent a broad spectrum of neoplasms,
ranging from benign growths to invasive cancer, and are
predominantly epithelial-derived tumours (i.e., adenomas or
adenocarcinomas).

• Epidemiologic studies have shown that a personal history of colon

adenomas places an individual at an increased risk of developing
colon cancer. Two complementary interpretations of this
observation are:

1. The adenoma may reflect an innate or acquired tendency of the

colon to form tumours, and
2. Adenomas are the primary precursor lesion of colon cancer.
Colon Cancer as a Genetic Model
of Cancer
• Tumour progression model: normal epithelium  adenoma 
carcinoma is associated with acquired molecular events.

Deduced from comparison of genetic alterations seen in normal

colon epithelium, adenomas of progressively larger size, and
malignancies.

• At least 5 to 7 major mutations may occur when a normal epithelial

cell progresses in a clonal fashion to carcinoma.

• Several genes associated with colorectal cancer risk have been

identified.

• Almost all gene mutations known to cause a predisposition to

colorectal cancers are inherited in an autosomal dominant fashion.
Colon Cancer as a Genetic Model
of Cancer
Family characteristics that suggest autosomal dominant inheritance of
cancer predisposition include the following:

1. Vertical transmission of cancer predisposition (refers to the presence of a

genetic predisposition in sequential generations).
2. Inheritance risk of 50% for both males and females. When a parent carries
an autosomal dominant genetic predisposition, each child has a 50%
chance of inheriting the predisposition. The risk is the same for both male
and female children.
3. Cancers in people with an autosomal dominant predisposition typically
occur at an earlier age than sporadic (nongenetic) cases.
4. An autosomal dominant predisposition to colorectal cancer may include a
predisposition to other cancers, such as endometrial cancer.
5. Two or more primary cancers may occur in a single individual. These could
be multiple primary cancers of the same type (e.g., two separate primary
colorectal cancers) or primary cancer of different types (e.g., colorectal
and endometrial cancer in the same individual).
Colon Cancer as a Genetic Model
of Cancer
• Hereditary colorectal cancer has two well-
described forms:
1. Familial adenomatous polyposis (FAP): due to germline mutations
in the APC gene (~1% of cases).

2. Hereditary nonpolyposis colorectal cancer (HNPCC) a.k.a Lynch

syndrome: caused by germline mutations in DNA mismatch repair
genes (~ 3-4% of cases).

• Sporadic colon cancer (~95% of cases).

 FAP
• Mutation in the APC gene on chromosome 5q in the epithelial cells lining the
colon causes the cell to escape cell-cycle control > Cells begin to divide to
form hundreds to thousands of polyps (or adenoma).
• In FAP, individuals inherit the one mutant copy of APC (heterozygous) in all
cells of the body (not only in the colon!).
• Each polyp is a clone of cells, all of which are heterozygous for APC
mutation. Development of polyps in the colon is a dominant trait.
• When the second copy of the APC is also mutated (homozygous), cancer
development ensues after additional genetic damage is accumulated:
mutation in Ras oncogene, deletions on chromosomes 18q (DCC) and 17p
(p53) an additional mutations.
 HNPCC
• A more common heritable colon cancer than FAP.

• Develops only after a small number of polyps have formed.

• Involved mutations in at least 8 genes on different loci mostly encode

DNA repair proteins.

• Inactivation of DNA mismatch repair (MMR) genes: MSH2

(chromosome 2p21), MLH1 (3p21), MLH3 (14q22) and MSH6 (2p16)
lead to genome instability > increased mutations > colon cancer.

• All cells of affected individual carry a defective allele an MMR gene.

When the remaining wild-type allele is also lost, genomic instability
leading to cancer ensues.
 HNPCC
George Jones has colorectal cancer. His
wife, Susan, is unaffected. They have
three children, George, Jr., Stephen and
Carol - all were at 50% risk of developing
HNPCC. Subsequently, George, Jr.
developed colorectal cancer and Carol
developed uterine cancer.
 
George, Jr., and his wife Connie have two
children. Although both children had a
50% chance of inheriting the HNPCC
gene, neither did.
 
Stephen and his wife, Gloria have two
children. Since Stephen is unaffected
there was no risk of HNPCC to his
children.
 
W: Normal
Carol and Bill Smith have two children. Both
w: Mutated had a 50% chance of inheriting the gene
for HNPCC, and both subsequently
developed colorectal cancer.