GENETIC CHANGES

IN CANCER
AND
CANCER TARGETED THERAPY
Syarifuddin Wahid
Department of Pathology
Faculty of Medicine, Hasanuddin Univ.
Normal Cell
DNA damage DNA repair
Environmental agents
(Chemicals, radiation,viruses)
FAILLURE of DNA repair
APOPTOSIS
FAILLURE APOPTOSIS
PERMANENT DNA DAMAGE (MUTATION)
GENETIC AND PHENOTYPIC CHANGES
1
P53 (TP53) Gene
stress of the cell
(anoxia, oncogene expression, and
DNA damage)

Activation of P53
cell cycle stop DNA repair
apoptosis

No mutation/carciogenesis
Inherited Mutation of DNA
Repair Genes and Cancer Risk
Inherited Mutation Cancer Risk
of DNA Repair Genes
DNA mismatch repair HNPCC
Nucleotid excision Skin Cancer
repair.
BRCA1 & BRCA2 Breast Ca.
Mutation in the genome of
Somatic cells
Activation of growth-
promoting oncogenes
Inactivation of
Tumor suppressor genes
Inactivation of gene
regulate apoptosis
Decreased apoptosis
Unregulated cell proliferation
Clonal Expansion
2
3
4
Activation of growth-
promoting oncogenes

INACTIVE
PROTOONCOGENE
MUTATION
(ONE ALLEL)
ACTIVE
ONCOGENE
(CELLULAR
ONCOGENE)
Oncogenes Lesion Cancer
NEU/HER2 Amplification Breast,ovary,stomach (Ad Ca)
H-RAS Point Mutation Colon, lung, pancreas
MYC Translocation Burkitts Lymphoma
RET Rearranggement Thyroid (Ca)
Daerah promoter VEGF manusia
Ket :
a. primer amplikasi dalam
kotak buram, polimorfisme
ditandai dengan angka-angka
dekat dengan tanda panah
(transciption start site). bsaHl
dan BsmFl adalah ensim
pemotong. b Haplotype gen
VEGF, (C) adalah Wild type
promoter
POINT MUTATION
ON VEGF GENE
-460T>C
+405C>G
Protooncogene
Cellular Oncogene
Viral Gene
Carcinogen
(chemical,
viral and
radiation)
Viral Oncogene
Normal production of growth factor
Normal growth
Devective immune survailance
Abnodrmal production of growth factor
Abnormal Growth
NEOPLASM
DNA
Mutation
Inactivation of
Tumor suppressor genes
and gene regulate apoptosis

Active
Genes
Inactive
Genes
MUTATION
(BOTH ALLELS , LOH)
TS Genes Function Cancer
RB Cell cycle Retinoblastoma
TP53 Cell cycle,apoptosis Sarcoma, lymphoma,
(Guardian of the genome) Adeno Ca
BRCA1 DNA repair Breast
MSH2,MLH1 Mismatch repair Colorectal (HNPCC)
DELETION
GROWTH AND
ANTIGROWTH SIGNAL
RETINOBLASTOMA (RB) GENE
RB RB homozygous (Normal)
1
st
mutation
RB rb heterozygous(N& M)
2
nd
mutation
homozygous/ loss of
rb rb heterozygosity
(Retinoblastoma)


(LOH)
(LOH)
MALIGNANT NEOPLASM
Clonal Expansion
Tumor Progression
Invasion and
metastasis
angiogenesis
Escape from immunity
Additional mutation
5
6
7
8
Metastatic subclone
Clonal expantion, growth,
Diversification, angiogenesis
Transformed Cells
Primary Tumor
INVATION
INTRAVASATION
EXTRAVASATION
Metastatic deposit
Angiogenesis
GROWTH
Tumor Cell
embolus
Ecape from imunity
transformation
progression
Proliferation
of genetically
Unstable cells
Tumor cells
variants
heterogeneity
Normal cell
Single
Tumor cell
1 gm
(10
9
cells)

1 kg
(10
12
cells)
30
doublings
10
doublings
Normal Cell
Carcinogen Induced changes
Tumor Cell
variants
Single tumor cell
Nonantigenic
Invasive
Metastatic
Requiring fewer growth factor
Metastases
Normal
Colon
cell
Increased
Cell
growth
Early
Stage
adenoma
Intermediate
Stage
adenoma
Late
Stage
adenoma
Carcinoma
Metastasis
APC gene loss
DNA loses methyl groups
RAS gene mutation
DCC gene loss
TP53 gene loss
PRL3
overexpression
MORPHOLOGIC
CHANGES
GENETIC CHANGES
MULTISTEPS CHANGES
IN COLON CANCER
CANCER TARGETED THERAPY

Tujuan utama:
Menghambat pertumbuhan dan
penyebaran sel tumor dengan
cara memblok signal
pertumbuhan sel tumor atau
menghambat layanan darah ke
jaringan tumor.
Sasaran obat
Molekul spesifik yang:
1. Terlibat dlm proses karsinogenesis,
pertumbuhan dan penyebaran
tumor.
2. Terlibat dalam angiogenesis.
3. Menjadi marker dari sel tumor
bersangkutan.
(Molecularly targeted therapy)
Transformasi: Onkogen HER2
1 = jumlah copy gen
2 = transkripsi mRNA
3 = ekspresi reseptor protein permukaan sel
4 = pelepasan reseptor dari bgn extraselluler
Normal Amplifikasi/Overekspresi
Cytoplasm
HER2 reseptor
protein
Cytoplasmic
membrane
Nukleus
HER2 DNA
HER2
mRNA
1
2
3
4
VEGF
Stem Cell Pro-B Pre-B Immature B
Mature B
Bone Marrow

Peripheral lymphoid
organ or tissue
IgM,IgD
No antigen dependence Self antigen Foreign antigen
Activated B
B CELL DEVELOPMENT
RAG-1 & RAG-2 expression
H chain
H & L chain
CD43+
CD43+
CD19+
CD10+
CD20
B220
CD43+
CD20
IgM(low)
CD43-
CD20
IgM(high)
CD20
IgM(high)
CD20

CD20 CD20 CD20 CD20 CD20

Tipe targeted therapy
1. Fokus pada molekul yang merupa-
kan komponen internal dan fungsi
sel. (Menggunakan molekul kecil yang
dapat mencapai sel dan meng-hambat
fungsi sel dan akhirnya mati).
- Single transduction inhibitor
(Imatinib mesylate, Genefitinib, Laptinib,
HER2 tyrosine kinase inhibitor),
- Biologic response Modifier Agent
(Denileukin diftitox), dan
- proteosome inhibitor (Bortezomib).
Tipe targeted therapy
2. Fokus pada molekul di bagian luar sel
(membran sel) misalnya reseptor atau molekul
membran lainnya.
(Menggunakan antibodi monoklonal)
mis: Anti HER2, Anti CD20
3. Fokus pada molekul (growh factor) yang ada
dalam sirkulasi
(Menggunakan antibodi monoklonal)
Mis : Anti VEGF
4. Fokus pada gen (Gene therapies).
JENIS TARGETED THERAPY
1. Menggunakan Small Molecule Drug
(SMD)
2. Menggunakan Monoclonal Antibody
(MAB)
3. Menggunakan Gene Therapy
Cara kerja MAB
Menghambat signal pertumbuhan tumor atau
yang memfasilitasi pertumbuhan tumor
Mengikat growth factor atau molekul
lainnya (mis. angiogenesis) yang ada dalam
sirkulasi sehingga tidak bisa binding
dengan reseptornya.
Binding dengan reseptor growth factor
atau angiogenesis sehingga tidak bisa
dicapai oleh growth factor atau molekul
angiogenesis.
Memicu internalisasi reseptor atau
pelepasan reseptor dari membran sel.
Cara kerja MAB
Sebagai pencari sel tumor.
Mengikat molekul yag ada di permukaan sel tumor
sehingga bahan aktip antikanker (kemoterapi atau
radioterapi) yang diikutkan di MAB dapat mencapai
dengan tepat sel tumor. (Mengantar obat
kemoterapi atau radioaktip mencapai target.
Mengefektifkan sistem imun tubuh membunuh
sel tumor (humanized MAB)
Binding dengan protein permukaan (reseptor atau
tumor marker) kemudian berinteraksi dengan
sistem imun tubuh ang akan membunuh sel target.
Memicu apoptosis sel tumor.

Mouse myeloma
Cell line
FUSION
Hybridomas producing
Monoclonal anti-X antibody
Antigen-X
Anti-X antibody-
producing spleen cells
In vitro selection in HAT medium
Clone cells
Screen supernatant for presence of anti-X antibody
MONOCLONAL
ANTIBODY
HUMAN/MOUSE CHIMERIC MONOCLONAL ANTIBODY (HUMANIZED MAB)
Genetic engineering
MONOCLONAL
ANYIBODY-LIKE
MOLECULE
Genetic engineering
Mouse myeloma
Cell line
FUSION
Hybridomas producing
Monoclonal anti-X antibody
Antigen-X
Screen supernatant for presence of anti-X antibody
Clone cells
In vitro selection in HAT medium
Anti-X antibody-
producing spleen cells
MONOCLONAL
ANTIBODY
Parent mouse
antibody
(cdr)
Idiotype
L-Chain
H-Chain
Antigen
Binding Site
Murine
Variable
region
(biru)
Constan
region
(merah)
-s-s-
Fab
papain
Fc
Human constant region
Human constant Fc region
HUMAN/MOUSE CHIMERIC
MONOCLONAL ANTIBODY
(HUMANIZED MAB)
Gambar 12. Struktur humanized
monoclonal antibody.
Constant region
a.amino manusia
(>90%)
Variable region
a.amino tikus (murin)
(<10%)
HUMAN/MOUSE
CHIMERIC MONOCLONAL ANTIBODY
(HUMANIZED MAB)
Keuntungan chimeric antibody
Pembuatan antigen binding site (Fab
variable region) yang spesifik pada mencit
akan menjamin ikatan efektif dengan target
antigen.
Unsur human pada Fc constan region
memungkinkan interaksi lebih efektif dengan
human effector mechanisms dari respon
imun pasien untuk membunuh sel target.
Unsur human pada struktur antibodi di atas
90% memperkecil kemugkinan timbulnya
reaksi penolakan/allergi/syok dari pasien.

Adenoma of increasing size and
degree of dysplasia
Hyperproliperative
epithelium
Invasive carcinoma
P53 mutation
And/or LOH
DC LOH
LOH of other
Genes on 18q
K-ras mutation DNA mutation
DNA methylation
abnormalities
Mismatch repair abnormallities
GASTROINTESTINAL CANCER, 2004.