Cancer diagnosis

1. Cancer diagnosis

2. Main Methods of cancer diagnosis

3. Imaging in Oncology is used for screening, detection, diagnosis, treatment and to follow
response to treatment. These are one of the best early non invasive method of cancer
diagnosis.
Conventional radiology is widely available, and cheap. It is however largely being
replaced by other techniques like CT and MRI for definition of tumor anatomy. Plain and
Contrast radiography (barium or iodine) is still part of initial evaluation of cancer. Many
cancers have been discovered following radiological tests done for unrelated diseases.
Ultrasound (US) is relatively cheap and safe. It has become instrumental in guiding
procedures such as biopsies and for assessment of fluid collections.
Mammography has become routine for breast cancer screening. This is the commonest
imaging technique that is being used for mass screening for cancer.
Radiological diagnosis

4. CT scan plays a critical role in cancer diagnosis, staging, follow up as well as in
relapse of neoplastic disease. It is increasingly being used to guide diagnostic
biopsies, as part of radiotherapy simulations.
MRI is a costly imaging method. Like CT, it is useful in diagnosis, staging, therapy
and follow up. It is also increasingly being used in minimally invasive procedures.
CT is however more widely available.
Positron emission tomography (PET) PET makes use of labeled isotopes active
which are tagged to metabolically active substances. When such substances are
administered, they concentrate on certain areas of the body and yield imaging
studies of metabolism. PET is useful in staging, detecting recurrences and
evaluation of several cancers such as head and neck tumors, brain tumors,
lymphomas, and colorectal cancers.
Radiological diagnosis

5. Cytological diagnosis
Diagnosing diseases by looking at single cells and small clusters of cells is
called cytology or cytopathology. It’s an important part of diagnosing some
types of cancer.
Compared with tissue biopsy, a cytology specimen usually:
•Is easier to get
•Causes less discomfort to the patient
•Is less likely to result in serious complications
•Costs less

6. Cytological diagnosis
Fine needle aspiration cytology (FNAC)
Fine needle aspiration cytology (FNAC) is a widely used cytological technique for the
diagnosis of cancer
Fine needle aspiration (FNA) uses a very thin, hollow needle attached to a syringe to
take out a small amount of fluid and very small pieces of tissue from the tumor. The
doctor can aim the needle while feeling the tumor, if it’s near the surface of the body.
If the tumor is deeper inside the body and can’t be felt, the needle can be guided
while being watched on an imaging test such as an ultrasound or CT scan.
The main advantages of FNA are that the skin doesn’t have to be cut, and in some
cases it’s possible to make a diagnosis the same day. The disadvantage is that
sometimes this needle can’t remove enough tissue for a definite diagnosis. Although
FNAC is a type of biopsy, it’s also classified as a cytology test.

7. Histopathological diagnosis
Diagnosing diseases by microscopic examination of suspected tissue that has been
excised by biopsy or surgical resection.
Biopsy: Biopsy is a surgical removal of small piece of tissue for microscopic
examination of a tissue.
There are three ways for the removal of tissue-
Endoscopy
Needle biopsy
Surgical biopsy

8. Endoscopy
A thin flexible tube with a tiny camera on the end is inserted into the body cavity. This
allows the doctor to view the internal surface of the abdomen. Endoscopic procedures
grant access to internal organs thereby enabling biopsy of the internal organs.
Needle Biopsy allows the clinician to obtain a core of tissue by inserting a needle
from a mass for cytological examination. It is increasingly being employed for tumors
in which there is a visible or readily palpable mass such as lymph nodes, breast or
thyroid. Using ultrasound, computed tomography or fluoroscopy guidance, needle
aspiration can also be used for deeper organs such as the liver. There is a possible
complication of tumor implantation along the tract of the needle.

9. Surgical Biopsy
There are two types of surgical biopsy.
Incisional biopsy is easy to perform. It involves the removal of a small part of a
large tumor for the purpose of laboratory diagnosis. This method is usually chosen
for lesions that are easy to access. Following diagnosis, the tumor is usually
completely removed surgically or treated by other modalities.
Excisional biopsy is an alternative to incisional biopsy. By this biopsy, the entire
tumor, often with some surrounding normal tissues are removed. It enables a more
complete pathological exam of the lesion and thus it is the most appropriate
collection method for small tumors. It is also the best method for evaluation of lymph
nodes; since pathological changes in lymph nodes may be focal and might be
missed when sampled by incisional biopsy. As expected, excisional biopsy might
cause more local trauma than incision biopsy.

10. Following collection of tissue specimen, it undergoes preparation prior to histological
exam. Specimen preparation can be permanent or frozen sections.
Permanent method involves the processes of fixation, embedding, sectioning and
staining. The tissue specimen is initially fixed in formalin, and then embedded in
paraffin wax to preserve its architecture and facilitate sectioning. Sectioning involves
cutting the specimen into thin slices that can be examined with the microscope. The
micro-sections are then finally stained prior to microscopic examination.
Frozen section is a rapid method that quickly prepares fresh tissue for microscopic
examination. It is easily used by surgeon within the operating suite to obtain an
immediate pathological interpretation of the specimen and thus decide on the next
therapeutic approach to pursue during surgery. Tissue is immediately sectioned and
stained. It has also enabled surgeons to establish adequacy of excision margins.

11. Haematological diagnosis
For haematological diagnosis marrow is aspirated by bone marrow aspiration
needle biopsied by trephine needle. It is useful for the diagnosis of leukemia.
This is important for staging.

12. Immunohistochemistry
Immunohistochemistry (IHC) is used to detect antigens or protein expression on a
fixed tissue section by means of an antibody that is specific for the antigen/protein.
The antibody antigen reaction is visualized by linking the antibody to an enzyme that
catalyzes a color producing reaction or to a substance that fluoresces.
IHC serves as an adjunct to regular histological exam of a tissue sample and is being
routinely used to detect the presence of antigens, proteins, and biomarkers in
neoplastic tissue samples.
It has been employed largely for the detection of estrogen and progesterone receptors
on breast tissues, to detect oncogenes and tumor suppressor gene products on tumor
samples as well as to characterize leukemias and lymphomas.

13. In immunohistochemistry large number of monoclonal antibodies are used for
1. Typing of malignant tumor.
2. Diagnosing T or B cell lymphoma by using monoclonal antibody
3. Classification of leukemia and lymphoma
4. Determination of primary metastatic tumour

14. The diversity of genomic alterations involved in malignancy had led to the development
of a variety of assays for complete tumor profiling. Thus, it is no longer adequate to
know the histopathology of a cancer. The new molecular diagnostics when integrated
into existing histomorphological classifications in surgical pathology provides additional
stratification for a more accurate cancer prognosis.
Detection of molecular markers in neoplastic tissue samples can be used to provide
accurate diagnosis, prognosis and prediction of response, resistance, or toxicity to
therapy. These molecular markers can be products of altered genes/DNA or abnormal
pathways.
Cytogenetic procedures study the chromosomes in the tissue sample with the aim to
identify any chromosomal changes that are peculiar to known cancer types.
Molecular diagnosis

15. FISH technique is a molecular cytogenetic technique in which probes are used to
confirm presence or absence of specific DNA sequences on chromosomes. It is used in
diagnosis of blood disorders or cancer which are due to specific genetic alterations on
the chromosomes.
PCR is a quantitative technique that permits amplification and analysis of target DNA
regions in tumor samples.
DNA microarray analysis is equipped to measure the expression levels of large number
of genes concurrently.

16. Flow cytometry is a technique that is used to examine and differentiate cells
based on certain physical and chemical properties. A sample of blood or tissue
cells in suspension is passed through the flow cytometer and the scatter emitted
by the cell where it meets the light is analyzed to better characterize the cell.
Electron microscopy is used when specific cellular or intracellular structures
need to be examined. Like IHC, it aids in a more accurate tumor classification.
Molecular cancer diagnostic techniques have been instrumental to identifying the
brc-abl in CML, HER-2/NEU expression in breast cancer.

17. Detection of Tumor markers
Cancer biomarkers are proteins which are released from cancers and whose
detection or increase in the serum may screen or confirm the presence of
certain cancers
Biochemical assays for tumor-associated enzymes, hormones and other
markers are not being used for the definitive diagnosis of cancer.
Instead, cancer biomarkers complement pathological examination and thus
play a role in the early detection, outcome prediction and detection of disease
recurrence.
In addition, in the present era of new therapeutic agents, biomarkers can help
to determine which tumors will respond to which treatments.

18. Detection of Tumor markers
The ideal biomarker should have a high specificity and sensitivity, especially if it is
to be useful for staging.
In addition, it should be easily detected in the patient’s blood or urine but not in a
healthy person.
Many of the current biomarkers in clinical practice lack enough sensitivity or
specificity to accurately serve as the sole diagnostic tool for the diagnosis of any
cancer.
It must be pointed out that despite the detection of biomarkers in a patient, a
histological exam is often necessary to confirm cancer.
Some biomarkers that are currently in clinical use are shown in Table 1.

19. CA 125 : Cancer antigen 125
CEA : Carcinoembryonic antigen
AFP : Alpha-Fetoprotein
HER2 : Human epidermal growth factor
receptor 2
PSA : Prostate specific antigen
HCG : Human chorionic gonadotropin

20. Detection of Tumor markers

21. Grading is a histologic measure of tumor aggressiveness and provides important
prognostic (predicting the development of a disease) information.
It is determined by examining the tissue specimen. Grade is based on the
morphologic appearance of tumor cells, including the appearance of the nuclei,
cytoplasm, and nucleoli; frequency of mitoses; and amount of necrosis.
For many cancers, grading scales have been developed.
Grading system is different in different types of cancers
• Gleason – prostate cancer
• Bloom-Richardson – breast cancer
• Fuhrman – kidney cancer
Tumor Grading

22. Four degrees of severity
• Grade:
GX Grade cannot be assessed (Undetermined grade)
G1 Well-differentiated (Low grade) (the cancer cells look very similar to normal cells and are growing slowly)
G2 Moderately differentiated (Intermediate grade) (the cells don't look like normal cells and are growing
more quickly than normal)
G3 Poorly differentiated (High grade) (the cancer cells look very abnormal and are growing quickly)
G4 Undifferentiated (High grade)

23. Differentiation
Another way of grading is by how differentiated cancer cells are. Differentiation refers to:
•how well developed the tumour cells are
•how cancer cells are organised in the tumour tissue
When cells and tissue structures are very similar to normal tissues, the tumour is called well differentiated. These
tumours tend to grow and spread slowly.
Grading is important for treatment and prognosis
Lower grade  better prognosis (outcome of diease)
Higher grade  worse prognosis
Important in treatment of  Primary brain tumors (astrocytomas)
Lymphomas
Breast cancer
Prostate cancer

24. Staging is the extent of spread of cancer in the body
Staging of cancer is based on-
- Location of the primary tumor
- Tumor size and number of tumors
- Lymph node involvement (spread of cancer into lymph nodes)
- Cell type and tumor grade (how closely the cancer cells resemble normal tissue)
- Presence or absence of metastasis
Staging - helps planning treatment
- helps estimating prognosis
- helps identifying clinical trials
Staging of Cancer

25. TNM - system
• Based on : T  extent of the tumor
N  extent of spread to the lymph nodes
M  presence of metastasis
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (has not spread)
T1, T2, T3, T4 Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement
N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)
Distant Metastasis (M)
MX Distant metastasis cannot be evaluated
M0 No distant metastasis
M1 Distant metastasis (cancer has spread to distant parts of the body)

26. Treatment of Cancer

27. Surgery, radiotherapy, and chemotherapy are the major pillars on which
current cancer therapies rest
Surgery plays vital role in the prevention, diagnosis, staging, cure and palliation. Many
premalignant lesions are usually surgically removed to prevent progression to cancer.
Family members with familial polyposis of the colon for example, are routinely being
offered colectomy to prevent eventual development of colon cancer. Mastectomy can
also be done prophylactically for patients at high risk for breast cancer
Incisional, excisional and needle biopsy techniques as well as endoscopy are surgical
methods that aid cancer diagnosis.
Surgery forms the basis of therapy for early cancer in which case it is employed as local
treatment for small tumors, to reduce the bulk of the disease, and for removal of
metastatic tumors.

28. Radiation therapy is the administration of ionizing radiation to a cancer patient for the
purpose of cure, palliation or as an adjunct to surgical treatment. Confirmation of
malignancy by pathological exam, ancillary workup and staging must be completed prior to
radiation therapy.
Radiation therapy is often used in conjunction with surgery for eradication of small, limited
human cancers. Preoperatively, radiation therapy may be given to shrink inoperable
tumors or to destroy unrecognized peripheral projections of the tumor.
This method is applicable to advanced tumors of the head and neck, colorectum and
bladder. On the other hand, radiation therapy can be given post operatively to eradicate
residual disease or to control subclinical disease in the wound or in the lymphnodes.
Radiation therapy is also used for palliation in instances like cancers of the central
nervous system and pathological metastasis to the bones

29. Chemotherapy
List of anti-cancer drugs in frequent use

30. Drugs binding to DNA:
A large class of anticancer drugs react directly with DNA. For instance, cis-platinum
reacts with DNA bases, causing intra-strand and inter-strand crosslinks which block
DNA replication and cause cell death, unless repaired.
Cis-platinum is the crucial component in many drug regimes used to treat common
carcinomas.
It is the single most important compound in the combination of drugs that has
revolutionized the treatment of testicular cancers, where cure rates of >95% can be
achieved.
Chemotherapeutic Drugs

31. Nucleoside analogs:
Following conversion to nucleotides in the cell, nucleoside analogues interfere directly
with DNA replication, impede it indirectly by limiting the synthesis of deoxy-nucleotide
triphosphate precursors, or cause strand breaks after incorporation into DNA.
5-fluorouracil (5-FU) is a widely employed member of this class, which acts mainly by
inhibition of thymidylate synthase (Figure 22.2). Thymidylate synthase is required for the
synthesis of thymidine.
Methotrexate is not a nucleoside analogue, but also interferes with deoxy-nucleotide
biosynthesis by inhibiting dihydrofolate reductase.
Thus, both compounds diminish the level of dTTP, the nucleotide precursor specifically
needed for DNA replication.

32. Topoisomerase inhibitors:
Etoposide exemplifies a third class of compounds which bind and inhibit enzymes involved in DNA
replication. Etoposide specifically binds to topoisomerase II and blocks the enzyme at a critical stage.
Topoisomerases are necessary for DNA replication (as well as for transcription), since they relax the
torsional stress that is caused by the unwinding of the DNA helix. Topoisomerase I enzymes
reversibly insert a single-strand break, allow the DNA strands to swivel around each other, and re-
ligate the strand-break.
Inhibitors of topoisomerase I used in cancer chemotherapy comprise innotecan, irinotecan and
topotecan.
Topoisomerase II enzymes catalyze a more dramatic reaction, in which a double strand break is
reversibly introduced and another DNA helix (or a distant part of the same helix) is passed through,
before the ends are resealed by the enzyme. This is a more fundamental reaction, which in addition
to relaxing torsional stress allows the untangling of DNA knots and loops.
Etoposide inhibits type II topoisomerases at a crucial stage of this reaction, i.e. after the helix has
been cleaved, but not yet been resealed. In this fashion, DNA replication is inhibited and DNA is
fragmented, more efficiently than by topoisomerase I inhibitors.

33. Microtubule-binding compounds:
Taxoles are perhaps the best-known among different compounds reacting with microtubules, while
vinblastine or vincristine are used for specific diseases. Some drugs of this class block the assembly
of or disrupt existing microtubuli, while others block the turnover of these dynamical structures. Either
way, cellular functions depending on microtubules are compromised or inhibited. The most important
process affected by interference with microtubule function is mitosis, but intracellular vesicle transport
and cell migration are also inhibited.
Biological agents:
Biological agents are diverse group of compounds that do not directly interfere with basic cellular
functions, such as DNA replication and mitosis. Rather, they act on signaling pathways controlling
cell proliferation and differentiation. By activating or inhibiting receptor molecules, they redirect
cancer cells in a more subtle fashion towards normal behavior. Hormones and antihormones used in
the treatment of breast cancer and of prostate cancer can be assigned to this category. They act
selectively on certain cancers since they activate or inhibit receptors that are specifically required for
their growth and survival.

34. How can chemotherapeutic drugs directed against DNA replication and mitosis or drugs
reacting with DNA itself act selectively on cancer cells at all?
Three major reasons have been recognized.

35. 1. Differences in proliferation:
Many cancers contain a higher proliferative fraction than normal tissues, and
many cancer cells replicate faster than most normal cells.
These differences constituted the main rationale in the early years of cancer
chemotherapy development.
Unfortunately, many normal tissues, too, contain faster replicating
compartments. Accordingly, treatments that aim purely at rapidly replicating
cells cause damage to such tissues as well.

36. 2. Defects in cellular checkpoints and DNA repair:
Many cancer cells are defective in DNA damage checkpoints. Combination treatment
together with compounds that interfere with DNA replication would then lead to
checkpoint arrest in normal cells, but to a mitotic catastrophe in cancer cells.
Normal cells react to DNA damage during drug or radiation therapy by checkpoint
activation, with cell cycle arrest and resume proliferation (if at all) only after DNA repair
is completed.
Because of defective checkpoint control, cancer cells proceed through mitosis and G1
irrespective of DNA damage. This can lead to mitotic catastrophes, mitotic arrest, or to
persistent double-strand breaks that elicit apoptosis during the next round of replication.
However, while most cancer cells die or arrest, a few may escape with severely
damaged genomes and increased genomic instability. These are responsible for
remissions and are usually resistant to treatment.

37. 3. Altered apoptosis
Another explanation for the selectivity of cytostatic drugs towards cancers is related to
altered apoptosis. Defects in apoptotic signaling and execution can contribute to
resistance against chemotherapy. However, many cancer cells can be considered as
being ‘poised’ for apoptosis. Inappropriate growth control, genomic instability, and
nucleotide imbalances generate pro-apoptotic signals, which do not elicit apoptosis
because anti-apoptotic signals prevail in cancer cells. In this critical constellation, drug
treatment may add further signals that ‘tip the balance’ towards apoptosis.
For instance, cancer drugs like cis-platinum, 5-FU, and etoposide lead to the induction and
activation of death receptors like FAS. Others, including methotrexate, activate the
intrinsic, mitochondrial pathway of apoptosis. The reaction of a cancer to drug treatment
therefore depends on which defects precisely are responsible for decreased apoptosis. If
the block to apoptosis is very efficient, it will protect the cell against drug-induced
apoptosis as well. For instance, strong overexpression of IAP type proteins like survivin
which inhibit caspases or strong overexpression of BCL2 which prohibits activation of the
intrinsic pathway can also cause resistance to chemotherapy.

38. Targeted therapies

39. Chemotherapy vs Targeted therapy

40. Targeted therapy in cancer
Signal transduction inhibitors

42. EGFR Inhibitors as Cancer Therapy
Epidermal growth factor receptor (EGFR) is a membrane-bound protein that is involved in signal transduction
pathways; it is critical in the regulation of cellular proliferation and survival. In normal tissue, EGFR is
expressed in many different cell types, including epithelial cells. In neoplasms, overexpression and
dysregulation of EGFR can occur. Activation of tumor cell EGFR through autophosphorylation can trigger a
series of intracellular events including cell proliferation, blocked apoptosis, invasion and metastasis, and
tumor-induced neovascularization -- the hallmarks of carcinogenesis.
Approved EGFR Inhibiting Agents
Two categories of drugs affect EGFR. Monoclonal antibodies such as panitumumab and cetuximab are given
intravenously, and their method of action is through extracellular binding with subsequent inhibition of EGFR
signaling pathways. Tyrosine kinase inhibitors (TKIs) such as erlotinib, gefitinib, and lapatinib are
administered orally. Their method of action is through intracellular binding and subsequent inhibition of EGFR
signaling pathways.

43. FDA-Approved EGFR Inhibitors

44. Proteasome inhibitor

47. The ubiquitin proteasome pathway plays a critical role in regulating many processes in
the cell which are important for tumour cell growth and survival. Inhibition of proteasome
function has emerged as a powerful strategy for anti-cancer therapy. Clinical validation
of the proteasome as a therapeutic target was achieved with bortezomib
• Bortezomib: 1st generation proteasome inhibitor
• 2nd generation proteasome inhibitors moving from bench to bedside
– Carfilzomib
– Ixazomib
– Marizomib
• Can block ubiquitin proteasome cascade upstream of the proteasome
– Deubiquitylating enzyme inhibitors

48. • A covalent, reversible inhibitor of proteasome chymotryptic activity
• Induces apoptosis in solid tumors and hematologic cancers, including multiple
myeloma
• Alters the bone marrow microenvironment to reduce tumor cell growth
• Efficacy in both previously untreated and relapsed multiple myeloma
Bortezomib

49. Immunotherapy is a treatment of disease by inducing, enhancing, or suppressing an immune response
Immunotherapy works by:
1. Stopping/slowing the growth of cancer cells
2. Stopping cancer from spreading to other parts of the body
3. Helping the immune system recognize cancer cells and increase its effectiveness at eliminating cancer
Why immunotherapy?
1. POWERFUL: Attacks anywhere in the body
2.SPECIFIC: Trained to recognize only cancer
3.MEMORY: Remembers cancer cells to fight them later
4. UNIVERSAL: Can be used to treat most cancers
Types of Immunotherapy
Monoclonal Antibodies
Cancer Vaccines
Non specific immunotherapies such as cytokines,
Adoptive T-Cell Transfer
Engineered antibodies
Immunotherapy

50. Monoclonal antibodies (mAb) are designed to target tumor-specific antigens. Treatment with mAb is
passive but specific. Using mAbs improve response rates. mAbs are derived from human antibodies, animal
antibodies, or a combination of the two
Examples: rituximab, trastuzumab, bevacizumab
Types of monoclonal antibodies used in cancer treatment
1. Nacked mAbs
2. Conjugated mAbs
1. Nacked mAbs boost a person’s immune response against cancer cells. Other work by blocking specific
proteins that is needed for cancer cell grow.
For example- Herceptin (transtuzumab) is an antibody against the HER2/neu protein. It is used to treat HER2
enriched breast cancer.
2. Conjugated mAbs are conjugated with radioactive particles, chemotherapeutic drugs, toxins. These mAbs
can be divided into groups depending on what they are linked to-
a. Radiolabeled Ab
b. Chemolabeled Ab
c. Immunotoxins
Monoclonal antibodies (mAb)

51. Radiolabeled mAbs have small radioactive particles attached to them. They deliver radioactivity directly to
cancerous cells and can be used to treat some types of Non-Hodgkin lymphoma. For example: Tiuxetan and
tositumomab are examples of radiolabeled mAbs.
Chemolabeled mAbs have powerful chemotherapy drugs attached to them. There are only two chemolabeled
antibodies approved by the FDA to treat cancer at this time.
Immunotoxins have toxins attached to them. There is no immunotoxins approved by the FDA to treat cancer at
this time, although many of them are being studied.

52. Cancer Vaccines
Cancer vaccines:
1. Educate immune system to target cancer
2. Trigger an immune response against a patient’s cancer
Two types of vaccines:
Preventative = prevent cancer
Vaccines against viruses. Some strains of human papilloma virus (HPV) have
been linked to cervical, anal, throat and some other cancers. Vaccines agains HPV
may help to protect6 against some of these cancers.
Patients who have chronic infection with hepatitis B virus are at high risk for liver
cancer. Getting HPV vaccine help to prevent this infection may therefore lower risk
of getting liver cancer.
Therapeutic = treat cancer
These vaccines boost immune system to mount an attack against cancer cells in
the body. Instead of preventing disease, they boost up the immune system to
attack a disease that already exists.

53. Types of cancer vaccines used to treat cancer

54. Non specific immunotherapies such as cytokines
Non specific therapies do not target cancer cells specifically.
Cytokines:
Cytokines are immune molecules made by some immune system cells. They are crucial in
controlling the growth and activity of other immune system cells and blood cells in the body.
Cytokines are injected, either under the skin, into a muscle or into a vein.
Interleukins
Interleukins are a group of cytokines that acts as chemical signals between white blood cells.
IL-2 helps immune system cells to grow and divide more quickly.
Synthetic IL2 was approved by FDA in 1992 to treat advanced kidney cancer

55. Interferon
These cytokines help the body to resist virus infections and virus mediated cancer. Among the three
different types of interferon IFN-α is used to treat cancer. It boosts the ability of certain immune cells
to attack cancer cells. It may also slow the growth of cancer cells as well as blood vessels that
tumors need to grow.
The FDA has approved IFN-α for use against the following cancers-
1. Chronic myelogenous leukemia
2. Follicular non-Hodgkin lymphoma
3. Cutaneous T-cell lymphoma
4. Kidney cancer
5. Melanoma
6. Kaposi sarcoma
Granulocyte-macrophage colony stimulating factor (GM-CSF) is a cytokine that causes the bone marrow
to make immune cells. GM-CSF is used to boost white blood cell counts after chemotherapy.

56. p53 based cancer therapy
Loss of p53 activity in tumors has spurred an enormous effort to develop new cancer treatments based on this
fact. The p53 gene therapy, Gendicine, is approved in China and its US counterpart, Advexin, has shown
activity in number of clinical trials.
Inactivation of p53 functions is an almost universal feature of human cancer cells. This has spurred a
tremendous effort to develop p53 based cancer therapies.
Gene therapy using wild-type p53, delivered by adenovirus vectors, is now in widespread use in China.
Other biologic approaches include the development of oncolytic viruses designed to replicate and kill only p53
defective cells and also the development of siRNA and antisense RNA's that activate p53 by inhibiting the
function of the negative regulators Mdm2, MdmX, and HPV E6.
The altered processing of p53 that occurs in tumor cells can elicit T-cell and B-cell responses to p53 that could
be effective in eliminating cancer cells and p53 based vaccines are now in clinical trial. A number of small
molecules that directly or indirectly activate the p53 response have also reached the clinic, of which the most
advanced are the p53 mdm2 interaction inhibitors. Increased understanding of the p53 response is also
allowing the development of powerful drug combinations that may increase the selectivity and safety of
chemotherapy, by selective protection of normal cells and tissues.

57. Nuclear Medicine
• Nuclear medicine is a way to diagnose and treat diseases using radioactive substances
• One of its most common uses it diagnosing and treating cancer
• It allows doctors to detect problems within the body without having to do invasive
surgery
• To diagnose, machines use properties of radioactive elements to create an image of
the body
• to treat Cancer doctors uses radiation

58. How Cancer is Detected by Nuclear Medicine
• Doctors give a patient radioisotopes by injection, inhalation, or orally
• The radioisotopes will spread and gather in certain parts of the body
• By using PET, SPECT, gamma cameras, bone scanners, an image of the body
can be created based on the properties of the radioactive element and
where it is gathering in the body
• These machines sense the gamma rays(energy) which are being given off

59. Common Radioisotopes Used to Detect Cancer
Type of Isotope What type of Cancer it Detects
Technetium-99 Brain Tumors
Iodine-131 Thyroid Cancer
Phosphorus-32 Skin Cancer
Holmium-166 Liver Cancer
Gallium-68 Pancreatic Cancer

60. Treating Cancer
• Once the cancer has been found it is treated using radiation
• The radiation damages the cancer cells when it gives of large amounts of
energy
• Radiation is not harmful to the patient because
• The radioisotopes used have a short half life, so the patient is not affected for very long
• It is minimally invasive
• Healthy cells are less affected by the radiation then the cancer cells are
• Radioisotopes damages rapidly dividing cancer cells because they are
sensitive to and easily damaged by radiation

61. Different Types of Radiation
• Skin Cancer is treated using External Beam Radiation Therapy (Teletherapy)
• This type of radiation uses low energy radiation and focuses it on the cancer
• The machines used areorthovoltage x-ray machines, Cobalt-60 machines, linear accelerators,
proton beam machines, and neutron beam machines
• Cancers in the eye, head, neck, and uterus are treated using Internal Radiation Therapy
(Brachytherapy)
• In Brachytherapy radiation is placed close to the cancer in a seed, wire, or rod
• This can be used with Teletherapy to give an extra boost of radiation to the large mass of
cancer cells

62. During Cancer Treatment
• During treatment doctors use machines like gamma cameras to make
sure the cancer is regressing
• Radioactive tracers like Copper-64, Iodine-124, and Flourine-18 are
used to trace the cancer
• During these procedures the size and shape of the cancer can be
determined
• If the cancer is not regressing doctors know that they must try a
different type of radiation

63. Disadvantages of using Nuclear Medicine
• Healthy cells that reproduce rapidly, like hair, can be killed during
radiation. This causes hair to fall out.
• It is very expensive.
• The radioisotopes can be dangerous to handle and dispose of.
• The procedures must be fast because the radioisotopes have a short half
life.
• Pregnant women can not be treated.
• Allergic reactions can occur.
• Radiation can not treat all cancers because sometimes it needs to be
combined with surgery or chemotherapy.

64. Common Radioisotopes in Treating Cancer
Radioisotope Cancer Used to Treat
Techtinium-99 Liver disorders, brain
tumors
Holomium-166 Liver Tumors
Iodine-131 Thyroid Cancer
Cesium-137, and Cobalt-60 are used to destroy other types of
cancer

65. Chaperon inhibitor
Molecular chaperone or heat shock proteins (HSP) are vital proteins that increase cell survival by
allowing it to combat stress caused by injurious stimuli through certain cyto-protective
mechanisms. These cytoprotective mechanisms of molecular chaperones, especially HSP 90, have
a negative effect designated to favor tumor growth and metastasis among breast cancer, leukemia,
pancreatic and ovarian cancer.
Stabilization of the structure of important agents in malignant transformation, such as kinases (Src
and Met-tyrosine kinases) and transcription factors (e.g., hypoxia inducible factor, HIF1) allows
molecular chaperones to stimulate angiogenesis by promoting endothelial cell proliferation and
permitting growth of cancer beyond the oxygen capacity of tissue diffusion.
Molecular chaperones disrupt the programmed cell death pathway (apoptosis) by inducing mutant
forms of tumor growth suppressors and DNA repair proteins (p53 and MSH2).
New multi-target antineoplastic drugs like Geldanamycin, purine scaffold inhibitors, and
Radicicol have been developed to oppose all such activity of molecular chaperones.

66. The new therapeutic agents or Heat Shock Protein inhibitors function by blocking the
intrinsic ATPase activity of molecular chaperones allowing oncogenic proteins (Raf-1,
Akt/PKB, ErbB2, Cdk4, Polo-1, Met) to be targeted by the ubiquitin proteasome pathway
due to no chaperone protection.
An example is the positive result of the phase II clinical trial of HER2 positive breast
cancer being treated by Hsp90 inhibitor 17-AAG followed with Trastuzumab.
Although directed towards distinct molecular targets, HSF inhibitors also inhibit other
multiple cancer promoting signaling pathways, increasing the efficacy in treatment.
Synergistically usage of these new molecular chaperone inhibitors with standard
chemotherapeutic drugs had positive results of tumor cell apoptosis and significant
regression in treatment of leukemia and breast cancer respectively.

67. Despite effective results in phase 1 of clinical trials, HSP inhibitors cause reduction in
stress-adaptive responses of normal cells leading to apoptosis.
However, greater affinity of HSP inhibitors towards tumoral chaperones specifically, is a
reason that many clinical trials have not reported this side effect, for example 17AAG has
100 times greater affinity for tumoral versus normal cell HSP90.
Although still in phase 2 of clinical trial, the development of HSP inhibitors provides an
exciting alternative for molecular-based therapy in cancer.
HSP inhibitors like Gantespib, have shown a more promising future with a broader
spectrum against various malignancies and better safety advantages in comparison to first
and second generations HSP inhibitors.
Overall the advanced mechanism-based use of HSP inhibitors, both alone and in
combination with other drugs, should help in the improvement of treatment of multiple
forms of cancer in the future with minimal side effects.

68. mTOR inhibitors are a class of drugs that inhibit the mammalian target of rapamycin
(mTOR), which is a serine/threonine-specific protein kinase that belongs to the family of
phosphatidylinositol-3 kinase (PI3K) related kinases (PIKKs).
mTOR regulates cellular metabolism, growth, and proliferation by forming and signaling
through two protein complexes, mTORC1 and mTORC2.
The most established mTOR inhibitors are so-called rapalogs (rapamycin and its analogs),
which have shown tumor responses in clinical trials against various tumor types.
mTOR inhibitors

69. mTOR signaling pathway in human cancer
Many human tumors occur because of dysregulation of mTOR signaling, and can confer higher susceptibility to
inhibitors of mTOR.
Deregulations of multiple elements of the mTOR pathway, like PI3K amplification/mutation, PTEN loss of
function, AKT overexpression, and S6K1, 4EBP1, and eIF4E overexpression have been related to many types
of cancers.
Therefore, mTOR is an interesting therapeutic target for treating multiple cancers, both the mTOR inhibitors
themselves or in combination with inhibitors of other pathways.
Upstream, PI3K/AKT signalling is deregulated through a variety of mechanisms, including overexpression or
activation of growth factor receptors, such as HER-2 (human epidermal growth factor receptor 2) and IGFR
(insulin-like growth factor receptor), mutations in PI3K and mutations/amplifications of AKT.
Downstream, the mTOR effectors S6 kinase 1 (S6K1), eukaryotic initiation factor 4E-binding protein 1 (4EBP1)
and eukaryotic initiation factor 4E (eIF4E) are related to cellular transformation.
S6K1 is a key regulator of cell growth and also phosphorylates other important targets. Both eIF4E and S6K1
are included in cellular transformation and their overexpression has been linked to poor cancer prognosis.

70. The development of rapamycin as an anticancer agent began again in the 1990s with the
discovery of derivatives such as temsirolimus (CCI-779). This was a novel soluble
rapamycin derivative that had a favorable toxicological profile in animals.
More rapamycin derivatives with improved pharmacokinetics and reduced
immunosuppressive effects have since then been developed for the treatment of cancer.
These rapalogs include temsirolimus (CCI-779), everolimus (RAD001), and ridaforolimus
(AP-23573) which are being evaluated in cancer clinical trials.
Rapamycin analogs have similar therapeutic effects as rapamycin. However they have
improved hydrophilicity and can be used for oral and intravenous administration. In 2012
National Cancer Institute listed more than 200 clinical trials testing the anticancer activity
of rapalogs both as monotherapy or as a part of combination therapy for many cancer
types.
First generation mTOR inhibitors

71. Rapalogs, which are the first generation mTOR inhibitors, have proven effective in a
range of preclinical models. However, the success in clinical trials is limited to only a
few rare cancers. Animal and clinical studies show that rapalogs are primarily cytostatic,
and therefore effective as disease stabilizers rather than for regression. The response
rate in solid tumors where rapalogs have been used as a single-agent therapy have
been modest. Due to partial mTOR inhibition as mentioned before, rapalogs are not
sufficient for achieving a broad and robust anticancer effect, at least when used as
monotherapy.
Another reason for the limited success is that there is a feedback loop between
mTORC1 and AKT in certain tumor cells. It seems that mTORC1 inhibition by rapalogs
fails to repress a negative feedback loop that results in phosphorylation and activation
of AKT. These limitations have led to the development of the second generation of
mTOR inhibitors.

72. Second generation mTOR inhibitors
The second generation of mTOR inhibitors is known as ATP-competitive mTOR kinase inhibitors.
mTORC1/mTORC2 dual inhibitors are designed to compete with ATP in the catalytic site of mTOR.
They inhibit all of the kinase-dependent functions of mTORC1 and mTORC2 and therefore, block
the feedback activation of PI3K/AKT signaling, unlike rapalogs that only target mTORC1.
These types of inhibitors have been developed and several of them are being tested in clinical
trials. Like rapalogs, they decrease protein translation, attenuate cell cycle progression, and inhibit
angiogenesis in many cancer cell lines and also in human cancer. In fact they have been proven to
be more potent than rapalogs.
Theoretically, the most important advantages of these second generation mTOR inhibitors is the
considerable decrease of AKT phosphorylation on mTORC2 blockade and in addition to a better
inhibition on mTORC1.

73. However, some drawbacks exist.
Even though these compounds have been effective in rapamycin-insensitive cell lines, they
have only shown limited success in KRAS driven tumors. This suggests that combinational
therapy may be necessary for the treatment of these cancers.
Another drawback is also their potential toxicity. These facts have raised concerns about the
long term efficacy of these types of inhibitors.
The close interaction of mTOR with the PI3K pathway has also led to the development of
mTOR/PI3K dual inhibitors. The inhibition of the PI3K/mTOR pathway has been shown to potently
block proliferation by inducing G1 arrest in different tumor cell lines. Strong induction of apoptosis
and autophagy has also been seen. Despite good promising results, there are preclinical evidence
that some types of cancers may be insensitive to this dual inhibition. The dual PI3K/mTOR
inhibitors are also likely to have increased toxicity.