CARCINOGENS AND

CARCINOGENESIS
Dr. A. Kabir
Department of Human Pathology, Faculty of Basic Clinical
Sciences, College of Medical sciences, UNIMAID

1
Introduction
A Carcinogen is an environmental agent
participating in the causation of neoplasm.
Such agents are said to be carcinogenic.

Carcinogenesis is the process that results in the

transformation of normal cells to neoplastic cells
by causing permanent genetic changes.

It is useful to remember that 80 - 90% of all

cancers may be related to environmental agents
including diets, lifestyles, and viruses.

Several environmental agents often act together

(co-carcinogenesis).
2
Introduction cont’d
The first ever evidence of any cause for neoplasia
came from the observation of Sir Percival Pott in
1775 that there was higher incidence of scrotal
cancer in industrial chimney sweeps in London
than in the general population.

Japanese investigators (Yamagiva and Ichikawa)

experimentally produced skin cancers in rabbits
by using coal tar.
Subsequently, hundreds of chemical carcinogens
were discovered.

Alterations in DNA cause changes in one or both

of the following types of important genes:
Proto-oncogenes
Tumor suppressor genes
3
Classification of carcinogens
A. Chemical carcinogenesis

B. Biologic carcinogenesis

C. Radiation carcinogenesis

4
CHEMICAL CARCINOGENESIS
Many chemical carcinogens have now been
identified.

Chemical carcinogens may be classified into two

categories:
1. Direct-acting
2. Indirect-acting.

Direct acting agents act directly, requiring no

metabolic conversion.

Indirect-acting or procarcinogens require

metabolic conversion into active carcinogens
(ultimate carcinogens).

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Characteristics of Chemical
Carcinogens
1) Chemical carcinogens are of wide and diverse chemical
nature.

2 ) Both synthetic and naturally occurring chemicals can

produce cancer.

3 ) Carcinogenesis is dose dependent i.e. the higher the dose

the greater the risk.

4 ) There is long time lapse between exposure and tumour

occurrence.

5 ) The neoplastic transformation is a multi-step process.

6 ) Strong binding affinity to DNA, RNA and other cellular

proteins

6
Major Chemical Carcinogens
A. DIRECT-ACTING CARCINOGENS
 Alkylating Agents
a) Anti-cancer drugs (e.g. cyclophosphamide,
chlorambucil, busulfan, melphalan, nitrosourea etc)
b) -propiolactone
c) Dimethyl sulfate
d) Diepoxybutane

 Acylating Agents
a) Acetyl-imidazole
b) Dimethylcarbamyl chloride
Mechanism of actions of direct –
acting (alkylating) carcinogens
 They
are activation-independent, and in general,
weak carcinogens.

 Many
are of therapeutic importance (cancer
chemotherapeutic agents).

Alkylating agents contain electron-deficient atoms

that react with electron-rich atoms in DNA.

– Cancers produced: Solid and hematological

malignancies.
B. INDIRECT-ACTING CARCINOGENS
(PROCARCINOGENS)
i) Polycyclic aromatic hydrocarbons
(found in tobacco, smoke, fossil fuel, soot, tar,
minerals oil, smoked animal foods, industrial and
atmospheric pollutants).
Examples:
a) Anthracenes (benza-, dibenza-, dimethyl
benza-)
b) Benzo(a)pyrene
c) Methylcholanthrene
Indirect-acting Carcinogens cont’d
 ii)Aromatic Amines, Amides, Azo Dyes
a) -naphthylamine
b) Benzidine
c) Azo-dyes (e.g. butter yellow, scarlet red etc)

iii) Naturally-occurring products

a) Aflatoxin B1
b) Actinomycin D
c) Mitomycin C
d) Safrole
e) Betel nuts
Indirect-acting Carcinogens cont’d
iv) Miscellaneous
a) Nitrosamines and nitrosamides
b) Vinyl chloride
c) Asbestos
d) Arsenical compounds
e) Metals (e.g. nickel, lead, cobalt, chromium etc)
f ) Insecticides, fungicides (e.g. aldrin, dieldrin,
chlordane etc)
g) Saccharin and cyclomates
Mechanism of Actions of Indirect-
acting Carcinogens
Polycyclic Aromatic Hydrocarbons
 Represent some of the most potent carcinogens,
they require metabolic activation and induce tumors
in a variety of tissues and species.

They are metabolized by cytochrome P450-

dependent mixed function oxidases to electrophilic
dihydrodial epoxides.

 These epoxides are strongly electrophilic and

combine with nucleophilic sites in the targets cells,
including DNA, RNA and proteins.
Aromatic amines and azo dyes
They are indirect-acting carcinogens.

– Source:
◆ In the past, the aromatic amines (β-
naphthylamine) were used in the aniline dye and
rubber industries.
◆ Azo-dyes were used for coloring food.

– Mechanism of action:
◆ Both aromatic amines and azo dyes are mainly
metabolized in the liver.

– Cancers produced: Bladder cancer

(naphthylamine and benzidine) and liver tumors
(azo dyes).
Nitrosamines
They are potent carcinogens.

– Source:
Before the advent of refrigerator, nitrites were
added as a preservative for meats and other foods.

– Mechanism of action:
Nitrites react with amines and amides in the diet
and are metabolized by commensal bacteria
within the gut and converted to carcinogenic
nitrosamines.

– Cancers produced: Mainly gastrointestinal

neoplasms.
Stages In Chemical Carcinogenesis
The induction of cancer by chemical carcinogens occurs after
a delay, often several years in humans.

Other factors that influence the induction of cancer are the

dose and mode of administration of carcinogenic chemical,
individual susceptibility and various predisposing factors.

Chemical carcinogenesis occurs by induction of mutation in

the proto-oncogenes and anti-oncogenes.

The phenomena of cellular transformation by chemical

carcinogens is a progressive process involving sequential
stages:
Initiation
Promotion
Progression ⇢ Cancer
Initiation of Carcinogenesis
Initiation is the first stage in carcinogenesis
induced by initiator chemical carcinogens.

The change so induced is sudden, irreversible and

permanent.

The Chemical carcinogens acting as initiators of

carcinogenesis could be Direct-acting or Indirect-
acting carcinogens.
Promotion of Carcinogenesis
Promotion is the next sequential stage in the chemical
carcinogenesis.

Promoters are chemical agents that are not mutagenic,

but which instead stimulate cellular proliferation.

Promoters of carcinogenesis are substances such as

phorbol esters, phenols, hormones, artificial
sweeteners and drugs like phenobarbital.

Characteristics of Promoters:
i) They require application following initiator exposure,
for sufficient time and in sufficient dose.

ii) They do not produce sudden change.

Characteristics of Promoters cont’d
iii) The change induced may be reversible.

iv) They do not damage the DNA per se and are thus
not mutagenic but instead enhance the effect of direct
-acting carcinogens or procarcinogens.

v) Tumour promoters act by further clonal proliferation

and expansion of initiated (mutated) cells.

Progression: Continuous proliferation of initiated cells

leads to secondary genetic abnormalities.

Many accumulated mutations finally immortalize the

cells.
Scheme of events in chemical carcinogenesis
Multistage carcinogenesis
Common carcinogens and
associated cancers
 Beta naphthylamine[rubber industry]-bladder Ca
 Asbestos- mesothelioma
 Nitrosamine [salted food] -GIT cancer
 Benz pyrene[cigar]- Ca lung
 Aflatoxin B1 [promoter]- liver Ca
 Vinyl chloride- liver haemangiosarcoma
 Nickel, chromium-lung Ca
 Arsenic-skin cancer
 Occupation-related carcinogens

Carcinogen Type of cancer Occupation

Arsenic Lung, skin, liver Mining and pesticide workers

Asbsestos Lung, mesothelium Construction workers
Benzene Leukaemia Petroleum, rubber, chemical workers

Chromium Lung Metal, electroplaters

Leather dust Nasal, bladder Shoe manufacturing
Radon Lung Underground mining
Soots, tars, oils Lung, skin, liver Coal, gas workers
Vinyl chloride Liver Rubber, PVC manufacturing
Wood dusts Nasal Furniture manufacturing
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BIOLOGICAL CARCINOGENESIS
The epidemiological studies on different types of
cancers indicate the involvement of transmissible
biologic agents in their development, chiefly
viruses.

Other microbial agents implicated in

carcinogenesis are as follows:
Bacteria
Parasites
Fungus

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VIRAL CARCINOGENESIS
It has been estimated that 15% ― 20% of all
cancers worldwide are due to persistent virus
infection.

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HPV ONCOGENESIS
 . HPV was first detected as etiologic agent in common
skin warts or verruca vulgaris (squamous cell
papillomas).
 Current evidence supports the implication of low-risk
HPV types 1,2, 4 and 7 in common viral warts.

 . Low-risk HPV types 6 and 11 are involved in the

etiology of genital warts (condyloma acuminata).

 . Viral DNA of high-risk HPV types 16, 18, 31, 33 and 45

has been seen in 75-100% cases of invasive cervical
cancer and its precursor.

 . High-risk HPVs are also involved in causation of other

squamous cell carcinomas and dysplasias such as of
anus, perianal region, vagina, vulva, penis and oral cavity.

25
HPV ONCOGENESIS cont’d
 Persistent infection with high-risk HPV types in target
epithelial cells drives the molecular hallmarks of cancer
and directly affect cell growth by following mechanisms:

 i) HPV integrates into the host cell DNA which results in

overexpression of viral proteins E6 and E7 from high-risk
HPV types.

 E6 and E7 from high-risk HPVs have high affinity for

target host cells than these viral oncoproteins from low-
risk HPVs.

 ii) E6 and E7 viral proteins cause loss of p53 and pRB,

the two cell proteins with tumour-suppressor properties.
 Thus the brakes in cell proliferation are removed,
permitting the uncontrolled proliferation.

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HPV ONCOGENESIS cont’d
 iii) These viral proteins also activate cyclins A, D
and E, and inactivate CDKIs, thus permitting
further cell proliferation.

 iv) They mediate and degrade BAX, a proapoptotic

gene, thus inhibiting apoptosis.

 v) They also activate telomerase, thereby

immortalising the transformed host target cells.

 Combined action of E6 and E7 induces genomic

instability.

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Transforming effects of HPV E6 and E7 proteins.

28
Mode of action of HPV proteins E6
and E7 on the cell cycle

29
EBV ONCOGENESIS
EBV is a human herpesvirus, which infects B
lymphocytes.

Patients may manifest as a short-lived infectious

mononucleosis or develop few human cancers.

The list of cancers produced includes:

 1. African form of Burkitt lymphoma.
 2. B-cell lymphomas in immunosuppressed.
 3. A subset of Hodgkin lymphoma.
 4. Nasopharyngeal carcinoma.
 5. Rare forms of T cell lymphomas and natural
killer (NK) cell lymphomas. 30
Pathogenesis
EB virus infects B lymphocytes by binding to the membrane
receptor CD21 (CR2).

The infection of B cells may be either productive (lytic) or

latent.

Productive/lytic infection:
It develops only in a few patients and results in death of
infected cells →release of virions → infection of other B cells.

Latent infection:
It occurs in majority of the cases.

The virus becomes latent inside the B cells and are

transformed or “immortalized” so that they are capable of
proliferation indefinitely.
Molecular basis of B-cell immortalization is related to two EBV
-coded genes: LMP1 (latent membrane protein 1) and EBNA2
(Epstein-Barr nuclear antigens 2).

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Pathogenesis of EBV infection

32
Possible evolution of EBV-induced Burkitt lymphoma

33
Nasopharyngeal carcinoma
o This tumor is endemic in South-East Asia, especially in
southern China, in some parts of Africa and in Eskimos.

o Almost 100% of nasopharyngeal carcinomas obtained from all

parts of the world contain EBV.

o The uniform association of EBV with nasopharyngeal

carcinoma suggests that EBV has a central role in the genesis
of the tumor, but genetic susceptibility and environmental
cofactors also contribute to tumor development.

o LMP-1 is expressed in nasopharyngeal carcinoma cells and, as

in B cells, activates the NF-κB pathway.

o NF-κB in turn upregulates the expression of factors such as

VEGF, FGF-2 that may contribute to oncogenesis.

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Hepatitis B and C Viruses
Epidemiologic studies have established a strong
link between primary hepatocellular carcinoma
and chronic infection with HBV and HCV.

It is estimated that 70% to 85% of hepatocellular

carcinomas worldwide are caused by infection
with hepatitis B virus (HBV) or hepatitis C virus
(HCV).

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Hepatitis Virus Oncogenesis in Liver
Cancer
i) Chronic and persistent viral infection with HBV or
HCV incites repetitive cycles of inflammation,
immune response, cell degeneration/cell death, and
regeneration of the hepatocytes which leads to DNA
damage of host liver cells.

ii. On regeneration, proliferation of hepatocytes is

stimulated by several growth factors and cytokines
elaborated by activated immune cells which
contribute to tumour development e.g. factors for
angiogenesis, cell survival etc.

36
Hepatitis Virus Oncogenesis in Liver
Cancer cont’d
iii) The activated immune cells also produce other
mediators, such as reactive oxygen species, that are
genotoxic and mutagenic.

iv) Activated immune cells produce nuclear factor kB

(NF-kB) that inhibits apoptosis, thus allowing cell
survival and growth.

v) HBV genome contains a gene HBx which activates

growth signaling pathway, inactivation of p53

In addition, viral integration can cause structural

changes in chromosomes that dysregulate oncogenes
and tumor suppressor genes.

HCV genome, such as the HCV core protein, may

activate many growth-promoting signal transduction
pathways and causes tumor. 37
HUMAN HERPESVIRUS 8 (HHV-8)
It has been shown that infection with HHV-8 or
Kaposi sarcoma-associated herpesvirus (KSHV) is
associated with Kaposi sarcoma, a vascular
neoplasm common in patients of AIDS.

The tumor that was originally described in elderly

eastern European men and later observed in sub-
Saharan Africa.

HHV-8 has lymphotropism and is also implicated

in causation of pleural effusion lymphoma and
multicentric variant of Castleman disease.

38
HUMAN HERPESVIRUS 8 (HHV-8)
Like other DNA viruses, the HHV8 viral genome
encodes proteins that interfere with the p53 and
Rb tumor suppressor pathways.

Some viral proteins also inhibit apoptosis and act

in multiple ways to accelerate cell cycle transit.

HHV8 encodes an inhibitor of the normal regulator

of NFκB (i.e., IκB).

As a result, HHV8 infection is associated with

unrestrained activation of NFκB leading to
development and progression of Kaposi sarcoma.

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HUMAN T-CELL LYMPHOTROPIC
VIRUSES (HTLV)
HTLV is an RNA slow-transforming retrovirus.

A link between HTLV-1 infection and cutaneous adult T-cell

leukaemia-lymphoma (ATLL) has been identified, while HTLV-2
is implicated in causation of T-cell variant of hairy cell
leukaemia.

Adult T-cell leukemia/lymphoma (ATLL) is endemic in certain

parts of Japan, the Caribbean basin, South America, and Africa,
and found sporadically elsewhere, including the United States.

The etiologic agent, HTLV-I, is tropic for CD4+ T lymphocytes

and has also been incriminated in the pathogenesis of a
number of neurologic disorders.

It is estimated that leukemia develops in 3%–5% of people

infected with HTLV-I after a latency period of 30–50 years.

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HTLV-1 ONCOGENESIS IN ATLL
 i) HTLV-1 genome has unique region called pX, which encodes an
essential viral oncoprotein— TAX.

 TAX protein up-regulates the expression of cellular genes

controlling T-cell replication.

 ii) TAX viral protein stimulates genes for cytokines (IL-2) and
their receptors in infected T cells which activates proliferation of
T cells by autocrine pathway.
 Macrophage is also stimulated by infected T cells to cause their
proliferation in a paracrine pathway.

 iii) The inappropriate gene expression activates pathway of the

cell proliferation by activation of cyclins and downregulation of
tumour suppressor genes CDKN2A/p16 and p53, thereby
stimulating cell cycle.

 iv) Initially, proliferation of infected T cells is polyclonal but

subsequently several mutations appear due to TAX-based
genomic instability in the host cell, and monoclonal proliferation
of leukaemia occurs.
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Pathogenesis of human T-cell leukemia

42
Viruses and human tumours

43
Bacteria
Helicobacter Pylori
Helicobacter pylori, a gram-positive spiral-shaped
bacterium, colonises the gastric mucosa and has been
found in cases of chronic gastritis and peptic ulcer.

It is now strongly implicated in the pathogenesis of

gastric lymphoma and gastric adenocarcinoma;

The development of gastric adenocarcinoma is similar

to that of HBV- and HCV-induced liver cancer, as it
involves increased epithelial cell proliferation in a
background of chronic inflammation.
■ H. pylori pathogenicity genes, such as CagA
(Cytotoxin –Associated A) also contributes by
stimulating unregulated growth factor pathways.

Chronic gastritis > Gastric atrophy >intestinal

metaplasia >dysplasia and ultimate cancer.
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Gastric lymphoma

Gastric lymphoma is a type of lymphoma called

lymphomas of mucosa-associated lymphoid tissue,
or MALTomas.

The pathogenesis seems to involve strain-specific H.

pylori factors, as well as host genetic factors.

Chronic H. pylori infection leads to polyclonal B-cell

proliferations that may give rise to a gastric
monoclonal B-cell tumor (MALT lymphoma) as a
result of accumulation of mutations.

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Parasites
There is good evidence, both epidemiological and
direct, to implicate certain parasites in the
aetiopathogenesis of some cancers.

Schistosoma haematobium with bladder cancer

formation (notably in Egypt).
 Inflammation triggered by the worm's eggs appears to
be the mechanism by which squamous cell carcinoma
of the bladder is caused.
 Chronic inflammation > metaplasia > dysplasia >
neoplasia.

The liver flukes Opisthorchis viverrini and Clonorchis

sinensis, which dwell in the bile ducts are associated
with cholangiocarcinoma particularly in the Far East
Asia and other fluke-infested areas.
46
Fungus
Mycotoxins are toxic substances produced by
fungi.

Those having the greatest relevance in human

carcinogenesis are the aflatoxins produced by
Aspergillus flavus.

Aspergillus flavus grows in contaminated stored

peanuts and grains and liberates aflatoxin
(aflatoxin B1).

Human consumption, especially by those with

HBV infection, is associated with development of
hepatocellular carcinoma in parts of Africa and
Asia. 47
RADIATION CARCINOGENESIS
Radiant energy, in the form of the Ultraviolet (UV) rays of sunlight or as
ionizing electromagnetic and particulate radiation, is carcinogenic

ULTRAVIOLET RAYS
The main source of UV radiation is the sunlight; others are UV lamps
and welder’s arcs.

In humans, excessive exposure to UV rays can cause various forms of

skin cancers—squamous cell carcinoma, basal cell carcinoma and
melanoma.

The degree of risk depends on the type of UV rays, the intensity of

exposure, and the quantity of the light-absorbing “protective mantle” of
melanin in the skin.

High incidence of these skin cancers occur in fair-skinned Europeans,

albinos who do not tan readily, and inhabitants of Australia and New
Zealand living close to the equator who receive more sunlight,
Mechanism of UV rays Carcinogenesis
The UV portion of the solar spectrum with wavelength range of
280-320 nm (UVB), is believed to be responsible for the
induction of cutaneous cancers.

The carcinogenicity of UVB light is due to formation of

pyrimidine dimers in DNA.

This is due to covalent crosslinking of pyrimidine bases,

particularly adjacent thymidine residues in the same strand of
DNA.

This distorts the DNA helix and prevents proper pairing of the
dimer with bases in the opposite DNA strand.

Such UV-induced DNA damage in normal individuals is repaired,

while in the predisposed persons who are excessively exposed
to sunlight such damage remain unrepaired.
UV rays Carcinogenesis cont’d
The following recessive hereditary diseases are
characterised by a defect in DNA repair
mechanism and are associated with high
incidence of cancers:
 i) Xeroderma pigmentosum
 ii) Ataxia telangiectasia
 iii) Bloom syndrome
 iv) Fanconi anaemia
Ionizing Radiation
Electromagnetic (x-rays, γ rays) and particulate (α
particles, β particles, protons, neutrons) radiations are
all carcinogenic.

Most frequently, radiation-induced cancers are

leukaemias;
others are cancers of the skin, thyroid, breast, ovary,
uterus, lung, myeloma, and salivary glands.

The evidence in support of carcinogenic role of

ionising radiation is cited in the following examples:

i) Higher incidence of radiation dermatitis and

subsequent malignant tumours of the skin was noted
in X-ray workers and radiotherapists who did initial
pioneering work in these fields before the advent of
safety measures.
Evidence in support of carcinogenic role of
ionising radiation:
ii) Miners in radioactive elements have higher incidence of cancers.

iii) Japanese atom bomb survivors of the twin cities of Hiroshima

and Nagasaki after World War II have increased frequency of
malignant tumours, notably acute and chronic myeloid leukaemias,
and various solid tumours of breast, colon, thyroid and lung.

iv) Accidental leakage at nuclear power plant in 1986 in Chernobyl

(in Ukraine) has caused long-term hazardous effects of radioactive
material to the population living in the vicinity.

v) It has been observed that therapeutic irradiation results in

increased frequency of cancers, e.g. in patients of ankylosing
spondylitis and in children exposed to radiation in utero during
investigations on the mother.

vi) Thorotrast, a thorium-containing contrast medium, used to be

employed in radioimaging. These patients were found to have about
twice higher incidence of malignant tumours.
Mechanism of ionising radiation
Radiation damages the DNA of the cell by one of the 2
possible mechanisms:

i) It may directly alter the cellular DNA.

ii) It may dislodge ions from water and other molecules of the
cell and result in formation of highly reactive free radicals that
may bring about the damage.

Damage to the DNA resulting in mutagenesis is the most

important action of ionising radiation.

It may cause chromosomal breakage, translocation, or point

mutation.

The effect depends upon a number of factors such as type of

radiation, dose, dose-rate, frequency and various host factors
such as age, individual susceptibility, immune competence,
hormonal influences and type of cells irradiated.
55