Exam 3 Week 2

Question 1

1. Identify the virus structure of Influenza virus?

• family
• stranded ness
• nuclei acid
• sense/polarity
• capsid type
• envelop or not

2. What are the respective hosts of the various influenza types?
   * which type is linked to pandemics and why?

Answer 1

1. Orthomyxoviridae - Influenza type A, B, C

A. Ss RNA; negative sense (-) RNA. Segmented. Type A and B has 8 segments and type C has 6 segments
B. Helical nucleocapsid; composed of RNA + NP, PB1, PB2, PA
C. Envelope contains 2 glycoproteins - H and N
D. 9 structural + 2 non structural proteins (NS); the 9 are H, N, PB1, PB1-F2, PB2, PA, M1, M2, NP

**Remember every helical nucleocapsid must have an envelope

2. Hosts 
Type A - human, swine, avine, equine
Type B - human only 
Type C - human only 
**Type A is linked to pandemics because of antigenic SHIFT - major mutation due to mix of human and animal resortment

Question 2

What factors limit effectiveness of an influenza vaccine

Answer 2

1. Antigenic drift ; H and N varies anitgenically due to point mutation

• antigenic drift leads to epidemics; existing ab in human
  population from previous infections by influenza virus may
  not efficiently neutralize virus.

**You make vaccine based on prediction of what strains of type A would be in the environment

Question 3

What relationship do specific structural components of the intact influenza virion have to the pathogenesis of the disease? (3)

Answer 3

Antigens (influenza virus)

1. Nucleocapsid and “M” protein
2. Hemagglutinin antigen; detected by hemagglutination, neutralization and C-fixation
3. H and N are both strain specific Antigens; influenza type A, Hong Kong strain

**H and N are major antigens. H is most important antigen

Question 4

Describe the process of the following in influenza virus

1. Replication
2. Viral transcription/ Viral protein translation
3. Viral genome replication

Answer 4

1. Replication (nucleus)
   - attach virus particle to cell surface receptor
   - Hemagglutinin of virus binds to sialic acid containing receptors.
   - Hemagglutinin initiate fusion between the virus envelop and the vacuole membrane
2. Viral transcription/ viral protein translation
   - Transcription (nucleus); (-) RNA serve as template for (+) RNA **diagram. Primer for RNA dependnet RNA polymerase (PB2PB1PA) is m7g (cap structure)
   - Translation (cytoplasm always); MP protein and other proteins come together and form the structural proteins
3. Viral genome replication
   - Production of new viral genome; RNA polymerase copy (-) RNA to (+) RNA. A negative RNA with multiple (+) RNA is called REPLICATIVE INTERMEDIATE
   - newly synthesized viral genomic RNAs then transported out of nucleus to the cytoplasm

Question 5

1. What factors are involved in the genetic variation exhibited by the influenza A virus?
2. What is the clinical significance of this genetic variation?

Answer 5

1. Antigenic shift
   - Pandemic (world wide infection spread); due to antigenic shift. Human virus has hemagglutinin from pig.
   - H major antigenic variation due to reassortment between
   human and animal influenza virus- “ antigenic shift” -
   responsible for pandemic which occur about every 10
   years, exchange RNA segments between animal influenza
   virus and human influenza virus; N protein antigenicity
   can also be changed as a result of reassortment of the N
   gene.
2. As a result of shift, presentation of entirely new
   antigens to population with no immunity - yields acute
   respiratory disease, no neutralization of virus by pre-
   existing antibodies

Question 6

1. What structural components of the influenza virion are involved in inducing protective immunity of the infected host?
2. Role of secretory IgA in resolving/modifying influenza infections

Answer 6

1. A. Major antigen for immunity = H, 11 H subtypes change in H
   affects antigenicity most, additive effect if N also
   changes

B. N antigenicity is also important, 8 N subtypes. 2 functions of Neuroaminidase;

• important in budding (viral release) of progeny virus
• lowers viscosity of mucus in vivo during infections

2. B. H & N varies antigenically due to point mutation -
   “antigenic drift”

C. antigenic drift leads to epidemics; existing ab in human
population from previous infections by influenza virus may
not efficiently neutralize virus.

*** “Antigenic Sin”: with each new infection with influenza A
an individual responds with the strongest antibody against
the 1st subtype, which infected that individual

Question 7

1. Describe general classification of retrovirus

Answer 7

1. A. Ss RNA ; diploid 35S genome joined by tRNA
   B. Complex capsid; helical nucleocapsid (house reverse transcriptase) with icosahedral/cylindrical outer shell
   C. Envelop

**RNA dependent - DNA polymerase is the reverse transcriptase

Question 8

Describe structure of retrovirus

1. Enzymatic complex
2. Envelope
3. RNA genome content ; chronic leukemia vs acute leukemia/sarcoma

Answer 8

1. Enzymatic complex
   - RNA dependent - DNA polymerase (reverse transcriptase)
   - DNA polymerase and RNAse
   - H and integrate; encoded by pol gene
   - PRO gene encodes protease. Either part of pol or adjacent to it
2. Envelope; cell membrane derived via building
   - 3 envelope proteins (ENV)
   - 4 internal capsid proteins (GAG gene)
3. RNA Genome = GAG - Pol - Env - ONC (+-)
   I) chronic leukemia; lack onco gene
   II) Acute leukemia/sarcoma; have oncogene but no envelop. ***exception is Ross sarcoma which has full complement of genes
   ** HIV ; GAG - Pol - ENV plus other encoding region

Question 9

Short description of major retroviridae

• subfamily

Answer 9

• Retrovirus is the family that has subfamily;

i) oncovirinae - tumor virus
II) lentivirinae - slow virus (AIDS)
iii) spumavirinae - non oncogenic and looks like soap sods (foamy virus or syncytial virus)

** Oncornavirinae classified as type B, C, D based on host range, antigenicity, virus morphology (location of core relative to virus structure)

Question 10

Role of RNA-dependent DNA polymerase (reverse

transcriptase)and other viral enzymes in viral replication.

Answer 10

• Replication; occur both in cytoplasm and nucleus. (+) RNA to (-) DNA to (+-) DNA - provirus - integrate integrate provirus into cellular DNA. There is an LTR (long terminal repeat) structure at the ends of the provirus - formed during transition from RNA to DNA. LTR has regulatory regions (TATA enhancers) within it. DNA dependent DNA polymerase converts ssDNA to DsDNA (provirus)

• 35s mRNA - GAG or GAGpol polyprotein
• 28s Env polyprotein (has to be proteolytically cleaved)
• 21s ONC protein (acute leukemia/sarcoma virus)

Question 11

Describe process of replication of retrovirus

A. Location
B. General scheme
C. Provirus formation

***describe integration process

Answer 11

Replication
A. Cytoplasm + nucleus

B. General scheme= (+) RNA to (-) DNA to (+-) DNA - provirus
—> integration provirus DNA at many sites within chromosomal DNA; Provirus integration is INTEGRASE MEDIATED

C. Provirus formation takes place in cytoplasm which is then
transported to the nucleus where integration occurs

D. the conversion of genomic RNA to proviral DNA produces a
long terminal repeat (LTRs) which are located at each end of the provirus; LTR has regulatory regions within it

Question 12

Retrovirus

1. Transcription results
2. Translation

Answer 12

1. Transcription from provirus yield two or three mRNAs
   - 35s mRNA
   - 28s mRNA
   - 21s mRNA
2. Translation fo mRNAs
   - 35s mRNA GAG or GAG -Pol polyprotein; Gag mRNA
   predominates
   - 28s Env polyprotein; polyprotein proteolytically cleaved
   into smaller proteins
   - 21s ONC protein; present in acute leukemia/ sarcoma virus
   - Proteolytic cleavage of polyprotein precursors to yield
   actual viral proteins, viral proteases encoded by PRO gene involved in specific cleavage

Question 13

DNA evidence RNA tumor virus

Answer 13

Unlike DNA tumor viruses, which transform cells or cause a lytic infection with virus production, retroviruses can transform cells and produce progeny virus, Also cause tumors in vivo

Question 14

Avian subgroup of retrovirus

Differentiate between chronic leukemia and acute leukemia - sarcoma

Answer 14

A. Chronic leukemia virus;

• In vitro - no transformation (no onco gene).
• In vivo - leukemia in animals after long latent period (activate protooncogenes in the cell).
• No defective envelop

B. Acute leukemia - sarcoma;
- In vitro - transform cells but no virus is produced (SRC/oncogene present). **Rous sarcoma virus is the exception in that it produce virus
- In vivo - cause sarcoma.
- Usually defective (no envelope) so need helper virus
that will supply the missing envelope for replication

Question 15

Retrovirus
1. Differentiate protooncogenes vs oncogene

2. Identify modes of protooncogens (4)

Answer 15

1. A. Oncogenes; found in different species. v- onc (viral oncogene)

B. Protooncogenes are also called c - onc and they serve a purpose (normal cell genes)
• C- onc (protooncogenes); find equivalence in v- onc (viral oncogene). **They come together and can form point mutations overtime.

3. Modes of protooncogenes activation; normally repressor gene keep then in check.
   I) mutation in repressor gene (caused by chemical carcinogen); protooncogene no longer repressed

II) insert leukemia provirus right next to protooncogene. LTR of leukemia virus “turns on” expression of protooncogenes or endogenous virus

III) translocation of c onc (protooncogene)from normal position of chromosome to position on another chromosome. Place protooncogene under influence of an enhancer or promoter which activates transcription of protooncogenes e.g burkitt lymphoma myc translocated to position under control of Ig enhancer

IV) Sarcoma or acute leukemia introduce provirus (oncogene) into cell DNA , this will “overdose” the cell with the oncogene protein. Some oncogene products may appear as fused proteisn e.g gag -myc

Question 16

Retrovirus

1. Functions of transforming proteins encoded by protooncogene - diverse

Answer 16

1. most are kinases that can phosphorylate a lot of other enzymes.

Question 17

Retrovirus

Give examples of antioncogenes

Answer 17

1. RETINOBLASTOMA gene(Wilms tumor) ; born with one allele mutation and later develop second allele mutation.
   - Normally Rb protein is phosphorylated-dephosphorylated
   during cell cycle
   - Alterations of Rb protein may alter its interaction with
   controls of the cell cycle
2. DNA tumor virus (Adenovirus)
   - Products of DNA tumor viruses, eg. EIA of adeno, or E7 of HPV-16, bind to Rb protein which may in turn alter the
   control of the cell cycle

** So far retinoblastomas, Wilm’s tumors, colorectal cancers,
lung cancers and breast cancers require loss or mutation of suppressor genes in their development

Question 18

Identify the following and Identify 3 components

• oxygenated products of poly unsaturated long-chain FA. Eikosi is Greek for 20. 20 carbon FA precursors

**Give examples of a potent vasoconstrictor vs a relatively inactive one

**identify activity of prostaglandin types from most to least

Answer 18

1. Eicosanoids
   - prostaglandins (PGs); PGD2, PGE2, PGF2alpha, PGI2
   - leukotrienes (LTs); LTC4, LTD4, LTE4
   - thromboxanes (TXs); TXA2

• TXA2 is a vasoconstrictor (platelet aggregator).
- TXA3 is relatively inactive

• *Eicosanoids are derived from FA precursors that are esterified to membrane phospholipid such as;
• Dihomo-y-linolenic acid
• Arachidonic acid
• eicosapentaenoic acid

**Activity of prostaglandin PGI2 > PGI1 and PGI3

Question 19

What is the most abundant and most important precursor of Eicosanoids

• synthesized from?
• how many C? Double bonds?
• what enzyme release this product from complex phospholipids (what 2 pathways)
• half life?

Answer 19

ARACHIDONIC ACID; made in liver from linoleic acid (essential FA)

• Linoleic acid is derived from dietary constituents - vegetable oil (sunflower oil)
• Arachidonic acid = Eicosa
• 20 C and 4 double bonds
• PHOSPHOLIPASE release arachdonic acid from complex phospholipids in different ways (diagram slide) - linear (Lipoxygenase and PGH synthase COX 1 and 2) vs cyclic pathways (PGH synthase, epoxygenase - CYP, free radicals)

• A lot of these prostaglandins have VERY SHORT HALF LIFE.

Question 20

1. Describe the cyclooxygenase (Prostaglandin G/H synthase) pathway
2. Describe 2 options for metabolism

Answer 20

1. Cyclooxygenase pathway aka prostaglandin G/H synthase;
   - from Arachidonic acid; form PGG2 (C15 hydroperoxide) and
   - PGH2 (C15 hydroxyl group)
   * which are both UNSTABLE. The number comes from original/substrate fatty acid (2 - arachnidonic acid)

**PGH2 - PGE2 (PGE synthetase), PGD2, PGI2, TXA2
2. Metabolism
(i) Hydration or
(ii) Oxidation of the15-hydroxyl gp to ketone
by prostaglandin 15-OH dehydrogenase, followed by Δ13 reduction, beta-oxidation and ω-oxidation

Question 21

1. Identify product of cyclooxygenase
   - 3 types
   - half life
   - receptor?
   - major effects? (4)
   - other targets

Answer 21

1. PROSTANOIDS
   A. prostacyclin, prostaglandins and thromboxanes.

B. Short half life. (Paracrine or autocirne)

C. cell surface receptors GPCR - activate G proteins; increase cAMP and decrease intracellular calcium. EP2, EP4, IP, DP or EPI, FP, TP - increase intracellular calcium

D. Major effects is on 4 types of smooth muscle

• vascular
• GI
• airway
• reproductive

E. Other targets; platelets, monocytes, kidneys, CNS, sensory nerve endings, endocrine organs, and the eye (this may probably involve smooth muscle)

Question 22

Differentiate COX 1 vs COX 2 vs COX 3

• location
• what inhibit COX 1 and COX 2 (2) - side effects
• what selectively inhibit COX 2
• what is major source of vascular Prostanoids

Answer 22

1. COX 1 (constitutive/ housekeeping - protect GI tract stomach mucusa from gastric acid by increasing stomach mucus)
   - found in endothelial cells, stomach and kidney
2. COX 2 (inducible); involved in inflammation. **COX 2 is major source of vascular prostanoids in endothelial cells
   - elevated by inflammation and cytokines (constitutively expressed in brain and kidney)
3. COX 3 ; new isoform

• Aspirin inhibit both COX1 and COX2
• 60% homologous between COX 1 and COX 2 but different functions
• NSAIDS/Aspirin (COX 1 and 2 inhibitors) adverse effect; GI ulcers/bleeding. Block acid production from parietal cell and also mucus production?
- New generation (Coxibs) inhibit COX-2 more selectively

Question 23

Identify 4 types of Prostanoids

Answer 23

1. PGI2 - prostacyclin
2. PGE2 - prostaglandin
3. TXA2 - Thromboxanes
4. PGF2a - Prostaglandin F2alpha

Question 24

Identify the effects of Prostacyclin - PGI2 on the following

1. Vascular
2. Airway
3. GI
4. Renal
5. Reproductive
6. Pain
7. Fever
8. Eye
9. Receptors

Answer 24

Prostacyclin - PGI2

1. Vascular; *INHIBITS PLATELET AGGREGATION by all agonist(thrombin, ADP, TXA2)
   - relax vascular smooth muscle
   - powerful vasodilator
2. Airway
   - relax respiratory smooth muscle
   - powerful bronchodilator
3. GI ; *INHIBITS GASTRIC ACID SECRETION, INCREASE MUCUS SECRETION
   - protects GI tract
4. Renal
   - increase GFR and renal blood flow
   - increase water and sodium excretion
   - stimulate renin release
5. Reproductive ;
   - relaxes uterine muscle
6. Pain; *INDUCES PAIN
7. Fever; N/A
8. Eye ; N/A
9. Receptors ; IP (Gs - increase cAMP)

Question 25

Identify the effects of Prostaglandin - PGE2 on the following

1. Vascular
2. Airway
3. GI
4. Renal
5. Reproductive
6. Pain
7. Fever
8. Eye
9. Receptors

Answer 25

• *prostaglandin (in high concentration) is basically like prostacyclin
  1. Vascular
• Vasodilator
• Enhances platelet aggregation (low conc)
• inhibit platelet aggregation (high conc)

2. Airway
   - powerful bronchodilator
3. GI; * INHIBIT GASTRIC ACID SECRETION, INCREASE MUCUS SECRETION
4. Renal
   - increase GFR and renal blood flow
   - increase water and sodium excretion
   - stimulate renin release
5. Reproductive **
   - contracts uterine smooth muscle (in low conc)
   - relaxes uterine smooth muscle (in high conc)
   - terminate pregnancy
   - causes dysmenorrhea (pain in menstruation)
6. Pain; INDUCES PAIN
7. Fever; INDUCES FEVER (DIRECT PYROGENS)
   - cytokines can stimulate PGE2 - fever
8. Eye : N/A
9. Receptors ; EP1-EP4 (Gs, Gq)

Question 26

Identify the effects of Thromboxanes - TXA2 on the following

1. Vascular
2. Airway
3. GI
4. Renal
5. Reproductive
6. Pain
7. Fever
8. Eye
9. Receptors

Answer 26

1. Vascular
   - SMC Mitogen
   - Potent vasoconstrictor
2. Airway; **MAJOR PRODUCT OF COX1
   - STIMULATES PLATELET AGGREGATION
   - AMPLIFIES SIGNAL OF THROMBIN AND ADP
3. GI
   - constricts airway smooth muscle
4. Renal
   - intra renal vasoconstriction result in decline in renal function
5. Reproductive
   - uterine muscle constriction
6. Pain
7. Fever
8. Eye
9. Receptors ; TP (Gq-PLC)

Question 27

Identify the effects of Prostaglandin F2alpha on the following

1. Vascular
2. Airway
3. GI
4. Renal
5. Reproductive
6. Pain
7. Fever
8. Eye
9. Receptors

Answer 27

1. Vascular ; vasoconstrictor
2. Airway ; constricts airway smooth muscle
3. GI
4. Renal
5. Reproductive
   - uterine muscle contraction
   - can terminate pregnancy
   - causes dysmenorrhea
6. Pain
7. Fever
8. Eye; ***DECREASES INTRAOCULAR PRESSURE (used in glaucoma)
9. Receptors ; FP (Gq-PLC)

Question 28

1. Which prostanoids inhibit platelet aggregation (2)
2. Which stimulate platelet aggregation (2)
3. Which act as vasoconstrictor (2)
4. Which act as vasodilator (2)

Answer 28

1. Inhibits platelet aggregation
   - Prostacyclin (PGI2)
   - Prostaglanding (high concentration)
2. Stimulates platelet aggregation
   - Thromboxanes (TXA2)
   - prostaglandin (low conc)
3. Vasoconstrictor
   - thromboxanes (potent)
   - PGF 2alpha
4. Vasodilator (vascular and airway)
   - prostacyclin (powerful)
   - prostaglandin - PGE2

Question 29

Identify Prostanoids

1. Inhibits gastric acid secretion, increases mucus secretion (2)
2. Increase GFR and renal blood flow, increase water and sodium excretion, stimulate renin release (2)
3. Intra-renal vasoconstriction resulting in decline in renal function
4. Terminate pregnancy and cause dysmenorrhea (2)
5. Relax uterine muscle (2)
6. Contract uterine muscle (3)

Answer 29

1. Inhibits gastric acid secretion, increases mucus secretion (2)
   - Prostacyclin (PGI2)
   - Prostaglandin (PGE2)
2. Increase GFR and renal blood flow, increase water and sodium excretion, stimulate renin release (2)
   - Prostacyclin (PGI2)
   - Prostaglandin (PGE2)
3. Intra-renal vasoconstriction resulting in decline in renal function
   - Thromboxanes (TXA2)
4. Terminate pregnancy and cause dysmenorrhea (2)
   - Prostaglandin
   - PGF2alpha
5. Relax uterine muscle (2)
   - Prostacyclin
   - Prostaglandin (high conc)
6. Contract uterine muscle (3)
   - Prostaglandin (low conc)
   - thromboxanes
   - PGF2alpha

Question 30

Identify Prostanoids

7. Induce pain (2)
8. Induce fever (direct pyrogens)
9. Decrease intraocular pressure

10. Identify receptor 
A. IP Gs increase cAMP 
B. EP1 -EP4 (Gs - Gq) 
C. TP (Gq-PLC) 
D. EP (Gq - PLC)

Answer 30

7. Induce pain (2)
   - prostacyclin
   - prostaglandin
8. Induce fever (direct pyrogens)
   - prostaglandin (cytokines can stimulate PGE2 - fever)
9. Decrease intraocular pressure
   - PGF2alpha

10. Identify receptor 
A. IP Gs increase cAMP; prostacyclin 
B. EP1 -EP4 (Gs - Gq); Prostaglandin 
C. TP (Gq-PLC); thromboxanes 
D. EP (Gq - PLC); PGF2alpha

Question 31

Identify prostaglandin derivative (1 of 3)

• Adjunct to NSAID therapy (200 mcg orally 4 times daily) to reduce ulcer formation in high risk patients (e.g. elderly and patients with concomitant debilitating disease)
  • Inhibits gastric acid secretion (increasing production of gastric
  mucus and mucosal secretion of bicarbonate)
  • Should be taken for the duration of the NSAID therapy
  • Contraindicated in pregnancy; May induce uterine contractions and induce labor

Answer 31

MISOPROSTOL (PGE1 analog, cytotec)

Question 32

Identify prostaglandin derivative (2/3)

2. • Ophthalmic preparation
   • Used for OPEN ANGLE GLAUCOMA to lower intraocular
   pressure; Increases aqueous humor outflow
3. • TEMPORARILY MAINTAINS PATENT DUCTUS arteriosus in
   newborns until surgery can be done,
   • Administer by IV infusion
   • Increase pulmonary blood flow (vasodilator), IMPROVES
   BLOOD OXYGENATION
   • Other uses: Erectile dysfunction

Answer 32

1. Latanoprost (PGF2 α analog, xalatan)
2. Alprostadil (PGE1, Prostin)
   - inhibit platelet aggregation

Question 33

1. Describe DA (ductus arteriosus)/ ligamentum arteriosum
2. 2 Prostanoids derivatives that keep DA open in fetus
3. What happens after birth for DA to close
4. Identify 2 disease states and treatment

Answer 33

1. In fetus DA carries blood from PA to the aorta (lungs are collapsed in fetus → pulmonary pressure > aorta)
2. PGE2/1 and PGI2 keep the DA open in fetus
3. After birth → ↓PGE2/1, PG I2 → DA closes
4. A. In some cyanotic heart diseases (TGV) ductus must be kept open:
   *Treatment - PGE1 “alprostadil” by continuous venous infusion (keep ductus open)

B. DA not closed
*Treatment - Indomethacin (closes ductus arteriosus)

Question 34

1. Identify product of lipoxygenase
   - what is the precursor of this product
   - how many types?
2. Properties of first 2 lipoxygenase products

Answer 34

1. LEUKOTRIENES

• Arachdonic acid converted to leukotrienes by lipoxygenase pathway 
• 5 different lipoxygenase in humans 
- 5-HPETE 
- Leukotrienes B4 (LTB4) 
- LTC4
- LTD4
- LTE4 

2. 5-HETE (5-HPETE) and Leukotriene B4 (LTB4)
   - Chemotactic agents for polymorphonuclear leukocytes,
   eosinophils and monocytes
   - LTB4 can also produce hyperalgesia
   - Human colonic epithelial cells synthesize LTB4. Patients with
   IBD contains substantial amounts of LTB4.

Question 35

Identify
- 3 chemoattractants for eosinophil that are very potent bronchoconstrictors (lipoxygenase products)

**3 major properties

Answer 35

CYSTEINYL LEUKOTRIENES

• LTC4 (LTA4 react with glutathione tripeptide glu-cys-gly)
• LTD4
• LTE4.
• Chemoattractant for eosinophils
• POTENT BRONCHOCONSTRICTORS (act principally on airway
  smooth muscle cells)
• INCREASE VASCULAR PERMEABILITY (1000 times more potent
  than histamine)
• COMPONENTS of SLOW REACTING SUBSTANCE of ANAPHYLAXIS; (SRS-A) that is secreted in asthma and anaphylaxis,

Question 36

Identify drugs that alter lipoxygenase (inhibit leukotrienes synthesis)

Answer 36

1. 4 current approaches to anti-leukotriene drug development 
A. Phospholipase A2 inhibitor 
B. FLAP inhibitor 
C. 5-LOX inhibitors *
D. Leukotriene receptor antagonist*

2. 5-lipoxygenase inhibitors ; Zileuton (Zyflo)
3. Competitive, leukotriene D4 receptor antagonist (Cys-LT1)
   - Zafirlukast (accolate)
   - montelukast (singular)

Question 37

Identify medication

• 5 LOX inhibitor
• no cysteinyl leukotrienes synthesis
  • monitor hepatic function - contraindicated in liver disease
  • Seldom used in US due to many drug interactions (theophylline etc)

Answer 37

ZILEUTIN - Zyflo

1) Inhibitor of 5-lipoxygenase (inhibits the synthesis of LTA4, B4, C4, D4 and E4)

2) Prophylaxis for asthma
• Adults and children age 12 or older
• Zileuton – 400-800 mg, 2-4 times daily

3) 4-5% of patients have elevated Hepatic transaminase (must MONITOR HEPATIC FUNCTION – levels 3 times above normal – is contraindicated)

4) Drug interactions of increased response for (Dec clearance)
• Theophylline (blood levels double)
• Warfarin
• Propranolol

5) Contraindicated in liver disease
6) Ergot alkaloids (Cafergot) contraindicated, (severe vomiting, vasospasms)
7) Because of safety issues, it is seldom used in USA

Question 38

Identify medication (2)

• leukotrienes receptor antagonist (competitive, reversible LTD4) receptor antagonist
• prophylactics not acute treatment of asthma
• alternative to low dose inhaled steroids

**which is better and why?

2. Identify all uses (5)

Answer 38

ZAFIRLUKAST/ACCOLATE and MONTELUKAST/SINGULAR
- Inhibit the leukotriene mediated effects on bronchoconstriction and vascular permeability

**Montelukast is better cause only side effect is headache and approved in children 1 year and older

**Zafirlukast age 5 and older; cause HA, pharyngitis, increased liver enzymes. Also drug interaction - inhibits CYP 3A4 and CYP2C9 and with warfarin

Uses
- Competitive, reversible LTD4 (cysteinyl Leukotriene 1, Cys-
LT1) receptor antagonist
- Prophylactic treatment for asthma (not for acute asthma)
- Exercise induced bronchoconstriction (montelukast, ages 15
years or older)
- Allergic Rhinitis
- Aspirin sensitivity induced asthma (montelukast only)

Question 39

1. Identify 3 major actions of aspirin and NSAIDS
   - MoA
   - common side effects
2. What is not classfied as NSAIDs? Why? When do you use this ?

Answer 39

1. A) Antipyretics; inhibit prostaglandin synthesis in hypothalamus
   B) analgesics; reduction of mild/moderate pain, pain associated with inflammation
   C) Anti-inflammatory; inhibits prostaglanding synthesis in localized areas
   • Chemically diverse but similar therapeutic actions
   • MoA; INHIBIT CYCLOXYGENASE (COX 1 and COX 2
   • Common side effects; GI ulcers, bleeding, fluid and sodium retention - inhibit prostaglandin mediated effects in kidney. Contraindicated in patients tha have hyper sensitivity to aspirin.
   • NSAID drug interaction ; ACE inhibitors (opposite action), steroids (GI ulcer), warfarin (increas bleeding risK)
2. ACETAMINOPHEN; not classified as NSAID becuase it is not anti-inflammatory. Alternative drug if you are aspirin sensitive. In patients with reye syndrome from viral infection, pls give acetaminophen not aspirin for their fever.
   * Side effects - HEPATIC TOXICITY (acute), RENAL TOXICITY (chronic)

Question 40

1. Identify medication
   • analgesic/antipyretic dose
   • Anti inflammation; use higher dose
   • Fatal dose (10-30g)
   - little daily dose used to prevent heart attack
   - low does also approved for risk reduction of preeclampsia in women

• *MoA
• *SIde effects (4)

Answer 40

ASPIRIN

MoA; IRREVERSIBLY INHIBITS platelet COX (COX 1); prevent platelet aggregation but also prolongs bleeding time. Stop aspirin long before surgery

• Side effects;
i) GI pain, bleeding and ulcers
II) Variable urate excretion - decrease if <2gm but increase if >5gm.
III) REYE’S SYNDROME in children - do not use in children with viral infection (chicken pox) - used acetaminophen instead. **Reye’s syndrome presents as fatal, fulminating hepatitis with cerebral edema
IV) salicism; mild intoxication with aspirin. TINNITIS, high freq hearing loss, HA, nausea, diminished vision. Reversible within 2-3 days after drug withdrawal

Question 41

1. Identify traditional NSAIDS (5) and derivatives

MoA

2. Identify Cox 2 specific NSAIDs

Answer 41

1. A. Propionic acid derivative; Ibuprofen, naproxen and oxaprozin
   *MoA; Competitive REVERSIBLE INHIBITOR OF COX 1 AND COX 2
   *Use; analgesic (mild/moderate pain), antipyretic, anti-inflammatory (rheumatoid and osteoarthritis). **Less GI ulcers and problems than aspirin
   *IBUPROFEN (Advil, Motrin); Fever in children, dysmenorrhea, acute migraine attacks, rheumatoid and osteoarthritis, dysmenorrhea
   *NAPROXEN (Aleve); greater anti-inflammatory action, can be used same as ibuprofen but in addition; acute gout, ankylosis spondyliti. Clearance reduced in liver disease, also increased RISK OF STOKE OR HEART ATTACH with prolonged use

B. Heteroarylacetic acid derivative : Ketorolac
C. Phenylacetic acid derivative : Diclofenac
D. Indole derivative: Indomethacin

2. COX-2 specific NSAIDs
   A. COXIBS (Celecoxib)

Question 42

Identify NSAID medication

• approved for POST OP PAIN - moderate to severe
• Not habit forming
• Adverse effects; GI bleeding, hepatic, lower dose is skinny pts to protect the liver (<110 lbs)

**contraindicated when?

2. Other uses

Answer 42

KETOROLAC (Heteroaryl acetic acid)

2. Topical prep use
   - seasonal allergy (allergic conjunctivitis)
   - recovery from cataract surgery (post op ocular inflammation)

IV prep; excellent analgesic action - post op pain.
- also inhibits platelet aggregation

Contraindications ; DO NOT USE IF YOU ARE ALREADY ON ASPIRIN/NSAIDS

• stop before surgery or active bleeding or during labor/delivery or during lactation
• hx of peptic ulcer or presence of GI bleeding
• renal disease
• don’t combine with probenecid in gout treatment

Question 43

Identify NSAID medication

• COX 2 selective
• used for; rheumatoid, osteoarthritis, ankylosis spondylitis
• ophthalmic - post op pain and inflammation
• cause more cardiac effects, GI pain, nausea, cramps, diarrhea, modest ALT elevation, dizzy, HA

**What combo drug is used in patients with high risk of gastric ulcers - both contraindicated in pregnancy

Answer 43

DICLOFENAC (phenylacetic acid); COX 2 selective
• more cardiac effects

• Arthrotec (Diclofenac + misoprostol) ;Used in patients with high risk of gastric ulcers. Both CONTRAINDICATED IN PREGNANCY

Question 44

Identify NSAID medication

COX 1 selective
• IV; used in non surgical repair of PDA (patent ductus arteriosus). Decreases PGE levels. 3 doses. Please measure urinary output after each dose - KIDNEY PROBLEMS (renal toxicity) if urine output is less that 0.6ml/kg/hr
• Adverse effect; cause BILIRUBIMENIA (same with ibuprofen), GI pain so take with food, decrease urine output

• *Oral vs IV use
• *contraindications

Answer 44

INDOMETHACIN (indole derivative)

Oral; acute gouty arthritis, rheumatoid and osteoarthritis, tendinitis, ankylosis spondylitis

IV; Nonsurgical repair of PDA (patent ductus arteriosus)

• *Contraindications;
• Hyperbilirubinemia (note - ibuprofen release bilirubin more than Indomethacin)
• renal failure

Question 45

IDENTIFY MEDICATION

selective COX 2 inhibitors
• low incidence of GI pain
• FDA warning; INCREASE RISK OF STROKE AND HEART ATTACK - blocks PGI2
• Uses; rheumatoid and osteoarthritis

• *Uses
• *drug interactions
• *Adverse effects

Answer 45

CELECOXIB

 USES
Rheumatoid and osteoarthritis
Ankylosing spondylitis
Primary dysmenorrhea
 Drug-Drug interactions
- Celecoxib metabolized by P450 Cyp 2C9
- monitor dose carefully when given with fluconazole
(inhibits Cyp 2C9)
- also inhibits Cyp2D6
 Adverse Effects
- GI pain (high doses), nausea

Question 46

General considerations for use and selection of NSAIDs

• MoA; same or diff
• aspirin sensitive?
• most common side effect
• don’t use in what trimester?
• used in what congenital condition ?

Answer 46

• ALL HAVE SAME MECHANISM, difference is in
  efficiency of cyclo-oxygenase inhibition
• If sensitive to aspirin (some asthmatics have higher
  incidence of cross sensitivity to aspirin), do not use
  NSAID
• MOST COMMON SIDE EFFECT IS GI & ULCERATION
  (worse aspirin and Indomethacin)
• Do not use in last trimester of pregnancy due to
  bleeding during delivery
• Premature closure of patent ductus arteriosus (decrease
  oxygenation)

Question 47

NSAIDs and pregnancy (3)

Answer 47

 Inhibit uterine motility (PGE & PGF)
 Induce bleeding in last trimester
 Premature closing of ductus arteriosus (Indomethacin)

Question 48

1. Prostaglandins in the kidney

2. explain effects of NSAID on kidney

Answer 48

1. Normally
   - Renal cortex stimulate prostaglandins and prostacyclin to increase renin release
   - PGE1, PGE2 and PGI2 →↑vasodilation (afferent) → ↑GFR →↑Na and water excretion
   - ↑water excretion also by ↓adenylyl cyclase → ↓ ADH effect
   - Loop diuretics → ↑ COX activity → ↑ Na and water excretion
2. NSAIDS
   - NSAIDs can decrease the effect of loop diuretics; lead to sodium and water retention
   - NSAIDs lower Renal PGI2, PGE2; Resulting in decreased renal
   blood flow and GFR, increase tubular reabsorption of water,
   Cl and Na
   - Common renal side effect with NSAID use is fluid (salt and
   water) retention
   - Acute renal failure can occur
    Indomethacin has highest Risk
    Increased risk with dehydration or poor renal perfusion

Question 49

Explains effects of NSAID
- Hyperkalemia and water retention

• *When is hyperkalemia most likely to occur
• *how to you assess water retention

Answer 49

Normally

• PGE2 ; inhibits ADH effect on collecting tubules (inhibit water retention)
• PGI2 and PGE2; stimulates renin release

NSAIDS
- will lower renal PG levels
-resulting in enhanced ability of ADH to increase permeability of
collecting tubules to water (water retention)
- decrease renin release thus lowers aldosterone levels (aldosterone normally increase K+ secretion in exchange for Na+)
- decrease K+ secretion (K+ retention)

• *HYPERKALEMIA - most likely to occur in; NSAID used in elderly, diabetics and other situation of diminished renal function
• *Monitor weight to assess water retention

Question 50

Identify medication

- not an NSAID 
 Alternative drug in people that are aspirin
sensitive
 Active metabolite of phenacetin
 Does not alter platelet function
 Does not affect uric acid levels
 Less GI upset

**Use ; what is it excellent in? Poor in?

Answer 50

Acetaminophen

• Excellent antipyretic and analgesic (mild to
  moderate pain, osteoarthritis) activity comparable
  to aspirin
• WEAK ANTI-INFLAMMATORY agent

Question 51

Acetaminophen

1. Mechanism
2. Therapeutic uses
3. Drug interactions
4. Adverse effects

Answer 51

1. Mechanism
   - Weak inhibitor of cyclo-oxygenase (COX-1 and COX-2)
   - Mechanism ;COX-3 inhibitor
   - 2006: activates Cannabanoid receptor
2. Therapeutic uses
   - Mild to moderate pain such as headache, myalgia, postpartum pain
   - Preferred in children with viral fever (eg. Reyes Syndrome)
3. Drug interactions
   - Alcohol
4. Adverse effects
   A. HEPATIC TOXICITY (acute); NUMBER 1 cause of drug induced liver failure in the US
   B. RENAL TOXICITY (chronic)

Question 52

What are gold salts

*Mechanism

Answer 52

Gold Salts - Auranofin and Gold sodium thiomalate

• A disease modifying anti-rheumatic drug (DMARD)
• Used for active rheumatoid arthritis, not responding to NSAIDs; also used in ankylosing spondolitis, etc
• Decrease pain and inflammation, prevent joint damage, and
  preserve structure and function of joints.
  **Very expensive and not first line due to side effects

MECHANISM
• Inhibition of function and maturation of mononuclear
phagocytes and T cell
• Decreased levels of rheumatoid factor
• Inhibits migration and phagocytosis by macrophages (gold
taken up by macrophages)

Question 53

Identify

**A disease modifying anti-rheumatic drug (DMARD)
 Administer IM, used for more aggressive
treatment
 Greater risk of chrysiasis and mucosal lesions
 Anemia and thrombocytopenia
 Anaphylactic rxn to injection
 Contraindicated in situations of
• Renal disease
• Lupus
• Presence of eczema or gold sensitivity

**Identify side effects

Answer 53

Gold sodium thiomalate

Side effects
 Develop rash and/or lesions of mucous
membranes
 Chrysiasis, Gold deposit in skin, gray color esp.
upon sun exposure
 Proteinuria and glomerulonephritis
 NOTE: The use of gold salts as DMARDs have gone
down. Methotrexate, sulfasalazine etc are more
commonly used DMARDs.

Question 54

Describe the relationships between the hallmarks of cancer, oncogenes and tumor suppressor genes

1. Hallmarks of cancer? (6 main, 2 extra)
   - How are they fundamentally acquired
2. Oncogenes vs tumor suppressor genes
   - which is gain of function
   - which is loss of function

Answer 54

1. Hallmarks of cancer ; acquired by 1 and 2
   A. uncontrolled proliferation (autocrine growth stimulation and lack of “cellular/contact inhibition”)

B. Immortalization; normal cell (except stem cell) has max number of cell divisions they can do. Not case for cancer cell.

C. Protect from antiproliferative signaling; no “density-dependent inhibition”

D. Protect from APOPTOSIS; don’t respond to “programmed cell death”

E. ANGIOGENESIS; solid tumors require new capillaries to support their growth (neovascularization)

F. Invasion and METASTASIS; solid tumors develop ability to invade neighboring tissues and distant sites

**A-D is universal hallmark of cancer. **E and F are solid tumors

G. Emerging properties;

• deregulate cellular energetics; reprogram cellular metabolism to support neoplastic proliferation
• evasion mechanisms for the immune system; cancer cells evade/escape being destroyed by immune cells

H; Enabling properties;

• genome instability and mutation; genetic alterations lead to tumor progression
• tumor promoting inflammation; inflammation can support multiple hallmark capabilities
• cancer cells in given tissue tend to dedifferentiated (can convert bacteria to precursor cells),
• aneuploidy/CYTOGENETIC abnormalities (acquire chromosome infusion events (abnormal karyotypes) - DETERMINE PROGNOSIS **)

2. Oncogenes; stimulatory effect on cell
   - GAIN OF FUNCTION mutations. Only need single hit to form malignancy
   - Result (5); sustained cellular proliferation, advance cell cycle progression, decrease requirement for growth factors, promote metastasis, protection from apoptosis
3. Tumor suppressor genes; normally protect cell from acquired hallmarks of cancer (by apoptosis)
   - LOSS OF FUNCTION mutations. Need to deactivate the 2 of them for you to contribute to cancer progression

Question 55

How cancer develops

1. 3 categories
   A. Factors contributing to generation of cancer cell
   B. Effects of these factors on the cell
   C. Pathological outcome of A and B (state progression from normal tissue to invasive carcinoma)
2. Slow or fast process?
3. Single or multi- hit In terms of origin?
   * *what does this explain?

Answer 55

How cancer develops
A. Genetic predisposition - exposure history environmental lifestyle - autonomous progression (once cancer cell initiates, it make choice to either survive or be eliminated)
B. Inherited mutation of genetic polymorphism - somatic mutations
C. Normal tissue - hyperplasia - dysplasia - carcinoma/invasive cancer

2. Very slow process occur over decades
   • cancer cells are clonal in Origin; e.g found that all tumor tissue had the same X chromosome inactivation while normal cell has different. Can then develop mutations after it develops making it resistant to therapies (heterogeneity)
3. Multi-step origin of cancer
   • Tumor don’t follow a single hit kinetic; Progressive mutations required over the course of time to generate full malignancy
   • More than one mutation required to form fully developed tumor
   • MULTI- HIT MODEL explains the fact that cancer presentation increase with age

Question 56

How are protooncogene-oncogenes and tumor suppressor genes converted to their malignant forms

1. Protooncogene conversion
   - types/mechanisms (3)
   * *explain 3 forms of mutations
2. Tumor suppressor
   - mechanism
   - types (4) ; tumor suppressor - familial disorders - sporadic/somatic disorders
   * *What is the most common ocular malignancy (pediatric condition) that occur in both sporadic and familial forms)

Answer 56

1. Protooncogene-oncogene conversion
   A. Proto-oncogene is the Norma/ (functional alleles)
   B. Conversion to oncogenes is mostly gain-of-function mutations
   - increased expression (hyperactivity e.g RAS oncogene)
   - loss of protein regulation with increased activity
   C. Viral mechanisms (HPV)
   D. Mutational mechanism
   - deletion/point mutation (lead to hyperactivity e.g RAS)
   - gene amplification (overexpression - Myc, ErbB)
   - chromosomal rearrangement (overexpression - Bcl2, Myc and novel product - BCR/ARL, PBX, PBL/RAR)
2. Tumor suppressor genes conversion; mutated (loss of function) for you to have cancer predisposition
   - loss of function in BOTH ALLELES lead to cancer
   - loss of heterozygosity defined; from 1 functional alleles to no functional alleles
   - 2 hit model; multi step model
   - E.g;
   A. RB1 (cell cycle control) - RETINOBLASTOMA (*prototype) - small cell lung carcinoma. Retinoblastoma is the most common ocular malignancy - AD with incomplete penetrance - (treatment - radioiodine or cryotherapy to remove tumor if diagnosed at early stage)
   B. TP53 (p53, cell cycle) - Li-Fraumeni syndrome - Lung and breast cancer
   C. BRCA1 (Ds break repair) - Familial breast cancer - Breast and ovarian cancer
   D. NF1 (GTPase activator) - Neurofibromatosis - ??

Question 57

How do genetic influence cancer predisposition

1. What percent of cancer if from genetics
2. Many Cancer predisposition follow what model?
3. What influence prognosis
4. What is likelihood of ultimately developing cancer from only one mutant allele?

• *Explain with examples - nature vs nurture
• what’s inbetween?

Answer 57

Genetics and cancer

1. 10% of cancer from genetics/hereditary
2. Many follow KNUDSON’S TWO-HIT MODEL but not all
3. Tumor biology of some sporadic tumors and tumors with an inherited predisposition are different, which may influence their prognosis
4. The likelihood that an individual who carries a mutant allele in inherited cancer gene will ultimately develop cancer is highly variable and unpredicted in most cases (because there are different mutations that have different effects)

**
A. Nature (genetics); APC - familial adenomatous polyposis
B. Nurture (environment); Radiation exposure (Chernobyl)
C. Inbetween; HNPCC, BRCA 1, BRCA 2 (mixture of both nature and nurture)
**There are high penetrance vs low penetrance genes in breast cancer

Question 58

Retinoblastoma

1. difference in familial and sporadic
   - bilateral vs unilateral
   - more common cases?
   - transmitted through Germline? **
   - single or multiple tumors? **
   - early or late onset? **
2. LOH (loss of heterozygosity) definition?
3. Knudson’s hypothesis
   - familial vs sporadic form
4. Somatic vs Germline mutations
5. How is 2nd Rob allele inactivated (2)

Answer 58

1. A. Familial - usually bilateral, (40% cases), Autosomal dominant with high penetrance (80%)
   - Mendelian transmission through Germline
   - Multiple tumors
   - Early onset

B. Sporadic - usually unilateral, (60% cases), low risk to progeny

• Not transmitted to progeny
• Single tumor
• Later onset

2. LOH
   - LOH refers to loss of function of one allele***
   - form 1 bad copy to 2 bad copies
   - LOH was discovered by RFLP analysis of Rb gene; RFLP was heterozygous in all tissues except tumor
3. Knudson’s hypothesis
   A. Familial form; only ONE MUTATION event is needed to make a cell w/o RBC product. So tumors occur MORE FREQUENTLY in familial form
   B. Sporadic form; TWO MUTATIONS (one in each allele) and in the same cell are needed to knock out Rb. This rarely happens and tumors are more often unilateral
4. A. Somatic - sporadic; single tumor in one eye and takes longer
   B. Germline - familial ; multiple tumors, early onset
5. A. Genetic; local events, somatic recombination, loss and duplication, chromosome loss
   B. Epigenetics; DNA methylation

Question 59

1. Identify condition
   - Autosomal dominant with high penetrance (80-100%)
   - symptoms include; rectal bleeding, diarrhea, anemia or abdominal pain
   - spontaneous mutation in 30% of cases
   **2 categories of spectrum of disease (fulminant vs attenuated)
   A) Most common form of hereditary polyps
   B) Asymptomatic till puberty form
2. Identify cancer types you would use primary vs secondary prevention for and state your reasoning

Answer 59

1. FAP - Familail adenomatous polyposis; spectrum of disease is FULMINANT FAP(more polyps) vs ATTENUATED FAP (less than 100 polyps)
   - Germline mutations in the adenomatous polyposis coli gene (APC) cause the most common form of hereditary polyposis syndromes termed familial adenomatous polyposis (FAP).
   - Juvenile Polyposis (ASYMPTOMATIC TILL PUBERTY) is also a autosomal dominant disorder caused by mutations in the SMAD4/DPC4 gene or BMPR1A/Alk3 gene. Note the less numerous polyps in this syndrome. Note the large and lobulated phenotype of the polyps in comparison to FAP polyps.
2. A. Primary prevention; cancer from genetic/environmental predisposition. Take measures to prevent the cancer
   - e.g FAP colorectal, Lynch colorectal, lung CA from smoking

B. Secondary prevention; cancer form random stem cell division (BAD LUCK)
- e.g pancreatic, small intestine, duodenum

Question 60

Overview of cancer predisposition (genetics)

1. What is the common gene function mutation in these inherited cancers?
   - give examples of inherited cancers
2. Examples of rare heritable syndrome
3. Common cancers with heritable forms (more distinct form or ones that hide)
4. Breast cancer grade **
   - Sporadic vs BRCA 1 vs BRCA 2
   * *which is most aggressive?

Answer 60

1. ** TUMOR SUPPRESSION (mutation) is the common team here; tumor suppression in DNA repair, cell cycle regulation, WNT pathway, DNA mismatch repair, cell cycle regulation, ubiquination.
   - e.g HBOC (BRCA 1 and 2), Cowden (PTEN gene), FAP (APC gene), HNPCC, Li-faumeni (TP53), Von Hippel lindau (VHL), multiple endocrine neoplasia (MEN1 and RET)
2. Rare heritable syndromes; Neurofibromatosis type 1, familial polyposis coli, von hipped lindau, ataxia telangiectasia, multiple endocrine neoplasia 2A
3. Common heritable syndrome; melanoma, breast/ovary syndrome, HNPCC, Li-Fraumeni
4. **Breast cancer grade
   A. Sporadic; grade 2 or 3
   B. BRCA 1; grade 3 (more aggressive than sporadic/BRCA 2)
   C. BRCA 2; similar to sporadic
   **BRCA 1 and 2 are both inherited/familial but their presentation is different

Question 61

How genomic instability is related to cancer progression and initiation

1. Chromosome instability In men
2. Outcome of chromosomal instability
3. Causes of chromosomal instability (7)

**What is goal of chromosome instability

Answer 61

Genomic instability

1. Chromosome instability In men ; loss of Y in blood is predictive marker for cancer
   - incidence/mortality for sex unspecified cancers are higher among men (reason unknown)

2 outcome of chromosomal instability

• chromosomal instability offers benefit of increased mutability to a cancer (lots of duplications and acquire hallmarks of cancer)
• translocation; may be defining or diagnostic markers
• specific translocation; often used in prognosis and treatment choice

3. Causes of chromosomal instability
   - mutations in genes involved in ; nucleotide metabolism, DNA replication, chromosome segregation and cell cycle checkpoints
   - telomere attrition
   - aneuploidy
   - hypomethylation
   - double stranded breaks (radiation and chemical)
   - cellular stresses; hypoxia, dysregulated pH, high osmolarity microenvironment
   - VDJ recombination errors

**Chromosome instability is a way of converting proto-oncogenes to oncogenes and the goal is getting the hallmarks of cancer

Question 62

How epigenetics (hypermethylation vs hypomethylation) integrates into mutation and cancer progression

1. Etiology
   - effect of hypermethylation vs hypomethylation
   - are reversible changes possible?
   - Effect on many genes possible?
2. Hypomethylation
   - common occurrence of cancer? (2)
   - strongest risk factor for hypomethylation?
3. Epigenetics in therapy
4. Why is IGH1 important? (Mutations of IGH1cause?)
5. Epigenetics biomarkers

Answer 62

1. Etiology
   - Gene silencing of tumor suppressors specifically by HYPERMETHYLATION
   - Activation of oncogenes by global HYPOMETHYLATION
   - Genomic instability
   - Reversible changes are possible
   - Effects on many genes at once are possible
2. Hypomethylation ; common occurrence in cancers is HYPOMETHYLATION of genome followed by hypermethylation of critical regions
   - lead to genome instability
   - abnormally high in CpG. Only 11% of genome are Aliu repeats
   - Strongest risk factor is AGE**
3. Epigenetics in therapy (reversible)
   - some cancers derived by epigenetics vs genetic. E.g leukemia is driven by epigenetics
   - evidence supports that epigenetics alterations may be a driving force of drug resistance in human cancer
4. IDH1 (isocitrate dehydrogenase 1)
   - **mutations in IDH1 cause buildup of R-enantiomer of the metabolite (R-2HG)
   - 90% of IDH1 mutations are R132H in glioblastoma
   - more secondary (76%)) than primary (5.6%) glioblastoma are IDH1 mutant
   - Epigenetically driven glioblastoma responds poorly to surgery
5. Epigenetics biomarkers
   - epigenetic alterations often occur early in cancer progression
   - offer a quantitative aspect not present in genetic mutations

Question 63

Developing/Research frontiers in our understanding of genetics of cancer

1. Personalized medicine
2. Environment and cancer
3. Monogenic vs polygenic disorders

Answer 63

Research on genetics of cancer - where do we go from here

1. Personalized medicine ; in chemotherapy
   - sequence tumor lead to personalized approach lead to better prognosis
   - e.g aspirin and % reduction of colorectal adenoma
2. Environment and cancer
   - genetic makeup influence risk to various carcinogens. E.g risk of lung cancer related to tobacco depend on genetics of pt (Missense mutation of CYP1A1)
   - gastric cancer more common in Japanese living in japan vs those living in America
3. Mendelian (monogenic) disorders compared with polygenic disorders
   A. Monogenic disorder; occur from variation/mutation in single gene. Most people that possess the mutant gene will exhibit disease
   B. Polygenic disorder; occur from variation/mutation in several different genes. Each mutation contributes to risk of acquiring disease phenotype % or risk due to any gene varies

Question 64

Cancer epidemiology

1. Definition of epidemiology
2. 2 central concepts

Answer 64

1. Epidemiology; Comparative study of distribution and determinants of disease and other health-related conditions within defined human populations.
2. Two central concepts:
   1. Disease is not randomly distributed.
   2. Disease causation is multifactorial.

• *For an epidemiologist, a population is the patient
• done by close observations and making linkage
• father of epidemiology is JOHN SNOW

Question 65

1. Most common cancer (2)
2. Women vs men
3. Trends of lung/liver cancer in man and women
4. Mortality from cancer trends

Answer 65

1. Most common ;
   - GENDER cancers followed by LUNG cancer
2. A. Cancer in men; prostate cancer highest
   B. Women; breast cancer highest
   **All downward trend lately
3. Between 1990 and 2004, lung cancer death rates in women and liver and bile duct deaths in men increased substantially. Liver cancer deaths, which declined between 1930-1970, have doubled in past 30 years and is expected to rise when hep c positive people develop hepatocellular cancer.
4. • Lung cancer decreasing mortality (less people smoking); LUNG CANCER STILL THE SECOND MOST COMMON CANCER
   • liver cancer increasing mortality

Question 66

*****Cancer epidemiology (FINCH - exam)

What is the most common cancer in both men and women

Answer 66

LUNG CANCER

Question 67

1. Overall survival trend in breast cancer
2. Childhood cancer survivors
3. Overall** - rates vs incidence of cancer

Answer 67

1. Between 1975 and 2012, the 5-year survival rate for breast cancer IMPROVED from a rate of 75 percent to a rate of 91 percent. This means that in 1975, 75 percent of women had not died of their breast cancer 5 years after diagnosis, but by 2012 this percentage increased to 91 percent.
2. This year’s ARN also includes IMPROVEMENTS in childhood survival since 1975.
   - These significant increases reflect IMPROVEMENTS IN TREATMENT, such as the combination of chemotherapies for childhood cancers
3. With time;
   - Rates going down
   - Incidence going up

Question 68

1. How do you get cancer

**Interaction of ? (3) 
A. Accumulation of what over time? 
B. 4 types of genes 
C. Result? 
D. Is origin monoclonal? 

2. Seven key changes (hallmark of cancer)

Answer 68

1. Complex interaction of genes, environment and chances.
   A. Progressive accumulation of NONLETHAL MUTATIONS
   B. 4 types of genes; I) proto-oncogenes, II) tumor suppressor genes, III) genes that regulate apoptosis, IV) genes involved in DNA repair
   C. These lead to excessive growth, local invasiveness and ability to metastasize
   D. Although perhaps monoclonal originally, end up very heterogeneous when clinically evident
2. Seven Key Changes-
   A. self-sufficient for growth
   B. insenstive to inhibition (contact and density)
   C. evasion of apoptosis,
   D. limitless reproduction,
   E. sustained angiogenesis (form new blood vessels)
   F. ability to invade and spread (metastasis)
   G. defects in DNA repair.
   *GF receptor example FLT3 in AML.

Question 69

1. Non - hereditary predisposing conditions
   A. What inflammation type?
   Examples
2. Immunodeficiency
   * before transplant, you give immunosuppressant to patient to avoid graft vs host disease. This can however lead to??
3. Non - hereditary predisposing factors (3)

Answer 69

1. A. CHRONIC INFLAMMATION
   I) Creates milieu with growth factors, cytokines, cellular damage
   II) Example:
   - Ulcerative colitis: colon
   - Also H. pylori gastritis, viral hepatitis, chronic pancreatitis
   - **Beware of so-called “precancerous” conditions- majority don’t lead to cancer, but some do
2. Immunodeficiency;
   - 5% congenital (PID) develop cancer
   - HIV and other immunosuppressed (lymphoma - diffuse large B cell lymphomas), kaposi sarcome (HIV related)
   - **Post transplant lympho- proliferative disorder; before transplant, you give immunosuppressant to patient to avoid graft vs host disease. This can however lead to = post transplant lympho-proliferative disorder
3. Factors
   A. Age; older age (more lifetime to acquire mutations)
   - MVA accidents is leading cause of childhood mortality followed by non hereditary cancer (soft tissue tumors etc)

B. Geography and environment ; stomach cancer in Japanese higher in those living in Japan vs America. Genetics don’t change but risk does

C. Radiation oncogenesis; UV rays. **High melanin decrease risk

• mess up DNA repair
• increase risk of melanoma (intense intermittent exposure) and nonmelanoma skin carcinoma (squamous cel and basal cel CA - cumulative effect)
• Radiation oncogenesis (ionizing radiation) ; mostly in sensitive tissues (blood - leukemia, thyroid, breast/lung/salivary gland), radioresistant tissues (GI tract, bone, skin)

Question 70

Case discussion (In 1980s - chemical reaction)

You are examining an 8 year old girl in Belarus in 1989 whose mother reports feeling a lump on her neck
It doesn’t hurt when you feel it and you notice some painless, swollen cervical nodes on the right side of her neck

**Example of what predisposing factor?

Answer 70

PAPILLARY THYROID CARCINOMA after I-131 exposure from Chernobyl

• Increases in thyroid cancer in children 0-4 at time of exposure, no increases in adults
• Papillary, poorly differentiated but very responsive to treatment
• 5X higher odds ratio in with exposures >1 Gy

**Example of non-hereditary predisposing factors

Question 71

Chemical carcinogens

Direct vs indirect acting agents

• *which require metabolic conversion?
• examples of each

Answer 71

1. DIRECT-ACTING AGENTS
   - No metabolic conversion needed
   - Typically weak carcinogens
   - E.g; alkyating agents (chemotherapeutics), acylating agents
2. INDIRECT-ACTING AGENTS
   - REQUIRE METABOLIC CONVERSION to a mutagenic intermediate
   Often become electrophilic intermediates and/or free radicals
   In the tightly controlled chemical factory of a cell, highly and indiscriminately reactive species are a BAD THING.
   - Cytochrome P450 enzyme isoforms matter
   CYP1A1 allele: Lung cancer risk 7X in smokers
   Happens to convert smoke into higher potency intermediates
   Nutrition, environment and other factors affect risk
   - e.g polycyclic/heterocyclic aromatic hydrocarbons, aromatic amines/azithromycin dyes, others (nitrites) - fossil fuels, cigarette smoke, **extremely potent agents - leukemia, increased smoked foods, natural plant and microbe toxins
   **AFLATOXIN B1 - aspergillus (mold) grow in improperly stored grains/nuts in Africa mostly

Question 72

Case discussion

You are working in the free clinic in Kyoto, JAPAN
50 year old women is brought in by husband for confusion, abdominal distention and bruising- you find ascites on exam and palmar erythema
Labs shows LIVER DYSFUNCTION and elevated AFP >400 (inflammation)

**diagnosis?

Answer 72

Hepatitis C and Hepatocellular Carcinoma (HCC)

• HCC accounts for 85 to 90% of the cases of primary liver cancer. Chronic hepatitis and cirrhosis precede the HCC
• Risk of developing HCC for a patient with HCV-related cirrhosis is ~ 2-6% per year and risk increases is 17-fold higher in HCV-infected patients compared to HCV-negative
• HCC develops after >2 decades of HCV infection and the increased risk is mostly to patients with cirrhosis/advanced fibrosis

Question 73

Case (3)

• You are transported to the 1930s and are working on occupational determinants of gastric ulcers while you notice that patients’ social standing often affects their outcome
• You notice that lung cancer seems to be on the rise and decide to study that
• You and Austin Hill fine 25X greater risk lung cancer in people smoking >25 cigarettes per day vs nonsmokers (no more than 1 a day on average for past year)
• What next steps might you take?
• *what is the major preventable cause of death particularly from longer canner?

Answer 73

British Doctor study ( to discover the extent/rates of lung cancer)

Effects on survival of stopping smoking cigarettes at age 25-34 (effect from age 35), age 35-44 (effect from age 40), age 45-54 (effect from age 50), and age 55-64 (effect from age 60)

• *people now use cigarettes less
• • TOBACCO USE is a major preventable cause of death, particularly from lung cancer.

Question 74

1. Identify primary prevention practices for cancer (6)
2. Secondary prevention
3. Proven cancer prevention strategies
4. Proven cancer prevention strategies (compelling non-RCT evidence) - 3

Answer 74

1. Primary prevention
   - Decrease alcohol and tobacco use
   - Decreased exposure to carcinogens
   - Decreased exposure to radiation and excessive sunlight
   - Access to clean water and healthy foods and avoidance of obesity
   - Practice of safe sex
   - Immunization and treatment of infections
2. Secondary prevention
   - Cancer Registration- International Agency for Research on Cancer (IARC) within WHO and Surveillance and Epidemiology and End Results (SEER)- US Federal Government
   - Both mass population and selective cancer screening
3. Proven prevention strategies
   A. Screening ; mammography for breast exam, fecal occult blood test for colorectal cancer
4. Proven cancer prevention (non-RCT evidence)
   A. Risk factor Avoidance; smoking prevention/cessation counseling, worker exposure reduction (asbestos)
   B. Immunization; Hep B and HPV
   C. Screening; Cervical PAP testing

Question 75

Lab diagnosis of cancer

1. Histology (3)
2. Cytology (3)
3. Immunohistocemistry

Answer 75

1. Histology - (CML aeur body)
   A. Biopsy/excision
   - Tissue fixed in formalin for preservation of histology
   - “Permanent sections”
   B. Frozen section
   - Intraoperative sampling and rapid interpretation
   - Histology very limited; prone to artifacts of freezing process
   C. History/clinical findings are essential to diagnosis; H&P

2. Cytology - Burkitt lymphoma 
A. FINE NEEDLE ASPIRATE (FNA)
- Less invasive
- Has limitations
B. PAP SMEAR 
- Cervix:  Scrapping of cervix to evaluate cell morphology
- Others:  eg body fluids, bronchial brushing
C. BODY FLUID
- Urine
- Pleural effusion
- CSF

3. Immunohistochemistry; technique to stain specific antigens in a cell

Question 76

Case 1 (lab diagnosis of cancer)

• 16 year old girl with bruising, “beefy gums” and fatigue
• Pancytopenia on CBC, characteristic cell on her smear
• • Smear showed a flat rod (AUEUR ROD)

Answer 76

AUER ROD - indicate CML (CHRONIC MYELOID LEUKEMIA)

Question 77

Case 2 (cancer diagnosis)

• 16 year old male with groin node “the size of a baseball” for past two months
• 16 pound weight loss. UA 7, LDH 1500
• FNA- sheets of small round blue cells with “starry-sky” appearance. FISH found t(8:14) involving c-myc and IGH
• Bilateral marrows- <25% involvement

Answer 77

Burkitt Lymphoma

Question 78

Identify following malignancies based on translocations and affected genes

1. (9;22) (q34;q11)
   Genes; ABL 9q34 and BCR 22q11
2. (8;21) (q22;q22)
   Genes; AML 8q22, ETO 21q22, PML 15q22, RARA 17q21
3. (8;14) (q24; q32)
   Genes; MYC 8q24, IGH 14q32
4. (11;14) (q13;q32)
   Genes; CCND1 11q13, IGH 14q32
5. (14;18) (q32;q21)
   Genes; IGH 14q32, BCL2 18q21
6. (11;22) (q24;q12)
   Genes; FLI1 11q24, EWSR1 22q12
7. (7;21) (p22;q22) and (17;21) (p21;q22)
   Genes; TMPRSS2 (21q22;3), ETZ1 (7p21.2), ETV4 (17q21)

Answer 78

Oncogenes created by translocations

1. CML (chronic myelogenous leukemia)
2. AML (acute myeloid leukemia)
3. Burkitt lymphoma
4. Mantle cell lymphoma
5. Follicular lymphoma
6. Ewing sarcoma
7. Prostatic adenocarcinoma

Question 79

Identify the following methods in cancer diagnosis

Technique to stain specific antigens in a cell
- Categorize tumors
- Determine site of origin of metastasis
- Detect molecules of PROGNOSTIC significance (how bad it will be). *Estrogen receptor in breast
- Detect molecules of PREDICTIVE significance (what drug may work). *Her-2/neu in breast and gastric cancer
Global function of certain genes???

Answer 79

IMMUNOHISTOCHEMISTRY

Question 80

Identify lab diagnosis of cancer

1. Special handling and fixation
   Outrageously expensive
2. • Count individual cells and characterize
     Cell antigens DNA content
   • Primarily used in lymphoma and leukemia

Answer 80

1. Electron microscopy

2. Flow cytometry

Question 81

Case 3 (cancer diagnosis)

• 16 year old male with fever, coughing and back pain- anterior mediastinal mass and pleural effusion on chest film. WBC 6, HgB 15, Plt 227, UA 7.8, AFP 2.4, Quantiferon gold negative, LDH 766
• Flow on pleural effusion- 52% cells strong + CD2,3,4,5,7, partial CD8,10, CD34+, cytogenetics show abnormal karyotype 46,XY,t(1;14)(p32;q11.2),?del(7)(q34,q36)[13]/46,XY[1]
• Marrow <25%

2 possibilities

Answer 81

Lymphoma vs Leukemia

Answer = T cell LYMPHOMA 
T-Lly= 10% NHL

Question 82

1. What is the best use of tumor markers
   - others
2. Currently used clinical tumor markers (6)
   - prostate cancer? Hepatoma? Choriocarcnimoa? Colon cancer? Pancreatic cancer? Ovarian cancer?
   * *what is problem with tumor markers

Answer 82

1. Tumor markers; BEST USE IS FOR FOLLOWING TREATMENT EFFECT; Have a tumor; tumor marker level is high; post-treatment marker level is low; monitor level for increase (suggests recurrence)
   - NONE have been proven to be sensitive or specific enough to diagnose cancer
   - can be a CLUE TO DIAGNOSIS

2. Currently used types 
PSA - Prostate Adenocarcinoma
Alpha FP - Hepatoma & seminoma
HCG - Choriocarcinoma 
CEA - Colon cancer
CA19.9 – Pancreatic cancer
CA125 – Ovarian cancer
**Problem: LOW SENSITIVITY/SPECIFICITY

Question 83

1. What do molecular diagnostic tests diagnose? (2)

Answer 83

1. Molecular diagnostic tests
   A. Diagnosis of malignant neoplasm
   - Clonality studies
   - Detect characteristic translocations for selected cases
   - Detect characteristic mutations for selected cases e.g Thyroid, Pancreas

B. Detect residual disease: More sensitive than histology

• BCR-ABL to detect residual CML
• Hereditary cancer predisposition testing
• Predictive
• Specific mutations make a tumor responsive to agents targeting the mutated genes
• EGFR, KRAS, BRAF (brain)
• Techniques routinely employed are fluorescence in situ hybridization (FISH), polymerase chain reaction (PCR), reverse transcriptase PCR (RT-PCR), DNA sequencing

Question 84

Case 4 (cancer diagnosis)

• 5 year old 5 days fatigue, epistaxis, hand pain and “red dots” on trunk. WBC 50, HgB 8, Plt 60, 59% blasts, LDH 3019
• t(9;22)(q34;q11.2); BCR-ABL1. FISH positive for BCR/ABL1= Philadelphia Chromosome

Answer 84

Leukemia (CML)

Question 85

What is holy grail of oncology

Answer 85

***Early detection of AGGRESSIVE disease
- Effective therapy against aggressive disease
- Combinations of immunohistochemistry and molecular diagnostics
i) Identify changes within a cell that suggest increased aggression
II) Identify changes that respond to specific therapies

Question 86

Identify 2 new technology (cancer diagnosis)

1. Fusion of molecular biology with microchip manufacture
2. Protein profiles
3. • using antibody for treatment of cancer
   • help immune system fight cancer

Answer 86

1. Microarray technology
   - allow for thousands of simultaneous reactions in a small space
   - human genome now takes a week
2. ProteOMICS
3. Immunotherapy
   - CAR T cell may likely be cure for leukemia

Question 87

Era of Omics

1. Benefits
2. Problem

Answer 87

1. Omics benefit
   - high throughput, cheaper - very powerful as a result
   - used for reasearch
   - give a lot more information than we currently know how to use; effective for personalized medicine
2. Omics problem
   A. Tumor heterogeneity; tumor generate more mutations as it develops
   B. Enormous amount of data; no consensus on best software to use in analyzing, problem with incorrect analysis

Question 88

1. Genetic susceptibility markers

• what studies help to identify genetic markers for cancer
• *state the translocation for each cancer (prostate vs lung)

2. Immunotherapy examples for cancer treatment

Answer 88

1. GWA (Genome Wide Association); help to identify genetic markers for cancer
   - prostate; chromosome 8q24
   - lung ; chromosome 15q25
   - Genes identified in these loci may also be the targets for chemopreventive drug development
2. Immunotherapy
   - ALK inhibitor (crizotinib) for treatment of congenital neuroblastoma
   - Ch14.18 targets GD2 on surface of neuroblastoma cells. Other things used are GM-CSF and IL-2
   - ATRA improve survival of acute promyelocytic leukemia
   - CAR T (chimeric antigen receptor cell’s); patients own T cells programmed against CD19 cells, grown and re-infused. Adverse effect is that it causes cytokine release syndrome

Question 89

1. Describe key components for wound healing (2)

2. What cells play central/important role in repair ? How? (3)

Answer 89

1. Wound healing ; repair of damaged tissues occurs by 2 types of reactions
   A. Regeneration; replace damaged components and return to normal state e.g liver (tissue stem cells) **INTACT TISSUE
   B. Scar formation (repair); complete restitution can’t occur so you lay down connective/fibrous tissue *DAMAGED TISSUE
2. MACROPHAGES play central role in repair by; i) clearing offending agents and dead tissue, II) providing growth factors for the proliferation of various cells, iii) and secreting cytokines that stimulate fibroblast proliferation and connective tissue synthesis and deposition.
   - The macrophages that are involved in repair are mostly of the alternatively activated (M2) type. It is not clear how the classically activated macrophages that dominate during inflammation, and are involved in getting rid of microbes and dead tissues, are gradually replaced by alternatively activated macrophages that serve to terminate inflammation and induce repair.

Question 90

Differentiate regeneration from repair by fibrosis

• type of injury
• inflammation type (ECM intact or damaged?)
• examples

**what is FIBROSIS

Answer 90

Regeneration vs repair

A. Repair by Regeneration; by proliferation of residual cells that survived injury (e.g liver stem cells form new regenerated liver)

• mild/superficial injury
• acute inflammation with intact ECM
• e.g of regeneration occurs in; rapidly dividing epithelia of the skin and intestines, and in some parenchymal organs, notably the liver

B. Repair by connective tissue deposition to form a scar

• severe injury
• injured tissues are incapable of complete restitution so repair occurs by laying down connective/fibrous tissue
• consequence of chronic inflammation (in lungs, kidneys liver etc) or in the myocardium after extensive ischemic necrosis (infarction)
• fibrosis can also occur from acute inflammation with damaged ECM (extensive deposition of collagen)
• e.g Neurons and cardiac myocytes (permanent cells) CANNOT regenerate

**Fibrosis; used interchangeably with scar. FIBROSIS means extensive deposition of collagen and other ECM components in a tissue

Question 91

Describe healing by first and second intention

- progression form 
Day 1 
Day 1-2 
Day 3 -7 
Day 5
End of first month

Answer 91

1. First intention; SURGICAL WOUND (planned)
   - fibroblast, ECM proteins, and collagen fibrils work here
   - Within 24 hours, neutrophils are seen at the incision margin, migrating toward the fibrin clot. They release proteolytic enzymes that begin to clear the debris. Basal cells at the cut edge of the epidermis begin to show increased mitotic activity.
   - Within 24 to 48 hours, epithelial cells from both edges have begun to migrate and proliferate along the dermis, depositing basement membrane components as they progress.
   - granulation tissue occur in day 3-7 by MACROPHAGES. BY DAY 3, neutrophils have been largely replaced by macrophages and granulation tissue
   - By day 5, neovascularization reaches its peak as granulation tissue fills the incisional space
   - By the end of the first month, the scar comprises a cellular connective tissue largely devoid of inflammatory cells and covered by an essentially normal epidermis.
2. Second intention ; damage is not controlled (UNPLANNED)
   - the larger the wound, the larger the granulation tissues
   - MYOFIBROBLASTS (modified fibroblasts); exhibits many of the ultrastructural and functional features of contractile smooth muscle cells WOUND CONTRACTION. Within 6 weeks, large skin defects may be reduced to 5-10% of their original size larger by contraction
   - When cell or tissue loss is more extensive, such as in large wounds, abscesses, ulceration, and ischemic necrosis (infarction) in parenchymal organs, the repair process involves a combination of REGENERATION and SCARRING

Question 92

Discuss process of cutaneous wound healing

Answer 92

Cutaneous wound healing; inflammation to proliferation to maturation

• Remodeling of connective tissue and parenchymal components
• collagenization and acquisition of wound strength
• Maturation and reorganization of the connective tissue (remodeling) produce the stable fibrousscar. The amount of connective tissue increases in the granulation tissue, eventually resulting in the formation of a scar

Question 93

Discuss the factors that influence outcome of wound healing and repair (3)

• *what is most important cause of delayed healing
• *what is most important systemic causes of abnormal wound healing

Answer 93

1. Systemic
   - DIABETES is one of most important systemic causes of abnormal wound healing
2. Local;
   A. INFECTIONS (most important cause of delayed healing)*. It prolongs inflammation and increase local tissue injury
   B. Mechanical factors; increased local pressure
   - Early motion
   - foreign bodies (steel, glass, bone)
3. Size location and type
   - face heals faster than foot
   - small wounds heal better than large blunt wounds
4. Other factors
   A. Diabetes; metabolic disease that compromise tissue repair for many reason and it is one of the most important SYSTEMIC CAUSES OF ABNORMAL WOUND HEALING
   B. Nutritional status; Vit C deficiency inhibits collagen synthesis and retards healing
   C. Glucocorticoid (steroid); result in weakness of the scar due to inhibition of TGF beta production and diminished fibrosis
   D. Poor perfusion; from artheriosclerosis and diabetes or to obstructed venous drainage (in varicose veins) also impair healing
   E. Mechanical factors and foreign bodies
   F. Type and extent of tissue injury

Question 94

Describe abnormalities in Tissue Repair

1. Overproduction of wound healing components (collagen) - 2
   - which remains raised and can spread? Which flattens?
   - which is most common in dark pigmented skin?
2. Too much granulation tissue
3. Inadequate granulation tissue (2 types of complication)
4. Excessive wound contraction
   - where?
   - occur form?

Answer 94

Abnormalities
1. Over production of collagen; both are similar in morphology initially; i) red/dark, raised and firm II) collagen fibers arranged in NODULAR whorls
A. Keloid; African American (can be inherited)
- extend beyond site of original injury
- rarely regress and continue to be composed of nodular whorls of thick collagen bundles
- if excised, most keloid will recur
- high incidence with dark pigmented skin

B. Hypertrophic scar
- flatten spontaneously over the course of one to several years; collagen nodules become smaller and bundles straighten out into parallel arrays

2. Exuberant granulation; proud flesh
   - formation of excessive amounts of granulation tissue, which protrudes above the level of the surrounding skin and blocks reepithelialization this process has been called: Proud Flesh
3. Inadequate granulation tissue - 2 types of complication
   A. Wound dehiscence
   B. Ulceration
   **Lead to; ruptures of the wound common after abdominal surgery
4. Contractions
   - Contractures, particularly prone to develop on palms,
   the soles and anterior aspect of the thorax.
   - Commonly seen after serious burns and can compromise the movement of joints.

Question 95

Define: Granulation Tissue , Angiogenesis

• *Identify 3 components of connective tissue repair

- why are newly formed vessels leaky? Result of this?

Answer 95

• *3 components of connective tissue repair
  1. Granulation tissue (pink, soft, granular appearance)
• formed by migration and proliferation of fibroblasts and deposition of loose connective tissue together with vessels and interspersed leukocytes
• HISTOLOGY; proliferation of fibroblasts and new thin-walled, delicate capillaries (angiogenesis), in a loose extracellular matrix, often with admixed inflammatory cells, mainly macrophages.
• AMOUNT OF GRANULATION TISSUE DEPEND ON SIZE OF TISSUE DEFICIT

2. Angiogenesis ; production of new blood vessels that supply oxygen and nutrients need for repair process
   - by VEGF (increase vascular permeability)
   - Newly formed blood vessels are leaky and result in edema. Leaky because; i) they have incomplete interendothelial junctions and II) the growth factor that drives angiogenesis (VEGF) increases vascular permeability.
3. Remodeling of connective tissue; maturation and reorganized of connective tissue lead to production of STABLE FIBROUS SCAR
   - amount of connective tissue increase in granuloma tissue and lead to scar formation

Question 96

Cancer chemo

**what are the 2 most common cancers that lead to cause of death

Answer 96

1. Lung cancer

2. Bronchial cancer

Question 97

Identify terminologies

1. cancer not detectable by the most sensitive measures
2. zero cancer cells present
3. The first treatment given for a disease. It is often part of a standard set of treatments, such as surgery followed by chemotherapy and radiation.
   Other names?

Answer 97

1. Remission
2. Cure
3. First line therapy
   * *Also called induction therapy, primary therapy, and primary treatment.

Question 98

Combination chemotherapy

• *know combination and cancer it target
• Hodgkin’s disease (2)
• Non-hodgkin’s lymphoma
• breast cancer (2)
• small cell lung cancer
• Germ cell
• cervical
• lymphomas
• ovarian
• pheochromocytoma
• testicular

Answer 98

Several drugs used to treat cancer 
E.g 
MOPP - Hodgkin disease 
ABVD - Hodgkin disease 
CHOP - Non-Hodgkin lymphoma 
CMF - breast 
CAF - breast 
PACE - small cell lung cancer 
VIP - germ cell 
BIP - cervical 
M-BACOD - lymphomas 
BEP- Ovarian 
CVD - pheochromocytoma 
PEB - testicular

Question 99

Describe cell cycle (5)

• *how is this important in cancer therapy?
• *following drugs work in what cell cycle

A. Cytosine arabinoside, hydroxylurea
B. 6-MP, methotrexate
C. Vincristine, vinblastine, paclitaxel
D. ALKYLATING agents, nitrosoureas, antitumor antibiotics, procarbazine, cisplantin, decarbazine

Answer 99

G1; presynthetic or post mitotic phase (18 hr)

• dormant Go enter cell cycle via G1 phase at any time
• The restriction point (or the R point) demarcates the commitment to enter S-phase. Once the cell is past the R-point it is committed to cell division.

S; synthetic phase (6-20hrs)

• The DNA is replicated in S-phase. The S-phase lasts 6-20 hr.
• It is the site of action of many anticancer drugs.
• **S phase specific drugs; Cytosine arabinoside, hydroxylurea
• **S phase specific self-limiting; 6-MP, methotrexate

G2; Postsynthetic phase (3hr)

• Protein and RNA synthesized
• The mitotic spindle apparatus is prepared in the G2 phase. The duration of the G2 phase lasts about 3 hr.
• the cell size doubles.

M; Mitotic phase (1hr)

• cell division occurs here and 2 daughter cells are produced
• **M phase specific; Vincristine, vinblastine, paclitaxel

G0
- the cell is dormant and may enter G1 phase at anytime

• *Some cancer drugs are cell cycle specific while some others are non - cell cycle specific
• ** CCNS ; ALKYLATING agents, nitrosoureas, antitumor antibiotics, procarbazine, cisplantin, decarbazine

Question 100

Common problems with cancer chemotherapy (4)

Answer 100

1. Dose-limiting toxicities
   (BM depression, organ-directed toxicity,neuropathies, etc.)
2. Resistance to chemotherapeutic agents
   - mutation of genes or overexpression of survival genes neutralize the effect of chemotherapeutic drugs.
3. Multidrug resistance (MDR)p-glycoprotein pumps
   - upregulation of p-glycoprotein which promotes the efflux of cancer chemotherapeutic drugs out of the cell and therefore makes it resistant to the action of chemotherapeutic drugs
4. Second Cancers – leukemia & lymphoma

Question 101

1. Classification of anti cancer drugs

2. General drug classes MoA

Answer 101

1. Cancer drug classification
2. ALKYLATING agents
3. Antimetabolites
4. Antibiotics
5. Vinca alkaloids
6. Hormones
7. Miscellaneous
8. Antibodies

2. 
A. Drugs that directly interact with DNA (ALKYLATING agents and drugs with platinum - cisplatin) 
B. Drugs that indirectly damage DNA; anthracyclines, topoisomerase inhibitor, miscellaneous (bleomycins, dactinomycin, mitomycin C) 
Antimetabolites; MTX, 5-FU, 6-MP
Tubulin-binding drugs
Miscellaneous agents
Hormones
Antibodies
Targeted Signal transduction Inhibitors

Question 102

1. Identify class of cancer therapy

• CCNS
• block DNA replication by adding alkyl group to N-7 of guanine in DNA. How do you do this?
• more prone to RESISTANCE (decreased permeability of uptake; increased nucleophiles or repair)
• e.g MELPHALAN (resemble phenylalanine); cell can take up drug thinking it is phenylalanine and then they undergo cell death

**What is mechanism

2. • example of drug that is generally toxic
   • toxicity (adverse effects) ?
3. examples of drugs (9)
   A. Which is not excreted (taken up by body rapidly) and used in Hodgkin’s disease (stage 3 and 4) as part of MOPP

B. MUST BE ACTIVATED FIRST. Toxicity include; hemorrhagic cystitis and SIADH (water intoxication). Used in burkitt lymphoma, ALL, other lymphomas/leukemia
**what is another prodrug?

C. Least toxic nitrogen mustard- only adverse effect is Hepatotoxicity. Used to treat CLL
Others ; Emcyt, Busulfan, Carmustine, Procarbazine; part of MOPP, Decarbazine (DTIC) and Temozolomine (T); ABVD

**what medication reduce likelihood of hemorrhagic cystitis

Answer 102

ALKYLATING AGENTS

• by Cross linking DNA; form cross bridges between 2 G (guanine of DNA)
• cross linking prevents DNA from being separated for synthesis or transcription

2. ACROLEIN is generally toxic (by product of cyclophosphamide activation)
   * *Toxicity; bone marrow suppression, nausea and vomiting (CNS); alopecia, cancer, other (fetal death)
3. Drugs
   A. Mechlorethamine

B. CYCLOPHOSPHAMIDE; used only when absolutely necessary. It is a PRODRUG that must be activated by cytochrome P450**

• Cyclophosphamide and Iphosphamide are both prodrugs
• **MESNA (Na2mercaptoethanesulfonate) is used to decrease hemorrhagic cystitis produced by acrolein. Drug works with both products (Ifex)

C. Chlorambucil

Question 103

Previously discussed ALKYLATING agents (all CCNS) are - mechlorethamine (not excreted), cyclophosphamide (prodrug) and chlorambucin (least toxic). Identify other ALKYLATING agents used as cancer therapy

D.

• originally phosphorylated to increase water solubility because the drug is combination of nitrogen mustard and estradiol
• Given orally; phosphate cleaved during absorption; in vivo binds to β-tubulin; antimitotic effects rather than alklyating effects (CCNS and M-phase)

E. Not a nitrogen mustard; a bis-methyl sulfonate

• CCNS
• Toxicity; Pulmonary fibrosis and hyperpigmentation of the skin

F.

• CCNS
• Toxicity; pulmonary fibrosis and nephrotoxicity; pancreatic –steptozotocin
• Breakdown in vivo to liberate alkylating and carbamylating species; highly lipophilic

G. Part of MOPP for Hodgkin’s disease

• CCNS
• Decreases DNA, RNA, protein synthesis; chromatid breakage and translocation. Inhibits G1 to S phase in cell cycle
• **Avoid MAO inhibitors and alcohol (cause HYPERTENSIVE CRISIS)

H.

• CCNS
• Methylates DNA and RNA; prevent transcription and translation
• for ABVD regimen for Hodgkin’s disease

Answer 103

D. Estramustine (Emcyt)

E. Busulfan (Myleran)

F. Carmustine (BCNU), Lomustine (CCNU), semustine (methyl-CCNU), streptozocin
**Nitrosourea; very lipophilic drugs that cross BBB so first line for brain tumors

G. Procarbazine (Mulutane); part of MOPP,

H. Decarbazine (DTIC) and Temozolomine (T); ABVD

Question 104

Identify class of cancer therapy

• drugs that contain platinum
• first line of therapy for LUNG CANCER
• 3 components (identify)
• CCNS or CCS?

IDENTIFY

• MoA (CCNS or CCS)
• toxicity (4)

**which is most toxic

Answer 104

1. Drugs containing platinum
2. CISPLATIN
3. CARBOPLATIN
4. OXALIPLATIN
5. MoA is CCNS; binds to GUANINE in DNA; forms intrastrand crosslinks with purine bases on DNA and binds extensively to protein
6. Toxicity; NEPHROTOXICITY and peripheral neuropathy
   - others; bone marrow suppression, ototoxicity (hearing loss)
   - avoid cisplatin is renal creatinine clearance is <60ml/ml
   - furosemide (lasix) get rid of toxic metabolites out of kidney

**Oxaliplatin, carboplatin are less toxic than cisplatin

Question 105

Identify class of cancer chemo

1. agents that indirectly damage DNA (3)
   - which is CCNS? CCS?
   - CARDIOTOXICITY? Prevented by?

Answer 105

1. Anthracycline; Doxorubicin, Daunorubicin - CCNS - CARDIOTOXICITY
2. Topoisomerase - active agents - CCS
3. Miscellaneous ; bleomycins (CCS), actinomycetes, mitomycin C

Question 106

Identify cancer medication - class of drugs that indirectly damage DNA

1. • indirectly damage DNA by tight binding between base pairs
   • CCNS
   • CARDIOTOXICITY
   • *identify MoA
2. • another related compound to #1
   • FREE RADICALS NOT PRODUCED
   • lower incidence of CARDIOTOXICITY

Answer 106

1. DOXORUBICIN
   A. MoA of Docorubicin/Adriamycin **ABVD
   - Tight binding between base pairs in DNA; interacts with DNA by intercalating the 2 strands of DNA and inhibition of transcription
   - Blocks the activity of topoisomerase II; relaxes supercoils and tangles in DNA for transcription
   - Single and double strand breaks in DNA
   - Inhibition of DNA repair.
   - Cause histone eviction from open chromatin
   B. CCNS
   C. Toxicity; CARDIOTOXICITY (irreversible) - prevented by DEXRAZOXANE
   D. Uses
   - breast cancer, sarcoma
   - MOPP
2. MITOXANTRONE
   - Binds to DNA like doxorubicin to produce drug-DNA-topoisomerase II complexes that lead to DNA strand breaks.
   - Free radicals not produced.
   - Lower incidence of cardiotoxicity than doxorubicin, but can be severe when it develops.

Question 107

Identify cancer medication - class of drugs that indirectly damage DNA

• 2 classes
• CCS
  1. MoA; forms a ternary complex with DNA topoisomerase II. Kills in S and G2 phases
• identify uses

2. MoA; Inhibitors of topoisomerase I
   - CCS; acts in S phase
   * *toxicity?
   * *what prodrug is activated by tissue carboxyesterases (high in carcinoma)

Answer 107

1. Epipodophyllotoxins; etoposide and tenopside. **Derivatives of podophyllotoxin
   Uses; testicular tumors (along with bleomycin + cisplatin); small cell lung cancer (along with cisplatin)
2. Camptothecin analogs; camptothecin, topotecan and ironotecan
   - SEVERE DIARRHEA
   * * IRINOTECAN is a prodrug activated by tissue carboxyesterases (high in carcinoma).

Question 108

Identify class of anti cancer therapy - class of antibiotics that indirectly damage DNA

• MoA; bind to reduced iron in cells and lead to free radical production. DNA scission occurs with inhibition of repair.
• CCS; G2 phase
• toxicity; PULMONARY FIBROSIS AND PNEUMONITIS
• Uses; testicular cancer

Answer 108

ANTIBIOTICS; Bleomycins

• A combination of several structurally related antibiotics.
• Most active in G2 phase.
• Unique toxicities – pulmonary fibrosis and pneumonitis (fatal 10-20%); cutaneous reactions; low grade fever; minimal BM suppression.
• Uses – Advanced testicular carcinoma (+combined with Vinblastine + Cisplatin; cure rate= 90%); lymphomas in combination therapy

Question 109

Identify class of cancer drugs - class of antibiotics that indirectly damage DNA

• CCNS
• some single strand breaks also occur
• MoA; Interaction of peptide loops of dactinomycin at purine-pyrimidine (dG-dC) base pairs of DNA and intercalate between the DNA strands. Prevents DNA transcription.

Identify
Potency
Toxicity
Uses

Answer 109

Actinomycetes (Actinomycin D)

• most potent anti-tumor agent known
• Unique toxicities – oral and GI ulceration; stomatitis.
• Therapeutic uses
  Methotrexate (MTX)-resistant choriocarcinoma
  Wilm’s tumor
  Rhabdomyosarcoma

Question 110

Identify class of cancer chemo

• Compounds that mimic endogenous biochemicals required for DNA, RNA synthesis or function of key enzymes.
• 3 components
  A. Resembles folic acid and binds to enzyme dihydrofolate reductase (DHFR)
  **Identify MoA
  CCNS or CCS?
  Uses
  Toxicity

Answer 110

1. ANTIMETABOLITES
   A. Folic acid; METHOTREXATE (MTX)
   B. Pyrimidines; 5-Fluorouracil (FU)
   C. Purines; 6-mercaptopurine (MP)
2. MTX inhibits dihydrofolate reductase (DHFR) to block the biosynthesis of thymidylic acid and purines - decreases DNA synthesis; pemetrexed also directly inhibits thymidylate synthase, GAR formyltransferase, AICAR formyltransferase
3. Application of Methotrexate and Pemetrexed:
   - Choriocarcinoma : (75-90% cure rate for methotrexate combined with dactinomycin)
4. Other Uses
   Maintenance in acute lymphocytic leukemia (ALL) in children; less active in adult leukemias
   Combination therapy of Lymphomas, carcinomas, sarcomas
5. Unique toxicities
   Oral & GI ulceration; hepatotoxicity; pulmonary toxicity

Question 111

Antimetabolites
1. Folic acid analogs

2. Leucovorin “rescue” function?
3. Example of Purine and pyrimidine antimetabolites
   - pro-drug which is converted to 5-FU by carboxyesterases and cytidine deaminases in the liver.

Answer 111

1. Folic acid analogs
   A. Methotrexate
   B. Trimetrexate
   C. Pemetrexate; directly affect thymidylate synthase
2. Minimize toxic effects of folate depletion in normal cells
   - Metothrexate depletes folate in both cancer cells and normal cells so you need leukovorin to help minimize effect of folate toxicity (administer 36 after MTX administration)
3. Capecitabine

Question 112

Other purine and pyrimidine antimetabolites (3)

1. • CCNS; G1 and S phase
   • MoA; Decreased DNA synthesis by inhibition of thymidylate synthase. Incorporation into DNA; unstable. Incorporation into RNA; altered function
   • toxicity; oral and GI ulceration. Stop at earliest signs of stomatitis and diarrhea
2. • CCS-S phase
   • ORAL ULCERATION
   • what is MoA/
3. • CCNS
   • First line chemo for pancreatic cancer
   • how does it inhibit DNA synthesis?
4. Purine antimetabolites **CSS at S phase
   - 6MP vs allopurinol

Answer 112

1. 5-FU (fluorouracil)
   - MoA; active form is 5-FdUMP. inhibits the action thymidyate synthase (way you get purines). This leads to depletionof nucleotide pools in the cells inhibiting DNA synthesis and replication. It also forms FUTP and FdUTP which cause DNA and RNA damage leading to cell death.
2. Cytarabine (Ara-C); Cystostar
   - Inhibits DNA polymerase alpha
   - Incorporation into DNA; unstable; chain termination
3. Gemcitabine
   - Inhibits DNA synthesis via many mechanisms after formation of active form (dFdCTP).
4. The metabolism of 6-MP is inhibited by the xanthine oxidase inhibitor allopurinol. Allopurinol is often prescribed to patients suffering from gout. If a patient is taking allopurinol, it is necessary to lower his dose of 6-MP, because the degradation and metabolism of 6-MP is blocked by allopurinol.

Question 113

Identify class of cancer therapy

• Includes what 3 drugs
• Inhibit adenosine deaminase directly or via metabolites; the build up of adenosine and deoxyadenosine nucleotides decreases DNA synthesis by inhibiting ribonucleotide reductase and other enzymes necessary for DNA synthesis.
• Used in hairy cell leukemia (cladribine is the drug of choice) and other leukemias and lymphomas.

Answer 113

ADENOSINE DEAMINASE INHIBITORS

- pentostatin, cladribine and flydarabine

Question 114

Identify class of cancer therapy

• plant alkaloids (2)
  1. CCS M phase
• MoA; Bind specifically to SOLUBLE TUBULIN, a key protein component of cellular microtubules, to block polymerization and arrest cellular mitosis in metaphase.
• identify toxicity?

2. CCS M phase (2)
   - MoA; Prevents microtubule deploymerization by binding to and stabilizing POLYMERIZED TUBULIN. Cells are arrested in late G2 or M phase (M phase specific).
   - identify toxicity?

Answer 114

TUBULIN - BINDING AGENTS

1. Vinca alkaloids; vincristine (VC), vinblastine (VB) and vinorelbine (VR)
   - toxicity; PERIPHERAL NEUROPATHY (VC especially), Alopecia (hair loss), nephrotoxicity SIADH secretion
2. Yew alkaloids; paclitaxel, docetaxel (synthetic analog of paclitaxel)
   - toxicity; PERIPHERAL NEUROPATHY (dose limiting)

Question 115

Identify cancer chemotherapy

• similar to structure to pesticide DDT
• blocks hormone production by adrenal Gland and also destroy both adrenal cancer cells and healthy adrenal tissue
• *Identify side effects
• effect on cell cycle

Answer 115

MITOTANE

• CCNS
• Toxicity; Fatigue and nausea. (From low cortisol)
• **Tx; STEROID hormone pills are usually given to minimize the side effects

Question 116

Identify class of anti cancer drugs

• cytokines that occur naturally in the body
• Inhibits tumors by regulating the host immune system of the patient. They also have direct activity against cancer cells.
• combat viral replication against host cells
• CCNS or CCS?
• toxicity?

Answer 116

INTERFERONS (INF alpha is an anti-cancer drug)

CCNS; slows G1 - S; S - G2
Toxicity; relatively NON-TOXIC

Question 117

Identify targeted therapies for cancer

1. Best used for Breast cancer, endometrial and prostate cancers (these cancers have receptors on their membranes)
2. Block cell surface receptors which promote growth or block receptors which facilitate tumor angiogenesis
3. Interaction of CTLA-4 with B7 blocks T cell activation
   - antibodies that target CTLA4 will facilitate T cell activation
4. Target intracellular growth pathways overexpressed/amplified in cancer

Answer 117

1. Hormones ; selectively kill cancer cells that have on hormone receptors on their membranes. E.g breast, endometrial and prostate cancer
   Drugs are; prednisone, progestin, antiestrogen, antiandrogen
2. Antibodies; ERBB1. There must be production of VEGF for angiogenesis to take place that promote cancer cell growth
   - humanized antibody against CD20 will suppress this growth
3. Cancer immunotherapy; slow moving field because tumor has a way of invading cells
4. Targeted inhibitors of cancer growth

Question 118

Identify hormone drugs used in targeted cancer therapy (4)

1. Anti-inflammatory properties and alter immune responses. They also causes apoptosis in certain leukemic cells
2. Used in hormone responsive cancers expressing progesterone receptor
3. Not a steroid. WEAK ESTROGEN ACTIVITY
   - Used in estrogen receptor positive breast cancer
4. Blocks androgen-induced growth. Normally combined with leuprolide or other luteinizing hormone releasing hormone (LHRH) agonist.

Answer 118

1. Prednisone
   - Hodgkin’s disease (MOPP), acute leukemias, relapsed hairy cell leukemia lymphomas.
   - manage hemolytic anemia and hemorrhagic complications of lymphomas and CLL
2. Progestin (synthetic progesterone and its derivatives)
3. Antiestrogens
   - TAMOXIFEN and Toremefine
4. Anti-androgens
   - Casodex (bicalutamide), eulixin (glutamine) and Nilandron (nilutamide)
   - The combination of anti-androgens with leuprolide facilitates total androgen ablation

Question 119

Identify antibodies used in cancer therapy (6)

• *remember first 4 (Drug, MoA and toxicity)
• *Identify toxicity
  1. Blocks VEGF and prevents angiogenesis

2. Blocks RNAK-RANK ligand in bone
3. Blocks Her2/c-Neu
4. Blocks CD20 on B cells

Answer 119

• • Toxicities not as bad as conventional chemotherapy
    1. Bevaczimab (Avastin)
• toxicity; IMPAIRED WOUND HEALING, HEMORHHAGE, THROMBOSIS

2. Denusomab
   - Toxicity; DERMATITIS, PROPENSITY FOR INFECTIONS
3. Trastuzumab (Herceptin)
   - Toxicity; HEPATOTOXICITY, PULMONARY TOXICITY RASH
4. Rituximab
   - Toxicity; HEADACHE, FEVER, DIARRHEA

Question 120

What is first line treatment of B-cell Non-Hodgkin lymphoma

Answer 120

R-CHOP REGIMEN

Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone

Question 121

Identify cancer immunotherapy targeted against cancer therapy? (4)

**MONOCLONAL ANTIBODIES (-mab) ; bind to PD-a or PGL-1 and reactivate T cells and destroy the tumor

1. PROSTATE CANCER use under investigation but FDA approved for metastatic melanoma
   - blocks CTLA4
   - toxicity?
2. Blocks CTLA4
   - toxicity?
3. Blocks PD-1
   - toxicity?
4. FDA approved for METASTATIC MELANOMA**

Answer 121

1. Ipilimumab
   - toxicity; COLITIS
2. Tremelimumab
   - toxicity; DIARRHEA, COLITIS, SKIN RASH
3. Nivolumab
   - toxicity; Fatigue, colitis, skin rash
4. Pembrolizumab
   - toxicity; fatigue and skin rash

**1 and 4 used in clinic; metastatic melanoma (4), prostate cancer (1)

Question 122

Identify targeted inhibitors of cancer growth

*3 major synthetic compounds
INHIBITORS - (-inib)
1. Blocks BCR-Abl kinase

2. Blocks EGFR signaling
3. Blocks ALK-1 kinase

Answer 122

1. Imatinib (Gleevec); synthesis inhibitor to BCR-Abl kinase
   - use; CML
2. Erlotinib, Gefitinib
3. Crizotinib

Question 123

Identify class of cancer chemo 
**Drugs that inhibit anti-apoptotic proteins; The Bcl-2 protein is an endogenous inhibitor of apoptosis 

1. Drugs that inhibit anti-apoptotic protein; binds to Bcl-2 and inhibits its anti-apoptotic activity
   - approved for tax of refractory CLL
2. Drugs targeting epigenetics signaling
3. Drugs targeting DNA repair process (PARP)
   - trap PARP and lead to DNA damage

Answer 123

1. Venetoclax
2. HDACs INHIBITORS; Vorinostat and Romidepsin
   - Histone acetylation is an important determinant of gene expression. Histone deacetylases (HDACs) are critical regulators of gene expression that enzymatically remove the acetyl group from histones. HDAC INHIBITORS have been found to have anti-cancer effects
3. PARP-1 inhibitors; OLAPARIB
   - The inhibition of PARP-1 leads to cellular apoptosis.

Question 124

Identify newer chemotherapy drugs (4)
*identify advantage of drug

1. Drug class; Anthracyline
2. Drug class; ER blocker - lacks partial estrogen activity
3. Drug class; IV nanoparticle, albumin-bound formation of paclitaxel
4. Drug class; organic platinum containing chemo
   - DOES NOT CAUSE platinum resistance

Answer 124

1. AMIRUBICIN; Reduced cardiotoxicty
2. FULVESTRANT; useful for estrogen responsive cancers
3. ABRAXANE; cremophor-free
   - paclitaxel protein-bound particles for injectable suspension
   - designed to give greater amount of chemo to cancer cells with FEWER SIDE EFFECTS
4. PICOPLATIN; does not cause platinum resistance

Question 125

Explain how inflammation, normally a beneficial immune response, can lead to cancer.

Answer 125

Inflammation to cancer

• First response to injury (acute INFLAMMATION); innate immunity. **New thing about lecture is how tumor is recognized – NEO ANTIGENS if expressed are more likely to be recognized
• If you don’t remove acute inflammation leads to CHRONIC INFLAMMATION (continual release of cytokines) - excessive epithelial proliferation lead to activation of oncogenes - tumor suppression lost (DCC and p53)- small to large to invasive tumor - METASTASIS
• cancer cells continue to proliferate and grow
• • In addition, continued inflammatory processes resulting in leukocyte and tissue derived pro-inflammatory cytokines can cause cancer.

Question 126

Describe the evidence that the immune response does have an important role in the recognition and elimination of tumor cells. (5)

• what types of tumor can regress spontaneously?
• immune cells infiltrate what?
• what is in circulation of cancer pt?
• tumor occur more frequently in what age group of pts?
• tumor arise in what types of patient

Answer 126

Evidence; Immune recognition of tumors

1) spontaneous regression of certain tumors does occur (without treatment, melanoma for instance)
2) Infiltration of solid tumors with immune cells.
3) Tumor-specific antibodies in circulation of cancer patients. Pick up tumors reactive antibodies in the blood or cancer pts.
4) tumors tend to occur more frequently in young and aged patients.
5) tumors often arise in immunosuppressed patients. E.g HIV (CD4 low - higher incidence of certain tumors)

Question 127

Describe what is meant by a tumor-infiltrating leukocyte (TIL). How do the numbers and types of leukocytes differ between tumor involved tissue and normal adjacent tissue.

Answer 127

TIL - Tumor infiltrating leukocytes

• Number and types of T cells (TIL) affect survival. The higher and better quality of cells the better chance of survival (DC, M1, helper CD4 T cells, cytotoxic CD8 T cells); anti cancer

A. 2 types of macrophages; M1 and M2. More M2 tend to enhance tumor growth (Th2, Th17). M1 are TUMOR KILLERS (Th1). The difference is in the cytokines they make

**High Tregs = poor prognosis

Question 128

Explain how different leukocytes can promote tumor progression vs. having a role in the elimination of tumor cells. ** Leukocytes that promote tumor vs eliminate tumor cells

A. cell types 
B. cytokine profiles
C. distribution 
D. associated features 
E. Functional impact

Answer 128

1. Pro-tumorigenic inflammation
   A. Cell types; M2 macrophage, myeloid derived suppressor cells, neutrophils, FOXP3, Tregs, Th17
   B. Cytokine profiles; Th2, Th17
   C. Distribution; peritumoral
   D. Associated features; STAT3 phosphorylation
   E. Functional impact; negative prognostic impact
2. Anti-cancer immunosurveillance
   A. Cell types; DC, M1 macrophage, helper CD4 T cells, cytotoxic CD8 T cells with memory effector phenotype
   B. Cytokine profiles; Th1, CX3CL1, CXCL9, CXCL10
   C. Distribution; intra tumors, close to cancer cells as well as at invasive front
   D. Associated features; high endothelial venules
   E. Functional impact; positive prognostic and predictive impact

Question 129

Explain the difference between a tumor associated (TAA) antigen vs. a tumor specific antigen (TSA). List different types of TAAs vs. TSAs.

• location

Answer 129

Tumor antigens (TAA or TSA); elicit both CMI and humoral immunity. The same antigen, different epitopes, elicit both T cells and antibody formation

1. TAA (tumor associated antigens); found on BOTH TUMOR AND NORMAL CELLS
   A. Re-expressed embryonic antigens
   B. Over-expressed self protein
   C. Examples of “self antigens” recognized by both immune effector mechanisms; tyrosinase, CEA, MAGE
   - CEA; expressed in gut but also lung and breast cancer
   - Tyrosinase; makes melanin
   - MAGE; first group of antigens discovered. Found in the TESTES during development ad can be expressed in tumors that develop later in life.
2. TSA (tumor specific antigens) ; found ONLY IN TUMOR CELLS (neoantigens)
   A. mutations in normal cellular proteins (Neoantigens)
   B. Oncogenic viral antigen

Question 130

Explain how tumor antigens (either TAA or TSA) are processed and presented to either CD4 or CD8 T cells.

• where is antigen captured?
• where is antigen presented to T cells?
• how are CD8s activated?

Answer 130

1. Step 1 - peptide antigen presented by MHC class I on normal cells
2. Step 2 - Cells undergo mutation and become cancerous
   3a. Step 3 (TSA - Nonself)
   - Presentation of mutant peptide from mutated cellular protein
   * *tumor escape immunity by downregulating class I
   3b. Step 3 (TAA - Self)
   - Reactivation of embryonic genes not normally expressed in the differentiated cell
   - Overexpression of normal self protein by a tumor cell changes density of self-peptide presentation, allowing recognition by T cells

Dendritic cells capture process and present peptides obtained from tumor debris
- Where is antigen captured? Tumor site.
- Where is antigen presented to T cells? Draining lymph node.
Stimulation of CD4+ T helper cells: TCR:MHC class II + peptide.
Th1, Th2, Tfh, Th17, Tregs produce cytokines (both pro and anti-tumor effects).
Polarization of Th1 vs. Th2.
- How are CD8s activated? “Cross presentation” Small peptides leak from endosomes and bind to MHC class I proteins.

Question 131

Explain similarities and differences between different mechanisms of killing between CTL, NK cells, and macrophages.

• which is direct cytotoxicity
• which is perforin mediated cytotoxicity
• which is nonspecific cytotoxicity

**what mediates macrophage toxicity

Answer 131

Mechanism of killing

1. NK cells; bind directly - DIRECT CYTOTOXICITY. Look for reduced MHC class I expression. Gamma delta T cells also act this way
2. Macrophages; kill. Within solid tumors have altered functions
   - NONSPECIFIC CYTOTOXICITY . NO mediates macrophage toxicity
   - Activation of macrophages is dependent on IFNγ and a second signal
   - Activated macrophages selectively kill tumor cells.
   - Activated macrophages release several cytotoxic factors.
3. CTL; deliver lethal hit. PERFORIN MEDIATED CYTOTOXICITY- tumor specific

Question 132

How is FAS/FASL killing related to granule-mediated killing of tumor cells?

Answer 132

1. FAS/FASL killing
   - FAS ligand (FASL) is present on lymphocytes binds FAS and induce apoptosis.
   - The killer cells that have this lack perforins and granzymes (for CTL killing) but can still kill
2. Granule-mediated killing

Question 133

Describe the ways tumor cells evade tumor directed immunity.

1. Tumor cells rely on 2 things for success
   - 5 ways to evade recognition
2. What 2 mutated gene products help tumor cells escape?

Answer 133

1. A. Neo-vascularization /angiogenesis; way in which tumor cells establish a source of nutrients

B. Mechanism to evade recognition
I. Down regulate MHC class I antigens
II. Down regulate tumor associated antigens (TAA)
III. Tumor cells release suppressive cytokines (TGF-beta, IL-10)
IV. Tumors induce the host to release suppressive cytokines
V. Tumors attract or stimulate the generation of Tregs and MDSCs.

2. Tregs or MDC
   - high levels of Tregs leads to poor prognosis

Question 134

Describe the difference between Treg and MDSC mediated evasion of immunity.

• *Evasion of anti-tumor immune response is mediated by Tregs and MDSC cells
• derived from ?

Answer 134

1. Treg evasion
   - lymphoid precursor, control immune responses
   - natural or thymic derived
   - Inducible or antigen specific
2. MDSC evasion (myeloid derived suppressor cells)
   - MDSC release Arginase**
   - granulocytic vs monocytic

Question 135

Describe the 4 modes of cancer therapy. Discuss limitations associated with each approach. Can different modes be utilized together? If so, how and
what might be the advantages of such an approach?

Answer 135

4 modes of cancer therapy (with limitations)

1. Surgery; remove as much of the bulk tumor as possible
2. Radiation therapy; destroy residual tumor in the surgical field, the immediate surrounding area and known sites of metastasis
3. Chemotherapy; use of cyto-reductive chemicals (adriamycin, platinum compounds etc) to reduce tumor burden and destroy micro-metastatic tumor deposits
4. IMMUNOTHERAPY
   - first cellular therapy approved was DC vaccine. Series of antibodies later approved (checkpoint inhibitors). IL2 was the first cytokine approved to treat renal cell cancer and now approved for melanoma
   - Advantage; MANY IMMUNOTHERAPY HAVE NO SIDE EFFECTS but some do - vascular leak syndrome
   - Disadvantage; EXPENSIVE

**Immunotherapy can be used in COMBINATION with conventional modes of cancer therapy.

Question 136

Describe the differences between passive and active immunotherapy. Name examples of each.

• which use own body’s immune system?
• which do not rely on body?

Answer 136

1. Passive immunotherapy; you make the reagent in your lab and assume it will function when you inject in the patient. Do not rely on body to attack the disease.
   A. MONOCLONAL ANTIBODY infusions; antibody binds to the tumor and mediate complement and lysis. List of approved antibodies;
   B. CYTOKINES
2. Active immunotherapy; stimulate body’s own immune system to fight the tumor
   - therapeutic vaccines
   - cell therapies
   - adjuvants

Question 137

1. What are the expectations following both conventional and immunotherapy approaches to cancer treatment.
2. What are the 3 Es of Immune editing?
3. Can cancer ever be considered a chronic disease?

Answer 137

1. Expectations; cancer patient wanted to be cancer free and have complete tumor regression. Outcomes where; some CR - complete response, PR; partial response, MR; some regressing, some arising - NR; no response. Our expectations are;
   - delay time to progression
   - delay time too recurrence
   - MAINTAIN QUALITY OF LIFE
2. Immune editing ; Dynamic interaction of elimination, Escape and equilibrium
   A. Elimination; immune system prevails
   B. Escape ; tumor prevails - death of host
   C. Equilibrium; co-existence btw immune system and tumor. Immune system keel proliferating tumor cells under control
3. Chronic disease

Question 138

There are a number of ways to utilize antibodies in cancer immunotherapy.
Describe different means of utilizing antibodies and discuss the origin of the antibody and how that origin may dictate the number of times the antibody can be infused.

1. Different sources of antibodies
2. Ways antibodies work

Answer 138

Antibodies

1. Different sources (suffix)
   A. -Omab; murine 100% mouse
   B. -ximab; chimeric (65% human) - bind to Fc region
   B. -zumab; humanized (>90% human)
   C. -umab; fully human (100% human)
   **Reduction in immunogenicity from full mouse (murine) to fully human ; inject only once in murine to avoid reaction?
2. Ways antibodies work
   A. TIL therapy (tumor vaccine); lymphodepletion prior to T cell transfer is followed by immune reconstitution
   • Lots of Tregs in the tumor so treat patients with Citoxane to deplete T cells
   • Another drug given to reduce number of Tregs and now response rate has increased. Works well in melanoma
   • Doesnt work in immunogenic cancer - ovarian
   - treat with tyrosinase; affected hair follicles by converting brown to white hair

Question 139

How can a biopsy obtained from a patient with metastatic melanoma be utilized in an immunotherapy strategy? Describe natural barriers to the
success of the strategy. How can these barriers be overcome?

Answer 139

1. Biopsy; active immunization - (Tumor vaccines) 
• Injection of purified
tumor antigen plus
adjuvant) 
• Injection of tumor antigen
on dendritic cells

2. Natural barriers
   • Lots of Tregs in the tumor so treat patients with Citoxane to deplete T cells
   • Another drug given to reduce number of Tregs and now response rate has increased. Works well in melanoma
   • Doesnt work in immunogenic cancer - ovarian

Question 140

Describe a preventative vs. a therapeutic vaccine. Discuss different ways to generate and utilize anti-tumor vaccines consisting of autologous or
allogeneic sources of tumor antigen.

Answer 140

1. A. Preventative vaccine
   - Vaccines designed to stimulate T cells or B cells
   to make tumor specific antibodies. These can prevent tumor recurrence.

B. Therapeutic vaccine; type of active immunotherapy; stimulate the body’s own immune system to fight the tumor. 3 different approaches
I) Transfect tumor with B7 which will stimulate T cell activation (CD8)
II) Transfect tumor cell with GM-CSF; this will recruit DC which will present tumor antigens to T cells
III) Autologous DC vaccine (provenge)

Question 141

1. Discuss different means of assessing the potency of immunotherapy strategies in the laboratory.
   - what is key for cancer therapy?
2. What are the FDA recent approved approaches to immunotherapy (3)

Answer 141

1. Biomarkers
   - EXPECTATIONS are key for any cancer therapy

2. 
A. DC vaccine; provenge 
B. Checkpoint inhibitors 
- Anti CTLA 4; ipilimumab (yervoy) 
- Anti PD1; pembrolizumab (keytruda) 
- Anti PDL1; atezolizumab (tecentria), avelumab (bavencio), druvalumab (imfinzi) 
C. CAR T cells 
- tisagenlecienucel (kmriah) 
- axicabtageneciloleucel (yescarta)

Question 142

Describe the Provenge vaccine in terms of how it is made and what the clinical results tell you about acceptable clinical outcomes.

Answer 142

PROVENGE vaccine ; prostate cancer

• Intradermal immunization
• prostate cancer molecule PAP with GM-CSF; GM-CSF induce monocytes to mature into dendritic cells. PAP internalized with GM-CSF and processed into peptides that are presented by MHC class II. The activated DC are infused into patient where they travel to the spleen and present PAP antigens to naive T cells
• EQUILIBRIUM - prolong life of patient (tumor cell and immune cells coexist)

Question 143

Describe different “Checkpoint Inhibitors”. How are these inhibitors related to peripheral tolerance mechanisms?

Answer 143

Checkpoint Inhibitors **most recent approved antibody (blood inhibitory signals)
- works against visceral disease

A. Anti-CTLA4 antibody; blocks binding of CTLA4 to CD28 to maintain T cell activation

B. PD1 and/or PDL-1; works on tumor cells

Question 144

Describe the steps necessary to generate a CART cell therapy.

**Does this therapy work against solid tumors? If not, why?

Answer 144

CAR T cell (3 generations)

• second generation most utilized now; link variable region and heavy and light chains to CD28 and also with CD3zeta. Maintain COSTMULATION and SIGNALLING
• Construct; make gene - transfect - purify - inject

**You can make in solid tumors but DO NOT WORK WELL

Question 145

What is cytokine storm and how can it be controlled during the administration of certain immunotherapies.

Answer 145

Cytokine Storm ; cytokine release syndrome; Elevation of cytokines correlated to tumor burden and also to an sCRS

CD19 CAR T cells can be associated with toxicities including;

• high grade fevers
• hypotension
• hypoxia
• neurological disturbances
• *May require aggressive medical support

Prevention

• developed biomarkers to monitor levels (based on IL6 levels in the body)
• have anti-IL6 antibody that they used to reduce the levels