Hansemann, Boveri, chromosomes and the gametogenesis-related theories of tumours.

Theodor Boveri (1862-1915) is often credited with suggesting (in 1914) the first chromosomal theory of cancer, especially in terms of abnormal numbers of chromosomes arising in cells by multipolar mitoses in adult cells. However, multipolar mitoses in animal cells had been described as early as 1875, and Hansemann (1858-1920), in publications between 1890 and 1919, included this mechanism among various ways by which abnormal chromosome numbers might arise in cells and cause tumour formation. Both theories were conceived in a period when gametogenic ideas of tumour formation were current. Boveri based his theory on the observation that some cells in early sea urchin embryos having abnormal chromosome complements wander from their usual developmental paths. His observation may have been seen by other authors at the time as support for Cohnheim's "embryonic cell rest" theory of cancer. Hansemann's contribution is seen as both the original, and the more significant of the chromosomal theories of cancer.

Alkylating agents and DNA polymerases.

Alkylating agents, for example nitrogen "mustards", are variably toxic, mutagenic, carcinogenic and teratogenic, but by mechanisms which have not been clearly established. In particular, the mechanisms both of their delayed toxic effects (which are primarily against dividing cells, in association with retardation of the rate of cell division, disruption of mitoses, and breakages and other abnormalities of chromosomes) and of their carcinogenic actions are not understood. The literature on the testing of thousands of analogues has demonstrated great variability of effects on the various cell biological phenomena, and no aspect of chemical structure or biochemical reactivity of these agents has been established as especially related to any particular effect. Here theories of the mechanisms of action of alkylating agents are reviewed and it is suggested that impairment of the functions of DNA polymerase complexes might contribute to some of the effects of alkylating agents. In particular, impairment of replicative fidelity of DNA during the S-phase could contribute to some of the mitotic and chromosomal effects, as well as to their carcinogenic and teratogenic potencies. Some aspects of testing the effects of alkylating agents on components of the DNA synthetic pathway are mentioned. Emphasis is given to consideration of the various relevant levels (conventional plasma/tissue; tissue/tumour cell cytoplasm; tumour cell cytoplasm/tumour cell nucleus and tumour nuclear karyoplasm/tumour chromatin] of the pharmacokinetics and pharmacodynamics of the agents and their metabolites.

Cancer morphology, carcinogenesis and genetic instability: a background.

Morphological abnormalities of both the nuclei and the cell bodies of tumour cells were described by Müller in the late 1830s. Abnormalities of mitoses and chromosomes in tumour cells were described in the late 1880s. Von Hansemann, in the 1890s, suggested that tumour cells develop from normal cells because of a tendency to mal-distribution and other changes of chromosomes occurring during mitosis. In the first decades of the 20th century, Mendelian genetics and "gene mapping" of chromosomes were established, and the dominant or recessive bases of the familial predispositions to certain tumour types were recognised. In the same period, the carcinogenic effects of ionising radiations, of certain chemicals and of particular viruses were described. A well-developed "somatic gene-mutational theory" of tumours was postulated by Bauer in 1928. In support of this, in the next three decades, many environmental agents were found to cause mitotic and chromosomal abnormalities in normal cells as well as mutations in germ-line cells of experimental animals. Nevertheless, mitotic, chromosomal, and other mutational theories were not popular explanations of tumour pathogenesis in the first half of the 20th century. Only in the 1960s did somatic mutational mechanisms come to dominate theories of tumour formation, especially as a result of the discoveries of the reactivity of carcinogens with DNA, and that the mutation responsible for xeroderma pigmentosum causes loss of function of a gene involved in the repair of DNA after damage by ultraviolet light (Cleaver in 1968). To explain the complexity of tumourous phenomena, "multi-hit" models gained popularity over "single-hit" models of somatic mutation, and "epigenetic" mechanisms of gene regulation began to be studied in tumour cells. More recently, the documentation of much larger-than-expected numbers of genomic events in tumour cells (by Stoler and co-workers, in 1999) has raised the issue of somatic genetic instability in tumour cells, a field which was pioneered in the 1970s mainly by Loeb. Here these discoveries are traced, beginning with "nuclear instability" though mitotic-and-chromosomal theories, single somatic mutation theories, "multi-hit" somatic theories, "somatic, non-chromosomal, genetic instability" and epigenetic mechanisms in tumour cells as a background to the chapters which follow.

Embryonic reversions and lineage infidelities in tumour cells: genome-based models and role of genetic instability.

Reversions to "embryonic precursor"-type cells and infidelities of tumour cell lineage (including metaplasias) have been recognized as aspects of various tumour types since the 19th century. Since then, evidence of these phenomena has been obtained from numerous clinical, biochemical, immunological and molecular biological studies. In particular, microarray studies have suggested that "aberrant" expressions of relevant genes are common. An unexplained aspect of the results of these studies is that, in many tumour types, the embryonic reversion or lineage infidelity only occurs in a proportion of cases. As a parallel development during the molecular biological investigation of tumours over the last several decades, genetic instability has been found much more marked, at least in some preparations of tumour cells, than that identified by means of previous karyotypic investigations of tumours. This study reviews examples of embryonic reversion and lineage infidelity phenomena, which have derived from the various lines of investigation of cancer over the last 150 or so years. Four categories of circumstances of the occurrence of embryonic reversions or lineage infidelities have been identified - (i) as part of the defining phenotype of the tumour, and hence being presumably integral to the tumour type, (ii) present ab initio in only some cases of the tumour type, and presumably being regularly associated with, but incidental to, the essential features of the tumour type, (iii) occurring later in the course of the disease and thus being possibly a manifestation of in vivo genetic instability and "tumour progression" and (iv) arising probably by genetic instability, during the processes, especially cell culture, associated with ex vivo investigations. Genomic models are described which might account for the origin of these phenomena in each of these circumstances.

The cell-type-specificity of inherited predispositions to tumours: review and hypothesis.

Most hereditary predispositions to tumours affect only one particular cell type of the body but the genes bearing the relevant germ-line mutation are not cell-type-specific. Some predisposition syndromes include increased risks of lesions (developmental or tumourous) of unrelated cell types, in any individual predisposed to the main lesion (e.g. osteosarcoma in patients predisposed to retinoblastoma). Other predispositions to additional lesions occur only in members of some families with the predisposition to the basic lesion (e.g. Gardner's syndrome in some families suffering familial adenomatous polyposis). In yet other predisposition syndromes, different mutations of the same gene are associated with markedly differing family-specific clinical syndromes. In particular, identical germline mutations (e.g. in APC, RET and PTEN genes), have been found associated with differing clinical syndromes in different families. This paper reviews previously suggested mechanisms of the cell-type specificity of inherited predispositions to tumour. Models of tumour formation in predisposition syndromes are discussed, especially those involving a germline mutation (the first 'hit') of a tumour suppressor gene (TSG) and a second (somatic) hit on the second allele of the same TSG. A modified model is suggested, such that the second hit is a co-mutation of the second allele of the TSG and a regulator which is specific for growth and/or differentiation of the cell type which is susceptible to the tumour predisposition. In some cases of tumour, the second hit may be large enough to be associated with a cytogenetically-demonstrable abnormality of the part of the chromosome carrying the TSG, but in other cases, the co-mutation may be of 'sub-cytogenetic' size (i.e. 10(2)-10(5) bases). For the latter, mutational mechanisms of frameshift and impaired fidelity of replication of DNA by DNA polyerases may sometimes be involved. Candidate cell-type-specific regulators may include microRNAs and perhaps transcription factors. It is suggested that searching the introns within 10(5)-10(6) bases either side of known of exonic mutations of TSGs associated with inherited tumour predisposition might reveal microRNA cell-type-specific regulators. Additional investigations may involve fluorescent in situ hybridisations on interphase tumour nuclei.

Carcinogen-induced impairment of enzymes for replicative fidelity of DNA and the initiation of tumours.

Not all carcinogens are mutagens, and many mutagens are not carcinogens. Among related chemicals, small changes of structure can markedly influence carcinogenic potency. Many tumours are genetically unstable, but some, especially 'benign' types, rarely exhibit 'progression' or show other evidence of genetic instability. Cells of particular tumour types exhibit identifiable particular 'sets' of phenotypic abnormalities (e.g. rapid growth, uniform nuclei, little cytoplasm and occasionally production of adrenocorticotrophic hormone by anaplastic small-celled carcinoma of the bronchus). Tumour cells pass their abnormalities on to their daughter cells, indicating that a genomic alteration probably underlies tumour formation. A possible mechanism, which might explain these phenomena is carcinogen-induced reduction of fidelity of replication of DNA polymerase complexes during S phase of normal tissue stem cells. A single 'hit' by a reactive agent (chemical or physical) on one of the major enzymic sites (synthesis, proofreading, mismatch repair-MMR) could cause multiple sequence abnormalities in the length of DNA synthesized by one DNA polymerase complex. Because this length of DNA (half a replication 'bubble') averages 15 000-150 000 nucleotides, the affected DNA could include two or more significant genomic elements (genes, especially for tumour suppression, regulatory loci and other elements). The particular mutant elements in the affected DNA could then determine the 'set' of phenotypic abnormalities exhibited by a resulting tumour. Non-genotoxic carcinogenicity, non-carcinogenic mutagenicity, structure-dependent chemical carcinogenicity and the phenomenon of 'sets' of phenotypic abnormalities could thus be accommodated. In experimental studies, the 'hallmark pattern' of mutation caused by this mechanism would be multiple mainly point mutations clustered within the length of half a replication 'bubble'. Such a 'hallmark pattern' of mutation might be detectable in carcinogen-treated cell cultures by the use of cycle-synchronized cultures, single cell subculturing, restriction (endonuclease) fragment length analysis of the clones and nucleotide sequencing of abnormal bands for localization in the human genome. If the mechanism is important to carcinogenesis generally, then non-carcinogenic mutagens should not cause the 'hallmark pattern' of mutations in either in vitro or in vivo systems. In human tumour cells, the 'hallmark pattern' of mutations may be demonstrable in genetically stable human tumours, but might well be lost or obscured by secondary mutations in genetically unstable tumours. Among different cases of the same type of human tumour, the clustered point mutations might be tumour-type specific in their location in the genome, but vary case-to-case in the precise 'points' mutated in the cluster region. New assays for assessing the carcinogenic potential of environmental and synthetic substances for human and animal populations may result. The hypothesis is not put forward to the exclusion of some established mechanisms of carcinogenesis for particular human tumours: for example, the 'two-hit' mutational hypothesis for retinoblastoma, the 'multiple sequential mutational' hypothesis for UV-induced lesions of the epidermis, and the possibility of adduct-induced frameshift mutations by some chemical carcinogens for experimental tumours.

Cardiac involvement in a case of acute lymphoblastic leukemia.

We present an extremely rare case of an immunocompromised patient with a T-cell acute lymphocytic leukemia relapse presenting as a right atrial tumor. Problems in diagnosis, vulnerability due to previous immunosuppression and bone marrow transplant, and successful surgical excision are highlighted. Cardiac involvement with hematologic neoplasms should be taken with more than academic interest, as it may be amenable to treatment.