Radiol Oncol 2006; 40(Suppl 1): S121-S126.
New discoveries in prostate cancer pathogenesis
Novosti pri patogenezi raka prostate
Gregor Mikuž
Institute of Pathology, Medical University Innsbruck, Austria
Background. Through PSA screening the rate of prostate cancers detected at an early stage has increased significantly; thus a decrease in mortality can be expected in the near future. Despite all scientific efforts, however, the molecular mechanisms underlying the development and progression of prostate cancer remain poorly understood. Prostate cancer is a disease of aging men and epidemiological evidence supports a major contribution to its development through diet, lifestyle and environmental factors.
Genetic instability is the basic phenomenon of tissue cell cancerisation. This instability can be hereditary or due to mutations and other chromosomal aberrations acquired during life. In recent years a large number of interesting data have been collected which show the relationships between focal atrophy and genetic instabi-lity of the prostate epithelia. Atrophy can be the result of prostatitis, ischemia as well as of oxidative stress (diet). Several chromosomal aberrations typical for prostate cancer (loss of 8p22; gain of 8q24 and X) can be already detected in the epithelia of the atrophic areas. Moreover also the deactivation of a gene (GSTP1) which encodes a carcinogene-detoxification enzyme has been found in such epithelia. Conclusions. Molecular pathology is slowly revealing the links which exist among age, atherosclerosis and oxidative stress (diet), inflammation and the pathogenesis of prostate cancer. In the near future perhaps this knowledge will enable us to actively prevent this most common malignancy of elderly men.
Kay words: prostatic neoplasms – diagnosis – therapy; pathogenesis
S122
Mikuž G / New discoveries in prostate cancer pathogenesis
Izhodišče. Rak prostate je trenutno najpogostejši zlohotni tumor moških, ki so starejši od 50 let. S PSA (prostata specifični antigen) presejanjem seveda število novih obolenj, ki so diagnosticirana v zgodnjem, ozdravljivem stadiju, stalno narašča, umrljivost pa bo začela že v bližnji prihodnosti vidno padati. Vkljub temu, da se veliko število raziskovalcev po celem svetu posveča raku prostate, ostajajo problemi njegove etiopatogeneze še vedno nerešeni in skrivnostni. Epidemiološke študije kažejo, da so vzroki nastanka tega raka verjetno združeni s starostjo, prehrano, življenjskimi navadami (life style) in tudi z neznanimi eksoge-nimi dejavniki.
Destabilizacija genetskega materiala v celicah je osnovni fenomen pri nastajanju raka. Destabilizacija je lahko prirojena ali pa jo povzročajo mutacije kromosomov, ki nastajajo tekom življenja. Novejše znanstvene raziskave kažejo, da destabilizacija genov začenja že z acinarno atrofijo, ki je lahko posledica vnetja, pre-krvavitvenih motenj in tudi “oksidacijskega stresa” (prehrana). Različne aberacije kromosomov, ki so zelo značilne za raka prostate (izguba 8p22; amplifikacija 8q24 in X kromosoma), lahko dokažemo že tudi v celicah atrofičnih acinov. Poleg tega je v teh celicah deaktiviran gen (GSTP1), pristojen za tvorbo encimov, ki skrbijo za detoksifikacijo karcinogenov.
Zaključki. Molekularna patologija počasi razkriva kavzalne povezave, ki obstajajo med starostjo, arteriosklerozo, prehrano, vnetjem in patogenezo raka na prostati. Mogoče nam bodo v bližnji prihodnosti ta odkritja pomagala v aktivni prevenciji tega najpogostejšega raka starejših moških.
Ključne beside: prostata, novotvorba – diagnostika – zdravljenje; patogeneza
Introduction
The incidence of prostate cancer has incre-ased greatly over recent decades and it is now the most common malignancy of men in many Western countries. The risk of prostate cancer is 1 in 6 and the risk of death due to prostate cancer is 1 in 341,2.
Through PSA (prostate specific antigen) screening the rate of prostate cancers de-tected at an early stage has increased si-gnificantly; thus a decrease in mortality can be expected in the near future3. One million prostate biopsies and some 200,000 prostatectomies in Western Europe and the U.S. are the direct consequence of PSA screening. For the same reason, scientific interest in prostate cancer has increased dramatically. The enormous amount of pro-Correspondence to: Prof. Gregor Mikuž MD, FRCPath, Institute of Pathology, Medical University Innsbruck, Innsbruck, Austria; Phone: + 43 512 900 371 301; Fax: + 43 512 58 20 88; E-mail: gregor.mikuz@i-med.ac.at
state tissue available for morphological, biochemical and molecular biological in-vestigations is obviously very helpful for a successful scientific work. Despite all these scientific efforts, however, the molecular mechanisms underlying the development and progression of prostate cancer remain poorly understood.
Prostate cancer is a disease of aging men in Western Europe and the U.S., with the highest rates among Afro-Americans and significantly lower rates among Asiatic men. Epidemiological evidence supports a major contribution through diet, lifestyle and environmental factors to the development of prostate cancer4. The level of animal fat intake and consumption of red meat are associated with an increased risk of prostate cancer, whereas vegetables pro-bably protect against cancer5,6. The familial predisposition is a risk factor only in < 10% of prostate cancer7. There is evidence of both autosomal dominant and X chromo-some linked inheritance in some families.
Radiol Oncol 2006; 40(Suppl 1): S121-S126.
Mikuž G / New discoveries in prostate cancer pathogenesis
S123
However, no known cancer syndrome in-cludes prostate cancer.
Pathogenesis
The cancer forerunner PIN (prostatic in-traepithelial neoplasia) is a morphological endpoint of intraglandular cancer development, but it does not explain the pathoge-nesis of this neoplasm. Recent studies5,8,9 reappraised the old (1954) hypothesis of Franks,10 that the atrophy of prostate glan-ds and the subsequent proliferation of the glandular epithelia represent the initial lesion which can develop into cancer.
Atrophy is encountered in more or less all (>90%) prostate biopsies performed for cancer detection and in >80% of autopsy samples.11,12 This type of atrophy is the focal atrophy which can be classified in 4 subtypes13 and not the very rare diffuse one, which is due to androgen decrease in circulating blood. But obviously, not all types of focal atrophy can be the starting point for cancer development. Only atrophy with hyperplasia of the basal cells showed a marked proliferative activity of the epi-thelia and a lower frequency of apoptosis in the atrophic glands.9 De Marzo propo-sed the name “proliferative inflammatory atrophy” (PIA) to underline the fact that the lesion is proliferative and associated with inflammation. Inflammation, however, is only one of the common causes of atrophy. But other causes like ischemia or oxidative stress (diet) may be just as frequent as in-flammation.
Genetic instability is the basic pheno-menon of tissue cell cancerisation. This instability can be hereditary or due to mutations and other chromosomal aberra-tions acquired during life. Once the genetic material has been disarranged, control and repair mechanisms do not work properly and new injuries lead to further instability.
Chronic inflammation and regeneration is an extremely complex injury which is able to severely disturb genetic programs invol-ved in the control of proliferative activity and apoptosis.
In recent years a large number of in-teresting data have been collected which show the relationships between prostati-tis, subsequent focal atrophy and genetic instability of the prostate epithelia. Even two prostate cancer susceptibility genes are somehow involved in the host response to infectious agents. Mutations can thus re-duce the ability to destroy such agents and lead to chronic infection.4,14 The RNASEL gene, located on chromosome 1q24-25, encodes an endoribonuclease which is in-volved in the degradation of viral and cel-lular RNA.15 Perhaps even more important the macrophage scavenger receptor 1 gene (MSR 1) located at 8p22, which encodes subunits of a macrophage scavenger whi-ch is capable of binding ligands including bacterial lipopopolysaccharide. Moreover the receptor is involved in the oxidation of high – (HDL) and low – (LDL) den-sity lipoprotein in serum. Mice without MSR gene are vulnerable to many bacterial and viral (Herpes simplex 1) infections.16 In the prostate this gene is expressed in the macrophagen at the site of infection. Mutations in MSR1 were detected in fami-lies with hereditary prostate cancer17 and even in 2.52% of men with sporadic prostate cancer [4]. Loss of chromosome 8p22 seems to be an early event in the prostate cancer progression. Our investigations sho-wed that a significant loss of 8p22 starts al-ready in the epithelia of the atrophic glands in the prostate.18
Another important step in the cance-risation is the gain of chromosome 8q24, which could also be demonstrated in the glands of the atrophic areas in the prosta-te.18 The gain of 8q24 means amplification of the oncogene c-myc, which is involved
Radiol Oncol 2006; 40(Suppl 1): S121-S126.
S124
Mikuž G / New discoveries in prostate cancer pathogenesis
Figure 1. FISH images of nuclei from prostate cells from atrophic areas. 3 signal for centromere X (Spectrum Orange) and 1 signal for centromere Y (Spectrum Green).
in the immortalisation of prostate cells in cell cultures.19 In the early stage of prostate cancer c-myc probably gives the cells a “proliferative advantage” allowing them to grow under unfavourable conditions. In advanced tumour stages, c-myc contributes to the androgen-independent growth of prostate cancer.20
Cytogenetical analysis (CGH and FISH) on atrophic areas also detected significant gains of the entire chromosome X (Figure 1) as sole aberration.21 The androgen receptor gene located on chromosome Xq11-13 enco-des the androgen receptor protein through which androgens exert their intracellular regulation of prostate growth and cellular differentiation. Additional androgen recep-tor gene copies are present in patients with prostate cancer due to polysomy of the chromosome X.22 Real time PCR demon-strated that even one additional copy of the androgen receptor gene may increase androgen receptor expression suggesting that even small increases in relative gene dosage could have biological significance.23
The growth of the prostate cancer is known to be extremely dependent on androgens. Therefore the androgen receptor is an im-portant mediator of androgen dependent cell growth. Examinations of androgen re-ceptor gene alterations in atrophic are-as are needed for the early diagnosis of prostate cancer, selection of prevention and treatment strategies. Thus far, it can be assumed that prostate cells with multiple copies of androgen receptor have a selective advantage also in low concentra-tion of androgen.24 A susceptibility locus on chromosome X, the HPCX (Hereditary Prostate Cancer X) was identified also in prostate cancer families. The X chromo-some linked PAGE4 gene is expressed in normal prostate and highly expressed in prostate cancer.25 Interestingly, a cell line that expresses PAGE4 showed a down-re-gulation of LPL (lipoprotein lipase), which is located on 8p22 and frequently deleted in prostate cancer and atrophy as already mentioned above.
Another link between inflammation and cancer represents the hypermetilation (inactivation) of GSTP1 gene which enco-des a carcinogene-detoxification enzyme. This enzyme defends the prostate epithelia against carcinogens and is present in the basal cells but not in the prostate carci-noma cells.4 The inactivity of the enzyme leads to damage of the epithelial DNA and to genetic instability.
One of the major objections to this the-ory is that atrophy of the prostate glands is not always associated with inflamma-tion. Atrophy, however, can also be due to ischemia.26 In fact, the arteries of the prostate glands show a significantly higher narrowing in patients with prostate can-cer than in control groups.27 The enzyme cyclooxygenase -2 (COX 2) could be a link among different causes, because COX2 is involved in carcinogenesis as well as in in-flammation and ischemia.28 Some studies
Radiol Oncol 2006; 40(Suppl 1): S121-S126.
Mikuž G / New discoveries in prostate cancer pathogenesis
S125
Figure 2. Hypothetical molecular pathogenesis of prostate carcinoma (modified after Nelson).4
clearly showed that daily use of non ste-roidal anti-inflammatory drugs (NSAIDs) significantly reduces the risk of prostate cancer.29 Moreover, genes (MSR 1) involved in prostate cancer pathogenesis are also involved in lipid metabolism.
Conclusions
Molecular pathology is slowly revealing the links which exist among age, atherosclero-sis and oxidative stress (diet), inflammation and the pathogenesis of prostate cancer (Figure 2). Our knowledge is still fragmen-tary but we are permitted to hope that in the near future we will be able to actively prevent (NSAIDs, antioxidants?) this most common malignancy of elderly men.
References
1.   Greenlee RT, Hill Harmon MB, Murray T, Thun M. Cancer statistics. CA Cancer J Clin 2001; 51: 15-36.
2.   http.//www.cancer.org. American Cancer Society. Cancer facts and figures: Graphical data. 2002.
3.   Horninger W, Berger A, Pelzer A, Klocker H, Oberaigner W, Schonitzer D. Screening for prostate cancer: updated experience from the Tyrol study. Curr Urol Rep 2004; 5: 220-5.
4.   Nelson G W, De Marzo A, Isaacs WB. Prostate cancer. N Engl J Med 2003; 349: 366-81.
5.   Giovannucci E, Rimm EB, Colditz GA, Stampfer MJ, Ascherio A, Chute CC, et al. A prospective study of dietary fat and risk of prostate cancer. J Natl Cancer Inst 1993; 85: 1571-9.
6.   Chan JM, Giovannucci EL. Vegetables, fruits, associated micronutrients, and risk of prostate cancer. Epidemiol Rev 2001; 23: 82-6.
Radiol Oncol 2006; 40(Suppl 1): S121-S126.
S126
Mikuž G / New discoveries in prostate cancer pathogenesis
7.   Carter BS, Beaty TH, Steinberg GD, Carter BS, Steinberg GD, Beaty TH, et al. Familial risk factors for prostate cancer. Cancer Surv 1991; 11: 5-13.
8.   De Marzo AM, Marchi VL, Epstein JI, Nelson WG. Proliferative inflammatory atrophy of the prostate: implications for prostatic carcinogenesis. Am J Pathol 1999 ; 155: 1985-92.
9.   Ruska KM, Sauvageot J, Epstein JI. Histology and cellular kinetics of prostatic atrophy. Am J Surg Pathol 1998; 22: 1073-7.
10. Franks LM. Atrophy and hyperplasia in the prostate proper. J Pathol Bacteriol 1954; 68: 617-21.
11. Postma R, Schroder FH, van der Kwast TH. Atrophy in prostate needle biopsy cores and its re-lationship to prostate cancer incidence in screened men. Urology 2005; 65: 745-9.
12. Billis A. Prostatic atrophy: an autopsy study of a histologic mimic of adenocarcinoma. Mod Pathol 1998; 11: 47-54.
13. De Marzo AM, Platz EA, Epstein JI, Ali T, Billis A, Chan YT, et al. A working group classification of focal prostate atrophy lesions. Am J Surg Pathol 2006; 30: 1281-91.
14. Nelson WG, De Marzo AM, DeWeese TL, Isaacs WB. The role of inflammation in the pathogenesis of prostate cancer. J Urol 2004; 172(5 Pt 2): S6-S12.
15. Zhou A, Hassel BA, Silverman RH. Expression cloning of 2-5A-dependent RNAase: a uniquely regulated mediator of interferon action. Cell 1993; 72: 753-65.
16. Thomas CA, Li Y, Kodama T, Suzuki H, Silverstein SC, El Khoury J. Protection from lethal gram-positive infection by macrophage scavenger receptor-dependent phagocytosis. J Exp Med 2000; 191: 147-56.
17.  Maier C, Vesovic Z, Bachmann N, Herkommer K, Braun AK, Surowy HM, et al. Germline mutations of the MSR1 gene in prostate cancer families from Germany. Hum Mutat 2006; 27: 98-102.
18. Yildiz-Sezer S. Verdorfer I, Schafer G, Rogatsch H, Bartsch G, Mikuz G. Assessment of aberrations on chromosome 8 in prostatic atrophy. BJU Int 2006; 98: 184-8.
19. Gil J, Kerai P, Lleonart M, Bernard D, Cigudosa JC, Peters G, et al. Immortalization of primary human prostate epithelial cells by c-Myc. Cancer Res 2005; 65: 2179-85.
20. Bernard D, Pourtier-Manzanedo A, Gil J, Beach DH. Myc confers androgen-independent prostate cancer cell growth. J Clin Invest 2003; 112: 1724-31.
21. Yildiz-Sezer S, Schäfer G, Rogatsch H, Bartsch G, Mikuz G. Gain of chromosome X in prostatic atrophy detected by CGH and FISH. Prostate 2006; 61: in press.
22. Ropke A, Erbersdobler A, Hammerer P, Palisaar J, John K, Stumm M, et al. Gain of androgen receptor gene copies in primary prostate cancer due to X chromosome polysomy. Prostate 2004; 59: 59-68.
23. Linja MJ, Savinainen KJ, Saramaki OR, Tammela TL, Vessella RL, Visakorpi T. Amplification and overexpression of androgen receptor gene in hor-mone-refractory prostate cancer. Cancer Res 2001; 61: 3550-5.
24. Visakorpi T, Kallioniemi AH, Syvanen AC, Hyytinen ER, Karhu R, Tammela T, et al. Genetic changes in primary and recurrent prostate cancer by comparative genomic hybridization. Cancer Res 1995; 55: 342-7.
25. Iavarone C, Wolfgang C, Kumar V, Duray P, Willingham M, Pastan I, et al. PAGE4 is a cytopla-smic protein that is expressed in normal prostate and in prostate cancers. Mol Cancer Ther 2002; 1: 329-35.
26. Meirelles LR, Billis A, Cotta AC, Nakamura RT, Caserta NM, Prando A. Prostatic atrophy: evidence for a possible role of local ischemia in its pathogenesis. Int Urol Nephrol 2002; 34: 345-50.
27.  Hager M, Mikuz G, Bartsch G, Kolbitsch C, Moser PL. Association between local atherosclerosis and prostate cancer. Br J Urol 2006; in press.
28. Hussain T, Gupta S, Mukhtar H. Cyclooxygenase-2 and prostate carcinogenesis. Cancer Lett 2003; 191: 125-35.
29. Nelson JE, Harris RE. Inverse association of prostate cancer and non-steroidal anti-inflammatory drugs (NSAIDs): results of a case control study. Oncol Rep 2000; 7: 169-70.
Radiol Oncol 2006; 40(Suppl 1): S121-S126.