**1. Introduction**

[149] Jackson EL, Willis N, Mercer K, *et al*. Analysis of lung tumor initiation and progres‐ sion using conditional expression of oncogenic K-ras. *Genes Dev* 2001;15:3243-8.

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2002;16:217-26, 229; discussion 230-2.

60 Oncogenesis, Inflammatory and Parasitic Tropical Diseases of the Lung

lung cancer diagnostics? *Oncol Rep* 2009;21:3-11.

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the lung of transgenic mice overexpressing the RON receptor tyrosine kinase. Recep‐

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Tobacco-smoke is associated with 75-90% of LC cases and ~50% occurs in developing countries (Parkin, et al. 2005; Parkin, et al. 1994). Several studies have demonstrated that organic and inorganic compounds are related with the development of cancer, including LC (Bradley and Golden 2006; De Palma, et al. 2008; Stavrides 2006). The association between cigarette smoking and various types of respiratory cancer has been demonstrated (U.S.EPA 2001) and many carcinogenic compounds present in cigarette smoke, such as polycyclic aromatic hydrocarbons (PAHs), have also been identified in airborne particles in different cities around the world (Adonis, et al. 1997; Gil, et al. 1995; Minoia, et al. 1997; Monarca, et al. 1998).

Cancer rates could further increase by 50% to 15 million new cases in the year 2020, according to the World Cancer Report (World Cancer Report, 2003). The report also reveals that cancer has emerged as a major public health problem in developing countries, matching its effect in industrialized nations. During 2008, more than 1.61 million of new LC cases and 1.31 million of deaths were reported worldwide (Ferlay et al, 2010), accounting for 13% of the total. More than half (55%), of the cases occurred in the developing countries. In South America the estimation for 2008, showed an incidence rate for men of 20.4 /100,000 inhabitant and a mortality rate of 18.8 /100,000 inhabitant (WHO, 2008). For the same period, the women showed a rates/100,000 inhabitant of 8.4 for incidence and 7.4 for mortality.

PAHs are metabolized to reactive DNA binding diols epoxides by phase I enzymes as cytochrome P4501A1 (CYP1A1) and detoxified by phase II enzymes as GSTs, before reaching their target. Adonis et al (2005), have proposed that the contribution of individual variations in metabolic activities of each or both phases, in regulating the clearance of DNA toxic

metabolites, are at least partially related to the individual host susceptibility to PAHs. Several polymorphisms have been described in CYP1A1, however, 3´noncoding region (Msp1, CYP1A1\*2A) has been the most studied (Gil et al, 1992; Adonis et al. 1997, Quiñones et al, 2001; Adonis et al, 2005a, 2005b, Ji et al, 2012).

changes in detection of pre neoplastic, pre invasive lesions or in the initial steps in LC devel‐ opment. LC has been described as one of the most aggressive diseases with multiples genomic changes or alterations in specific fragments of the DNA, some of them including genes associated with the cell system preservation within normal parameters. Some of the changes might promote a transformation from a normal cell into a tumour cell in a multistage process.

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The genomic age, the new images technologies and informatics, probably will demand in a short time from the government, health professionals (clinic and basic), public and private

Cancer diagnosis can be done in different stages of the disease. The cancer diagnosis has as main objectives to know the localization (place) and also to identify the stage (stage) and the histological characterization (kind). The knowledge of the place, stage and kind will help to define the treatment and will determine the survival and the clinic success. For LC the current technologies are arriving late, indeed more than 85% of the LC patients died after the diagnosis (McWilliams et al, 2009; Nakamura et al., 2001; Kennedy et al., 2007; Woolner et al., 1984). The main reason of the high mortality is related with the small fraction of the patients detected in

Obviously, the early diagnosis will load in the clinic success in term of treatment and survival. The use of new technologies as complementary tools might chance or improve the early detection and the treatment success. The use of the advanced technologies might reduce the mortality, thus it is possible not only detect early stages but also to have early treatment.

Early detection has a direct relationship with the population screening, in order to identify risk population, healthy population and or asymptomatic population, especially for LC asympto‐ matic in the early stages. Smoking habit is probably the main risk factor for LC, however additional factors might contribute to the risk of LC. Among the LC risk factors is valid to mention environmental pollution, occupational exposure, life style and genetic factors. That mean, that among the population is possible to find people with a high risk of LC, which would be the main candidates to a screening programme to detect pre neoplastic lesions or early

Within some of the news or advances technologies can be mentioned, Quantitative Automatic Cytology (QAC), Autofluorescence-reflectance bronchoscopy (AFB) and the tumor biomarker DR70, used in a pilot study for early detection of LC, in a high risk population. These tech‐ nologies have been studied in Chile in a LC risk population, exposed to high levels of air pollutants (Santiago) and on the other hand to high historical exposure to As in drinking water (Antofagasta). Part of these results, were presented in an oral presentation, titled "Pilot Study for Lung Cancer and Pre neoplastic Lesions", in the XXX1 Word Congress of Internal Medicine (WCIM, 2012), where the work got the Award for the First Best Research Work. This is a report of an ongoing prospective bimodality cancer surveillance study for high risk LC volunteers. This study has been done in 364 people, exposed naturally to environmental pollution and where the biomarkers, QAC and DR70 (Onko Sure), were used as tools in the detection of preneoplastic lesions (PNL) and neoplastic lesions (NL). The study has also included Auto‐ fluorescent Bronchoscopy (AFB) as an additional technique, to detect pre neoplastic or pre

early stages. This is mainly related with absence of symptoms in an early stage.

institutions, etc., new actions to improve the public health.

stages.

Additionally, the association between inorganic Arsenic (iAs) and skin, bladder, and lung carcinogenesis has been well-established. It is estimated than 220 million in 105 countries are exposed worldwide to iAs (Murcott, 2012). In the Northern Chilean region of Antofagasta, the population (close to 500,000 inhabitants) have been chronically exposed to As concentrations as high as 870 μg l–1 from 1958 through 1970, with some towns still registering concentrations of 600 μg l–1 by the year 2000 (Smith et al, 1998). This has occurred despite international guidelines placing the maximum tolerable arsenic exposure at 10 μg l–1 (IARC, 2004).

As occurs naturally in soil, water and air, the main sources of environmental As exposure in Chile are copper smelters and drinking water (Queirolo et al., 2000; De Gregori et al, 2003). Chile, with a population close to 17.1 million (http://data.worldbank.org/country/chile) and a total life expectancy at birth of 78 years, shows a high rate of lung cancer (LC), especially in the North of Chile. During 2007, Chile showed more than 2,500 LC cases and 1,900 deaths. Between 1990 and 2008 the LC national mortality rate/100.000 inhabitants for both gender increased since 10.8 to 14.6; while for the period 2003–2007, the Antofagasta region (Northern Chile) showed a rate mortality of 30.8/100.000, the second rate mortality higher after skin cancer (Vallebuona, 2011). To stratify by gender, the Antofagasta region for the same period showed for men the highest LC rate mortality/100.000 (53.1), higher than prostate (38.9), and skin (50.4).

The mechanism by which As causes cancer is still no clear and has been speculated that its carcinogenicity potency in humans might be modulate by concurrent exposure to other agents that modify the risk of cancer to As, as environmental pollution containing high levels of carcinogen compounds (Adonis et al, 2005) and or smoking (Thomas et al, 2001), as well as both genetic and epigenetic processes (Salnikow and Zhitkovich, 2008). As is metabolized through a series of reductions of pentavalents to trivalent species, followed by oxidative methylations to yield pentavalent methylated species. It is well recognized that inorganic As is methylated to monomethyl As acid (MMA) and dimethyl As acid (DMA) with a methyl group from S-adenosylmethionine. As reduction of As to the trivalent form is a prerequisite for oxidative methylation, pentavalent arsenicals are reduced by endogenous thiols such as glutathione (GSH) or by AsV reductases (Kala el al., 2000; Radabaugh & Aposhian, 2000, Zakharyan et al., 2001; Radabaugh et al., 2002). Liver is the main site of methylation, but methylation activity is present in all tissues (Vahter, 2002). Arsenic3 methyltransferase (As3MT) is the key enzyme in the biotransformation of iAs. As3MT catalyzes the transfer of a methyl group from S-adenosyl-methionine to trivalent arsenicals resulting in the production of Monometil As(MAs) and dimethylated arsenicals \*3 (DMAs). MAs is a susceptibility factor of iAs induced toxicity, before to be excreted in the urine.

As was mentioned before, the high incidence of lung cancer (LC) has been associated with cigarette smoking, however genetic diversity and environmental pollution must also be considered as risk factors, especially in those cities highly exposed to environmental carcino‐ gens. Although, there are many advances in the disease control, very little is known about changes in detection of pre neoplastic, pre invasive lesions or in the initial steps in LC devel‐ opment. LC has been described as one of the most aggressive diseases with multiples genomic changes or alterations in specific fragments of the DNA, some of them including genes associated with the cell system preservation within normal parameters. Some of the changes might promote a transformation from a normal cell into a tumour cell in a multistage process.

metabolites, are at least partially related to the individual host susceptibility to PAHs. Several polymorphisms have been described in CYP1A1, however, 3´noncoding region (Msp1, CYP1A1\*2A) has been the most studied (Gil et al, 1992; Adonis et al. 1997, Quiñones et al, 2001;

Additionally, the association between inorganic Arsenic (iAs) and skin, bladder, and lung carcinogenesis has been well-established. It is estimated than 220 million in 105 countries are exposed worldwide to iAs (Murcott, 2012). In the Northern Chilean region of Antofagasta, the population (close to 500,000 inhabitants) have been chronically exposed to As concentrations as high as 870 μg l–1 from 1958 through 1970, with some towns still registering concentrations of 600 μg l–1 by the year 2000 (Smith et al, 1998). This has occurred despite international

As occurs naturally in soil, water and air, the main sources of environmental As exposure in Chile are copper smelters and drinking water (Queirolo et al., 2000; De Gregori et al, 2003). Chile, with a population close to 17.1 million (http://data.worldbank.org/country/chile) and a total life expectancy at birth of 78 years, shows a high rate of lung cancer (LC), especially in the North of Chile. During 2007, Chile showed more than 2,500 LC cases and 1,900 deaths. Between 1990 and 2008 the LC national mortality rate/100.000 inhabitants for both gender increased since 10.8 to 14.6; while for the period 2003–2007, the Antofagasta region (Northern Chile) showed a rate mortality of 30.8/100.000, the second rate mortality higher after skin cancer (Vallebuona, 2011). To stratify by gender, the Antofagasta region for the same period showed for men the highest LC rate mortality/100.000 (53.1), higher than prostate (38.9), and skin (50.4). The mechanism by which As causes cancer is still no clear and has been speculated that its carcinogenicity potency in humans might be modulate by concurrent exposure to other agents that modify the risk of cancer to As, as environmental pollution containing high levels of carcinogen compounds (Adonis et al, 2005) and or smoking (Thomas et al, 2001), as well as both genetic and epigenetic processes (Salnikow and Zhitkovich, 2008). As is metabolized through a series of reductions of pentavalents to trivalent species, followed by oxidative methylations to yield pentavalent methylated species. It is well recognized that inorganic As is methylated to monomethyl As acid (MMA) and dimethyl As acid (DMA) with a methyl group from S-adenosylmethionine. As reduction of As to the trivalent form is a prerequisite for oxidative methylation, pentavalent arsenicals are reduced by endogenous thiols such as glutathione (GSH) or by AsV reductases (Kala el al., 2000; Radabaugh & Aposhian, 2000, Zakharyan et al., 2001; Radabaugh et al., 2002). Liver is the main site of methylation, but methylation activity is present in all tissues (Vahter, 2002). Arsenic3 methyltransferase (As3MT) is the key enzyme in the biotransformation of iAs. As3MT catalyzes the transfer of a methyl group from S-adenosyl-methionine to trivalent arsenicals resulting in the production of Monometil As(MAs) and dimethylated arsenicals \*3 (DMAs). MAs is a susceptibility factor

As was mentioned before, the high incidence of lung cancer (LC) has been associated with cigarette smoking, however genetic diversity and environmental pollution must also be considered as risk factors, especially in those cities highly exposed to environmental carcino‐ gens. Although, there are many advances in the disease control, very little is known about

guidelines placing the maximum tolerable arsenic exposure at 10 μg l–1 (IARC, 2004).

Adonis et al, 2005a, 2005b, Ji et al, 2012).

62 Oncogenesis, Inflammatory and Parasitic Tropical Diseases of the Lung

of iAs induced toxicity, before to be excreted in the urine.

The genomic age, the new images technologies and informatics, probably will demand in a short time from the government, health professionals (clinic and basic), public and private institutions, etc., new actions to improve the public health.

Cancer diagnosis can be done in different stages of the disease. The cancer diagnosis has as main objectives to know the localization (place) and also to identify the stage (stage) and the histological characterization (kind). The knowledge of the place, stage and kind will help to define the treatment and will determine the survival and the clinic success. For LC the current technologies are arriving late, indeed more than 85% of the LC patients died after the diagnosis (McWilliams et al, 2009; Nakamura et al., 2001; Kennedy et al., 2007; Woolner et al., 1984). The main reason of the high mortality is related with the small fraction of the patients detected in early stages. This is mainly related with absence of symptoms in an early stage.

Obviously, the early diagnosis will load in the clinic success in term of treatment and survival. The use of new technologies as complementary tools might chance or improve the early detection and the treatment success. The use of the advanced technologies might reduce the mortality, thus it is possible not only detect early stages but also to have early treatment.

Early detection has a direct relationship with the population screening, in order to identify risk population, healthy population and or asymptomatic population, especially for LC asympto‐ matic in the early stages. Smoking habit is probably the main risk factor for LC, however additional factors might contribute to the risk of LC. Among the LC risk factors is valid to mention environmental pollution, occupational exposure, life style and genetic factors. That mean, that among the population is possible to find people with a high risk of LC, which would be the main candidates to a screening programme to detect pre neoplastic lesions or early stages.

Within some of the news or advances technologies can be mentioned, Quantitative Automatic Cytology (QAC), Autofluorescence-reflectance bronchoscopy (AFB) and the tumor biomarker DR70, used in a pilot study for early detection of LC, in a high risk population. These tech‐ nologies have been studied in Chile in a LC risk population, exposed to high levels of air pollutants (Santiago) and on the other hand to high historical exposure to As in drinking water (Antofagasta). Part of these results, were presented in an oral presentation, titled "Pilot Study for Lung Cancer and Pre neoplastic Lesions", in the XXX1 Word Congress of Internal Medicine (WCIM, 2012), where the work got the Award for the First Best Research Work. This is a report of an ongoing prospective bimodality cancer surveillance study for high risk LC volunteers. This study has been done in 364 people, exposed naturally to environmental pollution and where the biomarkers, QAC and DR70 (Onko Sure), were used as tools in the detection of preneoplastic lesions (PNL) and neoplastic lesions (NL). The study has also included Auto‐ fluorescent Bronchoscopy (AFB) as an additional technique, to detect pre neoplastic or pre invasive lesions in the voluntaries with high likehood of malignance for LC, according to AQC and DR70.

exposed naturally to environmental air pollution (Metropolitan region) or to arsenic in

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65

In addition, we enrolled subjects who were suspected of having lung cancer (N=12) based on their clinical symptoms, with the final diagnosis completed in the study. These patients did not have previous tests performed on them such as cytology or CT and did not have any treatment. However, only 12 of them were in agreement to undergo to the AFB, while all of

The voluntaries were classified according to their risk score, which allowed for classification of the subjects in three risk categories: low, medium and high. Subjects with medium or high risk were invited to participate in the study. The LC risk predictor was applied to 508 volunteer participants, obtaining 364 subjects with medium to high-risk for LC. Of those, 224 were from

Sputum generation was induced by inhalation of 3% saline solution, after administration of two puffs of salbutamol. Patients were instructed to cough and expectorate before their Specimens were collected in 50 mL centrifuge tubes, followed by adding enough SedFix solution. Each tube was mixed with DTT solution and was shaken at 1800 rpm overnight. After centrifugation, a cell pellet was obtained; re suspended in an ethanol solution and was placed on slides. The cell DNA was stained with Feulgen thionin and was analysed by an automated

Furthermore, blood samples were taken in serum separator tubes in the morning before ingestion of any meal. The tubes were left at room temperature for 30 minutes. The serum was separated from the cells by centrifugation at 3,500 rpm for 10 min. Each serum specimen was diluted 1:200 with the diluent buffer and was tested along with the calibrators according to AMDL Diagnostics Onko Sure protocol (Radient Pharmaceuticals) as described in Adonis et

Participants with positive DR70 test (threshold>1.0), or an AQC score ≥4.6 were invited to have an AFB, using the Onco-LIFE device (Novadaq Inc., Richmond, Canada), under local anaes‐ thesia. The airways were examined by, White Light Broncoscopy (WLB) and Auto Fluores‐ cence Broncoscopy (AFB) and the visual findings were classified as normal, abnormal or suspicious, as described by Lam et al. (1998). Endobronchial mucosal biopsies were taken from all areas that were suspicious under WLB or AFB. In addition, surveillance biopsies were taken from epithelium with normal appearance in all subjects. An average of 2-3 biopsies was taken

Categorical variables were analysed by Fisher's exact test. Sensitivity, specificity, likeli‐ hood ratio (LR), Predictive Positive Value (PPV) and Predictive Negative Value (PNV) were calculated with 95% CI. Statistical significance was accepted at p<0.05. The sensitivity and specificity were assessed for each test and was used in analysis as a single test; two-test parallel combination and two-test series combination (Sullivan and Thomson, 2000,

cytometry-based scoring system, as described by Kemp et al. (Kemp et al, 2007).

drinking water (Antofagasta region) for at least 10 years.

them underwent a CT to rule out or confirm the LC.

Santiago and 140 were from the Antofagasta's region.

al. (2005) and Hatton et al. (2006).

from each of the participants.

Kruskal, 1998).