Prognostic Factors In Breast Cancer. With Special Reference to Cyclins A, B1, D1 and E, MMP-1 and Decorin

Breast cancer is a highly heterogenous malignancy, which despite of the similar histological type shows different clinical behaviour and response to therapy. Prognostic factors are used to estimate the risk for recurrence and the likelihood of treatment effectiveness. Because breast cancer is one of the most common causes of cancer death in women worldwide, identification of new prognostic markers are needed to develop more specific and targeted therapies. Cancer is caused by uncontrolled cell proliferation. The cell cycle is controlled by specific proteins, which are known as cyclins. They function at important checkpoints by activating cyclin-dependent kinase enzymes. Overexpression of different cyclins has been linked to several cancer types and altered expression of cyclins A, B1, D1 and E has been associated with poor survival. Little is known about the combined expression of cyclins in relation to the tumour grade, breast cancer subtype and other known prognostic factors. In this study cyclins A, B1 and E were shown to correlate with histological grade, Ki-67 and HER2 expression. Overexpression of cyclin D1 correlated with receptor status and non-basal breast cancer suggesting that cyclin D1 might be a marker of good prognosis. Proteolysis in the surrounding tumour stroma is increased during cancer development. Matrix metalloproteinases (MMPs) are proteolytic enzymes that are capable of degrading extracellular matrix proteins. Increased expression and activation of several MMPs have been found in many cancers and MMPs appear to be important regulators of invasion and metastasis. In this study MMP-1 expression was analysed in breast cancer epithelial cells and in cancer associated stromal cells. MMP-1 expression by breast cancer epithelial cells was found to carry an independent prognostic value as did Ki-67 and bcl-2. The results suggest that in addition to stromal cells MMP-1 expression in tumour cells control breast cancer progression. Decorin is a small proteoglycan and an important component of the extracellular matrix. Decorin has been shown to inhibit growth of tumour cells and reduced decorin expression is associated with a poor prognosis in several cancer types. There has been some suspicion wheather different cancer cells express decorin. In this study decorin expression was shown to localize only in the cells of the original stroma, while breast cancer epithelial cells were negative for decorin expression. However, transduction of decorin in decorin-negative human breast cancer cells markedly modulated the growth pattern of these cells. This study provides evidence that targeted decorin transduction to breast cancer cells could be used as a novel adjuvant therapy in breast malignancies.

Treatment-related renal side-effects in pediatric cancer patients

Background: The long-term side-effects of cancer treatments are of growing importance, since the number of pediatric cancer survivors has considerably increased. Renal side-effects should be noted early to prevent further deterioration. Renal dysfunction may also develop long after cancer treatment. Easy and reliable methods for assessing renal function are needed. Aims: The aims were to find the mechanisms behind methotrexate-induced renal damage by studying renal tubular cells (LLC-PK1cells), and to evaluate the usefulness of laboratory tests in assessing glomerular function in pediatric cancer patients by comparing an isotope clearance method with alternative methods. The aim was also to study the long-term effects of bone marrow transplantation (BMT) and high-dose methotrexate (HD-MTX) treatment in renal function. Results: Methotrexate induced time-dependent renal tubular cell swelling and cell death. In patients treated with HD-MTX a significant decrease in GFR was noted after a follow-up time of one to ten years. One year after BMTthe GFR was reduced, especially in patients treated with total body irradiation (TBI). GFR recovered slightly but remained stable thereafter. In glomerular function assessment the serum cystatin C (cysC) concentration showed a significant association with GFR measured by the isotope method. Conclusions: Methotrexate induced acute damage in renal tubular cells. In assessing GFR the isotope method still remains the method of choice, but the assay of cystatin C was the most reliable of other alternatives. Long-term follow-up of renal function is needed in BMT patients and patients treated with HD-MTX.

Surgical Treatment of Colorectal Cancer. Controversial Issues

Aims: This study was carried out to evaluate surgical treatment of colorectal cancer (CRC) with special interest in present status and controversial issues: stenting as a palliative procedure for metastasized CRC (I), duration of thromboprophylaxis after the surgical treatment of CRC (II), treatment of the increasing population of elderly people (III) and the quality of life (QoL) after surgery for rectal cancer with special reference to pelvic floor dysfunction (IV). Materials and methods: The material consisted of patients with CRC operated on at Turku University Hospital between 2003 and 2008. In study II the data was collected retrospectively from electronic archives. In other studies the follow-up data was collected at postoperative control visits. In study IV the RAND-36 standardized questionnaire and additional questions assessing urinary, sexual and anorectal dysfunction were used. Results: The results of the current study showed that self-expanding metallic stents provided an alternative to palliative surgery in the treatment of obstructive CRC. Low molecular heparin given s.c. for a median of 11 days until hospital discharge seemed to provide sufficient thromboprophylaxis after surgery. With preoperative selection elderly patients with rectal cancer were suitable for major surgery for rectal cancer with morbidity and mortality rates comparable to those in younger patients. There was no difference between preoperative and one year postoperative general QoL for operated rectal cancer patients. Postoperative pelvic dysfunction was associated with an impaired QoL in some dimensions. Conclusions: Many individual factors regarding the patient and the disease must be taken into account when making treatment decisions in CRC to ensure successful treatment of CRC, patient satisfaction and QoL.

Role of ErbB2 and ErbB4 in Cancer Growth, Prognosis and as Targets for Immunotherapy

ErbB receptors (EGFR, ErbB2, ErbB3 and ErbB4) are growth factor receptors that regulate signals of cell differentiation, proliferation, migration and survival. Inappropriate activation of these receptors is associated with the development and severity of many cancers and has prognostic and predictive value in cancer therapy. Drugs, such as therapeutic antibodies, targeted against EGFR and ErbB2, are currently used in therapy of breast, colorectal and head and neck cancers. The role of ErbB4 in tumorigenesis has remained relatively poorly understood. Alternative splicing produces four different isoforms of one ErbB4 gene. These isoforms (JM-a, JM-b, CYT-1 and CYT-2) are functionally dissimilar and proposed to have different roles in carcinogenesis. The juxtamembrane form JM-a undergoes regulated intramembrane proteolysis producing a soluble receptor ectodomain and an intracellular domain that translocates into the nucleus and regulates transcription. Nuclear signaling via JM-a isoform stimulates cancer cell proliferation. This study aimed to develop antibodies targeting the proposed oncogenic ErbB4 JM-a isoform that show potential in inhibiting ErbB4 dependent tumorigenesis. Also, the clinical relevance of ErbB4 shedding in cancer was studied. The currently used monoclonal antibody trastuzumab, targeting ErbB2, has shown efficacy in breast cancer therapy. In this study novel tissues with ErbB2 amplification and trastuzumab sensitivity were analyzed. The results of this study indicated that a subpopulation of breast cancer patients demonstrate increased shedding and cleavage of ErbB4. A JM-a isoform-specific antibody that inhibited ErbB4 shedding and consequent activation of ErbB4 had anti-tumor activity both in vitro and in vivo. Thus, ErbB4 shedding associates with tumor growth and specific targeting of the cleavable JM-a isoform could be considered as a strategy for developing novel ErbB-based cancer drugs. In addition, it was demonstrated that ErbB2 amplification is common in intestinal type gastric cancers with poor clinical outcome. Trastuzumab inhibited growth of gastric and breast cancer cells with equal efficacy. Thus, ErbB2 may be a useful target in gastric cancer.

Studies on 68Ga-Based Agents for PET Imaging of Cancer and Inflammation

Studies on ⁶⁸Ga-Based Agents for PET Imaging of Cancer and Inflammation Positron emission tomography (PET) is based on the use of radiolabeled agents and facilitates in vivo imaging of biological processes, such as cancer. Because the detection of cancer is demanding and is often obscured by inflammation, there is a demand for better PET imaging agents. The aim was to preliminarily evaluate new PET agents for imaging cancer and inflammation using experimental models. ⁶⁸Ga-chloride and peptides, ⁶⁸Ga-labeled through 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA), targeting matrix metalloproteinase-9 (MMP-9) were tested for tumor imaging. In addition, a ⁶⁸Ga-DOTA-conjugated peptide targeting vascular adhesion protein-1 (VAP-1), was tested for inflammation imaging. The ⁶⁸Ga-based imaging agents described here showed potential features by passing the essential in vitro tests, proceeding further to preclinical in vivo evaluation and being able to visualize the target. The target uptake and target-to-background ratios of ⁶⁸Ga-based agents were, however, not optimal. ⁶⁸Ga-chloride showed slow clearance caused by its binding to blood transferrin. In the case of ⁶⁸Ga-DOTA-peptides low in vivo stability and/or low lipophilicity led to too rapid blood clearance and urinary excretion. The properties of ⁶⁸Ga-labeled peptides are modifiable, as shown with matrix metalloproteinase-9 targeting ligands. In the conclusion of this PhD thesis, ⁶⁸Ga-based agents for PET imaging of cancer and inflammation could be applied in the development of drugs, earlier diagnostics and following-up of the efficacy of therapies.

Imaging of Tumour Microenvironment for the Planning of Oncological Therapies Using Positron Emission Tomography

Tumour cells differ from normal tissue cells in several important ways. These differences, like for example changed energy metabolism, result in altered microenvironment of malignant tumours. Non-invasive imaging of tumour microenvironment has been at the centre of intense research recently due to the important role that this changed environement plays in the development of malignant tumours and due to the role it plays in the treatment of these tumours. In this respect, perhaps the most important characteristics of the tumour microenvironment from this point of view are the lack of oxygen or hypoxia and changes in blood flow (BF). The purpose of this thesis was to investigate the processes of energy metabolism, BF and oxygenation in head and neck cancer and pancreatic tumours and to explore the possibilities of improving the methods for their quantification using positron emission tomography (PET). To this end [18F]EF5, a new PET tracer for detection of tumour hypoxia was investigated. Favourable uptake properties of the tracer were observed. In addition, it was established that the uptake of this tracer does not correlate with the uptake of existing tracers for the imaging of energy metabolism and BF, so the information about the presence of tissue hypoxia cannot therefore be obtained using tracers such as [18F]FDG or [15O]H2O. These results were complemented by the results of the follow-up study in which it was shown that the uptake of [18F]EF5 in head and neck tumours prior to treatment is also associated with the overall survival of the patients, indicating that tumour hypoxia is a negative prognostic factor and might be associated with therapeutic resistance. The influences of energy metabolism and BF on the survival of patients with pancreatic cancer were investigated in the second study. The results indicate that the best predictor of survival of patients with pancreatic cancer is the relationship between energy metabolism and BF. These results suggest that the cells with high metabolic activity in a hypoperfused tissue have the most aggressive phenotype.

Identification of Epigenetic Targets in Prostate Cancer for Therapeutic Development

Recurrent castration resistant prostate cancer remains a challenge for cancer therapies and novel treatment options in addition to current anti-androgen and mitosis inhibitors are needed. Aberrations in epigenetic enzymes and chromatin binding proteins have been linked to prostate cancer and they may form a novel class of drug targets in the future. In this thesis we systematically evaluated the epigenenome as a prostate cancer drug target. We functionally silenced 615 known and putative epigenetically active protein coding genes in prostate cancer cell lines using high throughput RNAi screening and evaluated the effects on cell proliferation, androgen receptor (AR) expression and histone patterns. Histone deacetylases (HDACs) were found to regulate AR expression. Furthermore, HDAC inhibitors reduced AR signaling and inhibited synergistically with androgen deprivation prostate cancer cell proliferation. In particular, TMPRSS2- EGR fusion gene positive prostate cancer cell lines were sensitive to combined HDAC and AR inhibition, which may partly be related to the dependency of a fusion gene induced epigenetic pathway. Histone demethylases (HDMs) were identified to regulate prostate cancer cell line proliferation. We discovered a novel histone JmjC-domain histone demethylase PHF8 to be highly expressed in high grade prostate cancers and mediate cell proliferation, migration and invasion in in vitro models. Additionally, we explored novel HDM inhibitor chemical structures using virtual screening methods. The structures best fitting to the active pocket of KDM4A were tested for enzyme inhibition and prostate cancer cell proliferation activity in vitro. In conclusion, our results show that prostate cancer may efficiently be targeted with combined AR and HDAC inhibition which is also currently being tested in clinical trials. HDMs were identified as another feasible novel drug target class. Future studies in representative animal models and development of specific inhibitors may reveal HDMs full potential in prostate cancer therapy

The role of extracellular matrix macromolecules in cancer and diabetic macroangiopathy – with special reference to decorin and hyaluronan

The central role of extracellular matrix (ECM) macromolecules in diseases such as cancer and atherosclerotic vascular diseases including diabetic macroangiopathy is indisputable. Decorin and hyaluronan (HA) represent vital ECM macromolecules in the microenvironment of cells and are centrally involved in human cancer and cardiovascular biology. In cancer, decorin is considered to play a tumor suppressive role. However, there is some discrepancy whether malignant cells express it. Regarding HA, its contribution to the development of atherosclerotic vascular diseases has been well established. Nevertheless, the precise role of HA in arterial narrowing associated with diabetes is not known. The present study focused on two vital ECM macromolecules, namely decorin and HA. First, decorin expression was studied in human tumorigenesis. Furthermore, the effect of adenovirus-mediated decorin transduction on selected cancer cell lines was investigated. The results invariably showed that cancer cells completely lacked decorin expression. The study also demonstrated that transducing cancer cells with decorin adenoviral vector markedly inhibited their malignant behavior. In line with this, a strong induction of decorin expression in normal human embryonic stem cells (hESCs), but not in abnormal hESCs was observed during their differentiation. Secondly, the significance of HA in the development of diabetic macroangiopathy in response to hyperglycemia was evaluated. Results showed that the synthesis of HA by vascular smooth muscle cells was significantly increased in response to high glucose concentration. This increase was associated with the diminished ability of the cells to contract collagen-rich matrix suggesting that HA participates in the disturbed vascular remodeling of diabetic patients. The results of this study support endeavours to develop novel ECM macromolecule -based therapies targeting cancer and cardiovascular diseases.

Toll-like receptor 9 in breast cancer

The innate immune system recognizes microbial features leading to the activation of the adaptive immune system. The role of Toll-like receptor 9 (TLR9) is to recognize microbial DNA. In addition to immune cells, TLR9 is widely expressed in breast cancer in addition to other cancers. Breast cancer is the most common cancer in women, affecting approximately one in eight in industrialized countries. In the clinical setting, breast cancer is divided into three clinical subtypes with type-specific treatments. These subtypes are estrogen receptor (ER)-positive, HER2-positive and triple-negative (TNBC) breast cancer. TNBC is the most aggressive subtype that can be further divided into several subtypes. TNBC tumors lack ER, progesterone receptor and HER2 receptor. Therefore, the current clinically used targeted therapies are not suitable for TNBC treatment as TNBC is a collection of diseases rather than one entity. Some TNBC patients are cured with standard chemotherapy, while others rapidly die due to the disease. There are no clinically used iomarkers which would help in predicting which patients respond to chemotherapy. During this thesis project, we discovered a novel good-prognosis TNBC subtype. These tumors have high TLR9 expression levels. Our findings suggest that TLR9 screening in TNBC patient populations might help to identify the patients that are at the highest risk regarding a relapse. To gain better understanding on the role of TLR9 in TNBC, we developed an animal model which mimicks this disease. We discovered that suppression of TLR9 expression in TNBC cells increases their invasive properties in hypoxia. In line with the clinical findings, TNBC cells with low TLR9 expression also formed more aggressive tumors in vivo. TLR9 expression did not, however, affect TNBC tumor responses to doxorubicin. Our results suggest that tumor TLR9 expression may affect chemotherapyrelated immune responses, however, this requires further investigation. Our other findings revealed that DNA released by chemotherapy-killed cells induces TLR9-mediated invasion in living cancer cells. Normally, extracellular self-DNA is degraded by enzymes, but during massive cell death, for example during chemotherapy, the degradation machinery may be exhausted and self-DNA is taken up into living cells activating TLR9. We also discovered that the malaria drug chloroquine, an inhibitor of autophagy and TLR9 signalling does not inhibit TNBC growth in vivo, independently of the TLR9 status. Finally, we found that ERα as well as the sex hormones estrogen and testosterone regulate TLR9 expression and activity in breast cancer cells in vitro. As a conclusion, we suggest that TLR9 is a potential biomarker in TNBC. ------- Sisäsyntyisen immuniteetin tehtävä on tunnistaa mikrobien molekyylirakenteita, mikä saa aikaan adaptiivisen immuunijärjestelmän aktivoitumisen. Tollin kaltainen reseptori 9 (TLR9) on dna:ta tunnistava sisäsyntyisen immuniteetin reseptori, jota ilmennetään myös useissa syövissä, kuten rintasyövässä. Rintasyöpä on naisten yleisin syöpä, johon joka kahdeksas nainen sairastuu elämänsä aikana. Kliinisesti rintasyöpä jaotellaan kolmeen alatyyppiin, joista kolmoisnegatiivinen rintasyöpä on aggressiivisin. Tämän tyypin syövät eivät ilmennä hormonireseptoreja (estrogeeni- ja progesteronireseptori) tai HER2-reseptoria. Tästä johtuen kolmoisnegatiivisten potilaiden hoitoon ei voida käyttää rintasyövän nykyisten hoitosuositusten mukaisia täsmähoitoja. Kolmoisnegatiivinen rintasyöpä ei kuitenkaan ole yksi sairaus, koska molekyylitasolla sen on osoitettu koostuvan lukuisista, biologialtaan erilaisista syöpämuodoista. Tällä hetkellä kliinisessä käytössä ei ole biomarkkeria, jonka avulla kolmoisnegatiivisen rintasyövän alatyypit voisi erottaa toisistaan. Löysimme uuden kolmoisnegatiivisen syövän alatyypin, joka ilmentää vain vähän TLR9-proteiinia. Tällä alatyypillä on erittäin huono ennuste ja tulostemme perusteella TRL9-tason selvittäminen voisi seuloa huonoennusteiset syövät kolmoisnegatiivisten syöpien joukosta. Kehitimme eläinmallin, jolla voidaan tutkia matalan ja korkean TLR9-tason vaikutuksia kolmoisnegatiivisten kasvainten hoitovasteeseen. Toinen löytömme oli, että kemoterapialla tapettujen syöpäsolujen dna saa aikaan elävien syöpäsolujen TLR9-välitteistä invaasiota. Normaalisti entsyymit hajoittavat yksilön oman solunulkoisen dna:n. Erikoistilanteissa, kuten syöpähoitojen yhteydessä, jolloin solukuolema on massiivista, elimistön oma koneisto ei ehdi tuhoamaan solunulkoista dna:ta ja sitä voi kertyä eläviin soluihin, joissa se aktivoi TLR9:n. Kolmanneksi havaitsimme, että malarialääke klorokiini, joka estää TLR9:n toimintaa ja jolla on syövänvastaisia vaikutuksia soluviljelyolosuhteissa, ei estänyt TLR9-positiivisten tai TLR9-negatiivisten kasvainten kasvua käyttämässämme eläinmallissa. Neljänneksi soluviljelykokeittemme tulokset osoittivat, että sukupuolihormonit estrogeeni ja testosteroni sekä estrogeenireseptori osallistuvat TLR9:n ilmentymisen ja aktiivisuuden säätelyyn. Tuloksemme osoittavat, että TLR9 potentiaalinen biomarkkeri kolmoisnegatiivisessa rintasyövässä.

The Role of PME-1 in Cancer: Therapeutic Implication

Protein phosphatase 2A (PP2A) plays a major role in maintaining cellular signaling homeostasis in human cells by reversibly affecting the phosphorylation of a variety of proteins. Protein phosphatase methylesterase-1 (PME-1) negatively regulates PP2A activity by reversible demethylation and active site binding. Thus far, it is known that overexpression of PME-1 in human gliomas contributes to ERK pathway signaling, cell proliferation, and malignant progression. Whether PME-1-mediated PP2A inhibition promotes therapy resistance in gliomas is unknown. Specific PP2A targets regulated by PME-1 in cancers also remain elusive. Additionally, whether oncogenic function of PME-1 can be generalized to various human cancers needs to be investigated. This study demonstrated that PME-1 expression promotes kinase inhibitor resistance in glioblastoma (GBM). PME-1 silencing sensitized GBM cells to a group of clinically used indolocarbazole multikinase inhibitors (MKIs). To facilitate the quantitative evaluation of MKIs by cancer-cell specific colony formation assay, Image-J software-plugin ‘ColonyArea’ was developed. PME-1-silencing was found to reactivate specific PP2A complexes and affect PP2A-target histone deacetylase HDAC4 activity. The HDAC4 inhibition induced synthetic lethality with MKIs similar to PME-1 depletion. However, synthetic lethality by both approaches required co-expression of a pro-apoptotic protein BAD. In gliomas, PME-1 and HDAC4 expression was associated with malignant progression. Using tumor PME-1, HDAC4 and BAD expression based stratification signatures this study defined patient subgroups that are likely to respond to MKI alone or in combination with HDAC4 inhibitor therapies. In contrast to the oncogenic role of PME-1 in certain cancer types, this study established that colorectal cancer (CRC) patients with high tumor PME-1 expression display favorable prognosis. Interestingly, PME-1 regulated survival signaling did not operate in CRC cells. Summarily, this study potentiates the candidacy of PME-1 as a therapy target in gliomas, but argues against generalization of these findings to other cancers, especially CRC.