Zur Therapie des metastasierten hormonsensitiven oder kastrationsresistenten Prostatakarzinoms (mHSPC, mCRPC) gab es in den letzten Jahren zahlreiche neue Erkenntnisse aus klinischen Studien. Die neu zugelassenen Behandlungsoptionen machen die Therapieplanung und Therapiesequenz anspruchsvoller. Hinzu kommt, dass die Lokaltherapie des metastasierten Prostatakarzinoms zunehmend an Bedeutung gewinnt. Im neuen Update 6.2 der S3-Leitlinie zum Prostatakarzinom vom Oktober 2021 wurden die neuen Entwicklungen bei den Empfehlungen zur Behandlung des mHSPC und mCRPC umgesetzt, deren wichtigsten Neuerungen und die daraus resultierenden Empfehlungen für die Praxis dargestellt werden. / There have been numerous new findings from clinical trials in recent years regarding the treatment of metastatic hormone-sensitive or castration-resistant prostate cancer. The newly approved treatment options make therapy planning and therapy sequencing more challenging. In addition, local therapy of metastatic prostate cancer is becoming increasingly important. In the new German guidelines on prostate cancer (version 6.2, October 2021), new developments in the recommendations for the treatment of mHSPC and mCRPC were implemented, and their most important resulting recommendations for the clinical practice are presented in this review.

Lay Abstract / Prostate cancer (PrCa) is a leading cause of cancer-related death in men worldwide. Standard treatments for unresected PrCa include radiation therapy, androgen deprivation or anti-androgen therapies. However, many patients develop resistance to these therapies indicating a need for a new treatment that can enhance their therapeutic efficacy. Our studies show a promising new strategy to achieve this task using canagliflozin, an FDA-approved medication currently used to treat diabetes, kidney and heart failure. We found that canagliflozin interrupts cellular energy production, inhibits biosynthetic pathways and improves the efficacy of radiotherapy in radiation naïve and radio-resistant human PrCa models. In addition, we found that canagliflozin has promising anti-androgen activity by reducing the protein levels and the activity of androgen receptor (AR) in PrCa cells and tumors both alone and in combination with commercially available anti-androgens. These promising findings suggest that canagliflozin could be used in combination with current standard-of-care therapies for the treatment of PrCa. Given that canagliflozin is an approved medication, tolerated well by diabetic and non-diabatic individuals, the work presented here generates a basis for rapid investigation of this new treatment in early phase clinical trials. / Thesis / Doctor of Philosophy (PhD)

Le cancer de la prostate (CaP) est devenu un véritable problème de santé publique dans les pays industrialisés. L'hormonothérapie reste le traitement de première ligne le plus efficace dans les cancers avancés mais il n'empêche pas la progression vers un stade androgéno-indépendant (AI), pour lequel la chimiothérapie s'avère peu efficace. Une des stratégies pour améliorer les thérapies actuelles consiste à cibler des gènes de survie surexprimés dans les CaPs AI afin de restaurer la sensibilité aux traitements du CaPs. Hsp27, protéine surexprimée dans ces cancers, à un effet cytoprotecteur qui engendre une résistance aux traitements. Elle est maintenant reconnue comme une cible thérapeutique importante. Rocchi et al. ont développé un oligonucléotide antisense (ASO) de deuxième génération (OGX-427) qui cible l'ARNm d'Hsp27. OGX-427 est actuellement en essai clinique phase II chez des patients atteints de CaPs au Canada et aux Etats-Unis. Mon projet de thèse a porté sur l'étude des mécanismes d'action d'Hsp27 impliqués dans l'évolution AI du CaP. Cette étude a pour but d'améliorer la sureté pharmacologique d'OGX-427, mais aussi d'identifier de nouvelles cibles thérapeutiques visant spécifiquement les cellules tumorales. Mes travaux de thèse ont montré que lors d'un stress cellulaire induit par hormonothérapie et/ou chimiothérapie, Hsp27 interagit avec le facteur eucaryotique d'initiation de la traduction eIF4E et le protège de sa dégradation par la voie ubiquitine/protéasome. Ceci maintient la synthèse protéique et engendre une survie cellulaire impliquée en partie dans l'effet cytoprotecteur médié par Hsp27. / Prostate cancer (PC) has become a real public health issue in industrialized countries, mainly due to patients' relapse by castration-resistant (CR) disease after androgen ablation. One strategy to improve current therapies in advanced PC involves targeting genes that are activated by androgen withdrawal, either to delay or prevent the emergence of the CR phenotype. Hsp27 is over-expressed in this cancer and has been shown to play a cytoprotective role leading to treatments resistance. This protein is now considered as promising therapeutic target. Rocchi, P. et al. developed and patented a second generation antisens oligonucleotides (ASO) targeting Hsp27 that has been licensed (OGX-427) and phase II clinical trials are currently in process in PC in Canada and USA. My PhD project focused on the study of Hsp27 action mechanisms involved in CRPC progression. The present study aims to improve pharmacological safety of OGX-427 and to identify new therapeutic targets specific of CRPC cells. The results of my PhD have shown that during cell stress induced by hormone- and/or chemotherapy, Hsp27 interacts with eukaryotic translation initiation factor eIF4E and protects it from degradation by the ubiquitin/proteasome pathway. This maintains protein synthesis and leads to cell survival, partly involved in the cytoprotection mediated by Hsp27. Our work therefore concerned the characterization of the interaction site between Hsp27 and eIF4E in order to identify potential inhibitors of this interaction that could delay CRPC progression.

Introdução: O Câncer de próstata metastático (mCaP) é uma doença incurável com progressão para o mCaP resistente à castração (mCPRC) após terapia de deprivação androgênica. Os microRNAs (miR) -23b e -27b tem ação antioncogênica e são suprimidos neste contexto. O gene da ciclina G1 (CCNG1) codifica uma quinase dependente de ciclina com potencial de inibição do crescimento e é um dos alvos dos miR-23b/-27b. Objetivos: Estimular os miR-23b/-27b isoladamente e em conjunto para avaliar e comparar o crescimento tumoral e a expressão do gene alvo CCNG1 em relação ao grupo controle em xenenxertos de PC-3M-luc-C6 em camundongos atímicos castrados. Métodos: Xenoenxertos subcutâneos da linhagem celular PC-3M-luc-C6 foram implantados em camundongos machos BALB/c nude. Os animais foram castrados 10 dias após o implante e utilizamos injeções intratumorais para induzir o aumento da expressão dos miR-23b/-27b separadamente e em conjunto através de Pre-miR® específicos. Realizamos avaliações semanais da bioluminescência (BLI) para avaliar o crescimento tumoral após a castração. Utilizamos a reação em cadeia de polimerase reversa em tempo real (qRT-PCR) para analisar a expressão da CCNG1 e os animais foram sacrificados 21 dias após a castração. Dividimos um total de 21 xenoenxertos nos seguintes grupos de tratamento: 4 no grupo controle, 5 no grupo Pró miR-23b, 6 no grupo Pró miR-27 e 6 no grupo Pró miR-23b associado ao Pró miR-27b. Resultados: Confirmamos o sucesso da transfecção dos miRs por qRT-PCR, e apresentamos o achado de superexpressão relativa da CCNG1 em relação ao grupo controle em: 9% (p=0,76), 46% (p=0,05) e 203% (p=0,01) nos grupos Pró miR-23b, Pró miR-27b e Pró miR-23b associado ao Pró miR-27b respectivamente. Comparamos o crescimento proporcional de cada tumor através da BLI, por meio da leitura no momento da castração ao final do experimento. Obtivemos um crescimento de 13,5; 8,69; 5,96 e 9,98 vezes nos grupos: controle, Pró miR-23b, Pró miR-27b e Pró miR-23b associado ao Pró miR-27b respectivamente. Conclusão: Demonstramos um modelo in vivo de CPRC que apresentou supreexpressão da CCNG1 após o tratamento intratumoral que aumentou a expressão dos miRs -23b e -27b. Este conjunto de miRs tem ação antioncogênica descrita no contexto do mCPRC e a sua estimulação neste contexto aumentou a expressão da CCNG1. Nosso estudo sugere que a CCNG1 deve apresentar uma ação pró-apoptótica quando superexpresso pelos miRs-23b/-27 no CPRC / Introduction: Metastatic prostate cancer (mPCa) is an incurable disease that invariably progresses to castration-resistant mPCa (mCRPC) after androgen deprivation therapy. The microRNAs miR-23b/-27b have been reported as tumor suppressors and are underexpressed in this context. The cyclin G1 gene (CCNG1) encodes a cyclin-dependent kinase with potential growth inhibitory activity that is a potential target of miR-23b/-27b. Objectives: We aim to explore a bioluminescent xenograft model of CRPC in castrated mice the effect positive modulation of the miR-23b/-27b on CCNG1 expression and mCRPC growth. Material and Methods: We injected subcutaneous xenografts of PC-3M-luc-C6 PCa cell line in BALB/c nude male mice. We neutered the animals after 10 days and used intratumoral injections up-regulating miR-23b/-27b separately and simultaneously through specific Pre-miRTM. We used weekly bioluminescence imaging (BLI) to assess tumor growth after castration and real-time polymerase chain reaction (qRT-PCR) to analyze the expression of CCNG1. We sacrificed the animals 21 days after castration. We randomized 21 xenografts in experimental groups as follows: n=4 in the negative control group; n=5 in Pro miR-23b group; n=6 in Pro miR-27b group and an n=6 tumors in the Pro miR-23b plus Pro miR-27b. Results: We confirmed successful transfection of both miRNAs with overexpression of CCNG1 of 9% (p=0.76), 46% (p=0.05) and 203% (p=0.01) in the Pro miR-23b, Pro miR-27b and Pro miR-23b plus -27b groups respectively. We compared the fold-change in BLI growth by the end of experiment finding an increase of 13.5-fold, 8.69-fold, 5.96-fold and 9.98-fold in groups Pro miR-negative control, Pro miR-23b, Pro miR-27b and Pro miR-23b plus Pro miR-27b groups respectively. Conclusions: We showed an in vivo model with overexpression of CCNG1 upon artificial upregulation of miR-23b and -27b in CRPC. This cluster of antineoplastic miRNA increased the expression of this cyclin, often described as oncogenic. Our study suggests that CCNG1 has a pro-apoptotic role when up-regulated by miR-23b/-27b in CPRC

Introduction: Prostate-specific membrane antigen (PSMA)-based imaging and theranostics have played an important ole in the diagnosis, staging, and treatment of prostate cancer (PCa). We aimed to evaluate the acceptance and use of PSMA theranostics among German urologists.- Methods: An anonymous online questionnaire was sent via survio.com to the members of the German Society of Urology (DGU). - Results: Seventy-two percent of participants performed PSMA positron emission tomography (PET) imaging regularly in biochemically recurrent PCa. Overall, 61% of participants considered PSMA-radioligand therapy to be very useful or extremely useful. PSMA PET imaging in high-risk PCa is more often considered by urologists working in a university setting than in nonuniversity settings or medical practices (51% vs. 25%, p < 0.001). Most perform PSMA-radioligand therapy as an option after all approved systemic treatments for metastatic metastatic castration-resistant PCa (56%) or after cabazitaxel (14%). A total of 93.9% and 70.3% of respondents consider the lack of reimbursement by health insurance to be the main obstacle to using PSMA PET imaging or radioligand therapy, respectively. - Discussion/Conclusion: PSMA-based maging/theranostics are already widely applied but would find even more widespread use if reimbursement is clearly regulated by health insurance in Germany.

Le cancer de la prostate est la forme de cancer la plus fréquente et la troisième cause de décès par cancer chez l’homme dans les sociétés occidentales. Alors que la plupart des cancers de la prostate localisés sont éradiqués chirurgicalement, la plupart des tumeurs métastatiques répondant initialement aux thérapies par privation d’androgènes deviennent résistantes au traitement, causant généralement le décès du patient. Les gènes suppresseurs de tumeur PTEN et p53 étant fréquemment mutés dans les cancers de la prostate métastatiques et résistants à la castration, le laboratoire d’accueil a généré des modèles murins dans lesquels Pten et/ou Trp53 sont sélectivement invalidés à l’âge adulte dans les cellules épithéliales prostatiques dans le but de déterminer les évènements clés conduisant à la progression du cancer de la prostate. Notre étude révèle que l’invalidation de PTEN stimule la prolifération des cellules épithéliales prostatiques et conduit à des néoplasmes prostatiques intraépithéliaux en quelques mois. Cette hyper-prolifération induit un stress réplicatif et une réponse aux dommages de l’ADN qui va conduire à un arrêt progressif de la croissance cellulaire et une entrée en sénescence. Les cellules sénescentes sécrètent de nombreuses cytokines et de chimiokines, et peuvent accumuler des mutations contribuant ainsi à la progression de la tumeur. Il est notable qu’en l’absence de Trp53, les épithéliums prostatiques dépourvus de Pten développent des néoplasmes prostatiques intraépithéliaux entrant en sénescence. Cependant, la formation d’adénocarcinomes est accélérée et des tumeurs sarcomatoïdes pouvant générer à long terme des métastases apparaissent. En l’absence de Pten, certaines cellules épithéliales prostatiques perdent leur identité moléculaire en exprimant des marqueurs caractéristiques de cellules souches et différenciation neuroendocrinienne. Nous avons également mis en évidence des cellules épithéliales prostatiques déficientes en PTEN et p53 résistantes à la castration exprimant à la fois des marqueurs de cellules basales et luminales. En conclusion, nos travaux ont permis une avancée dans la compréhension des mécanismes conduisant à des formes incurables de cancer de la prostate. Les traitements actuels ayant des effets secondaires importants et pouvant générer des résistances, le développement de nouvelles stratégies thérapeutiques permettant l’élimination des cellules sénescentes mais aussi des cellules épithéliales prostatiques exprimant des marqueurs de cellules basales et luminales dans les lésions précancéreuses représente des perspectives intéressantes pour traiter le cancer de la prostate. / Prostate cancer (PCa) is a leading cause of male cancer death worldwide. While most locally PCa are curable, metastatic tumors initially respond to androgen deprivation therapy but ultimately relapse to castration-resistant prostate cancer (CRPC), which is a lethal disease. Since the tumor suppressor genes PTEN and p53 are frequently mutated in metastatic and CRPC, the host laboratory generated mouse models in which Pten and/or Trp53 are selectively ablated in adult prostatic epithelial cells (PECs) in order to unravel the key events leading to prostate cancer progression. Our study reveals that Pten ablation stimulates PECs proliferation forming prostatic intraepithelial neoplasia (PIN) within a few months. This hyper-proliferation induces replicative stress and a DNA damage response (DDR), which in turn leads to a progressive growth arrest with characteristics of cell senescence. As senescent cells secrete a large number of cytokines and chemokines, and can accumulate other mutations, they might contribute to tumor progression. Importantly, in the absence of Trp53, most Pten-null PECs develop PINs that enter senescence. However partial loss of PECs identity is detected as we show enhanced stemness and focal neuroendocrine differentiation of luminal Pten-null PECs. In some cases, adenocarcinoma and sarcomatoid tumors are formed, and more than one-third of the latter develop metastases. Strikingly, we also show formation of a castrate-resistant cell entity of both Pten and Pten/Trp53-null PECs sharing luminal and basal markers. Taken together, as current treaments lead to side effects and resistance, the development of therapeutic strategies to eliminate senescent cells/and or PECs expressing luminal and basal/stem progenitor in pre- cancerous lesions represents promising option for prostate cancer treatment.