Résumé en Français:Le régorafénib est une des dernières options thérapeutiques pour les patients atteints d’un cancer colorectal chimio-réfractaire de stade avancé (CCRa). Cet inhibiteur de multiples tyrosine kinases n’est pas dépourvu de toxicité ce qui limite son utilisation en dernière ligne chez ces patients dont l’état général est dégradé, alors même que son efficacité n’est pas certaine chez tous les patients. Son mécanisme d'action reste largement inconnu, ce qui rend difficile l'identification de biomarqueurs prédictifs cliniquement utiles. C’est dans ce contexte que se situe ce projet de thèse, dont l’objectif est d’identifier les patients qui pourraient ou pas bénéficier du regorafenib. Pour atteindre cet objectif, nous avons développé à la fois nous avons entamé des projets de recherche translationnelle et mécanistiques.Nos études translationnelles se sont portées sur le monitoring de la réponse thérapeutique dans des biopsies liquides récoltées dans le cadre d’un essai clinique prospectif incluant des patients souffrant d’un CCRa et traités au régorafénib (RegARd-C). Nous avons d’abord confirmé la valeur pronostique de l’ADN libre circulant (ADNlc) avant traitement. De même, nous avons démontré qu'un haut volume tumoral métaboliquement actif avant traitement était associé à un mauvais pronostic. Combinés, ces marqueurs sont restés des prédicteurs de la survie sans progression (SSP) et globale (SG) des patients. Par la suite, nous avons mesuré l’ADN tumoral circulant (ADNtc) en suivant les mutations tumorales pré-identifiées dans le tissu tumoral des patients par séquençage. Nous avons démontré qu’une augmentation de plus de 50% de l’ADNtc après seulement 14 jours de traitement quel que soit le nombre de mutations suivies, indiquait un moins bon pronostic en termes SSP et SG. En outre, nos données suggèrent que ADNtc et ADNlc sont indépendants mais complémentaires dans leur valeur prédictive. Aussi, nous avons mis en évidence le rôle important de l’antigène carbohydrate 19-9 en tant que marqueur pronostique et prédictif précoce de la survie de ces patients.Ayant observé un profil général de résistance chez les patients, nous avons investigué les mécanismes potentiels de résistance intrinsèque et acquise au régorafénib dans des lignées cellulaires représentatives de CCR et avons trouvé différents degrés de résistance intrinsèque dans ces lignées. Nous avons dès lors exploré les mécanismes de résistance au régorafénib dans des cellules que nous avons rendues plus résistantes que les lignées parentales. L’investigation des voies de signalisation des MAPK et de PI3K/AKT a montré que cette dernière est un acteur majeur dans la résistance acquise dans la lignée HCT-116. Une autre observation basée sur des changements morphologiques particuliers des cellules nous a conduits à investiguer en détail un phénotype sénescent induit par le régorafénib, la sénescence étant reconnue comme causant la résistance aux médicaments. A cet égard, le comportement des deux lignées était différent. Les cellules SW480 étaient capables d'acquérir des propriétés de sénescence stables suite à la sécrétion de facteurs favorisant celle-ci ainsi qu’un arrêt du cycle cellulaire. En accord avec le fait que ces cellules tumorales dormantes peuvent avoir un effet positif sur le devenir du patient, tant que celui-ci reste sous traitement, elles pourraient contribuer à la rechute de la maladie dès l’arrêt du traitement. Les cellules HCT-116 quant à elles présentent des propriétés de sénescence à court terme et développent une résistance acquise sous traitement au régorafénib continu via une transition épithélio-mésenchymateuse (TEM), également associée à une résistance aux médicaments. Ce dernier mécanisme pourrait avoir un effet délétère sur le patient comme l’apparition de sous-clones plus agressifs qui induise la progression de la maladie et assombrit le pronostic.Nous avons également investigué la p-glycoprotéine comme un possible mécanisme de résistance additionnel et avons montré que dans les cellules SW480 traitées au régorafénib, ce dernier serait capable de surmonter la résistance induite par cette protéine. Cependant, une augmentation de l'expression de la p-glycoprotéine n’est observée dans les cellules HCT-116 qu'après une courte exposition au régorafénib et plus dans les cellules traitées en continu.En conclusion, nous avons contribué à une meilleure compréhension des différents mécanismes de résistance au régorafénib dans le CCR. Nous avons indiqué la sénescence, la TEM et probablement la p-glycoprotéine comme acteurs majeurs potentiels; et avons souligné l’hétérogénéité de cette maladie. Est-ce que le régorafénib gagnera-t-il une meilleure place comme traitement efficace dans le CCR ?Notre travail propose plusieurs pistes pour répondre à cette question. / Abstract:Regorafenib is one of the last treatment options for patients with chemo-refractory metastatic colorectal cancer (mCRC), associated with some efficacy but with important toxicities impairing its use in patients with poor general condition. As a multi-targeted tyrosine kinase inhibitor, its mechanism of action remains largely unknown, challenging the identification of clinically useful predictive biomarkers. The ultimate aim of our work was to contribute to the identification of mCRC patients unlikely to benefit from regorafenib. To achieve this objective, we moved from translational to mechanistic studies.Our translational studies focused on therapy response monitoring using liquid biopsies obtained from a prospective clinical trial in mCRC patients treated with regorafenib (RegARd-C trial). We first, confirmed the prognostic value of cell-free DNA (cfDNA) level before treatment. Similarly, we found that high level of pre-treatment metabolically active tumor volume was associated with poor prognosis. When combined, these markers remained predictors of patients’ progression-free (PFS) and overall survival (OS).Then, we measured circulating tumor DNA (ctDNA) based on tumor-specific mutations already identified in patients’ tumor tissue by NGS. We demonstrated that an increasing ctDNA level more than 50% after 14 days of treatment, either based on one or on multiple mutations, is correlated with patients’ clinical outcome in terms of PFS and OS. Furthermore, our data strongly suggested that both baseline cfDNA and ctDNA dynamics are strong complementary predictors of both PFS and OS. Also, we highlighted the leading role of Carbohydrate Antigen 19-9 as a prognostic and early predictive biomarker of mCRC patients’ outcome.Having observed an overall resistance to regorafenib in the majority of patients, we investigated the potential related intrinsic and acquired resistance mechanisms in representative CRC cell lines and found rather different degrees of intrinsic resistance to regorafenib in these cell lines. We then explored potential mechanisms of resistance after short and long-term exposure to regorafenib. The investigation of MAPK and PI3K/AKT pathways pointed to the latter as a major player in acquired resistance.Another observation based on particular cell morphological changes led us to investigate in deep a drug-initiated senescence-like phenotype that is also known to cause drug resistance. SW480 cells were able to acquire stable senescent-like properties, also promoted by a specific senescence-associated secretome, and cell cycle arrest. In line with tumor cell dormancy this phenotype may have a positive impact on patient’s outcome as long as he is under treatment. However, dormant cells contribute to disease recurrence after drug withdrawal. In contrast, HCT-116 cells undergo senescent properties after short exposure and develop acquired resistance triggering EMT, which is also associated with drug resistance. This latter mechanism could be deleterious for the patient as the appearance of more aggressive tumor subclones may induce disease progression and worsen clinical outcome.We also investigated Multi-Drug Resistant protein 1 (MDR1) as a possible additional mechanism of resistance and we found that regorafenib seems to overcome MDR in SW480 treated cells while in HCT-116, an increase of MDR1 expression was observed after short and long exposure compared to parental cells.In conclusion, we contributed to a better understanding of different mechanisms of resistance to regorafenib in CRC. We pointed to cell plasticity such as senescence and EMT in addition to possible MDR as major players; and certainly highlighted the high heterogeneity of the disease. Will regorafenib gain a better place as an efficient drug in CRC? Our work provides some insights for answering this question. / Doctorat en Sciences biomédicales et pharmaceutiques (Médecine) / info:eu-repo/semantics/nonPublished

PROBLEM: Colorectal cancer (CRC) is a top three leading cause of death among western countries. Epidemiological evidence shows a positive correlation between western diet, which consists of high-fat, meat and processed foods. Positive correlations indicate that diets high in fruits and vegetables could greatly decrease risk of CRC. Specifically the ubiquitous spice, turmeric, and its main active constituent have been broadly researched to determine its efficacy in the treatment and prevention of CRC. RESULTS: Curcumin proves to be effective in the treatment and prevention of CRC. It acts as a chemosensitizer for chemotherapeutics which increases their effectiveness especially against chemoresistant CRC cell lines. In many in vitro studies curcumin has inhibited critical pathways involved in CRC progression such as Wnt/β-catenin and sonic hedgehog pathway. Curcumin can also act as a ligand for VDR, which is significant because high vitamin D intake is associated with a decreased risk of CRC. In vivo, curcumin has minimized tumor growth in animal models. In clinical trials curcumin proves to be a naturally derived, non-toxic agent. CONCLUSION: Curcumin and turmeric should be further studied for its use against CRC, specifically its use in nanotechnology and NDDS as either a stand-alone nutraceutical or a chemosensitizer. Additionally, it would likely be advantageous to prescribe turmeric in the diet in combination with black pepper, heat, and oil (which increases its bioavailability) in patients at high risk of developing CRC.

Colorectal cancer is one of the most common cancers in the United States and confronting its challenges has remained a problem to the United States health sector, especially among outpatient clinics. Guided by health belief model, the purpose of this needs assessment was to identify patients age 50 and older in outpatient clinic located in a large metropolitan city in Texas who should receive information on the need for colorectal cancer screening based on their risk for developing colorectal cancer as outlined by American Cancer Society. A sample of 70 charts of patients age 50-75 years was randomly selected and audited using descriptive statistics. Among the patients aged 50-75 years attending the outpatient clinic, 25.7% were African Americans, 71.4% were Hispanic, and 2.9% were Caucasians; 42.9% were male and 57.1% were female. The rate of colorectal cancer screening was 12.9%, a rate that is lower than the rate for all Texans, which was 54.1% - 59.2%. CRC screening was ordered for 62.9% of all patients; 24.2% of clinic patients were identified as being at high risk for colorectal cancer. The low rate of screening may hamper early detection of colorectal cancer in outpatient clinics setting. It is recommended that the outpatient clinic develop intensive campaign to increase patient awareness about the need for and benefits of colorectal cancer screening, especially for those at high risk for developing colorectal cancer. The findings of this study may raise awareness on the chasm in quality of health care availability and provide insight on colorectal cancer and its prevention.

Indiana University-Purdue University Indianapolis (IUPUI) / Pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC) are among the most commonly diagnosed forms of cancer in the United States. Due to their widespread prevalence and high mortality rate, it is vital to develop effective therapeutic drugs to combat these deadly diseases. In both PDAC and CRC, the multifunctional factor nuclear factor kappa B (NF-kB), a central coordinator of cellular immune responses, is activated abnormally, leading to tumorigenesis and cancer progression. Therefore, controlling NF-kB activity is critical in the treatment of these cancers. In a previous study, we identified a new mechanism by which NF-kB activity is regulated by an epigenetic enzyme known as protein arginine methyltransferase 5 (PRMT5). We showed that overexpression of PRMT5 not only activated NF-kB, but also significantly promoted several characteristics associated with cancer, including increased cell proliferation, migration, and anchorage-independent growth in both PDAC and CRC cells. Moreover, in order to examine the therapeutic potential of PRMT5 in these cancers, we adapted the state-of-the-art AlphaLISA technique into a high throughput screen (HTS) platform to screen for PRMT5 inhibitors. As a result, we successfully identified the small molecule PR5-LL-CM01 as our lead hit. Further validation experiments confirmed that PR5-LL-CM01 is a potent and specific PRMT5 inhibitor that exhibits significant anti-tumor efficacy in both in vitro and in vivo models of PDAC and CRC. Additionally, in a second screen, we discovered two natural compounds, P1608K04 and P1618J22, that can also function as the PRMT5 inhibitors. These findings further highlight the robustness of the PRMT5- specific AlphaLISA HTS technique. To conclude, we describe here for the first time a novel role of PRMT5 as a tumor-promoting factor in PDAC and CRC through NF-kB activation. By successfully developing and applying an innovative AlphaLISA HTS technique, we discovered PR5-LL-CM01, P1608K04, and P1618J22 as novel PRMT5 inhibitors, with PR5-LL-CM01 showing the strongest potency in both PDAC and CRC models. Therefore, we demonstrated that PRMT5 is a promising therapeutic target in PDAC and CRC, and the novel PRMT5 inhibitor PR5-LL-CM01 could serve as a promising basis for new drug development in PDAC and CRC.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23411号 / 医博第4756号 / 新制||医||1052(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 妹尾 浩, 教授 藤田 恭之, 教授 山下 潤 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18127号 / 医博第3847号 / 新制||医||1001(附属図書館) / 30985 / 京都大学大学院医学研究科医学専攻 / (主査)教授 千葉 勉, 教授 松田 道行, 教授 野田 亮 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18502号 / 医博第3922号 / 新制||医||1005(附属図書館) / 31388 / 京都大学大学院医学研究科医学専攻 / (主査)教授 武藤 学, 教授 千葉 勉, 教授 松田 道行 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20229号 / 医博第4188号 / 新制||医||1019(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 武藤 学, 教授 原田 浩, 教授 山田 泰広 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20239号 / 医博第4198号 / 新制||医||1019(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 妹尾 浩, 教授 野田 亮, 教授 武藤 学 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13221号 / 論医博第2168号 / 新制||医||1033(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 松田 道行, 教授 小川 誠司, 教授 武藤 学 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM