A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Members of the ErbB subfamily of receptor tyrosine kinases are critical regulators of normal mammary gland development, and alterations in their signaling have been associated with breast tumorigenesis. ErbB4 expression in breast carcinomas predicts improved patient survival and inversely correlates with tumor grade, metastasis and disease recurrence. When examined in the context of the breast cancer molecular subtypes, ErbB4 expression is rarely expressed in the triple-negative tumor subtype, which is associated with poor prognosis. Recently, our lab discovered a genomic context for the loss of ErbB4 expression in metastatic, refractory triple-negative breast cancer (TNBC) samples by next generation sequencing technology. The goal of this study was to examine the effects of ErbB4 overexpression on the growth and migration of TNBC cell lines. A GFP-containing construct was used to overexpress ErbB4 in the ErbB4-negative TNBC cell lines BT-20, BT-549 and MDA-MB-468. An empty vector construct was used as the control. Expression was confirmed by western blot and fluorescence microscopy to detect expression of ErbB4 or GFP respectively. Cell motility and growth was assessed with a transwell migration assay and a sulforhodamine B assay to measure cell density, respectively. Our data indicates that overexpression of ErbB4 resulted in no significant difference in the migration of BT-549 or MDA-MB-468 cells but resulted in a slight increase in the migration of BT-20 cells. ErbB4 had a growth inhibitory effect on BT-549 and BT-20 cells but showed no difference in the growth of MDA-MB-468 cells. This data suggests that multiple ErbB4-mediated mechanisms occur to alter the growth of TNBC cells. Although the translational significance of ErbB4 loss may be in its ability to predict outcome in patients with TNBC, more work is needed to elucidate the molecular mechanisms mediating its function.

Les récepteurs de la famille HER jouent un rôle majeur dans le développement du cancer. Alors qu’EGFR, HER2 et HER3 sont très bien étudiés et ciblés par des anticorps thérapeutiques, le dernier récepteur de cette famille, HER4, n’est que peu étudié et son implication dans la cancérogénèse est controversée. Il n’existe à ce jour pas d’anticorps thérapeutique anti-HER4 sur le marché ou en phase clinique. Ce récepteur est présent à la surface en quatre isoformes (JMa/CYT1 ; JMa/CYT2 ; JMb/CYT1 ; JMb/CYT2). Les isoformes JMa sont activées par clivage du récepteur, contrairement aux deux isoformes JMb. Le clivage de ces isoformes conduit à la libération de la partie intracellulaire du récepteur, appelée 4ICD. Ce fragment peut être dirigée au noyau ou dans d’autres compartiments cellulaires, impliquant HER4 dans des signalisations oncogéniques ou suppresseurs de tumeur. La littérature décrivant une activité pro-apoptotique de 4ICD et de la NRG1, le principal ligand de HER4, nous avons étudié la signalisation de ces isoformes afin de déterminer leurs rôles au niveau tumoral. Nos résultats indiquent que la NRG1 induit une signalisation suppresseur de tumeur via JMa/CYT1 et une signalisation oncogénique via JMa/CYT2. Sur la base de ces résultats, nous avons développé un criblage original d’anticorps anti-HER4 par phage display, sur des cellules exprimant l’isoforme JMa/CYT1 et stimulées par la NRG1. Nous avons caractérisés quatre anticorps anti-HER4, dont l’activité et les signalisations de certains sont modulées par la NRG1. Deux de ces anticorps, caractérisés comme étant des agonistes du récepteur HER4, induisent la mort des cellules tumorales par des mécanismes que nous sommes en train d’élucider. De manière similaire a la NRG1, un des anticorps induit la relocalisation de 4ICD-CYT1 a la mitochondrie pour induire la mort cellulaire. Ces résultats prometteurs ouvrent la voie à un ciblage thérapeutique du récepteur HER4 a l’aide d’anticorps agonistes pour le traitement des cancers / HER family is composed by four members which play a major role in cancer development. EGFR, HER2 and HER3 are well described and targeted with therapeutic monoclonal antibodies. HER4, the last one, is poorly described with a contentious role in cancerogenesis. Nowadays, there is no therapeutic antibody targeting HER4 in clinic. Four isoforms of the receptor are addressed to the plasma membrane and are called JMa/CYT1; JMa/CYT2; JMb/CYT1 and JMb/CYT2. JMa isoforms are activated by cleavage, but not JMb isoforms. Following their activation, JMa isoform cleavage releases the intracellular part of the receptor called 4ICD. This part can be directed to the nucleus or others subcellular compartments, involving HER4 in oncogenic or tumor suppressor signalling. Because a pro-apoptotic activity of 4ICD and its main ligand NRG1 have been described, we studied JMa isoforms signaling to determine their roles in cancer. We demonstrated that NRG1 induce a tumor suppressor signalling from JMa/CYT1 and an oncogenic signalling from JMa/CYT2. Based on these results, we developed an innovative screening for anti-HER4 antibodies by whole cell panning with phage display. To this end, we used NRG1- stimulated cells expressing JMa/CYT1 isoforms. We characterized four anti-HER4 antibodies and functions of some of them are affected and modulated by NRG1. Two antibodies were characterized as agonistic anti-HER4 antibodies and induce cell death of cancer cells by different mechanisms. Like NRG1, one of them induce mitochondrial localization of 4ICD-CYT1 to induce cell death. These promising results pave the way to a therapeutic targeting of HER4 receptor with agonistic antibodies to treat cancer

Bipolar disorder is a heritable psychiatric disorder, and several of the genes associated with bipolar disorder and related psychotic disorders are involved in the development and maintenance of white matter in the brain. Patients with bipolar disorder have an increased incidence of white matter hyper-intensities, and quantitative brain imaging studies collectively indicate subtle decreases in white matter density and integrity in bipolar patients. This suggests that genetic vulnerability to psychosis may manifest itself as reduced white matter integrity, and that white matter integrity is an endophenotype of bipolar disorder. This thesis comprises a series of studies designed to test the role of white matter in genetic risk to bipolar disorder by analysis of diffusion tensor imaging (DTI) data in the Bipolar Family Study. Various established analysis methods for DTI, including whole-brain voxel-based statistics, tract-based spatial statistics (TBSS) and probabilistic neighbourhood tractography, were applied with fractional anisotropy (FA) as the outcome measure. Widespread but subtle white matter integrity reductions were found in unaffected relatives of patients with bipolar disorder, whilst more localised reductions were associated with cyclothymic temperament. Next, the relation of white matter to four of the most prominent psychosis candidate genes, NRG1, ErbB4, DISC1 and ZNF804A, was investigated. A core haplotype in NRG1, and three of the four key single nucleotide polymorphisms (SNPs) within it, showed an association with FA in the anterior thalamic radiations and the uncinate fasciculi. For the three SNPs considered in ErbB4, results were inconclusive, but this was consistent with the background literature. Most notable however, was a clear association of a non-synonymous DISC1 SNP, Ser704Cys, with FA extending over most of the white matter in the TBSS and voxel-based analyses. Finally, FA was not associated with a genome-wide supported risk SNP in ZNF804A, a finding which could not be attributed to a lack of statistical power, and which contradicts a strong, but previously untested hypothesis. Whilst the above results need corroboration from independent studies, other studies are needed to address the cellular and molecular basis of these findings. Overall, this work provides strong support for the role of white matter integrity in genetic vulnerability to bipolar disorder and the wider psychosis spectrum and encourages its future use as an endophenotype.

<p>Funding: Magnus Bergvall Cancer Foundation; Percy Falk foundation for research in breast and prostate cancer; Nyckelfonden; Örebro University Hospital; Lions cancer research foundation, Region Uppsala-Örebro</p>

Primary brain tumours, and especially the most common form malignant gliomas, usually display a pronounced resistance to other treatment modalities when surgery fails to cure. Growth factors, such as EGF and its receptor, frequently amplified and overexpressed in malignant gliomas, and factors associated with multidrug resistance have been suggested to at least partially explain the poor outcome. The aim of this thesis was to characterise factors in primary brain tumours associated with the development of resistance with focus on the epidermal growth factor receptor (ErbB) family, and multidrug resistance (MDR). Influences of irradiation on the expression and activity of P-glycoprotein (Pgp) in malignant gliomas was evaluated. The effects showed that irradiation increased the efflux activity of Pgp in rat brain vascular endothelial cells, but not in glioma cells. In the intracranial BT4C glioma model, Pgp was detected in the capillary endothelium in the tumour tissue but not in glioma cells. Expression of several factors coupled to MDR (Pgp, MRP1, LRP, and MGMT) in primary brain tumours were analysed and correlated to clinical data. In gliomas, Pgp and MRP1 were predominantly observed in capillary endothelium and in scattered tumour cells, whereas LRP occurred only in tumour cells. In meningiomas, expression of the analysed markers was demonstrated in the capillary endothelium, with a higher expression of Pgp and MRP1 in transitional compared to meningothelial meningiomas. A pronounced expression of MGMT was found independently of the histopathological grade or tumour type. Survival analysis indicated a shorter overall survival for patients suffering from low-grade gliomas with high expression of Pgp. To explore the importance of the epidermal growth factor receptor (EGFR), expression levels of the family members (EGFR, ErbB2-4) were analysed and their relations to various clinical parameters were evaluated in gliomas and meningiomas. In gliomas, the highest EGFR expression was observed in high-grade tumours, while ErbB4 expression was most pronounced in low-grade tumours. In meningiomas, expression of EGFR, ErbB2, and ErbB4 was observed in the majority of the tumours. An intriguing observation in low-grade gliomas was a significantly decreased overall survival for patients with high EGFR protein expression. The effects of different time schedules for administration of the selective EGFR inhibitor ZD1839 in relation to irradiation of glioma cells were analysed. The analyses showed a heterogeneity in the cytotoxic effects of ZD1839 between cell lines, and it was obvious that some of the cell lines showed sensitivity to ZD1839 despite no or low expression of EGFR. The study also demonstrated the importance of timing of ZD1839 administration when this agent is combined with irradiation. In conclusion, in order to enhance the efficacy of radiotherapy by various drugs in malignant gliomas it may be essential to inhibit drug efflux activity in endothelial cells and to deliver drugs in an optimal timing in relation to radiotherapy. The heterogeneity in expression of drug resistance markers, as well as the ErbB family reflects the complexity in classification of primary brain tumours, and indicates that subgroups of patients with low-grade gliomas expressing Pgp and EGFR might benefit from more aggressive and individualised treatment.

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Schizophrenia is a complex disorder affecting 1% of the population and is highly heritable, but the majority of contributing genetic factors has remained elusive. Current risk estimates for clinical practice are primarily determined by family history and associated empirical risk. Copy number variants (CNVs) may hold the key to explaining the missing heritability in schizophrenia research; schizophrenia risk estimates as high as 30% have been found for the most-studied CNV associated with schizophrenia, 22q11. Currently, there are methods to identify CNVs though previously collected data from SNP microarrays that would facilitate these types of studies. To determine if algorithms that call CNVs from microarray data are robust four genomic regions with putative CNVs called by the Wellcome Trust Consortium using Birdseye in Birdsuite with Affymetrix 6.0 array raw SNP intensities, primarily affecting genes CHD1L, COX5B, PAK7, ZFYVE20, were validated using Taqman real-time qPCR assays in 29 samples by research groups at VCU and Dublin. CNVs called from the algorithm were 100% validated at VCU though there were false negatives from the algorithm that were validated. Two samples at loci with putative duplications were not called by the Dublin group, which may be because of differing sensitivities of the Taqman assays to be able to detect a 50% difference in copy number between duplications and diploid controls, or because of another technical or analytical difference between the two sites. Deletion frequency of one common CNV found in the gene ERBB4, was assessed by qPCR in both Irish singleton (ICCSS) and Irish family (IHDSF) samples and compared with Irish control (Trinity Biobank) and North American control populations. The ERBB4 deletion frequency was not significantly different when comparing the Irish controls to the Irish singleton or the Irish family samples though the family samples were different when compared against the North American control population, which suggests population stratification, rather than a true association between ERBB4 and increased schizophrenia risk. Current clinical practice has been improved by knowledge and evaluation of CNV-related disorders that include risk for psychosis and additional phenotypes. Genotyping of individuals with known psychosis has led to improved patient care for non-psychosis-related phenotypes associated with CNVs. Individuals with suspected genomic disorders that are found to have CNVs can be counseled on potential psychosis risk and potential risk to their offspring. Recurrent CNVs may hold promise in future clinical practice in order to individualize risk estimates in the general patient population, and increase the number of individuals able to receive anticipatory treatment to minimize disease severity.

Le cancer de la prostate est le cancer le plus fréquemment diagnostiqué et la troisième cause de mortalité liée au cancer chez les hommes au Canada. Un quart des patients diagnostiqués développeront une forme plus agressive de ce cancer. Bien que nous possédions plusieurs indices cliniques pronostiques dans les cancers localisés (score de Gleason, taux sérique d’antigène prostatique spécifique (APS), stade, etc.), ceux-ci sont insuffisants pour adéquatement distinguer les patients à faible risque de progression de ceux à haut risque. A ce jour, aucun biomarqueur pronostique n’est encore utilisé en clinique. Les cliniciens ont donc besoin de nouveaux outils plus efficaces pour stratifier ce cancer et pour s’assurer d’adapter au mieux le traitement à chaque patient. En nous basant sur la littérature et sur des études préliminaires (cohortes de moins de 65 patients), notre hypothèse est que les protéines PUMA-NOXA et les récepteurs membranaires de la famille ERBB seraient, lorsqu’utilisés en combinaison, des biomarqueurs prédictifs de la progression du cancer de la prostate. Les objectifs de cette thèse sont : 1) identifier et valider de bons anticorps pour chaque biomarqueur d’intérêt, 2) définir les niveaux d’expression de chaque biomarqueur sur une cohorte de 285 patients, et 3) établir les corrélations entre les niveaux d’expression et les données cliniques des patients. Dans l’optique d’une utilisation en clinique, des anticorps de type monoclonal ont été choisis pour identifier les biomarqueurs d’intérêts. Ces anticorps ont été testés et validés pour leur spécificité par immunobuvardage de type western blot et par immunofluorescence. La localisation de la protéine d’intérêt a été validée sur des échantillons de tissus de patients suivie de l’optimisation du multi-marquage sur les cellules épithéliales et basales. Après perfectionnement de l’analyse d’images, nous avons montré qu’une expression extrême (faible ou forte) de PUMA couplée à une forte expression de NOXA dans les glandes bénignes est associée à la rechute biochimique des patients. La présence de ces biomarqueurs dans les glandes bénignes permet d’envisager d’améliorer l’identification lors des premières biopsies des patients se qualifiant pour la surveillance active. Par ailleurs, le suivi de l’expression des récepteurs de la famille ERBB dans les glandes tumorales permet une stratification des patients atteints d’un cancer de la prostate en fonction des risques de rechute biochimique, de développement de métastases et de mort liée au cancer. Ainsi, les patients présentant la combinaison d’une forte expression de EGFR et d’une faible expression de ERBB3 sont les plus susceptibles de mourir spécifiquement de leur cancer de la prostate, en particulier si les cellules tumorales présentes en plus une faible expression de ERBB2 entrainant un fort risque de développer des métastases. Mon projet de doctorat aura donc permis d’identifier et de valider des biomarqueurs d’intérêt pour prédire l’évolution du cancer de la prostate et démontrer l’intérêt de suivre ces biomarqueurs en combinaison afin d’obtenir une meilleure stratification des patients. Ces résultats devront être validés sur une cohorte indépendante et multicentrique en vue de fournir aux cliniciens un plus grand nombre d’outils pour leur permettre de réaliser une stratification fine des patients atteints d’un cancer de la prostate, et ouvrirait la voie à de nouvelles stratégies thérapeutiques plus ciblées. / Prostate cancer is the most frequently diagnosed cancer and the third leading cause of cancer-related death in men in Canada. A quarter of patients will develop a more aggressive form of this cancer. While there are several clinical prognostic variables for localized prostate cancer (Gleason score, prostate specific antigen (PSA) levels, stage, etc.), these are insufficient to adequately distinguish between low and high-risk of progression cases. As a result, clinicians need new, more effective tools to stratify this cancer and to ensure that treatments are best tailored to each patient. To date, no prognostic biomarker has yet been used clinically. Based on the literature and preliminary studies of small cohorts (less than 65 patients), we hypothesize that the protein expression of PUMA-NOXA and ERBB family members could help with the prediction of prostate cancer progression. The objectives of this thesis are: 1) to identify and validate antibodies for each biomarker of interest, 2) to define the expression levels of each biomarker on a 285 patient cohort, 3) to evaluate the correlation between marker expression levels and patient clinical data. For clinical use, monoclonal-type antibodies were chosen to identify the biomarkers of interest. These antibodies were validated for specificity by western blot and immunofluorescence techniques. The localization of the protein of interest was further identified within samples of patient tissues and additional optimization involving combinatorial staining for epithelial and basal cells. After refining the imaging and statistical analysis of PUMA and NOXA in benign glands, we found that extreme (weak or strong) PUMA expression coupled with high NOXA expression was associated with biochemical relapse. In addition, these proteins have significant potential for predicting disease evolution based on the initial radical prostatectomy sample. The presence of these proteins in benign glands would allow the identification of patients less suitable for active surveillance. Additionally, statistical analysis of ERBB family receptors in tumor glands, when used alone, allow stratification of prostate cancer patients for the prediction of biochemical relapse, development of metastases and also specific death from prostate cancer. Moreover, patients expressing a combination of high EGFR expression and low ERBB3 expression are at high risk of biochemical relapse and are at higher risk of prostate cancer specific mortality. In addition, coupling this high EGFR – low ERBB3 combination to a low ERBB2 expression helps classify patients at high risk of developing metastases. My doctoral research project will have made it possible to identify and validate biomarkers of interest for predicting the progression of prostate cancer and demonstrating the interest of combining these biomarkers in order to achieve better stratification of patients with prostate cancer. In the context of clinical utility, these results need to be validated on an independent and multicenter cohort in order to confirm these findings. This would eventually provide clinicians with a greater number of tools at their disposal to correctly anticipate patient trajectories and possibly identify new therapeutic targets for the control of the disease.