La voie de signalisation de l’inflammasome est impliquée dans plusieurs pathologies inflammatoires dont la fibrose pulmonaire et plus récemment, elle a été mise en lumière dans le développement de la fibrose hépatique. L’activation de ce complexe permet la maturation et la libération de la cytokine pro-inflammatoire IL-1β par les cellules immunitaires telles les macrophages, après reconnaissance de motifs bactériens ou de signaux de danger. L’objectif de cette thèse était de montrer les mécanismes moléculaires et cellulaires par lesquelles l’inflammasome est impliqué dans la fibrose hépatique. Par une première approche avec un hepatotoxique, le CCl4, chez la souris, nous avons observé que nos stratégies bloquantes de la signalisation de l’inflammasome ne permettent pas de faire le lien direct avec le développement de la fibrogénèse. Dans une seconde approche in vitro, nous avons montré que les fibroblastes hépatiques répondent à des médiateurs pro-inflammatoires comme l’IL-1β, le TNF-α et l’IL-8 par un déséquilibre de la balance MMP/TIMP favorable à la fibrolyse, une exacerbation de la réponse inflammatoire et la diminution de l’expression d’un marqueur d’activation des fibroblastes, l’α-SMA. Enfin, la mise en co-culture de ces fibroblastes avec différents macrophages a montré des effets similaires après activation de l’inflammasome par le LPS et les cristaux de MSU dans les cellules immunitaires, suggérant ainsi un rôle indirect de l’activation de l’inflammasome sur la réponse des fibroblastes hépatiques activés. / Inflammasome pathway is implicated in several inflammatory diseases such as pulmonary fibrosis. Nowadays, several data exist and suggest the implication of this pathway in liver fibrosis development. Once activated, the inflammasone pathway leads to the production and the release of IL-1β, a pro-inflammatory cytokine, by immune cells such as macrophages. The aim of this thesis was to describe the molecular and the cellular mechanism underlining the implication of the inflammasome pathway in liver fibrosis development. To assess this hypothesis, we have firstly inhibited inflammasome pathway in CCl4 hepatotoxicity mouse model. However, this approach did not clearly establish the implication of this pathway in liver fibrosis development. Thus in a second part, we have used an in vitro approach and demonstrate that liver fibroblasts response to pro-inflammatory mediators such as IL-1β, TNF-α and IL-8, and lead to a change in MMP/TIMP balance. The changes conduce to fibrosolysis, an exacerbation of the inflammatory response and the decrease in the expression of α-SMA, an activation marker of fibroblasts. Finally, by co-culturing the fibroblasts with different macrophages, we showed similar effects after inflammasome activation by LPS and the MSU crystals in immune cells, suggesting an indirect role of the activation of inflammasome on the response of activated liver fibroblasts.

Abstract Interstitial lung diseases (ILD), including interstitial pneumonias (IP), represent disorders with variable degrees of parenchymal inflammation and/or fibrosis offer an ideal model to investigate the histopathological features in relation to the course of these diseases. The most common IP is idiopathic pulmonary fibrosis (IPF) with the histological pattern of usual interstitial pneumonia (UIP) exhibiting the histological hallmark of fibroblast foci (FF). Surgical lung biopsy (SLB) is not usually needed for diagnosis of IPF, but the lung biopsy samples taken by SLB confers the diagnosis in atypical cases. The safety of SLB in IPF/UIP has been a controversial issue. The acute exacerbation occasionally occurs during the course of IPF/UIP, but pathological features related to this event are poorly understood. Recent studies suggest that one important determinant in the pathogenesis of ILDs, as in IPF, is oxidant stress and an imbalance of the redox-state in the lung. Thiol containing redox-regulated proteins which paticipate in the antioxidant defence of the lung include thiorexin (Trx) and gamma-glutamylcysteine synthetase (γGCS), also called glutamate-cysteine ligase (GLCL), the rate-limiting enzyme of glutathione (GSH) synthesis. The goal of this research was to evaluate the safety of SLB and the relationships between the histological findings and the course of IPF/UIP, and to investigate the above mentioned defense mechanisms in a variety of ILDs by means of immmunohistochemical analyses, Western Blotting and immunoelectronmicroscopy. No deaths occurred in the following 30 days after 34 video-assisted thoracoscopic lung biopsy (VATS). The number of FF in the lung sample predicted the survival, but it was not associated with acute exacerbation of IPF/UIP before death. Diffuse alveolar damage was a common feature in autopsy samples. The studied redox regulated defense enzymes were expressed in bronchial epithelium, metaplastic alveolar epithelium and alveolar macrophages, but the fibrotic areas generally showed no expression. In IPF/UIP VATS is a safe diagnostic method and counting the number of FF represents a reproducible and reliable method for predicting patient survival. Alterations in the redox regulated defense enzymes further point to the importance of oxidant burden in the fibrotic lung.

The purpose of this thesis was to extend our understanding of the assessment and interpretation of aerobic exercise function of paediatric patients with cystic fibrosis (CF). The first investigation sought to establish (1) the validity of traditional criteria to verify maximal oxygen (V ̇O2max) during a maximal cardiopulmonary exercise test (CPET); and (2) the utility of supramaximal verification (Smax) to confirm V ̇O2max. Traditional criteria significantly underreported V ̇O2max, whilst Smax was shown to provide a valid measurement in this patient group. The reproducibility of this CPET protocol, over the short- (48 h) and medium- (4-6 weeks) term, was then established in study two. V ̇O2max was repeatedly determined with no learning effect over 48 h (typical error (TE): ∆150 mL; ∆9.3%) and 4-6 weeks (TE: ∆160 mL; ∆13.3%). Supplementary maximal and submaximal CPET parameters should be incorporated for a comprehensive evaluation of a patient, however they are characterised by greater variability over time. The influence of mild-to-moderate CF on aerobic exercise function and the matching of muscle O2 delivery-to-O2 utilisation during ramp incremental exercise to exhaustion were then examined in study three. Aerobic function was impaired in CF, indicated by very likely reduced fat-free mass normalised V ̇O2max (mean difference, ±90% CI: -7.9 mL∙kg-1∙min-1, ±6.1), very likely lower V ̇O2 gain (-1.44 mL∙min-1∙W-1, ±1.12) and a likely slower V ̇O2 mean response time (MRT) (11 s, ±13). Arterial oxygen saturation was lower in CF, supporting the notion that centrally mediated O2 delivery may be impaired during ramp incremental exercise. Although a faster rate of fractional O2 extraction would be expected in the face of reduced O2 delivery, this was not observed, suggesting additional impairment in O2 extraction and utilisation at the periphery in CF. The fourth study then demonstrated the clinical utility of CPET to assess the response to 12 weeks treatment with Ivacaftor, using a case-based design. Whilst one patient with relatively mild disease demonstrated no meaningful change in V ̇O2max, the second demonstrated a 30% improvement in V ̇O2max, due to increased O2 delivery and extraction. Furthermore, changes in aerobic function were detected earlier than spirometric indices of pulmonary function. This study demonstrated that CPET represents an important and comprehensive clinical assessment tool and its use as an outcome measure in the functional assessment of patients is encouraged. Study five investigated the V ̇O2 kinetics in this patient group. During moderate intensity cycling, the phase II V ̇O2 time constant (τ) (p = 0.84, effect size (ES) = 0.11) and overall MRT (p = 0.52, ES=0.33) were not slower in CF. However, both were slowed during very heavy intensity cycling (p = 0.02, ES = 1.28 and p = 0.01, ES = 1.40, respectively) in CF. Cardiac output and muscle deoxygenation dynamics were unaltered in CF, however, the arterial-venous O2 content difference (C(a-v ̅)O2) was reduced (p=0.03) during VH and ∆C(a-v ̅)O2 correlated with the phase II τ (r= -0.85; p=0.02) and MRT (r = -0.79; p=0.03) in CF. This study showed that impaired oxidative muscle metabolism in this group is exercise intensity-dependent and mechanistically linked to an intrinsic intramuscular impairment, which limits O2 extraction and utilisation. In conclusion, this thesis has provided guidelines for a valid and reproducible CPET protocol for children and adolescents with mild-to-moderate CF, demonstrated the utility of CPET as clinical outcome measure and furthered our understanding of the factors responsible for impaired aerobic exercise function in this patient group.

Magister Scientiae Dentium - MSc(Dent) / Betel nut/quid chewing is a habit that is commonly practiced in the Indian subcontinent. This age-old social habit is still practiced by Indians in Durban, Kwazulu Natal (South Africa). The betel nut/quid is prepared in a variety of ways. The quid may be prepared with or without tobacco. This habit is said to be associated with the development of premalignant lesions,namely, Oral Submucous Fibrosis (OSF) which increases the susceptibility for malignancy of the oral mucosa and the foregut. The aim of this study was to investigate the prevalence of betel nut/quid chewing (with or without tobacco), the associated habits (smoking and alcohol consumption) and awareness of the harmful effects of the chewing habit among Indians in Durban, KwaZulu-Natal.A cross-sectional study design was chosen utilising a self-administered questionnaire and semi-structured interviews to collect data. Consenting participants were requested to complete a self-administered, structured questionnaire. The study population included any person in the Durban area who chewed betel nut/quid/tobacco. Only persons willingly and who consented to be part of the study, were included. The sample size was based on convenience. People were approached at the pan shops, leisure markets, traditional functions and at the dental practice the researcher operated at. A total of 101 respondents were interviewed.A significantly higher proportion of females chewed betel nut/quid from the total of the respondents. The results showed that the habit is increasingly practiced in the younger age group (20-39 years). There was evidence to show that the chewing habit is used more by the employed than the unemployed (p=0.055). Of the sample population, 78% were born in South Africa and the rest were immigrants from Pakistan, India and Dubai. All respondents from the migrant community were males. The most important reasons for chewing betel nut were for enjoyment and at special functions. More than two third indicated family members (aunts,uncles and cousins) influence as a reason for chewing, in comparison to influences by parents or grandparents. The study also indicated that parents were far more likely to influence betel nut chewing if grandparents did so (p-value= 0.000). In addition, the study revealed that family members (aunts, uncles and cousins) were far more likely to influence betel nut chewing if parents did so (p=0.000).The most popular ingredients chewed were betel nut, betel leaf, lime and pan masala and the most popular combinations were betel nut/lime/betel leaf quid preparation, betel nut alone,betel nut/betel leaf/lime/tobacco/pan masala and betel nut/betel leaf/lime/pan masala. Two thirds of the respondents do not know that betel nut chewing is harmful to their health, thus indicating a lack of awareness on the risks associated with the chewing habit, and the majority have not attempted to give up the habit. Most of the respondents retained their chewing habits after being informed about the risks. A little more than half the study population reported neither smoking nor drinking.The present study found that betel nut/quid chewing habits continue to be enjoyed by many people and most are unaware of the hazardous effects of the habit. More younger people are using the habit as compared to previous studies. This is probably because it is an affordable and easily accessible habit. It is recommended that aggressive awareness programmes on the harmful effects of betel nut/quid chewing be developed, similar to that for smoking cessation.Government health warnings need to be instituted, for example, by having written warnings on packagings. Taxes need to be imposed on the betel nut and condiments thereby reducing access to most people. Age restrictions need to be imposed on purchasing of the betel nut/quid thus making access difficult for the children.

La Thrombospondine-1 (TSP-1) représente l'un des principaux activateurs endogènes du TGF-?1 et possède des propriétés anti-angiogéniques et immunomodulatrices. L'un de ses récepteurs, le CD47, joue un rôle critique dans son effet anti-angiogénique et module l'inflammation. Après obstruction urétérale unilatérale (UUO), l'expression de la TSP-1 augmente, est corrélée à celle du TGF-?1 et du collagène III et décroît avec la réparation tissulaire qui accompagne la désobstruction urétérale. L'utilisation de souris knock-out pour la TSP-1 a permis de montrer qu'elle participe au développement des lésions tubulaires rénales en favorisant les altérations vasculaires et le recrutement des cellules inflammatoires. Cet effet pro-inflammatoire dépend, au moins en partie, du facteur chimiotactique MCP-1, de l'augmentation du rolling leucocytaire et de l'activation de la voie Th17. Les souris knock-out pour CD47 bénéficient également d'une protection tubulaire et vasculaire. Cependant, elles présentent une fibrose interstitielle accrue associée à une augmentation de l'expression de la TSP-1 et du TGF-?1 qui pourrait compromettre une éventuelle récupération rénale. L'étude préliminaire de modèles de néphroangiosclérose chez le rat et la souris révèle que la TSP-1 est surexprimée dans le parenchyme rénal au cours de l'hypertension artérielle. L'intensité de son expression est corrélée à la sévérité des lésions histologiques, suggérant son rôle physiopathologique. Ces résultats montrent que la TSP-1 et le récepteur CD47 participent au développement de la fibrose rénale et représentent donc des cibles thérapeutiques potentielles au cours des maladies rénales chroniques. / Thrombospondin-1 (TSP-1) is a major endogenous activator of TGF-β1 and has anti-angiogenic and immunomodulatory properties. One of its partners, receptor CD47, plays a critical role in its anti-angiogenic activity and also regulates inflammation. After unilateral ureteral obstruction (UUO), TSP-1 expression increases, correlates to TGF-β1 and collagen III expression and decreases with renal repair after desobstruction. Use of TSP-1 knock-out mice allowed us to demonstrate that TSP-1 favours renal injury by increasing vascular lesions and inflammatory cells recruitment. This pro-inflammatory effect depends, at least in part, on chemotactic factor MCP-1, increasing in leukocyte rolling and engagement of T cells in Th17 pathway. CD47 knock-out mice also benefit from tubular and vascular protection after UUO. However, they exhibit increased interstitial fibrosis associated with higher expression of TSP-1 and TGF-β1, which could compromise renal repair. Preliminary study of nephroangiosclerosis models in rats and mice revealed that TSP-1 expression is induced in renal tissue by arterial hypertension and is correlated to the severity of histological lesions, suggesting its physiopathological role. These results show that TSP-1 and CD47 are involved in renal fibrosis and that they represent potential therapeutic target in the management of chronic kidney disease.

La mucoviscidose (CF pour Cystic Fibrosis) est la conséquence de la mutation du gène codant pour le canal chlorure CFTR. Une des stratégies thérapeutiques proposées pour compenser la déficience de CFTR serait de stimuler une voie alternative à CFTR de sécrétion d'ions chlorures. En 2008, le canal ANO1 a été identifié comme CaCC (canal chlorure activé par le calcium) et alors proposé comme cible thérapeutique dans le contexte de la mucoviscidose. Des travaux précédents de notre laboratoire ont montré que l'activité et l'expression d'ANO1 étaient diminuées en contexte CF par rapport au contexte non-CF. Les mécanismes de régulation d'ANO1 n'étant pas connus, les objectifs principaux de ce travail étaient d'étudier la régulation d'ANO1 par les microARN. Nous avons donc, dans un premier temps, identifié un microARN, miR-9 qui est surexprimé dans les cellules CF et qui régule directement ANO1. Nous avons montré que la régulation d’ANO1 par miR-9 entraîne une diminution d’expression et d’activité d’ANO1 ainsi que de la vitesse de migration des cellules. Dans le contexte de la mucoviscidose, il nous a semblé plus intéressant de pouvoir augmenter l’expression d’ANO1 dans le but d’augmenter les efflux chlorures, nous avons donc fait synthétiser une molécule qui empêche la fixation de miR-9 à ANO1, un TSB (Target Site Blocker) ANO1. Nous avons alors démontré que l’utilisation de notre TSB ANO1 permettait d’augmenter l’expression d’ANO1, son activité chlorure et la migration cellulaire dans différents modèles in vitro et in vivo. L’ensemble de ses résultats suggère que notre TSB ANO1 pourrait être une cible thérapeutique intéressante chez les patients atteints de mucoviscidose. / Cystic Fibrosis (CF) is the consequence of the mutation of the chloride channel CFTR. One of the therapeutic strategy proposed in CF to compensate the CFTR deficiency is to stimulate others chlorides channels. In 2008, the channel ANO1 was identified as CaCC (calcium-activated chloride channel) and then proposed as a therapeutic target in CF. Previous works from our lab have shown that ANO1 activity and expression are reduced in the CF context compared to non CF. Mechanisms of ANO1 regulation being unknown, the objectives of this work were to study ANO1 regulation by microRNA. First, we identified a microRNA, miR-9, which is overexpressed in CF cells and directly regulates ANO1. We have then shown that ANO1 regulation by miR-9 induces decreases of ANO1 expression and activity, and migration rate of cells. In the context of CF, it seems more interesting to increase ANO1 expression in order to increase the chloride efflux, we thus designed a target site blocker (TSB ANO1) which prevents miR-9 fixation on ANO1. In different models in vitro and in vivo, we demonstrated that our TSB ANO1 increases ANO1 expression, ANO1 activity and migration rate of cells. These results suggest that ANO1 TSB could be considered as an interesting therapeutic target in CF.

La mucoviscidose est une maladie génétique due à des mutations du gène CFTR (Cystic Fibrosis Transmembrane conductance Regulator), conduisant à un défaut d'adressage de la protéine CFTR à la membrane apicale des cellules épithéliales, ou à un déficit de sa fonction de canal à ions chlorure. Ce travail a consisté à étudier les vésicules extracellulaires (EV), microvésicules (MV) et exosomes (Exo), comme vecteurs de la protéine CFTR et de son ARN messager. La preuve de concept du transfert de matériel biologique d'intérêt par l'intermédiaire d'EV, d'abord apportée sur un modèle de cellules animales (CHO), a été validée en cellules humaines. Les EV ont été isolées à partir de surnageant de Calu-3, cellules exprimant la protéine CFTR de manière endogène, et de A549 transduites par le vecteur adenoviral Ad5-GFP-CFTR, surexprimant la protéine de fusion GFP-CFTR. Les cellules cibles choisies, A549 et CF15, étaient déficientes en CFTR. Le transfert s'est révélé plus efficace en système homologue (A549/A549) qu'en système hétérologue (A549/CF15). Par ailleurs, l'utilisation d'inhibiteurs métaboliques suggère que les EV ne suivent pas une voie d'internalisation cellulaire unique, mais que plusieurs mécanismes sont mis en jeu, dont l'endocytose clathrine dépendante et la macropinocytose. Les deux types d'EV sont capables de rétablir la fonction canal associée au CFTR dans les cellules CF15 de façon dose-dépendante, mais avec un effet de seuil minimum. L'activité CFTR reste stable pendant 3 jours, et à un niveau encore détectable après 5 jours. Notre travail démontre l'intérêt potentiel des MV et Exo comme vecteurs de biothérapie de pathologies génétiques / Cystic fibrosis is a genetic disease in which its prognosis depends on the lung damage. It is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR), resulting in a dysfunctional CFTR protein normally located at the plasma membrane of epithelial cells. This thesis is a study of a novel therapeutic approach to use extracellular vesicles (EVs), microvesicles and exosomes, as transfer vectors for CFTR mRNA and protein to target cells. The proof of concept for the transfer of CFTR mRNA and protein was first done in the CHO hamster model. To validate this concept on human cells, we used human bronchial Calu-3 cells, which express the endogenous CFTR protein, and A549 lung epithelial cells transduced by the adenoviral vector Ad5-GFP-CFTR to overexpress the fusion exogenous protein GFP-CFTR. We show that EVs produced by these cells could transfer a new functionality to CF15 target cells carrying the CFTRdeltaF508 mutation and the transfer seems to be more efficient in a homologous cell system versus a heterologous system. Interestingly, the exosomes seem to be more efficient in CFTR transfer than the microvesicles. A study of the mechanism of EVs cellular uptake show that it is temperature dependent and that endocytosis and macropinocytosis are implicated. Collectively, this study demonstrates the potential application of EVs for CFTR transfer and functional correction of the genetic defect in human CF cells

La fibrose digestive est une complication secondaire tardive de la radiothérapie dans 5 à 10% des patients traités pour des tumeurs de la sphère abdomino-pelvienne. Elle est caractérisée par une accumulation de matrice extracellulaire synthétisée par les cellules mésenchymateuses. La transition endothélium-mésenchyme (EndoMT), est un processus au cours duquel les cellules endothéliales expriment des marqueurs mésenchymateux en réponse au stress. L'EndoMT a été identifiée comme une source de cellules mésenchymateuses participant à la fibrose chez des patients atteints de maladie inflammatoire chronique de l'intestin. Cette étude s'est donc concentrée sur le rôle de l'EndoMT dans le développement de la fibrose intestinale radio-induite et d'identifier des cibles thérapeutiques potentielles.Nos résultats ont révélé pour la première fois l'existence de l'EndoMT au niveau de la paroi rectale chez l'homme après radiothérapie. L'utilisation de souris exprimant la GFP sous le contrôle du promoteur endothélial Tie2, nous a permis de localiser les cellules mésenchymateuses possédant une origine endothéliale, confirmant l'existence de l'EndoMT radio-induite dans notre modèle préclinique de rectite radique. In vitro, nous avons confirmé le changement phénotypique des cellules endothéliales irradiées.Ce projet s'est ensuite concentré sur un acteur potentiel de l'EndoMT radio-induite, Hey2. La génération d'un modèle murin déficient pour Hey2 dans l'endothélium a révélé une diminution des dommages muqueux et de la fréquence l'EndoMT après irradiation. L'inhibition de Hey2 représente une nouvelle approche thérapeutique attrayante dans la réduction de la fibrose digestive radio-induite. / Fibrosis is identified as a chronic side effect occurring after radiotherapy for pelvic tumors in 5 to 10 % of patients. This pathological healing process is characterized by an accumulation of extracellular matrix synthesized by mesenchymal cells. Endothelial to mesenchymal transition (EndoMT), is a processes during which endothelial cells express mesenchymal markers in response to stress. EndoMT is identified as a source of mesenchymal cells taking part to fibrosis development in patients suffering from inflammatory bowel diseases. Then, this study focused on the potential participation of EndoMT in radiation-induced intestinal fibrosis and tried to identify new therapeutics targets. Interestingly, our results showed for the first time EndoMT in rectal tissues from patients who developed radiation proctitis following radiotherapy. We used an in vivo approach to follow the mesenchymal cells having an endothelial origin in a mouse model expressing the GFP under the control of an endothelial promoter, Tie2 (Tie2-GFP). Thereby, our results confirmed the existence of radiation-induced EndoMT in our preclinical model of radiation proctitis. In vitro characterization showed that irradiation induced a modulation of the endothelial phenotype through a mesenchymal profile, a hallmark of EndoMT. This project also focused on a potential molecular actor, Hey2. In this context, we generated a transgenic mouse model in which Hey2 gene expression is repressed specifically in the endothelial compartment and observed a decrease in radiation-induced mucosal damages and EndoMT frequency. Consequently, inhibiting Hey2 expression could represent a new interesting therapeutic strategy.

Four studies investigating the assessment of glycaemic control in cystic fibrosis are presented within this thesis. The first was a validation study of continual glucose monitoring (CGM) in cystic fibrosis (CF). 50 stable adults with CF underwent home CGM for 3 days, during which time they attended the CF centre for OGTT. Gold standard fasting (0 hour) plasma glucose and 2 hour plasma glucose values during OGTT were compared with concurrent CGM sensor glucose values using a 'limits of agreement' analysis. CGM was found to be valid in adults with CF, with its accuracy being consistent with that published in non-CF populations. The next investigation compared OGTT with CGM with several objectives: to determine whether OGTT is a relevant and adequate measure of glycaemia in CF, find out whether CGM could offer a superior alternative to OGTT and explore whether OGTT and CGM results are associated with prior change in lung function and weight in adults with CF. Data from the first study was used to show that the OGTT can only identify abnormal glycaemic control in CF at a late stage, and that CGM is a more relevant reflection of everyday glycaemia in CF. No correlation was found between prior change in lung function and nutritional status in CF and glycaemia measured by OGTT or CGM. The subsequent study investigated whether CGM could identify early abnormal glycaemic control in CF. This involved ten non-CF healthy controls undergoing the same study protocol as the 50 stable adults with CF, to determine 'normal' glycaemic control parameters. Of 25 CF patients with normal glucose tolerance by OGTT, 19 (76%) had significantly higher mean and/or variability of CGM levels than healthy controls. This lead to changes in their management, including 2 subjects being commenced on insulin therapy. The final investigation was a questionnaire study, asking the 50 CF patients to provide information on their experience of undergoing CGM. 58% of patients responded, with replies indicating that they found CGM broadly acceptable, interfering little in their lives and that their experiences were generally positive. This insight into patients' experiences of CGM can be used to guide future clinical and research roles for this tool. These studies have provided novel data regarding the assessment of glycaemic in CF. Information captured by CGM has greater relevance to CF patients' daily lives than OGTT. CGM can identify early problems with glycaemic control leading to changes in management that may not be detected by conventional measures. CGM offers potential in further clinical application and research to improve the lives and outcomes for adults with CF.

Small Intestinal Neuroendocrine Tumors (SI-NETs) are indolent neoplasms with an increasing annual incidence of approximately 1/100 000 people. They are often diagnosed at a late stage, restricting treatment efficacy. The aim of this thesis was to investigate clinical aspects of patients with advanced and/or disseminated disease with regard to clinical signs and management of abdominal fibrosis, the role of locoregional surgery and liver transplantation, as well as the ex vivo sensitivity of tumor samples to cytotoxic and targeted agents. Additionally, novel serum biomarkers for the diagnosis and prognosis of SI-NETs were investigated. In Paper I, abdominal fibrosis induced by serotonin and other cytokines from tumor cells, was associated with clinically significant symptoms of intestinal ischemia and/or obstructive uropathy, and was linked to advanced disease. Prompt recognition and minimally invasive intervention with superior mesenteric vein stenting and/or percutaneous nephrostomy and J stent treatment were effective in disease palliation. Paper II challenged the role of prophylactic, upfront locoregional surgery in Stage IV, which conferred no survival advantage in asymptomatic SI-NET patients. The option of delayed surgery as needed seemed to be comparable in all the outcomes examined, whilst also offering the advantage of fewer re-operations for intestinal obstruction in patients with already disseminated disease. Paper III confirmed that most young patients (<65 years) with SI-NET and liver metastases had a favorable survival with standardized multimodality treatment and that survival figures reported after liver transplantation for NETs do not surpass these figures. In Paper IV, 145 biomarkers were analyzed in blood serum using two different multiplex proximity assays. Subsequent ELISA and immunohistochemical analyses identified DcR3, TFF3 and midkine as novel serum biomarkers for SI-NETs. In Paper V, SI-NET samples were profiled with respect to sensitivity ex vivo to a panel of standard chemotherapeutics and targeted agents using a short-term total cell kill assay. SI-NETs exhibited variable but generally intermediate sensitivity ex vivo compared with other cancer diagnoses, calling for individualized selection of therapy.