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Nicotinamide adenine dinucleotide (NAD) is a key regulator of several metabolic and signaling pathways that are relevant in cancer cell survival. Cancer cells have an increased energy demand associated with an increased NAD turnover. Nicotinamide phosphoribosyltransferase (NAMPT), a key enzyme of the NAD salvage pathway, plays a crucial role in maintaining the intracellular NAD levels and in regulating the activity of NAD-dependent enzymes, such as sirtuins (SIRTs). The inhibition of NAMPT activity and the use of phytochemicals, such as resveratrol, represent novel therapeutic approaches in cancer therapy. Based on these facts, this thesis aimed to investigate (1) the chemotherapeutic potential and molecular mechanisms of FK866, a specific NAMPT inhibitor, and resveratrol on hepatocarcinoma cells and to find out whether there are differences compared to primary human hepatocytes; (2) to address the impact of NAMPT inhibition on the energy metabolism in cancer cells; and (3) to investigate the roles of NAMPT and SIRT1 in resveratrol´s mode of action and chemotherapeutic effects. This work demonstrates that FK866 and resveratrol possess potent chemotherapeutic effects in hepatocarcinoma cells which were absent in human hepatocytes. Hepatocarcinoma cells display a dysregulation in the AMP-activated kinase (AMPK)/mammalian target of rapamycin (mTOR) signaling as well as in the NAMPT-mediated NAD salvage pathway compared to human hepatocytes. FK866-induced NAMPT inhibition induces ATP depletion associated with AMPK activation and mTOR inhibition whereas resveratrol induces caspase3-mediated apoptosis that is not dependent on NAMPT and SIRT1 function. NAMPT and SIRT1 are differentially regulated by resveratrol in hepatocarcinoma cells and human hepatocytes. This work also reveals that resveratrol activates p53-induced cell cycle arrest in hepatocarcinoma cells which is partly mediated by SIRT1 inhibition. In summary, this thesis provides new insight into the role of the NAMPT-mediated NAD salvage pathway in energy metabolism and characterized FK866 and resveratrol as promising potential chemotherapeutic agents for treatment of hepatocellular carcinoma.

Purpose: To evaluate the efficiency of a multimodality approach consisting of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) as bridging therapy for patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) and to evaluate the histopathological response in explant specimens. Materials and Methods: Between April 2001 and November 2011, 36 patients with 50 HCC nodules (1.4–5.0 cm, median 2.8 cm) on the waiting list for liver transplantation were treated by TACE and RFA. The drop-out rate during the follow-up period was recorded. The local efficacy was evaluated by histopathological examination of the explanted livers. Results: During a median follow-up time of 29 (4.0–95.3) months the cumulative drop-out rate for the patients on the waiting list was 0, 2.8, 5.5, 11.0, 13.9 and 16.7% at 3, 6, 12, 24, 36 and 48 months, respectively. 16 patients (with 26 HCC lesions) out of 36 (44.4%) were transplanted by the end of study with a median waiting list time of 13.7 (2.5–37.8) months. The histopathological examination of the explanted specimens revealed a complete necrosis in 20 of 26 HCCs (76.9%), whereas 6 (23.1%) nodules showed viable residual tumor tissue. All transplanted patients are alive at a median time of 29.9 months. Imaging correlation showed 100% specificity and 66.7% sensitivity for the depiction of residual or recurrent tumor. Conclusion: We conclude that TACE combined with RFA could provide an effective treatment to decrease the drop-out rate from the OLT waiting list for HCC patients. Furthermore, this combination therapy results in high rates of complete tumor necrosis as evaluated in the histopathological analysis of the explanted livers. Further randomized trials are needed to demonstrate if there is a benefit in comparison with a single-treatment approach. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

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Background and Aims: Morphometric features such as the Milan criteria serve as standard criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Since it has been recognized that these criteria are too restrictive and do not adequately display the tumor biology, additional selection parameters are emerging. Methods: Concise review of the current literature on patient selection for downstaging and LT for HCC outside the Milan criteria. Results: The major task in patients outside the Milan criteria is the need for higher granularity with patient selection, since the benefit through LT is not uniform. The recent literature clearly shows that beneath tumor size and number, additional selection parameters are useful in the process of patient selection for and during downstaging. For initial patient selection, the alpha fetoprotein (AFP) level adds additional information to the size and number of HCC nodules concerning the chance of successful downstaging and LT. This effect is quantifiable using newer selection tools like the WE (West-Eastern) downstaging criteria or the Metroticket 2.0 criteria. Also an initial PET-scan and/or tumor biopsy can be helpful, especially in the high risk group of patients outside the University of California San Francisco (UCSF) criteria. After this entry selection, the clinical course during downstaging procedures concerning the tumor and the AFP response is of paramount importance and serves as an additional final selection tool Conclusion: Selection criteria for liver transplantation in HCC patients are becoming more and more sophisticated, but are still imperfect. The implementation of molecular knowledge will hopefully support a more specific risk prediction for HCC patients in the future, but do not provide a profound basis for clinical decision-making at present.

Liver cancer is the fourth leading cause of cancer-related mortality worldwide with limited therapeutic options. Thus, novel treatment strategies are urgently required. While the oncogenic kinase, proviral integration site for Moloney murine leukemia virus 2 (PIM2), has been shown to be overexpressed in liver cancer, little is known about the role of PIM2 in this tumor entity. In this study, we explored the functional relevance and therapeutic potential of PIM2 in liver cancer. Using PIM2‐specific siRNAs, we examined the effects of PIM2 knockdown on proliferation (WST-1 assays and spheroid assays), 3D-colony formation and colony spread, apoptosis (flow cytometry and caspase 3/caspase 7 activity), as well as cell cycle progression (flow cytometry, RT-qPCR and western blot analysis) in the two liver cancer cell lines, HepG2 and Huh‐7. In subcutaneous liver cancer xenografts, we assessed the effects of PIM2 knockdown on tumor growth via the systemic delivery of polyethylenimine (PEI)-complexed siRNA. The knockdown of PIM2 resulted in potent anti-proliferative effects in cells grown on plastic dishes, as well as in spheroids. This was due to G0/G1 cell cycle blockade and the subsequent downregulation of genes related to the S phase as well as the G2/M phase of the cell cycle, whereas the apoptotic rates remained unaltered. Furthermore, colony formation and colony spread were markedly inhibited by PIM2 knockdown. Notably, we found that HepG2 cells were more sensitive to PIM2 knockdown than the Huh‐7 cells. In vivo, the therapeutic nanoparticle-mediated delivery of PIM2 siRNA led to profound anti-tumor effects in a liver cancer xenograft mouse model. On the whole, the findings of this study underscore the oncogenic role of PIM2 and emphasize the potential of targeted therapies based on the specific inhibition of PIM2 in liver cancer.

Objective: Hepatocellular carcinoma (HCC) often develops in patients with alcohol-related cirrhosis at an annual risk of up to 2.5%. Some host genetic risk factors have been identified but do not account for the majority of the variance in occurrence. This study aimed to identify novel susceptibility loci for the development of HCC in people with alcohol related cirrhosis. - Design: Patients with alcohol-related cirrhosis and HCC (cases: n=1214) and controls without HCC (n=1866), recruited from Germany, Austria, Switzerland, Italy and the UK, were included in a two-stage genome-wide association study using a case–control design. A validation cohort of 1520 people misusing alcohol but with no evidence of liver disease was included to control for possible association effects with alcohol misuse. Genotyping was performed using the InfiniumGlobal Screening Array (V.24v2, Illumina) and the OmniExpress Array (V.24v1-0a, Illumina). - Results: Associations with variants rs738409 in PNPLA3 and rs58542926 in TM6SF2 previously associated with an increased risk of HCC in patients with alcohol-related cirrhosis were confirmed at genome-wide significance. A novel locus rs2242652(A) in TERT (telomerase reverse transcriptase) was also associated with a decreased risk of HCC, in the combined meta-analysis, at genome-wide significance (p=6.41×10⁻⁹, OR=0.61 (95% CI 0.52 to 0.70). This protective association remained significant after correction for sex, age, body mass index and type 2 diabetes (p=7.94×10⁻⁵, OR=0.63 (95% CI 0.50 to 0.79). Carriage of rs2242652(A) in TERT was associated with an increased leucocyte telomere length (p=2.12×10⁻⁴⁴). - Conclusion: This study identifies rs2242652 in TERT as a novel protective factor for HCC in patients with alcohol-related cirrhosis.

Die vorliegende Arbeit untersucht die Rolle des Metabolismus in der Entstehung und Progression des Hepatozellulären Karzinoms (HZK). Der Schwerpunkt der Studie liegt auf Veränderungen zentraler Stoffwechselwege, unter anderem der Glykolyse, der Gluconeogenese, des Citratzyklus und anderer Prozesse des Zellstoffwechsels. Umfassende Multiomikanalysen, wie etwa Proteomik, Metabolomik und gezielte Genomsequenzierung wurden angewandt, um in vivo die Mechanismen der HZK Entstehung zu verstehen. Es wurden zwei Systeme untersucht: das ASV-B Mausmodell und klinische Patientenproben. Die Kohorte bestehend aus Biopsien und Resektaten von 95 Patienten umfasste 47 Fälle von HZK und 48 Fälle ohne HZK. Das Proteom des Mausmodells und der Patientenkohorte zeigen eine deutliche Herabregulierung wesentlicher Energie bereitstellender Kreisläufe im HZK: Glykogenstoffwechsel, de novo Synthese von Glukose, Glutaminaufnahme in den Citratzyklus, des weiteren sind 60% der Enzyme des Citratzyklus, und des Transports von Pyruvat in Mitochondrien im HZK herabreguliert. In dieser Arbeit wurde ein Isoformenwechsel auf mehreren Ebenen des zentralen Kohlenstoffmetabolismus gezeigt. Sowohl das Mausmodell, als auch die Gewebeproben von HZK-Patienten weisen Isoformenwechsel der Phosphoglyzeratmutasen und der Pyruvatkinasen auf. Die Hauptmerkmale finden sich sowohl in Modellmäusen, als auch in Patienten, und stellen so einen universalen metabolomischen Fingerabdruck des HZK dar. Darüber hinaus demonstriert diese Studie, dass die Proteomanalyse von bioptischen Material ein aussagekräftiges und ausreichendes molekular-diagnostisches Instrument für die Krebsforschung ist: die Proteomanalyse von Lebermaterial erlaubt die Unterscheidung von Tumorgewebe und tumorfreien Proben und die Dokumentation des Krankheitsverlaufs. / The present work evaluates the role of metabolism in development and progression of hepatocellular carcinoma (HCC). This study focuses on changes of central metabolic pathways, including glycolysis, gluconeogenesis, tricarboxylic acid (TCA) cycle and other processes involved in cellular metabolism and known to be dysregulated during cancer formation. Comprehensive multiomics analyses, such as proteomics, metabolomics and targeted genome sequencing, were applied in order to better understand HCC developmental mechanisms in vivo. Two main systems were studied: the ASV-B mouse model and clinical samples from human patients. The human cohort was composed of biopsy and surgery material from 95 patients: 47 HCC and 48 non-HCC. Proteomic data from both mice and humans show a clear downregulation of the main energy-producing pathways in HCC. Glycogen metabolism, de novo glucose synthesis, glutamine uptake to the TCA cycle, approximately 60% of enzymes of TCA cycle, and transport of pyruvate to mitochondria are downregulated in HCC. An isoform switch at various levels of central carbon metabolism was demonstrated in this work. Both mice and humans with HCC reveal isoform switches at the level of phosphoglycerate mutases and pyruvate kinases. The key features are found in both mouse and human, showing a universal metabolic HCC fingerprint. This study also demonstrates that proteomic analysis of the bioptate material is a strong and sufficient molecular diagnostic tool for research in cancer: the proteomic analysis of liver material allows the distinction of tumor samples from non-tumor samples and also to track the level of disease progression. Targeted genome sequencing revealed that no clear distinction between cancer and precancerous conditions could be made exclusively from the mutation analysis. Human metabolomic data remains inconclusive, possibly due to the different sources of tissue samples.

Hepatocellular carcinoma (HCC) is the most common liver malignancy that usually develops in patients suffering from chronic liver diseases. One of the major problems faced in the treatment of HCC is severe chemoresistance. Endoplasmic reticulum (ER) stress and hepatic stellate cells play an important role in tumour survival and growth as well as fibrosis. This study further investigates the crosstalk between ER-stress and hepatic stellate cells in HCC resistant cells as well as their relation to chemoresistance markers expression. Mice with chemically induced HCC were divided in 3 different treatment group; one was only treated with doxorubicin, one only with pharmacological ER-stress inhibitor 4μ8C, and one was treated with a combination of doxorubicin and 4μ8C. Tumour burden, fibrosis and cell proliferation were assessed through histological analysis and ImageJ processing. Chemoresistance markers expression was evaluated through mRNAs determination using real-time qPCR. While the combined treatment consisting of doxorubicin and pharmacological ER-stress inhibitor (4μ8C) has shown to positively reduce tumour progression, ferroptosis and collagen deposition, consequently decreasing fibrosis, drug resistance markers’ expression, on the other hand, seems to be more intricate, thus indicating that further investigations are probably needed. / Hepatocellulärt karcinom (HCC) är den vanligaste maligniteten i levern som vanligtvis utvecklas hos patienter som lider av kroniska leversjukdomar. Ett av de största problemen vid behandling av HCC är svår kemoresistens. Stress i endoplasmatiska retikulum (ER) och hepatiska stellatceller spelar en viktig roll för tumörernas överlevnad och tillväxt samt för fibros. I denna studie undersöks vidare samspelet mellan ER-stress och hepatiska stellatceller i HCC-resistenta celler samt deras relation till uttryck av kemoresistensmarkörer. Möss med kemiskt inducerad HCC delades in i tre olika behandlingsgrupper; en behandlades enbart med doxorubicin, en enbart med den farmakologiska ER-stresshämmaren 4μ8C och en behandlades med en kombination av doxorubicin och 4μ8C. Tumörbörda, fibros och cellproliferation bedömdes genom histologisk analys och ImageJ-bearbetning. Kemoresistensmarkörernas uttryck utvärderades genom bestämning av mRNA med hjälp av qPCR i realtid. Medan kombinationsbehandlingen bestående av doxorubicin och farmakologisk ER-stresshämmare (4μ8C) har visat sig minska tumörprogressionen, ferroptos och kollagenavlagring och därmed minska fibros, verkar uttrycket av läkemedelsresistensmarkörer å andra sidan vara mer invecklat, vilket tyder på att det troligen behövs ytterligare undersökningar.