Ovarian high-grade serous cancer (HGSC) is the most lethal gynecologic malignancy and well-characterized models may improve patient outcomes. Patient-derived xenografts (PDXs) recapitulate disease heterogeneity; however, to be useful in predicting response to novel chemotherapeutics, they must reflect the response of the donor tissue to standard chemotherapy. The objectives of this study were: first, to evaluate the response of PDXs’ to platinum therapy and compare this response to that of the donor; and second, to determine whether treatment with chemotherapy enriches for tumourigenic cells. Eighteen samples formed tumours in the mammary fat pads of NOD-Scid-IL2Rγnull mice and were treated with Carboplatin. There was a 100% concordance between sample status and PDXs response to chemotherapy. HGS histology was confirmed for all cases. A conclusion regarding post-chemotherapy tumourigenicity could not be made due to inadequate statistical power. PDXs represent useful tools for evaluation of novel therapies and identification of patients who are platinum-resistant/sensitive.

High-grade serous ovarian cancer (HG-SOC) is the most lethal gynecologic malignancy. Although most respond to initial therapy, the vast majority of patients eventually recur and die of their disease. Understanding intra-tumor cellular heterogeneity and inter-patient variability is necessary to effectively cure HG-SOC. The work described in this thesis should help to speed the progress of ovarian cancer research in several ways. First, I generated a robust xenograft model that recapitulates the cellular heterogeneity of HG-SOC. In addition, I performed gene expression profiling on a subset of xenografts and showed that they recapitulate the inter-patient diversity of this disease. Second, I applied this model to pre-clinical testing of a folate-targeted imaging agent and showed that it can identify metastatic studding by PET/CT and fluorescence imaging. Using my xenograft model, I investigated the properties of tumor-initiating cells (TIC) and demonstrated that TIC in HG-SOC are rare. Furthermore, although CD133 marks most TIC, heterogeneity in the phenotype is observed within individual tumors and between different patients. Finally, I used a transformative technology, CyTOF, to develop a novel pipeline for prioritization of candidate TIC markers, as well as for characterization of cellular heterogeneity in primary HG-SOC samples.

Proteins secreted or shed by tumors can be found in serum. Detecting these proteins by mass spectrometry (MS) is difficult, due to the wide dynamic range of protein concentrations in serum. To circumvent this issue, we mined the conditioned media of epithelial ovarian cancer (EOC) cell lines which is a less complex fluid to work with. We hypothesize that some of the proteins shed or secreted by EOC cell lines are similar to those secreted or shed by EOC tumors and that some of these proteins can be used as biomarkers. We mined the conditioned medium of four ovarian cancer cell lines (HTB75, TOV-112D, TOV-21G and RMUG-S) by two-dimensional liquid chromatography-mass spectrometry. Our study identified 1208, 1252, 885, and 463 proteins from the HTB-75, TOV-112D, TOV-21G, and RMUG-S cell lines respectively. In all, we identified 2039 proteins from which we focused on 420 extracellular and plasma membrane proteins. High abundance proteins such as albumin and immunoglobulins, which are problematic for serum proteomics, did not interfere with our study. Several known markers of EOC including CA-125, HE4, Mesothelin, and KLK6, were identified in this study. The list of 420 extracellular and membrane proteins was cross-referenced with the proteome of ascites fluid to generate a final list of 51 potential candidates. According to Ingenuity Pathway Analysis, two of the top 10 diseases associated with our list of 51 proteins were cancer and reproductive diseases. Of the 51 candidates, 10 proteins were selected for verification in sera from ovarian cancer patients and healthy individuals. Clusterin showed a significant difference between cancer patients and normal, with sera from cancer patients showing higher levels. Another protein, NPC2, did not show a difference in sera between cancer and normals. Protein expression studies using immunohistochemistry showed that NPC2 is highly expressed in ovarian cancer tissue and absent in normal ovarian surface epithelium. In summary, clusterin and NPC2 appear to play a role in ovarian cancer pathobiology and their role in EOC need to be studied further.

High-grade serous ovarian cancer (HG-SOC) is the most lethal gynecologic malignancy. Although most respond to initial therapy, the vast majority of patients eventually recur and die of their disease. Understanding intra-tumor cellular heterogeneity and inter-patient variability is necessary to effectively cure HG-SOC. The work described in this thesis should help to speed the progress of ovarian cancer research in several ways. First, I generated a robust xenograft model that recapitulates the cellular heterogeneity of HG-SOC. In addition, I performed gene expression profiling on a subset of xenografts and showed that they recapitulate the inter-patient diversity of this disease. Second, I applied this model to pre-clinical testing of a folate-targeted imaging agent and showed that it can identify metastatic studding by PET/CT and fluorescence imaging. Using my xenograft model, I investigated the properties of tumor-initiating cells (TIC) and demonstrated that TIC in HG-SOC are rare. Furthermore, although CD133 marks most TIC, heterogeneity in the phenotype is observed within individual tumors and between different patients. Finally, I used a transformative technology, CyTOF, to develop a novel pipeline for prioritization of candidate TIC markers, as well as for characterization of cellular heterogeneity in primary HG-SOC samples.

The cancer antigen 125 (CA125) is a cell-surface mucin which is over-expressed by the majority of ovarian cancers. However, its biology and the role it plays in ovarian cancer is largely unknown, although other cell-surface mucins have been shown to play a role in apoptosis, cell growth and tumour immune evasion. To analyse the function of CA125 in ovarian cancer, we initially knocked down the expression of CA125 using RNA interference. Knocking down CA125 expression using in vitro transcribed short interfering RNAs (siRNAs) induced a potent cell death response, which has been well characterised in the literature as an induction of an interferon response and resulting in cell apoptosis. Subsequently, using the short hairpin RNA expression vector, pSUPER, which has been shown to knock down genes with high efficiency with reduced off-target affects, we generated stable sub-lines of the ovarian cancer cell line, OVCAR-3, which had been transfected with pSUPER constructs targeting CA125. Intriguingly, these sub-lines had a range of abnormal mitotic events and nuclear defects. However, there was no clear association with the level of CA125 knock down. This could be either due to clonal selection from the parent OVCAR-3 cell line or in addition to CA125 knock down, additional genetic changes are required to occur to favour a state of survival. Similar to the in vitro data, xenografts of the sub-clones into SCID mice generated inconclusive results as to whether CA125 knock down contributes to tumour growth, invasion and metastasis in vivo. More recently, we have been able to achieve high levels of short-term CA125 knock down using synthetic siRNAs designed to reduce off-target affects. These preliminary in vitro and in vivo experiments conducted with pSUPER sub-lines should be repeated using synthetic siRNAs to confirm the role of CA125 in this context. Given the role which the cytoplasmic tail of cell-surface mucins plays in its function, we generated a polyclonal antibody recognising the CA125 cytoplasmic tail, designated M16.1. Immunofluorescence imaging of CA125 in ovarian cancer cell lines, OVCAR-3 and PEO-1, using the OC125 extracellular domain antibody indicated cell-surface localisaton of CA125. However, in addition to the cell-surface localisation, the M16.1 antibody localised to the cell cytoplasm, indicating cleavage and release of the CA125 cytoplasmic tail into the cytosol. Additionally, M16.1 co-localised with α-tubulin at perinuclear sites and to areas resembling microtubule organising centres. However, M16.1 did not co-localise with γ-tubulin at the centrosome, indicating association with non-centrosomal microtubules. Furthermore, depolymerisation of microtubules on ice for 1 hour resulted in loss of diffuse cytoplasmic M16.1 staining but co-localisation between M16.1 and α-tubulin at non-centrosomal sites remained. Intriguingly, when microtubules were allowed to reform at 37oC in PEO-1 cells which had CA125 knocked down by synthetic siRNAs, the ability to reform radial asters was impaired, possibly indicating the CA125 cytoplasmic tail involvement in anchoring microtubules to non-centrosomal sites. Furthermore, we also cloned a portion of CA125 encompassing the cytoplasmic tail, transmembrane domain and 9 tandem repeats. When this construct was transfected into COS-1 cells, the CA125 cytoplasmic tail localised to microtubule bundles during metaphase. Mitotic involvement of the endogenous CA125 cytoplasmic tail was confrmed in OVCAR-3 and PEO-1 cells using M16.1. Given this association and also the results from the pSUPER sub-lines with CA125 knockdown, CA125 may be involved in controlling the fidelity of mitosis, which is grossly altered during tumourigenesis. More recently, it was identified that galectin-1 (Gal-1), an S-type lectin, is a ligand for CA125. Gal-1 is a potent inducer of T cell apoptosis and has been implicated as playing a major role in immune evasion for cancer cells. Consequently, we analysed the expression of CA125 and Gal-1 in ovarian cancer and confirmed the two molecules were expressed concurrently at the mRNA level by RT-PCR. Moreover, immunofluorescence studies also confirmed that CA125 and Gal-1 interacted with each other at the cell-surface of 27/87 cells, an ovarian cancer cell-line. Therefore, we hypothesised that CA125 presents Gal-1 to the immune system, which then induces T cell apoptosis and allows the tumour to escape the immune system. However, CA125 did not protect tumour cells from recognition or killing by T cells, which was shown by no differences in IFN-γ secretion or tumour lysis by cytotoxic T cells using influenza peptide pulsed pSUPER sub-lines with CA125 knockdown. The work described in this thesis suggests that CA125 plays a major role in the aetiology and progression of ovarian cancer through its actions on mitosis, microtubule organisation and immune evasion.

Cardiovascular disease (CVD) causes 45% of on-duty firefighter fatalities, a high fraction even when compared to the risk of CVD found in other first-responder professions like police work and emergency medical services. Monitoring and managing firefighter cardiac health is important for both individual health and public safety. In our study, we are interested in assessing the utility of the most commonly used risk assessment scoring, known as the Framingham Risk Score, in evaluating the atherosclerotic risk in asymptomatic firefighters. To this end we determined FRS for 159 male firefighters from Gwinnett County, Georgia, and compared their risk categorization against their known atherosclerotic burden as determined by CIMT and CAC. While the 20% FRS threshold, corresponding to medium risk, had a high specificity for both CAC and CIMT, it also had a low sensitivity (17% and 40%, respectively), indicating that a large percentage of individuals with clinically significant atherosclerosis are being misclassified. By adjusting the FRS threshold downward, we were able to raise the sensitivity greatly with only a modest loss of specificity. Following percutaneous transluminal coronary angioplasty for the treatment of coronary artery disease, stents are commonly implanted at the treatment site to prevent recoil and negative remodeling. To combat in-stent restenosis, an arterial healing response that results in luminal loss in stented arteries, anti-restenotic drugs like sirolimus (SES) and zotarolimus (ZES) are commonly eluted by stents to suppress cell proliferation at the treatment site. While comparative studies have revealed significant difference between bare metal stents (BMS), SES, and ZES in both clinical and histological arterial response, the molecular basis of these differences remains poorly understood. We conducted a comparative gene expression profiling study using microarrays to examine differences in gene expression and pathway function in coronary arteries exposed to ZES, SES, and BMS in a porcine animal model. These molecular profiles suggest a model of delayed restenosis, resulting from a drug-induced suppression of inflammatory responses and proliferative processes, rather than an elimination of restenosis. microRNAs play a regulatory role in metastasis-related epithelial to mesenchymal transitions and mesenchymal to epithelial transitions in ovarian cancer cells. We previously showed that over-expression of miR-429 in ovarian cancer cells drove a transition from mesenchymal phenotypes to epithelial phenotypes both in morphology and expression of markers like ZEB1, ZEB2, and E-cadherin. Our study represents the first time course analysis of miR-429-induced MET in ovarian cancer cells. We transfected Hey cells with miR-429 and assayed gene expression over the course of 144 hours at regular intervals. The cell morphology and gene expression of our transfected cells changed to become more epithelial-like at 24 and 48 hours and then became more mesenchymal-like by 144 hours. By 144 hours the average gene expression levels for 98.6% of our genes were not significantly different from the levels they started from at 0 hours when we adjusted for baseline expression changes observed in our negative control treated cells. This suggests the use of microRNAs as cancer therapies and driving cancer cells to a more drug susceptible state.

Aims: This thesis had three aims: to review evidence evaluating the effectiveness of decision aids at increasing cancer patients’ treatment-related knowledge and reducing decisional conflict; to explore the decision-making processes of ovarian cancer patients who had opted for or against CA-125 testing during post-treatment surveillance; and to elicit patients’ and health professionals’ views on the proposed development of a decision aid aimed at helping women decide for or against CA-125 testing during post-treatment surveillance for ovarian cancer. Methods: A systematic review was conducted of evidence relating to the effectiveness of cancer treatment-related decision aids at increasing treatment-related knowledge and reducing decisional conflict. In the qualitative study, semi-structured interviews were conducted with ovarian cancer patients (n = 18) and health professionals (n = 6) in an outpatient gynecological oncology clinic. Framework analysis was used to identify themes in the qualitative data. Results: Overall, results from the systematic review supported previous research where decision aids were found to improve patient knowledge and reduce decisional conflict across a range of cancer treatment-related decisions. However, the lack of psychometric support for the treatment-related knowledge measures used in the majority of the studies compromised their ability to address the review question. In the qualitative study, accurate knowledge about CA-125 testing in post-treatment surveillance was found to greatly influence participants’ decision-making processes. Most women with less knowledge about the test chose to have testing based on the false belief that earlier detection of recurrence would lead to earlier treatment and prolonged survival. There was strong enthusiasm from patients and health professionals for the development of the proposed decision aid to assist women facing this treatment decision. Conclusions: The systematic review findings add to previous research supporting the use of decision aids in cancer-related treatment decisions and advocate for their continued development, evaluation and implementation into the healthcare system. The need for a decision aid to ensure accurate knowledge about CA-125 and to aid decision-making for women with ovarian cancer was supported. As well as assisting women with this decision, the proposed decision aid may ultimately support health professionals in practicing shared decision-making regarding CA-125 testing with ovarian cancer patients.

Less than half of patients with epithelial ovarian cancer (EOC) survive five years following diagnosis, underscoring the imperative need for improved treatment. Many patients, including those with advanced disease, initially respond to platinum agents, which constitute the backbone of therapy. However, tumors ultimately become resistant, rendering further treatment ineffective. Additionally, the poor tolerability of these agents warrants the exploration of more targeted treatments – one such strategy is exploiting synthetic lethal genetic relationships. Recent genomic sequencing efforts have revealed that as many of half of EOCs have homologous recombination (HR) alterations. HR is a critical pathway for the repair of platinum-induced ICLs, thus compromised HR is hypothesized to explain the initial response to chemotherapy in many patients. Accordingly, women whose tumors harbor mutations in the critical HR genes, BRCA1 or BRCA2 (BRCA1/2), demonstrate improved prognosis. BRCA1/2 mutations also confer exquisite sensitivity to inhibitors of the enzyme, poly(ADP-ribose) polymerase 1 (PARPis), hence loss of BRCA1/2 and PARP1 is synthetic lethal. A number of models have been proposed to explain this synthetic lethality, yet a consensus model that accounts for the diverse cellular roles of BRCA1/2 and PARP1 has yet to be established. Delineating the precise molecular underpinnings of PARPi action in BRCA1/2-deficient cells will aid clinicians in identifying the appropriate population of women with EOC likely to benefit from PARPi treatment and provide insight into resistance mechanisms that arise in these patients. Combining this approach with retrospective analysis of PARPi clinical trials will best define the proper indication for PARPi in EOC and other human cancers.

Cancer cells, unlike normal tissue, frequently rely on glycolysis for the production of energy and the metabolic intermediates required for their growth regardless of cellular oxygenation levels. This metabolic reconfiguration, termed the Warburg effect, provides a potential strategy to preferentially target tumours from a therapeutic perspective. The present study sought to investigate the glycolytic phenotype of breast and ovarian cancer, and assess the possibility of exploiting several glycolytic targets therapeutically. Initially the growth dependency of breast and ovarian cancer cells on the availability of glucose was established. An array of 10 compounds reported to inhibit key enzymes of the glycolytic pathway were investigated and compared against an extended panel of breast and ovarian cancer cell line models. All inhibitors investigated, targeted against multiple points of the pathway, were shown to block the glycolytic pathway as demonstrated by glucose accumulation in the culture media combined with decreased lactate secretion, and attenuated breast and ovarian cancer cell proliferation in a concentration dependent manner. Furthermore their mechanism of action was investigated by flow cytometric analysis and their antiproliferative effect was associated with induction of apoptosis and G0/G1 cell cycle arrest. The glycolytic inhibitors were further assessed in combination strategies with established chemotherapeutic and targeted agents and several synergistic interactions, characterised by low combination index values, were revealed. Among them, 3PO (a novel PFKFB3 inhibitor) enhanced the effect of cisplatin in both platinum sensitive and platinum resistant ovarian cancer cells suggesting a strategy for treatment of platinum resistant disease. Furthermore robust synergy was identified between IOM-1190 (a novel GLUT1 inhibitor) and metformin, an antidiabetic inhibitor of oxidative phosphorylation, resulting in strong inhibition of breast cancer cell growth. This combination is proposed for the treatment of highly aggressive triple negative breast tumours. An additional objective of this research was to investigate the effect of the oxygen level on sensitivity to glycolysis inhibition. Breast cancer cells were found to be more sensitive to glycolysis inhibition in high oxygen conditions. This enhanced resistance at low oxygen levels was associated with upregulation of the targeted glycolytic enzymes as demonstrated at both the mRNA (by gene expression microarray profiling, Illumina BeadArrays) and protein level (by Western blotting). Manipulation of LDHA (Lactate Dehydrogenase A) by siRNA knockdown provided further evidence that downregulation of this target was sufficient to significantly suppress breast cancer cell proliferation. Finally, the expression of selected glycolytic targets was examined in a clinical tissue microarray set of a large cohort of ovarian tumours using quantitative immunofluorescence technology, AQUA. The role of the glycolytic phenotype in ovarian cancer was suggested and interesting associations between the glycolytic profile and clear cell and endometrioid ovarian cancers revealed. Increased PKM2 (Pyruvate kinase isozyme M2) and LDHA expression were demonstrated in clear cell tumours and also low expression of these enzymes was significantly correlated with improved survival of endometrioid ovarian cancer patients. Taken together the findings of this study support the glycolytic pathway as a legitimate target for further investigation in breast and ovarian cancer treatment.

Les cancers de l’ovaire représentent la première cause de décès par cancer gynécologique. L’échec des traitements, lié à l’apparition d’une chimiorésistance, implique de trouver de nouvelles stratégies thérapeutiques. Dans ce cadre, le laboratoire a mis en évidence la coopération de deux molécules anti-apoptotiques surexprimées dans les cancers de l’ovaire, Mcl-1 et Bcl-xL, qui empêchent alors le déclenchement de la mort cellulaire par apoptose. L’inhibition de ces cibles est alors mise en place. Un BH3-mimétique inhibiteur de Bcl-xL a été développé par la société Abbvie, l’ABT-737, qui possède un dérivé administrable par voie orale l’ABT-263 en essai clinique. En revanche, aucun inhibiteur de Mcl-1 n’est actuellement en clinique. L’inhibition de cet anti-apoptotique est donc l’un des objectifs du laboratoire. Sachant que Mcl-1 est extrêmement régulée, que l’inhibition de la voie de signalisation PI3K/Akt/mTOR conduit à l’inhibition de cet anti-apoptotique, et que le calcium est capable de moduler cette voie, nous nous sommes demandés si la modulation des flux calciques permettait l’inhibition de Mcl-1 dans nos cellules. Ces travaux de thèse ont pu montrer dans un premier temps que la chélation calcique par le BAPTA-AM permettait d’inhiber Mcl-1 via la voie mTORC1 et de sensibiliser les cellules à l’ABT-737. Dans un second temps, l’étude de l’effet d’un inhibiteur des flux calciques en essais cliniques, le carboxyamidotriazole a permis de mettre en évidence que l’inhibition des canaux calciques capacitifs pouvait entraîner l’inhibition de Mcl-1 de nouveau en inhibant mTORC1 et induire la mort cellulaire en combinaison avec l’ABT-737. Enfin des observations morphologiques ont montré que le CAI induisait un changement morphologique aboutissant à la mort des cellules. Ce type de mort semble être lié à une perturbation du métabolisme des cellules cancéreuses IGROV1-R10 et se rapprocherait d’une mort récemmement décrite dans la littérature : l’autosis. / Ovarian cancer is the leading cause of death from gynecological cancer. There is an urgent need to find new therapeutic strategies due to failure of treatments associated to development of chemoresistance. In this context, the laboratory has shown the cooperation of two anti-apoptotic proteins overexpressed in ovarian cancer, Mcl-1 and Bcl-xL, for preventing apoptotic cell death. ABT-737, a Bcl-xL inhibitor BH3-mimetic, was developed by Abbvie and has a clinically derivative named ABT-263. In contrast, no Mcl-1 inhibitor is currently available in clinic. The inhibition of this anti-apoptotic protein is therefore one of the objectives of the laboratory. Since inhibition of PI3K / Akt / mTOR signaling pathway leads to inhibition of Mcl-1 expression and calcium is able to modulate this pathway, we wondered if the modulation of calcium fluxes allowed the inhibition of Mcl-1 in ovarian cancer cells. First we were able to show that calcium chelation by BAPTA-AM allowed to inhibit Mcl-1 expression via mTORC1 pathway and to sensitize the cells to ABT-737. In a second step, we investigated the effect of an inhibitor of calcium fluxes that is evaluated in clinical studies, carboxyamidotriazole. We show that the inhibition of capacitive calcium channels could lead to Mcl-1 down-expression via inhibition of mTORC1 and promote apoptosis in combination with ABT-737. Finally, we observed that CAI induces a morphological change resulting in cell death. This type of death seems to be related to disruption of metabolism in IGROV1-R10 cancer cells and would be close to a cell death recently described in the literature: autosis.