Indiana University-Purdue University Indianapolis (IUPUI) / There has been vast and growing amount of healthcare data especially with the rapid adoption of electronic health records (EHRs) as a result of the HITECH act of 2009. It is estimated that around 80% of the clinical information resides in the unstructured narrative of an EHR. Recently, natural language processing (NLP) techniques have offered opportunities to extract information from unstructured clinical texts needed for various clinical applications. A popular method for enabling secondary uses of EHRs is information or concept extraction, a subtask of NLP that seeks to locate and classify elements within text based on the context. Extraction of clinical concepts without considering the context has many complications, including inaccurate diagnosis of patients and contamination of study cohorts. Identifying the negation status and whether a clinical concept belongs to patients or his family members are two of the challenges faced in context detection. A negation algorithm called Dependency Parser Negation (DEEPEN) has been developed in this research study by taking into account the dependency relationship between negation words and concepts within a sentence using the Stanford Dependency Parser. The study results demonstrate that DEEPEN, can reduce the number of incorrect negation assignment for patients with positive findings, and therefore improve the identification of patients with the target clinical findings in EHRs. Additionally, an NLP system consisting of section segmentation and relation discovery was developed to identify patients' family history. To assess the generalizability of the negation and family history algorithm, data from a different clinical institution was used in both algorithm evaluations.

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Pancreatic cancer is still a dismal disease. The high mortality rate is mainly caused by the lack of highly sensitive and specific diagnostic tools, and most of the patients are diagnosed in an advanced and incurable stage. Knowledge about precursor lesions for pancreatic cancer has grown significantly over the last decade, and nowadays we know that mainly three lesions (PanIN, and IPMN, MCN) are responsible for the development of pancreatic cancer. The early detection of these lesions is still challenging but provides the chance to cure patients before they might get an invasive pancreatic carcinoma. This paper focuses on PanIN, IPMN, and MCN lesions and reviews the current level of knowledge and clinical measures.

L’Adénocarcinome Canalaire Pancréatique (ACP), la forme majeure de cancer du pancréas, est un des cancers les plus mortels du fait de son agressivité d’invasion locale et de dissémination vasculaire et de l’absence de méthode de détection précoce de la maladie. Nous avons développé un nouveau modèle d’invasion in vivo, sur la membrane chorio-allantoïdienne de l’embryon de poulet, permettant d’analyser les mécanismes d’interactions entre les cellules tumorales pancréatiques et leur microenvironnement. Nous avons montré que dans ce modèle les gènes codant pour les protéines sécrétées nétrine-1 et CXCL4L1/PF4v1 sont surexprimés dans les cellules tumorales au cours du processus d’invasion et que cette surexpression est également retrouvée dans les échantillons de patients humains. Nos études fonctionnelles ont indiqué que la nétrine-1 et CXCL4L1 pourrait jouer le rôle de régulateurs de la progression tumorale selon le modèle suivant : a) la chimiokine CXCL4L1 exercerait de façon paracrine une activité angiostatique sur les cellules endothéliales de l’ACP alors que b) la nétrine-1 aurait une activité pro-tumorale en agissant à la fois sur les cellules tumorales et sur les cellules endothéliales. Ces résultats ont permis d’une part de valider notre modèle en confirmant que les gènes surexprimés sélectionnés peuvent être impliqués dans la progression tumorale chez les patients. D’autre part, notre étude a permis de démontrer que les protéines CXCL4L1 et nétrine-1 constituent de nouvelles cibles thérapeutiques et/ou diagnostiques potentielles pour le cancer du pancréas. / Pancreatic Ductal Adenocarcinoma (PDAC), the major form of pancreatic cancer, is one of the deadliest cancers because of its propensity for local invasion and vascular dissemination and the lack of early diagnostic strategy. We have developed a new in vivo invasion model, on the chick embryo chorioallantoic membrane, allowing the analyze of mechanisms governing interactions between pancreatic tumor cells and their host microenvironment. We showed in its model that the genes encoding netrin-1 and CXCL4L1/PF4v1 secreted proteins are up-regulated in tumor cells in the course of the invasion process and we confirmed these up-regulation was also observed in human patients. Our functional studies indicated that netrin-1 and CXCL4L1 may play regulator roles in tumor progression according to the following model: a) CXCL4L1 chimiokine may have an angiostatic activity on endothelial cells by a paracrine mechanism of action whereas b) netrin-1 may have a pro-tumoral activity by acting on both endothelial and tumor cells. These results allowed in one hand to validate our model by showing that selected up-regulated genes may be involved in PDAC progression in human patients. On the other hand, our work provided evidence that CXCL4L1 and netrin-1 constitute new potential therapeutic and/or diagnostic targets for pancreatic cancer.

Bakterielle Toxine stellen eine wirkungsvolle und effektive Alternative zur Therapie von Tumorerkrankungen dar. Das vom Clostridium perfringens Typ A produzierte Clostridium perfringens enterotoxin (CPE) gehört zu der Gruppe der porenbildenden Toxine und weist eine rezeptorspezifische zytotoxische Wirkung auf, welche über die Membranrezeptoren Cldn3 und Cldn4 entfaltet wird. Diese liegen vor allem in Epithelialkarzinomen wie dem Brust-, Prostata-, oder Kolon-, sowie dem Pankreaskarzinom (PK) stark hochreguliert vor. Ziel dieser Arbeit war die Anwendung des neuen selektiven und effizienten „Onkoleaking“ Suizid-Gentherapie Konzepts für die Behandlung von Cldn3 / 4 überexprimierender PK unter Verwendung eines nicht-viralen translations-optimierten CPE exprimierenden Vektors (optCPE). Weiterhin sollte in dieser Arbeit der genaue molekulare Mechanismus der CPE-vermittelten Zytotoxizität in vitro und auch in vivo analysiert werden. Für die in vitro Analysen wurden verschiedene humane PK Zelllinien, Patienten abgeleitete Xenotransplantate (PDX) und deren abgeleiteten Zellen bezüglich ihrer Cldn3 / 4 Expression und Sensitivität sowohl gegenüber rekombinantem CPE (rekCPE) als auch nach optCPE Gentransfer untersucht. Es konnte eine positive Korrelation zwischen der Effizienz CPE vermittelter Zytotoxizität und der Höhe der Cldn3 / 4 Überexpression gezeigt werden. Des Weiteren wurde die Verfügbarkeit und Zugänglichkeit der CPE Rezeptoren für die Toxinbindung als kritischer Faktor für die durch Porenbildung induzierte Zytotoxizität beschrieben. Auch eine detaillierte Analyse verschiedener apoptotischer und nekrotischer Signalwege und deren Schlüsselmoleküle waren vom besonderen Interesse. Von noch größerer Wichtigkeit war jedoch die Anwendbarkeit und der Nachweis der antitumoralen Wirksamkeit der optCPE-basierten Suizid-Gentherapie mit Hilfe des intratumoralen Jet-Injektion Gentransfers in verschiedenen Luziferase-exprimierenden CDX und PDX Modellen des PK. Alle in vivo Studien zeigten eine selektive optCPE vermittelte Verminderung der Tumorvitalität in Verbindung mit Nekrose, die in fast allen Fällen mit einer Reduktion des Tumorvolumens einher ging. Die tierexperimentellen Studien belegen damit die Effektivität der CPE-basierten Gentherapie im Pankreaskarzinom. Mit diesen neu gewonnenen Erkenntnissen zum „Onkoleaking“ Konzept der CPE Suizid-Gentherapie und deren Wirkungsmechanismen sind Kombinationen mit konventionellen Therapien möglich. / Bacterial toxins have evolved to an effective therapeutic option for cancer therapy and numerous studies demonstrated their antitumoral potential. The Clostridium perfringens enterotoxin (CPE), produced by the anaerobic Clostridium perfringes bacteria, is a pore-forming (oncoleaking) toxin, which binds to its receptors claudin-3 and -4 (Cldn3 / 4) and exerts a selective, receptor-dependent cytotoxicity. The transmembrane tight junction proteins Cldn3 and Cldn4 are known CPE receptors and are highly upregulated in several human epithelial cancers such as breast, colon, ovarian and pancreatic cancer. This study aimed at the evaluation of the potential of oncoleaking gene therapy using a non-viral translation optimized CPE vector (optCPE) as a new suicide approach for the treatment of Cldn3  /  4 overexpressing pancreatic cancer (PC) in vitro and in vivo. We demonstrated the successful in vitro use of optCPE gene transfer in a panel of human PC cells and more importantly patient derived PC xenograft (PDX) derived cells. We showed significant reduction of cell viability in all Cldn3 / 4 overexpressing PC cells after optCPE transfection. Furthermore a positive correlation between CPE cytotoxicity and level of claudin expression was shown. We revealed accessibility of CPE receptors for toxin binding as determining for optCPE mediated cytotoxicity. Since investigation of optCPE induced cell death mechanism was of particular interest, detailed analyses of apoptotic and necrotic key players were performed. By this, caspase dependent- and independent apoptosis and necrosis activation after gene transfer was demonstrated, which was dependent on amount of expressed optCPE and accessibility of Cldn. More importantly, this study demonstrated the applicability and antitumoral efficacy of optCPE gene therapy by the non-viral intratumoral jet-injection gene transfer in vivo in different luciferase-expressing CDX and PDX pancreatic cancer models. The animal experiments demonstrated the selective CPE mediated tumor growth inhibition, associated with reduced tumor viability and effective induction of tumor necrosis. This further corroborated the advantages of this novel oncoleaking strategy. With this gain of knowledge about our new oncoleaking concept of suicidal gene therapy and its mechanism of action, novel combinations with conventional therapies are possible to further improve therapeutic efficacy and to overcome resistance in pancreas carcinoma.

El càncer de pàncrees és altament agressiu i representa la cinquena causa de mort al mon occidental. Anteriorment, en el nostre laboratori, vam identificar que el receptor tissular del plasminogen (tPA) hi està sobre-expressat i juga un paper important el la progressió tumoral. En la present tesi hem profunditzat en l'estudi del mecanisme molecular de tPA i seus receptors en aquest càncer. En primer lloc hem caracteritzat en detall la interacció de tPA amb Annexina A2 (principal receptor de tPA en endoteli i altament expressada en pàncrees) demostrant que les dades publicades sobre la seqüència responsable de la interacció no eren correctes. A més a més hem caracteritzat les proteïnes de lisats cel·lulars pancreàtics que interaccionen amb tPA mitjançant un assaig pull down i posterior anàlisi proteòmic. de tot identificant un conjunt de possibles lligands de tPA. D'entre aquests hem seleccionat galectina 1, una lectina que mai s'ha descrit que interaccioni amb tPA, per realitzar la caracterització bioquímica i funcional del seu paper com a nou lligand de tPA en càncer de pàncrees. / Pancreatic cancer is a highly aggressive disease and represents the fifth cause of death in occidental world. Our laboratory has previously reported tissue type plasminogen activator (tPA) over expression in this cancer and its role in tumoral progression. During the present thesis we have studied tPA and its molecular mechanism through its receptors in this tumor.We have first characterized tPA interaction with annexin A2 (its main receptor in endothelium and highly expressed in pancreas). Our results showed that published data about the sequence responsible of this interaction was not correct. We have also identified a set of new putative tPA receptors in pancreatic cell lisates using a pull down assay and proteomic analysis. One of the proteins identified was galectin 1, a lectin with not know relation with tPA. We performed a biochemical and functional characterization of the interaction between these two proteins in pancreatic cancer.

El sistema TK/GCV es, problamente, la estrategia suicida mejor caracterizada hasta el momento. No obstante, se desconocen muchos aspectos relacionados con su mecanismo de acción. Con el objetivo de indentificar condicionantes de la respuesta TK/GCV, realizamos un estudio comparativo de la expresión de genes y de las vías de señalización que se activan en células sensibles y en células resistentes al tratamiento. Así, pudimos asociar la actividad de la quinasa Chk1, y la expresión de genes involucrados en el control del ciclo celular, con una mayor respuesta al sistema suicida. Así mismo, determinamos que la combinación de TK/GCV con el inhibidor de Chk1 UCN-01 produce un efecto antagónico en las células sensibles a TK/GCV. Por otro lado, la terapia combinada capaz de lisar las células e inducir muerte celular por fosforilación de GCV, en un único agente (ICOVIR11), resultó en una potenciación de sus efectos citotóxicos, permitiendo la compensación de la pérdida de potencia secundaria al uso de un promotor selectivo de tumor. Más aún, la expresión de TK como gen tardío de ICOVIR11,permitió la monitorización in vivo y de manera no invasiva, de la actividad TK y la replicación viral. / Although extensively characterized, the paradigmatic suicide system TK/GCV conceals the details of its ultimate mechanism of action. In order to shed some light on this issue, we conducted a series of experiments with resistant and sensitive cell lines, allowing us to identify cell cyclerelated genes that are deregulated in cells with induced resistance to TK/GCV. In addition, the association of Chk1 activation with a greater sensitivity to TK/GCV, pointed out the relevance of the cell cycle status at the moment of receiving the treatment, and its control in response to genotoxic insults. Treatment with a Chk1 inhibitor induced, in sensitive cells, an antagonistic effect on TK/GCV cytotoxicity. On the other hand, single-agent combination therapy of TK/GCV with adenoviral lysis resulted in enhanced cytotoxicity. In this setting the expression of TK as a late gene in an oncolytic adenovirus minimized the loss of potency associated to the conditioning of viral replication. On top of that, TK expression allowed for in vivo, real time, non-invasive monitoring of viral replication in mice, and was used to analyze the effects of treatment schedule on treatment outcome.

Pancreatic cancer is characterized by its desmoplastic tumor microenvironment and the infiltration of immunosuppressive cells. It is a devastating disease where most patients are diagnosed at a late stage and the treatment options are few. The development of new treatments is surly needed. One treatment option explored is the use of immunotherapy with the intent to activate the immune system and change the balance from pro-tumor to anti-tumor. This thesis presents the idea of using oncolytic adenoviruses called LOAd-viruses that are armed with immunostimulatory- and microenvironment-modulating transgenes. For effective treatment of pancreatic cancer, the virus needs to be able to be given in addition to standard therapy, the chemotherapy gemcitabine. In paper I, the immunomodulatory effect of gemcitabine was evaluated in blood from pancreatic cancer patients receiving their first 28-day cycle of treatment with infusions day 1, 8 and 15 followed by a resting period. Gemcitabine reduced the level of immunosup-pressive cells and molecules but the effect did not last throughout the resting period. On the other hand, gemcitabine did not affect the level or proliferative function of effector T cells indicating that gemcitabine could be combined with immunotherapy. The LOAd700 virus expresses a novel membrane-bound trimerized form of CD40L (TMZ-CD40L). In paper II, LOAd700 showed to be oncolytic in pancreatic cancer cell lines as well as being immunostimulatory as shown by its capacity to activate dendritic cells (DCs), myeloid cells, endothelium, and to promote expansion of antigen-specific T cells. In paper III, LOAd703 armed with both 4-1BBL and TMZ-CD40L was evaluated. LOAd703 gave a more profound effect than LOAd700 on activation of DCs and the virus was also capable of reducing factors in stellate cells connected to the desmo-plastic and immunosuppressive microenvironment. In paper IV, LOAd713 armed with TMZ-CD40L in combination with a single-chain variable fragment against IL-6R was evaluated. The virus could kill pancreatic cancer cells lines through oncolysis and could also reduce factors involved in desmoplasia in stellate cells. Most interestingly, LOAd713 could reduce the up-regulation of PD-1/PD-L1 in DCs after CD40 activation. Taken together, LOAd703 and LOAd713 seem to have interesting features with their combination of immunostimulation and microenvironment modulation. At present, LOAd703 is evaluated in a clinical trial for pancreatic cancer (NCT02705196).

Pancreatic cancer is still a dismal disease. The high mortality rate is mainly caused by the lack of highly sensitive and specific diagnostic tools, and most of the patients are diagnosed in an advanced and incurable stage. Knowledge about precursor lesions for pancreatic cancer has grown significantly over the last decade, and nowadays we know that mainly three lesions (PanIN, and IPMN, MCN) are responsible for the development of pancreatic cancer. The early detection of these lesions is still challenging but provides the chance to cure patients before they might get an invasive pancreatic carcinoma. This paper focuses on PanIN, IPMN, and MCN lesions and reviews the current level of knowledge and clinical measures.

Indiana University-Purdue University Indianapolis (IUPUI) / Sequestration at the aggresome and degradation through autophagy are two approaches by which a cell can counteract the toxic effect of misfolded proteins. Tuberous sclerosis (TS) and cancer cells can become dependent on autophagy for survival due to the high demand for protein synthesis, thus making protein clearance a potential therapeutic target. Because of its histone deacetylase (HDAC) inhibitory activity, we hypothesized that 4-phenylbutyrate (4-PBA) inhibits HDAC6 and aggresome formation to induce TS cell death. We found that 4-PBA treatment increases cell death and reduces bortezomib-induced aggresome formation. To link these results with HDAC inhibition we used two other HDAC inhibitors, trichostatin A (TSA) and tubastatin, and found that they also reduce bortezomib-induced protein aggregation. Because tubulin is a target of HDAC6, we next measured the effect of the HDAC inhibitors and 4-PBA treatment on tubulin acetylation. As expected, tubastatin increased tubulin acetylation but surprisingly TSA and 4-PBA did not. Because 4-PBA did not significantly inhibit HDAC6, we next hypothesized that 4-PBA was alternatively inducing autophagy and increasing aggresome clearance. Surprisingly, autophagy inhibition did not prevent the 4-PBA-induced reduction in protein aggregation. In conclusion, we found 4-PBA to induce cell death and reduce aggresome levels in TS cells, but we found no link between these phenomena. We next hypothesized that loss of the Ral guanine nucleotide exchange factor Rgl2 induces cell death via autophagy inhibition in pancreatic adenocarcinoma (PDAC) cells. KRas is mutationally activated in over 90% of PDACs and directly activates Rgl2. Rgl2 activates RalB, a known regulator of autophagy, and Rgl2 has been shown to promote PDAC cell survival. We first confirmed that loss of Rgl2 does increase cell death in PDAC cells. Initial experiments using doubly tagged fluorescent p62 and LC3 (autophagy markers) suggested that loss of Rgl2 inhibited autophagosome accumulation, but after developing a more sophisticated quantitation method we found loss of Rgl2 to have no effect. We also measured endogenous LC3 levels, and these experiments confirmed loss of Rgl2 to have no effect on autophagy levels. Therefore, loss of Rgl2 increases cell death in PDAC cells, but does not have a significant effect on autophagy.