Background: Drugs targeting angiogenic pathway remain the mainstay of treatment for metastatic renal cell carcinoma (mRCC). Tyrosine Kinase Inhibitors (TKI) as Sunitinib, Pazopanib as single agents and humanised monoclonal antibody bevacizumab (Bev) in combination with Interferon- α2a (IFN) have established as the first-line therapy for mRCC. Despite improvements in treatment, there are multiple questions which remain unanswered. In the combination of Bev and IFN, the respective role of each drug and whether any additional anti-angiogenic activity is gained by adding IFN to Bev remains unknown. As the clinical benefit obtained with these cytostatic agents does not always correlate with the conventional response assessment techniques as RECIST, it is necessary to reconsider the methods by which we assess benefit from these therapies. In this thesis, I report three studies aiming to answer these questions. Methods: With the clinical trial reported here, I explore whether Bev induced changes in vascular parameters measured by Dynamic Contrast Enhanced MRI (DCE-MRI) is significantly enhanced by the addition of IFN. In a phase II, randomised, open labelled, multicentre trial, treatment naïve mRCC patients were randomised to receive Bev on its own or in combination with a low dose (3MU) or standard dose (9MU) IFN. DCE-MRI was used to assess the changes in vascularity with the primary endpoint being, changes in transfer coefficient (Ktrans) after six weeks of treatment. I also report two retrospective imaging-based studies, using contrast-enhanced CT scans, performed to improve the methodology of response assessment for these antiangiogenic therapeutics. Here I explore the use of a) combining changes in size and arterial phase contrast enhancement measured using CT scan and b) changes in CT texture as methods of therapeutic response assessment in mRCC patients treated with TKI. Results: With the phase 2 clinical trial, we faced significant difficulty in recruitment as a result of restrictions in access to treatment in NHS, other competing studies and restrictions proposed by the DCE-MRI inclusion criteria. With slow recruitment, an unplanned analysis was performed after 21 patients were recruited. Analysis of primary endpoint showed no trend in the difference between arms with no correlation found between change in Ktrans and addition of IFN to bevacizumab. Effect size analysis performed due to the small numbers recruited failed to show any significance in the observed difference in Ktrans. Change in Ktrans and Kep may identify a group of patients likely to have PFS > 6 months, but this observation needs to evaluation in a larger sample size. Measuring size and change in arterial phase enhancement retrospectively using CT, a new criterion "modified" Choi, which prerequisite a combination of a decrease in arterial phase density by 15% and a decrease in size by 10% for response was proposed. Response assessment was measured with RECIST, Choi and modified Choi individually in 20 evaluable patients retrospectively and clinical benefit compared with Kaplan-Meier statistics and Log-Rank test. Response assessment as defined by the modified Choi criteria successfully identified patients who received clinical benefit from the treatment. Time to progression (TTP) was 448 days for the partial response and 89 days for stable disease as per the new criteria which were statistically significant with a p-value of 0.002. The second retrospective analysis explored the textural changes in enhanced CT scan. Performed in collaboration with researchers from Brighton University who developed the software algorithm used to assess changes in entropy and uniformity, 87 metastases from 39 patients with mRCC were analysed at baseline and after two cycles of TKI treatment. Textural parameters and response assessment criteria were correlated with TTP. After two cycles of TKI, the decrease in tumour entropy was 3%-45%, and increase in uniformity was 5%-21%. At a threshold change of -2% with uniformity, on a coarse scale of 2.5, the textural change was able to separate responders from non-responders. With Kaplan-Meier analysis comparing all four criteria, the percentage change in uniformity was statistically more significant than for RECIST, Choi, and Modified Choi criteria. Cox regression analysis showed that texture uniformity was an independent predictor of time to progression. Discussion: With the studies reported here, I was able to demonstrate the importance of improving the methodology in assessment of therapeutic response to targeted anti-angiogenic therapy in metastatic renal cell carcinoma. Even though the clinical trial, terminated early due to slow recruitment, did not reach its primary endpoint, changes in other vascular parameters as Kep combined with changes Ktrans showed tendency towards identifying a group of patients who derived clinical benefit of >6months with these therapies. This is particularly exciting as given the vascular stabilisation effect proposed for bevacizumab, the effusion parameter Kep may be a better tool in assessing response rather than Ktrans and warrants further assessment in a larger cohort. Modified choi criterion and textural analysis are two important methodological improvements in response assessment of cytostatic anti-angiogenic therapy. In the analyses reported here, both techniques have shown superiority over RECIST in response assessment and differentiating mRCC patients who is likely to gain clinical benefit by TKI therapy. Validation of these criteria on a larger patient cohort is important. As these criterions are assessed on standard enhanced CT scans, incorporating these criteria, especially modified choi criterion, as part of standard CT assessment could be performed and will provide a real world validation. Retrospective assessment using larger cohort of patients from previous phase 3 trials or inclusion of these parameters prospectively in phase 3 trials would also help us in evaluating these modalities further.

Le syndrome von Hippel Lindau (VHL) prédispose au développement de multiples tumeurs hautement vascularisées, telles que des hémangioblastomes rétiniens ou du système nerveux central, des phéochromocytomes et des carcinomes rénaux à cellules claires (CCRCC). Les patients atteints de ce syndrome sont porteurs d’une mutation du gène VHL. Ce gène, composé de trois exons, est transcrit en deux ARN messagers par épissage alternatif de l’exon 2. L’ARNm composé des 3 exons (variant #1) est la forme majoritairement exprimée par rapport à l’ARNm dépourvu de l’exon 2 (variant #2). Toutefois, une diminution du ratio variant #1/variant #2 a été essentiellement décrite dans deux situations : (i) dans les tissus embryonnaires humains et en particulier le rein, et (ii) dans certains CCRCC. Ces données suggèrent un rôle potentiel de ce variant #2 dans la tumorigenèse rénale. Deux protéines, pVHL213 et pVHL160, sont produites à partir du variant #1 et elles agissent comme suppresseurs de tumeur. Au début de ce travail, l’expression de l’isoforme protéique pVHL172 produite à partir du variant #2 restait à démontrer et sa fonction était inconnue. Les travaux effectués au cours de cette thèse ont permis de mettre en évidence l’expression de pVHL172 dans des lignées cellulaires et dans des tissus tumoraux grâce à un nouvel anticorps monoclonal de souris dirigé contre les trois isoformes protéiques humaines de pVHL. Pour savoir si l’isoforme pVHL172 a un rôle de suppresseur de tumeur, des lignées cellulaires tumorales rénales exprimant stablement cette protéine ont été établies puis des expériences de xénogreffes de ces cellules chez la souris ont été réalisées. Non seulement pVHL172 n’inhibe pas la formation de tumeurs mais son expression induit un phénotype tumoral plus agressif avec une composante sarcomatoïde plus importante ainsi qu’une vascularisation immature plus conséquente que dans les tumeurs contrôles (n’exprimant pas pVHL). De plus, pVHL172 augmente l’expression des métalloprotéases de matrice MMP1 et MMP13, en partie via l’activation de la voie de signalisation Smad-dépendante du TGF-β. Par ailleurs, des partenaires protéiques de cette protéine ont été recherchés par une analyse protéomique différentielle. Les réseaux d’interaction réalisés à partir des protéines identifiées concernent entre autres la régulation de la matrice extracellulaire et le contrôle qualité des protéines. En conclusion, ce travail a montré que le gène VHL produit des isoformes protéiques avec des fonctions distinctes voire antagonistes, ce qui implique que la balance de leur expression influencerait la progression tumorale rénale. Chez certains patients, une augmentation de l’expression de pVHL172 pourrait être corrélée à une pathologie plus sévère. Ce travail montre l’intérêt de poursuivre l’étude des fonctions de cette protéine pour une meilleure compréhension de son implication dans le cancer du rein et dans la maladie VHL afin d’envisager de nouvelles approches thérapeutiques. / VHL disease predisposes to the development of multiple and highly vascularized tumors, including central nervous system and retinal haemangioblastomas, phaeochromocytomas and clear cell renal cell carcinomas (ccRCCs). Patients with VHL disease harbor a mutant allele of the VHL gene. This gene is transcribed into two mRNAs by alternative splicing of the exon 2. The mRNA variant #1 composed of 3 exons usually predominates over the mRNA variant #2 lacking exon 2. A decrease of the variant #1/variant #2 ratio was however described in 2 situations: (i) in embryonic tissues, particularly in the kidney, and (ii) in some ccRCCs. These data suggest a potential role for the variant #2 in kidney tumorigenesis. pVHL213 and pVHL160 are the two proteins encoded by the mRNA variant #1 and act as tumor suppressors. At the beginning of this Ph.D. project, the expression of pVHL172 isoform encoded by the mRNA variant #2 remained to be established and its function was unknown. The experiments performed during this Ph.D. shed light on pVHL172 expression in cell lines and in tumor tissues using a newly produced mouse monoclonal antibody recognizing the three human pVHL isoforms. To examine if pVHL172 had a tumor suppressor function, human kidney tumor cell lines stably expressing this isoform were established, characterized and then grafted in mice. pVHL172 not only inhibits tumor formation, but its expression also induces a more aggressive phenotype with a higher sarcomatoid component and a more immature vasculature compared to control tumors (that do not express any pVHL). Moreover, pVHL172 increases the matrix metalloproteases MMP1 and MMP13 expression, partly by the activation of the Smad-dependent TGF-β signalling pathway. Besides, we looked for protein partners of pVHL172 by a differential proteomic analysis and showed that interaction networks obtained with the identified proteins are related to extracellular matrix regulation and protein quality control. To conclude, this work demonstrated that the VHL gene encodes protein isoforms with distinct and even antagonistic functions. The balance of expression of these isoforms is likely to influence kidney tumor progression. For some patients, an increase of pVHL172 expression could be correlated with a more severe pathology. This work shows the importance of further studying this isoform’s functions to better understand its involvement in kidney cancer and in VHL disease, so that new therapeutic approaches could be developed.

Hypoxia Inducible Factor-1α in Renal Cell Carcinoma Departments of Surgical and Perioperative Sciences, Urology and Andrology; Radiation Sciences, Oncology; Medical Biosciences, Pathology; and Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden Background: Renal cell carcinoma (RCC) accounts for approximately 2-3% of all human cancers. A distinguished feature of RCC is vascularisation and among the three dominating RCC types conventional RCC (cRCC) generally is more vascularised than papillary RCC (pRCC) and chromophobe RCC (chRCC). Angiogenesis is a critical step in tumour progression controlled by a balance involving molecules that have positive and negative regulatory activity. A balance distorted by metabolic stress such as hypoxia, acidosis, and inflammation. Hypoxia-Inducible Factor 1α (HIF-1α) is a key transcription factor in angiogenesis and tumour progression, targeting more than a 100 genes involved in vascular growth and regulation, iron metabolism and erythropoesis, collagen matrix formation, regulation of extracellular pH, glucose uptake and metabolism, proliferation, apoptosis, differentiation, and cell viability. Methods: Tumour tissue and corresponding kidney cortex from nephrectomised RCC patients was used in order to characterize HIF-1α expression and one of its target genes, Glucose Transporter 1 (GLUT-1). All tumour samples were thoroughly described regarding tumour type, TNM stage, nuclear grade, tumour size, vein invasion, and patient survival. Utilizing RT-PCR, Westen Blot and Tissue micro array (TMA) we studied HIF-1α mRNA and protein expression as well as GLUT-1 protein expression, correlating them to each other and clinicopathological parameters. Results: Using Western Blot, HIF-1α protein expression differed significantly between the different RCC types and kidney cortex. In cRCC, high expression of HIF-1α was an independent prognostic factor for favourable prognosis. TMA is a useful method to analyze HIF-1α protein expression in RCC. HIF-1α levels were significantly lower in locally aggressive cRCC and patients with high levels of HIF-1 tended to have a better prognosis. GLUT-1 levels were higher in cRCC than in other RCC types and for cRCC a correlation to HIF-1α was seen. HIF-1α mRNA levels were significantly lower in cRCC compared to other RCC types and kidney cortex. An inverse correlation between HIF-1α protein expression and mRNA levels was observed. Summary: These results demonstrate a discrepancy between RCC types, highlighting the need to separately evaluate biological events in different RCC types. Overexpression of HIF-1α protein is not necessarily all bad and translational regulation appears more critical than anticipated. Further studies are encouraged to clarify angiogenic pathways in RCC.

Background: Angiogenesis is recognised as a critical step in tumour progression. The angiogenic switch is activated by various trigger signals, such as hypoxia, low pH, and genetic mutations. Renal cell carcinoma (RCC) is often an aggressive tumour, and advanced disease has limited treatment options and bad prognosis. This study was focused on markers of angiogenesis in RCC: endoglin (CD105) and CD31 assessing microvessel density (MVD), and carbonic anhydrase (CA) IX and hypoxia-inducible factor (HIF)-2α expressed at hypoxia. Upregulation of HIF is also associated with inactivation of the von Hippel-Lindau (VHL) tumour suppressor gene, which is common in conventional/clear cell (c)RCC. Method: A tumour bank containing 308 tumours from patients operated 1982-2003 was used. The tumours were well characterised regarding tumour type, TNM stage, nuclear grade, tumour size, and patient survival. The tumours were prepared in tissue microarrays and fresh frozen in whole sections. To analyse the expression of endoglin, CD31, CA IX, and HIF-2α mRNA, immunohistochemistry and real-time PCR were used. Results: There was a higher endoglin expression in cRCC than in papillary (p)RCC and chromophobe (ch)RCC, and a higher CD31 expression in cRCC than in pRCC. MVD correlated inversely to TNM stage and nuclear grade in cRCC. There was also an inverse correlation between tumour diameter and CD31 expression in cRCCs. Patients with cRCC with high MVD had a more favourable prognosis than patients with lower MVD. Endoglin and CD31 were not independent prognostic factors. The CA IX expression was higher in cRCC than in pRCC and chRCC. Patients with cRCC expressing low CA IX had a significantly less favourable prognosis compared with those with higher expression. CA IX is an independent prognostic factor. There was a higher HIF-2α mRNA expression in cRCC than in pRCC and chRCC. In cRCC, there was a significant inverse correlation between HIF-2α mRNA expression, and TNM stage and nuclear grade. There was also an inverse correlation between HIF-2α mRNA expression and tumour size among patients with cRCC. HIF-2α was not an independent prognostic factor. Conclusion: In these studies, the factors related to hypoxia and vascularity were all inversely correlated to tumour aggressiveness in cRCC. MVD, CA IX, and HIF-2α expression were also higher in cRCC than in pRCC and chRCC. The relationship between angiogenesis, vascularity, and hypoxia is ambiguous. A line of reasoning including mutations increasing angiogenesis in advanced disease may also be applied to RCC. Measurements of individual angiogenic factors seem to provide prognostic information, and can potentially be combined in patient monitoring and treatment.

Background: Renal cell carcinoma (RCC) is most lethal of the urological cancers, with more than 40% dying of the disease. About 30% of the patients have metastases at initial diagnosis and up to 40% undergoing nephrectomy for localized RCC develop metastasis. A follow-up protocol based on accurate prognostic variables allows identification of low and high risk patients and selection of those most likely to benefit from adjuvant therapy. I have studied a number of prognostic patient-related factors, including tumour stage and grade, angiogenetic factors and tumour markers, in order to improve follow-up guideline as well as to try to predict prognosis and clinical outcome for individual patients. Material and Methods: The studies are based on patients treated for RCC between 1982 and 2002. All patients eligible for surgery with or without metastasis were treated with nephrectomy and were followed according to a scheduled follow-up programme. Serum samples were collected after obtained informed consent. Multiple clinicopathological, laboratory variables and preoperative radiological examinations were analyzed. Results: Study I- After nephrectomy in 187 patients with non-metastatic RCC, 30% developed metastases during the follow-up. The risk for metastases was greater for more advanced stage and was adjusted by size and DNA ploidy. The median time to the diagnosis of metastases was 14.5 months. Metastases occurred in 43% of the patients within one year, within 2 years in 70% and 80% in 3 years. Patients with tumours less than 5 cm and diploid pT1>5cm and pT2 tumours survived longer than those with larger and aneuploid tumours. The 5-years survival rate for pT1, pT2, pT3 tumours were 95%, 87%, and 37% respectively. In pT3 tumours DNA ploidy had no relation to survival time. Study II and IV- The median survival time for patients with metastatic RCC was 7 months. Cytoreductive nephrectomy was associated with longer survival time. Factors including performance status (PS), number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum, vein invasion, capsule invasion had independent prognostic value with Cox multivariate analysis. Study III- The incidence of adrenal tumour involvement was 5.3 %, unaffected of RCC type, tumour location or side. Gender (male) and locally advanced tumours (pT3 > 5cm) were factors predicting adrenal involvement. The presence of adrenal involvement was a significant adverse prognostic variable, indicating a significantly shorter survival in patients both with and without distant metastases. Conclusion: Optimal follow-up guidelines are important from both medical and economic perspectives. The risk for progression depends mainly on stage, which in combination with other prognostic factors may allow more individualized and cost effective follow-up, in some cases by avoiding unnecessary examinations in a third of the patients. Cytoreductive nephrectomy in patients with good PS, metastases limited to one organ, low ESR, normal calcium and no vein invasion were factors associated to long survival time. Soluble angiogenic factors in serum gave no prognostic information. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion during preoperative work up. Ipsilateral adrenal involvement is a highly adverse prognostic factor and should be staged as M1a in the TNM staging system.

Renal Cell Carcinoma (RCC) has low 5 year survival rate and is resistant to radiation and chemotherapy. Phenethyl Isothiocyanate (PEITC) is a naturally occurring phytochemical that has a variety of anti-cancer properties. Here we explore two anti-cancer properties of PEITC: induction of apoptosis and induction of cell cycle arrest in RCC cells and the underlying mechanisms. We used two human RCC cell lines Caki-1 and Caki-2. Survival and cell proliferation was assayed using Calcein AM. Annexin V staining was used to measure apoptosis. Caspase-3/7 induction was measured using a fluorescent substrate. Cell cycle was studied using Propidium Iodide staining. DNA damage was determined using phospho [gamma]-H2AX antibody. Protein expression and phosphorylation was determined using immunoblotting. PEITC significantly reduced survival of Caki-1 and Caki-2 cells and inhibited their proliferation as determined by Calcein AM. 15 and 20 [mu]M PEITC induced apoptosis in both cell lines and induced caspase-3/7 activity. Western blot analysis revealed caspase-8, caspase-9 and Bid cleavage as well as upregulation of the death receptors Fas and DR5. Lower doses (up to 10 [mu]M) arrested Caki-1 cells in G2/M phase, and this was associated with increased p38 and MK2 (Thr334) phosphorylation. The p38 inhibitor SB203850 inhibited this G2 arrest induced by PEITC. 15 and 20 [mu]M PEITC treatment resulted in increased [gamma]-H2AX phosphorylation suggesting DNA damage, but this was completely blocked by caspase inhibitor. In summary, our study shows that PEITC induces apoptosis in Caki-1 and Caki-2 cells by upregulating Fas and DR5 and activating the downstream apoptosis cascade. PEITC does not cause direct DNA damage to the cells; the observed DNA damage is a result of the apoptotic process and is blocked by caspase inhibitor. PEITC induces G2/M arrest in Caki-1 cells and the mechanism involves p38 phosphorylation which activates MK2. Inducing cell cycle arrest and apoptosis may play an important role in the anti-cancer properties of PEITC. Fully understanding the mechanism by which PEITC induces apoptosis and cell cycle arrest in RCC cells may lead to development of novel chemotherapeutic drugs against RCC. / text

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Les carcinomes rénaux (RCC) sont subdivisés en plusieurs sous-types, définis selon des critères histologiques, phénotypiques et génétiques. Le diagnostic différentiel de ces tumeurs est primordial avec des conséquences pronostiques et thérapeutiques. Génétique et diagnostic : Nous avons étudié les données cliniques, histologiques, immunohistochimiques et génétiques d'une série de RCC papillaires (PRCC) de type 1 et 2. Une caractérisation génomique exhaustive complétée par NGS nous a permis de classer les PRCC de type 2 dans plusieurs groupes d'évolution variable. Nos résultats fournissent des informations inédites sur la pathogenèse des PRCC qui donnent des pistes pour un traitement personnalisé. Métabolisme, grade tumoral et phénotype : Dans une série de RCC à cellules claires (ccRCC), nous avons analysé les caractéristiques de ces tumeurs et l'expression des protéines impliquées dans le métabolisme et les isoformes de HIF. Cette étude nous a permis de mettre en évidence quantitativement une corrélation entre l'expression de MCT1, GLUT1 et CAXII et le grade de Fuhrman, et qualitativement une localisation périphérique de HIF2alpha et la co-localisation des protéines HIF2alpha et HAF. Stratégies théranostiques : Dans l’optique de définir les traitements les plus appropriés pour les patients atteints de RCC, nous avons fait un parallèle entre la sensibilité aux thérapies ciblées des patients (in vivo) et de cellules dérivées de la tumeur initiale (in vitro). Nous avons démontré que la réponse chez les patients et dans les cellules était équivalente et donc que des tests in vitro sont une piste pour définir des traitements personnalisés des patients atteints de ccRCC. / Renal carcinomas (RCC) are divided into several subtypes, defined by histological, genetic and phenotypic criteria. The differential diagnosis of these tumors is important with prognostic and therapeutic implications. Genetics and diagnosis: We studied the clinical, histological, immunohistochemical and genetic of papillary RCC (PRCC) type 1 and 2 cohort. An extensive genomic characterization completed by NGS has allowed us to classify type 2 PRCC in several groups of variable clinical evolution. Our results provide new information on the pathogenesis of PRCC that provide perspectives for personalized treatment. Metabolism, tumor grade and phenotype: In a series of clear cell RCC (ccRCC), we analyzed the characteristics of these tumors and the expression of proteins involved in the metabolism and isoforms of HIF. This study allowed us to demonstrate quantitative correlation between the expression of MCT1, GLUT1 and CA XII and Fuhrman grade, and qualitatively peripheral HIF2alpha localization and co-localization of proteins HIF2alpha and HAF. Theranostic strategies: In order to define the most appropriate treatment for patients with RCC, we made a parallel between sensitivity to targeted therapies of patients (in vivo), and cells derived from the original tumor (in vitro). We have demonstrated that the response in patients and in cells and was similar, thus in vitro assays are a way to define personalized treatment for ccRCC.