Small intestinal neuroendocrine tumours (SI-NETs) are rare, hormone producing and proliferate slowly. Patients usually display metastases at time of diagnosis, the tumours are difficult to cure, and the disease course is unpredictable. The gene expression pattern was investigated in paper I, with emphasis on aggressive disease and tumour progression. Expression microarrays were performed on 42 tumours. Unsupervised hierarchal clustering revealed three clusters that were correlated to clinical features, and expression changes from primary tumour to metastasis. Eight novel genes, ACTG2, GREM2, REG3A, TUSC2, RUNX1, TGFBR2, TPH1 and CDH6 may be of importance for tumour progression. In paper II, expression of ACTG2 was detected in a fraction of SI-NETs, but not in normal enterochromaffin cells. Inhibition of histone methyltransferase and transfection of miR-145 induced expression and no effect was seen after DNA methylation or selective EZH2 inhibition in vitro. miR-145 expression was reduced in metastases compared to primary tumours. Overexpression of ACTG2 inhibited cell growth, and inducing ACTG2 may have therapeutic effects. TCEB3C (Elongin A3) is located on chromosome 18 and is imprinted in some tissues. In paper III a reduced protein expression was detected. The gene was epigenetically repressed by both DNA and histone methylation in a tumour tissue specific context. The expression was also induced in primary cell cultures after DNA demethylation and pyrosequencing revealed promoter region hypermethylation. Overexpression of TCEB3C inhibited cell growth by 50%, suggesting TCEB3C to be a tumour suppressor gene. In paper IV, 69 biomarkers were analysed in blood serum using multiplex proximity ligation assay. Nineteen markers displayed different levels between patients and controls. In an extended cohort, ELISA analysis showed elevated serum levels of Mindin, DcR3 and TFF3 in patients and protein expression in tumour cells. High levels of DcR3 and TFF3 were associated with poor survival, and DcR3 may be a marker for liver metastases. Mindin, DcR3, and TFF3 are potential novel diagnostic biomarkers for SI-NETs.

This qualitative multi case research asks how the needs of caregivers of primary malignant brain tumour (PMBT) patients are met through structured neuro-oncology programs in Canadian centres. Utilizing telephone interviews with eleven social workers and one psychologist the study analyses their perspectives on the scope and nature of services to brain tumour patients and their caregivers. PMBT is a rare and palliative disease often with neurocognitive and neurobehavioral effects posing special challenges for caregivers. Health care system reliance on family caregivers has resulted in significant implications for their emotional and physical risk. Findings show exclusive patient focused health care in ambulatory programs with fragmented care resulting in marginalization and invisibility of caregivers. This approach is inconsistent with current literature promoting collaborative family centered care, recommended for continuity of care throughout the illness trajectory. Recommendations focus on systemic caregiver service improvements.

BACKGROUND: We have recently shown that standard treatments for prostate cancer, specifically hormone therapy (HT) and radiation therapy, induce antigen-specific immune responses in human patients. However, the contribution of these antigen-specific immune responses to clinical outcomes is not known. HYPOTHESIS: HT induces tumour-specific antibody and T cell responses that delay or prevent tumour recurrence. METHODS: We utilized the androgen-dependent Shionogi tumour cell line. Male DD/S mice bearing established Shionogi tumours (~64 mm2) were castrated to induce tumour regression, similar to HT in human prostate cancer patients. Control mice were not castrated. Mice were monitored for tumour recurrence. Tumour-specific antibody responses were measured by immunoblot, and T cell responses by ELISPOT and immunohistochemistry. Tumour-specific antigens were identified by serological screening of a cDNA expression library (SEREX). RESULTS: Following castration, 32/33 mice experienced complete tumour regression, while the remaining mouse experienced partial tumour regression. Of the 32 mice that underwent complete regression, 72% (23/32) experienced tumour recurrence 3-70 days post-castration, while the remaining 28% (9/32) remained tumour-free for the duration of the experiment until they were sacrificed for analysis (64-86 days post-castration). Shionogi tumours became heavily infiltrated by CD3+ T cells between 7-14 days post-castration, after which T cell infiltrates became progressively more sparse. Castration induced antibody responses to one or more tumour proteins in approximately one third of mice with an average latency of 21 days. The most common antibody response was against poly(A) binding protein, nuclear 1 (PABPN1). Interestingly, 71% (17/24) of mice with recurrent tumours had an antibody response against PABPN1, whereas only 11% (1/9) of mice that remained tumour-free had a PABPN1-specific antibody response. Put another way, the mean tumour-free interval for those mice that had a PABPN1 antibody response was approximately 25 days compared to approximately 63 days for those mice that did not have a PABPN1 antibody response. However, we found a moderate correlation between the timing of the PABPN1-specific antibody response and growth rate of the recurrent tumour, such that if a mouse had a PABPN1-specific antibody response that occurred shortly after castration, it was more likely to have a slower growing recurrent tumour. IFN-γ ELISPOT assays revealed that castration also induced a PABPN1-specific T cell response that persisted for the duration of the experiment (up to 92 days post-castration). Unexpectedly, this T cell response was exceedingly stronger in recurrent mice versus non-recurrent mice and was accompanied by splenomegaly in recurrent mice. Anti-CD3 staining of the recurrent tumours showed that the CD3+ T cells were confined to the periphery and stroma of the tumours. CONCLUSIONS: In the androgen-dependent murine Shionogi carcinoma model, HT induces robust antibody and T cell responses to PABPN1 that are associated with unfavourable outcomes. To determine why those mice that do not have PABPN1-specific antibody and T cell responses have better outcomes, we will further delineate the T cell response with respect to CD4+ versus CD8+ subpopulations. Additionally, we will investigate the use of immunomodulatory agents to amplify host CD8+ T cell responses and thereby improve the therapeutic effects of HT.

Kawasaki disease (KD) is a multisystem vasculitis that results in localized coronary artery elastin breakdown and aneurysm formation. It is the leading cause of acquired heart disease of children in North America. Despite conventional treatment, a significant proportion of patients continue to develop coronary sequelae. The mechanisms of arterial aneurysm formation in KD are not known. Using a murine model of KD, Lactobacillus casei cell wall extract-induced coronary arteritis, the processes leading to coronary aneurysm formation were examined. Vessel damage occurred as a result of the increased enzymatic activity of the elastase, matrix metalloproteinase (MMP)-9. MMP-9 protein and activity levels were elevated in the heart post-disease induction. Expression and activity were specific for and localized to inflamed coronary arteries. The pro-inflammatory cytokine, tumour necrosis factor (TNF)-α, was required for increasing local MMP-9 expression. Importantly, MMP-9-deficient animals had a significantly reduced incidence of elastin breakdown. Furthermore, in a cohort of KD patients, serum MMP-9 did not correlate with coronary outcome, highlighting the importance of local expression of this elastase. Intravenous immunoglobulin (IVIG) and aspirin/salicylate are therapeutic agents in current use for the treatment of KD, though their exact mechanisms of action in KD are not known. The biologic effects of IVIG and salicylate on critical stages of disease development were examined. IVIG and salicylate had differential effects on TNF-α expression, with therapeutic concentrations of IVIG inhibiting, and salicylate inducing, TNF-α expression leading to an indirect modulation of MMP-9 expression. Interestingly, TNF-α expression and MMP-9 activity were both directly inhibited by the metal-chelating drug doxycycline. Treatment of affected mice with doxycycline significantly improved coronary outcome. Inhibiting both the inflammatory response as well as the downstream effects of inflammation were of therapeutic value in this model of KD. These results taken together demonstrate the importance of MMP-9 in the pathogenesis of coronary artery aneurysms in KD. Targeting MMP activity holds the promise of transforming KD from the leading cause of acquired heart disease to a self-limited febrile illness.

The optimal way to detect and treat cancer is to target cancer cells exclusively without affecting the surrounding tissue. One promising approach is to use radiolabelled molecules to target receptors that are overexpressed in cancer cells. Since the epidermal growth factor receptor (EGFR) family is overexpressed in many types of cancer, it is an attractive target for both diagnostic and therapeutic applications. This thesis can be divided into two parts. In part one (paper I), studies were conducted to modulate radionuclide uptake in tumour cells. The results showed that it was possible to modulate the cellular uptake of 125I delivered by trastuzumab (targeting HER2) by adding EGF (targeting EGFR). In part two (papers II-V) a high affinity EGFR-targeting affibody molecule (ZEGFR:955)2 was selected and analysed both in vitro and in vivo. In papers II, III and V, the results obtained when using (ZEGFR:955)2 were compared with those obtained with the two EGFR-binding molecules, EGF and cetuximab. These studies demonstrated that the affibody molecule bound specifically to EGFR (probably to subdomain III) with high affinity (~50 nM in biosensor analysis and ~1 nM in cellular studies) and produced intracellular signalling changes similar to those with cetuximab. In paper IV, in vivo studies were made, demonstrating that [111In](ZEGFR:955)2 gave a tumour-specific 111In uptake of 3.8±1.4% of injected dose per gram tumour tissue, 4 h post-injection. The tumours could be easily visualized with a gamma camera at this time-point. The results of these studies indicated that the affibody molecule (ZEGFR:955)2 is a possible candidate for radionuclide-based imaging of EGFR-expressing tumours. The biological effects of (ZEGFR:955)2 might be of interest for therapy applications.

Cerebral malaria (CM) is a severe complication of Plasmodium falciparum infection, predominantly experienced by children in sub-Saharan Africa. Patients with CM are comatose and often convulse, develop retinal haemorrhages and motor abnormalities. Recent histological studies on brain tissue obtained from patients who have died from CM have identified heterogeneity in brain pathology. As a result, CM is considered to be a complex disease that may be comprised of a number of syndromes. Patients admitted to hospital with CM are treated with anti-malaria drugs; however, even in the best equipped hospitals, a large number of CM patients die within the first 24-hours following hospital admission before the anti-malarial treatment can have an effect. For this reason, it is critical that the mechanisms leading to CM are elucidated in order to develop effective adjunct therapies. Experimental cerebral malaria (ECM) caused by P. berghei ANKA (PbA) infection of susceptible mice displays many features of human CM. A key feature of this model is the pivotal role of the host immune response in pathogenesis, particularly the involvement of T cells. Evidence, predominantly from ECM studies, suggests that tumour necrosis factor (TNF) superfamily (TNFSF) members play critical roles in the immunopathology associated with CM. The first hypothesis investigated in this thesis was that key immune response pathways contribute to the development of CM and, despite the heterogeneity observed between CM patients, common pathways exist that may be targeted to prevent CM. The second hypothesis tested was that members of the TNF superfamily modulate the immune response to infection and are involved in the development of pathology observed in severe malaria (SM). In order to investigate the above hypotheses, three projects were carried out. First, we examined the great heterogeneity in brain expression profiles between ECM-susceptible CBA/CaH (CBA) and C57BL/6 (B6) mice at the peak of disease, as well as the significant differences in circulating cytokine expression and expansion of microglia in brain tissue. We found that, despite these differences, common therapeutic and preventative strategies existed to disrupt the development of ECM in the two ECM-susceptible mouse strains. Second, studies in ECM mice have identified T cells and TNFSF members, TNF and lymphotoxin (LT)-a, as critical mediators of ECM pathology. We extend these studies to examine the role of the TNFSF member LIGHT in ECM. Specific blockade of LIGHT signalling through its receptor, LTβR, in PbA-infected B6 mice abrogated the hallmark features of ECM brain pathology and improved the control of parasite growth. Importantly, specific blockade of LIGHT-LTβR signalling caused the expansion of splenic monocytes and an overall enhanced capacity to remove and process antigen during infection. Together, this study discovered a novel pathogenic role for LIGHT and LTβR in ECM and identified this TNF family receptor-ligand interaction as a potential target for therapeutic intervention in SM. Finally, we investigated the role of LTa in human SM and, more specifically, CM. We tested whether the polymorphisms within the gene encoding LTa (LTA) were associated with susceptibility to SM in Papuan Highland children and adults who had migrated from an area without malaria pressure to a region where malaria is endemic. Despite a lack of association between single nucleotide polymorphisms (SNPs) in the LTA/TNF locus and susceptibility to SM in Papuan Highland children and adults, we found a significant association between a SNP in the LTa-related gene encoding galactin-2 (LGALS2) and susceptibility to CM in children, but not adults in this study population. Interestingly, no association was found between this SNP and susceptibility to CM in Tanzanian children originating from and living in a malaria endemic region. These results suggest that there may be differences in the mechanisms leading to CM in adults and children, as well as between individuals from malaria endemic and non-endemic areas. Together, the findings outlined in this thesis are important to both the understanding of the underlying mechanisms leading to CM and to the development of improved interventions and adjunct therapies.

Research Doctorate - Doctor of Philosophy (PhD) / Reversible protein phosphorylation plays a central role in the regulation of intracellular signalling, and is controlled by the opposing activities of protein kinases and phosphatases. Deregulation of these mechanisms can result in increased proliferation and enhanced survival, which is a hallmark feature of malignant transformation. For example, over 90% of chronic myeloid leukaemia (CML) patients express the BCR/ABL oncoprotein, which exhibits unrestrained tyrosine kinase activity. In addition, activating mutations within the receptor tyrosine kinase, c-KIT, contribute to the pathogenesis of gastrointestinal stromal tumours (GIST), systemic mastocytosis, acute myeloid leukaemia (AML), testicular seminoma and melanoma. The advent of small molecule tyrosine kinase inhibitors, such as imatinib, has revolutionised the treatment of malignancies driven by these oncogenic kinases. However, a proportion of patients are either unresponsive or develop resistance, and as such, relapse and disease progression is a major clinical problem. In order to improve the treatment outcome for these patients, a greater understanding of the signalling pathways regulated downstream of BCR/ABL and c-KIT is required. The data presented in this thesis indicates that oncogenic BCR/ABL and mutant c-KIT both require inhibition of the tumour suppressor, protein phosphatase 2A (PP2A), to induce tumourigenesis. PP2A is a large family of serine/threonine phosphatases that provide the fine control on signalling pathways by governing the rate and duration of phosphorylation. The heterotrimeric PP2A enzyme is comprised of a structural subunit (PP2A Aα and Aβ), a catalytic subunit (PP2Acα and cβ) and a regulatory subunit, which consists of three unrelated families: B55 (α, β, γ, δ), B56 (α, β, γ, δ, ε) and B" (PR72/130 / PR70/48). Binding of the regulatory subunit to the core PP2A AC dimer directs both the substrate specificity and cellular localisation of the enzyme. The combinatorial assembly of these individual components permits the formation of distinct complexes which have been implicated in numerous cellular functions such as proliferation, survival and mitosis. In particular, important roles for PP2A in various aspects of malignant transformation are beginning to emerge. Recent work demonstrates that PP2A is functionally inactivated by BCR/ABL in myeloid progenitor cells. Using the mouse myeloid progenitor cell line, FDC-P1, these observations were confirmed in the current study. Detailed investigation into the underlying mechanisms have demonstrated for the first time that active BCR/ABL increases the expression of the PP2A structural and certain regulatory subunits. This alters the PP2A holoenzyme composition and results in the abundance of complexes containing B55α and B56α. Consequently, B56γ, a known tumour suppressive subunit, appears to be simultaneously displaced. To investigate which subunits are functionally important for BCR/ABL-mediated leukaemogenesis, individual PP2A subunits were targeted with shRNA sequences in WT BCR/ABL FDC-P1 cells. Subsequent evaluation identified B56α as a key player which facilitates the leukaemic phenotype. In accordance with an increase in PP2A activity, knockdown of B56α significantly inhibited the cellular growth and reduced the clonogenic potential of BCR/ABL⁺ myeloid progenitors. Furthermore, suppression of the B56δ subunit in WT BCR/ABL FDC-P1 cells appears to delay progression through the cell cycle. Together, these findings provide new insights into the biology of PP2A and begin to define the precise mechanisms by which BCR/ABL induces leukaemogenesis via PP2A in CML. Investigation of the regulation of PP2A was also extended to the oncogenic tyrosine kinase, c-KIT. Using FDC-P1 cells expressing imatinib-sensitive (V560G) or –resistant (D816V) mutant c-KIT, this work demonstrates for the first time that constitutive activation of c-KIT impairs the activity of PP2A, and this is essential for tumourigenesis. Pharmacological reactivation of PP2A with FTY720 significantly reduced the proliferation, impaired the clonogenic potential and induced apoptosis of oncogenic c-KIT cells, whilst having no effect on empty vector controls or WT c-KIT cells stimulated with stem cell factor (SCF). These cytotoxic effects of FTY720 are mediated, in part, by the rapid dephosphorylation, and hence inactivation, of oncogenic c-KIT receptors. These promising in vitro findings were translated into an in vivo model, where the daily administration of FTY720 significantly delayed the growth of mutant c-KIT⁺ tumours. Furthermore, FTY720 markedly prevented the infiltration of D816V c-KIT tumour cells into secondary lymphoid organs, such as the spleen and bone marrow. As a result, the survival of FTY720-treated mice was significantly prolonged compared to saline-treated controls. Overall, this body of work greatly enhances our understanding of PP2A function and identifies the complex mechanisms of PP2A regulation by the oncogenic tyrosine kinases, BCR/ABL and c-KIT. Taken together, the data suggests that inhibition of PP2A may represent a general mechanism employed by constitutively active kinases to facilitate tumour growth. As such, this work supports the future application of PP2A-activating agents in a broad range of human malignancies.

Together, colorectal (CRC) and bladder cancer (BlCa) are responsible for a large percentage of cancer related morbidity and mortality in Western society. A dramatic reduction in patient survival occurs as these cancers progress towards invasive and metastatic disease, from a five year survival rate of about 90% for localised disease to approximately 5-10% for advanced disease involving distant metastasis. A greater understanding of disease progression will lead to enhanced screening, diagnostic and treatment strategies, in turn providing an improved prognosis for the patient. The purpose of this study was to expand the current molecular knowledge of CRC and BlCa by elucidating the role of Mxi1 mutations and MTSS1 expression in CRC and BlCa respectively, and to examine the diagnostic potential of these genes. The Mxi1 coding region for 41 tumours, collected by the South Western Sydney Colorectal Cancer Tumour Bank from 2000-2001, was screened for mutations using Dideoxy Fingerprinting (ddF) and sequencing. Sequence alterations were detected in 34% of tumours. Three different polymorphisms and three mutations were detected. One mutation could possibly affect the tumour suppressor function of Mxi1. The presence of a gene mutation did not correlate to any clinical characteristics and is therefore not a suitable diagnostic marker. Microsatellite instability (MSI) status however, significantly correlated with tumour grade. Expression levels of MTSS1 and an associated gene, MTSS2, were examined in 16 BlCa cell lines, 9 clonally-derived BlCa sublines, and 30 transitional cell carcinomas (TCCs) collected by the Heinrich-Heine University from 1993-2000. Variable gene expression was observed in BlCa cell lines and tumour samples. No significant correlation of MTSS expression and invasive ability was observed for the cell lines or tumour samples. Further studies eliminated promoter methylation and p53 functional status as mechanisms involved in MTSS1 and MTSS2 down-regulation. Functional studies performed on stable MTSS1-expressing BlCa lines found that although migration was increased, cells displayed reduced anchorage-independent growth. The invasive ability of these cells was unchanged confirming that expression does not correlate with invasive ability. These data support the role of MTSS1 as a tumour suppressor and not as a metastasis suppressor gene. Although MTSS1 may not be useful in predicting more invasive disease, its role as a tumour suppressor in cancer may be useful.

Together, colorectal (CRC) and bladder cancer (BlCa) are responsible for a large percentage of cancer related morbidity and mortality in Western society. A dramatic reduction in patient survival occurs as these cancers progress towards invasive and metastatic disease, from a five year survival rate of about 90% for localised disease to approximately 5-10% for advanced disease involving distant metastasis. A greater understanding of disease progression will lead to enhanced screening, diagnostic and treatment strategies, in turn providing an improved prognosis for the patient. The purpose of this study was to expand the current molecular knowledge of CRC and BlCa by elucidating the role of Mxi1 mutations and MTSS1 expression in CRC and BlCa respectively, and to examine the diagnostic potential of these genes. The Mxi1 coding region for 41 tumours, collected by the South Western Sydney Colorectal Cancer Tumour Bank from 2000-2001, was screened for mutations using Dideoxy Fingerprinting (ddF) and sequencing. Sequence alterations were detected in 34% of tumours. Three different polymorphisms and three mutations were detected. One mutation could possibly affect the tumour suppressor function of Mxi1. The presence of a gene mutation did not correlate to any clinical characteristics and is therefore not a suitable diagnostic marker. Microsatellite instability (MSI) status however, significantly correlated with tumour grade. Expression levels of MTSS1 and an associated gene, MTSS2, were examined in 16 BlCa cell lines, 9 clonally-derived BlCa sublines, and 30 transitional cell carcinomas (TCCs) collected by the Heinrich-Heine University from 1993-2000. Variable gene expression was observed in BlCa cell lines and tumour samples. No significant correlation of MTSS expression and invasive ability was observed for the cell lines or tumour samples. Further studies eliminated promoter methylation and p53 functional status as mechanisms involved in MTSS1 and MTSS2 down-regulation. Functional studies performed on stable MTSS1-expressing BlCa lines found that although migration was increased, cells displayed reduced anchorage-independent growth. The invasive ability of these cells was unchanged confirming that expression does not correlate with invasive ability. These data support the role of MTSS1 as a tumour suppressor and not as a metastasis suppressor gene. Although MTSS1 may not be useful in predicting more invasive disease, its role as a tumour suppressor in cancer may be useful.

Together, colorectal (CRC) and bladder cancer (BlCa) are responsible for a large percentage of cancer related morbidity and mortality in Western society. A dramatic reduction in patient survival occurs as these cancers progress towards invasive and metastatic disease, from a five year survival rate of about 90% for localised disease to approximately 5-10% for advanced disease involving distant metastasis. A greater understanding of disease progression will lead to enhanced screening, diagnostic and treatment strategies, in turn providing an improved prognosis for the patient. The purpose of this study was to expand the current molecular knowledge of CRC and BlCa by elucidating the role of Mxi1 mutations and MTSS1 expression in CRC and BlCa respectively, and to examine the diagnostic potential of these genes. The Mxi1 coding region for 41 tumours, collected by the South Western Sydney Colorectal Cancer Tumour Bank from 2000-2001, was screened for mutations using Dideoxy Fingerprinting (ddF) and sequencing. Sequence alterations were detected in 34% of tumours. Three different polymorphisms and three mutations were detected. One mutation could possibly affect the tumour suppressor function of Mxi1. The presence of a gene mutation did not correlate to any clinical characteristics and is therefore not a suitable diagnostic marker. Microsatellite instability (MSI) status however, significantly correlated with tumour grade. Expression levels of MTSS1 and an associated gene, MTSS2, were examined in 16 BlCa cell lines, 9 clonally-derived BlCa sublines, and 30 transitional cell carcinomas (TCCs) collected by the Heinrich-Heine University from 1993-2000. Variable gene expression was observed in BlCa cell lines and tumour samples. No significant correlation of MTSS expression and invasive ability was observed for the cell lines or tumour samples. Further studies eliminated promoter methylation and p53 functional status as mechanisms involved in MTSS1 and MTSS2 down-regulation. Functional studies performed on stable MTSS1-expressing BlCa lines found that although migration was increased, cells displayed reduced anchorage-independent growth. The invasive ability of these cells was unchanged confirming that expression does not correlate with invasive ability. These data support the role of MTSS1 as a tumour suppressor and not as a metastasis suppressor gene. Although MTSS1 may not be useful in predicting more invasive disease, its role as a tumour suppressor in cancer may be useful.