Brain metastasis is a frequent occurrence in cancer patients and carries a high mortality rate. The incidence of brain metastasis is on the rise, highlighting the need for improved therapeutic intervention. Immune cells have been shown to promote disseminated tumour cells to colonise the lung and liver. Therefore, we aim to determine whether immune cells also facilitate brain metastasis by describing the host immune response to tumour cells attached to the brain vasculature. We developed a model of brain metastasis by using ultrasound guidance to perform intracardiac injection of tumour cells. Using this method, we identified highly and weakly brain metastatic cell lines. To understand how cancer cells develop into brain metastases, we analysed brains harvested 4 h- 14 d after tumour injections. At 4 h after intracardiac injection, only cell lines that developed into brain metastases were found adhered to the brain vasculature in high numbers. A small number of arrested tumour cells clustered with CD45⁺ immune cells. These tumour-CD45 clusters persisted over time whilst the frequency of solitary tumour cells declined. Tumour-associated CD45⁺ immune cells were identified to be Ly6G⁺Gr-1⁺CD11c⁻ myeloid cells. Considerably more tumour-CD45⁺ immune cell clusters were found within the brain vasculature when tumour cells were injected into mice bearing a primary tumour. Increased tumour-CD45⁺ immune cells clusters correlated with an increased number of brain metastases in the same group of mice. We also found a positive association between increased tumour-immune clusters and levels of tumour and host derived G-CSF. To establish a causal relationship between tumour cell-CD45 clusters and metastases, we developed an experimental setup for transcranial imaging. Our results suggest that tumour recruited immune cells may promote tumour cell colonisation of the brain and provides a framework for further investigation.

Epidermal growth factor receptor (EGFR) is frequently overexpressed in the majority of triple negative breast cancer patients (TNBC). However, the molecular determinants behind their limited response to EGFR-targeted therapies are poorly understood. Here, both the acute and chronic responses of TNBC to the EGFR-targeted therapy, cetuximab (CTX), have been investigated. The expression of EGFR has been analyzed in a cohort of 2000 breast cancer tumours from the public dataset as well as in a panel of breast cancer cell lines. Furthermore, the response of TNBC cell lines to CTX has been investigated using conventional biochemical methods. Finally, a comprehensive transcriptomic profiling of an acquired CTX-resistant TNBC model by RNA sequencing has been performed to understand the molecular determinants of acquired CTX resistance. The results confirmed that EGFR is highly expressed in TNBC in comparison to non-TNBC breast cancer tumours and cell lines, which was associated with adverse clinical outcomes. Targeting EGFR in TNBC cell lines using CTX failed to completely inhibit the EGFR signalling pathway and was associated with an increase in ADAMs-mediated release of endogenous EGFR ligands, EGF and TGFα. Inhibition of ADAMs (ADAM10 and ADAM17) significantly enhanced the anti tumour efficacy of CTX both in vitro and in vivo. Furthermore, transcriptomic profiling of the acquired CTX-resistant TNBC cell line (MDA-MB-468CR) revealed an activation of several key oncogenic pathways and genes, including the TGFβ/BMP pathway. Blocking BMP receptors (BMPRs) restored the sensitivity of resistant cells to CTX treatment. Collectively, current findings offer alternative strategies that could enhance the CTX response in TNBC. We further reported that simultaneous targeting of both EGFR and BMPR pathways could overcome CTX resistance, which might have important implications for the treatment of TNBC.

Over one in five cancer patients will develop brain metastases and prognosis remains poor. Effective chemotherapeutics for primary systemic tumours have limited access to brain metastases owing to the blood-brain barrier (BBB). The aim of this study was to develop a strategy for specifically permeabilising the BBB at sites of cerebral metastases. Tumour necrosis factor was injected intravenously into mouse models of haematogenously induced brain metastasis. BBB permeability was assessed through histology and in vivo MRI and SPECT. Tumour burden and neuroinflammation were assessed after injection of TNF with Caelyx or a novel therapeutic. Mechanism of permeabilisation was investigated through histology and receptor-specific agonist antibodies. Administration of TNF dose-dependently permeabilised the BBB to exogenous tracers selectively at sites of brain metastasis, with peak effect after six hours. Metastasis-specific uptake of radiolabelled trastuzumab was also demonstrated following systemic cytokine administration. Administration of liposomal doxorubicin formulations in conjunction with TNF reduced tumour burden and mean metastasis size. Localised expression of TNFR1 was evident on the vascular endothelium associated with brain metastases. Human brain metastases displayed a similar TNF receptor profile compared to the mouse model. These findings describe a new approach to selectively permeabilise the BBB at sites of brain metastases, thereby enabling detection of currently invisible micrometastases and facilitating tumour-specific access of chemotherapeutic agents. We hypothesize that this permeabilisation works primarily though TNFR1 activation and, owing to the similar TNFR1 expression profiles in mouse models and human condition, the strategy has the potential for clinical translation.

L’adénovirus a été étudié dans l’optique de développer de nouveaux traitements pour différentes maladies. Les vecteurs adénoviraux (AdV) sont des outils intéressants du fait qu’ils peuvent être produits en grandes quantités (1X1012 particules par millilitre) et de par leur capacité à infecter des cellules quiescentes ou en division rapide. Les AdVs ont subi bon nombre de modifications pour leur permettre de traiter des cellules tumorales ou pour transporter des séquences génétiques exogènes essentielles pour le traitement de maladies monogéniques. Toutefois, les faibles niveaux d’expression du récepteur primaire de l’adénovirus, le CAR (récepteur à l’adénovirus et au virus coxsackie), réduit grandement l’efficacité de transduction dans plusieurs tumeurs. De plus, certains tissus normaux comme les muscles n’expriment que très peu de CAR, rendant l’utilisation des AdVs moins significative. Pour pallier à cette limitation, plusieurs modifications ont été générées sur les capsides virales. L’objectif de ces modifications était d’augmenter l’affinité des AdVs pour des récepteurs cellulaires spécifiques surexprimés dans les tumeurs et qui seraient exempts dans les tissus sains avoisinant. On peut mentionner dans les approches étudiées: l’utilisation de ligands bispécifiques, l’incorporation de peptides dans différentes régions de la fibre ou la substitution par une fibre de sérotypes différents. Notre hypothèse était que les domaines d’interaction complémentaire (K-Coil et ECoil) permettraient aux ligands de s’associer aux particules virales et d’altérer le tropisme de l’AdV. Pour ce faire, nous avons inclus un domaine d’interaction synthétique, le K-Coil,dans différentes régions de la fibre virale en plus de générer des mutations spécifiques pour abolir le tropisme naturel. Pour permettre la liaison avec les récepteurs d’intérêt dont l’EGF-R, l’IGF-IR et le CEA6, nous avons fusionné le domaine d’interaction complémentaire, le E-Coil, soit dans les ligands des récepteurs ciblés dont l’EGF et l’IGF-I, soit sur un anticorps à un seul domaine reconnaissant la protéine membranaire CEA6, l’AFAI. Suite à la construction des différents ligands de même que des différentes fibres virales modifiées, nous avons determiné tout d’abord que les différents ligands de même que les virus modifiés pouvaient être produits et que les différentes composantes pouvaient interagir ensemble. Les productions virales ont été optimisées par l’utilisation d’un nouveau protocole utilisant l’iodixanol. Ensuite, nous avons démontré que l’association des ligands avec le virus arborant une fibre modifiée pouvait entraîner une augmentation de transduction de 2 à 21 fois dans différentes lignées cellulaires. À cause de la difficulté des adénovirus à infecter les fibres musculaires occasionnée par l’absence du CAR, nous avons cherché à savoir si le changement de tropisme pourrait accroître l’infectivité des AdVs. Nous avons démontré que l’association avec le ligand bispécifique IGF-E5 permettait d’accroître la transduction autant dans les myoblastes que dans les myotubes de souris. Nous avons finalement réussi à démontrer que notre système pouvait induire une augmentation de 1,6 fois de la transduction suite à l’infection des muscles de souriceaux MDX. Ces résultats nous amènent à la conclusion que le système est fonctionnel et qu’il pourrait être évalué dans des AdVs encodant pour différents gènes thérapeutiques. / Adenoviruses have been studied as a way to develop new treatments for different diseases. Adenoviral vectors (AdV) are considered interesting tools for this propose, because they can be produced at high titers (1X1012 particles per millilitre) in laboratory and they have the capacity to infect non-dividing and dividing cells. AdV have been often modified in order to obtain the ability to kill tumour cells or to deliver exogenous genetic sequences essential to treat monogenic disease. However, weak expression of the primary adenovirus receptor, the CAR (Coxsackie and adenovirus receptor) reduces greatly the transduction efficiency of AdV for the tumour cells. Moreover, some normal tissues express low amount of CAR, like the skeletal muscle, reducing the appeal of using AdV as a gene delivery vehicle for this tissue. To address this problematic, many modifications were done on the adenoviral capsid. The goal of these modifications were to generate an AdV able to target specific cellular receptors that were expressed in tumour cells but not in normal cells. Several approaches were done to modify the tropism of AdV, such as incubation with a bispecific ligands, incorporation of peptides within the adenoviral fiber structure or substitution of the viral fiber with a different serotype fiber. The hypothesis of my project was to determine if an interaction domain fused within a ligand could bind the complementary domain incorporated on a virus and change the tropism of the AdV. The first step was to include a synthetic interaction domain, the K-Coil, within specific region of the adenoviral fiber, as well as inserting two point mutations to abolish the natural tropism. To target the EGF-R, IGF-IR and the CEA6, we fused the complementary interaction domain, the E-Coil, to the respective ligand known as the EGF and the IGF-I or to a single domain antibody (known as AFAI) that bind specifically to CEA6. The specific interaction between the E-Coil and K-Coil was used to associate the ligand with the fiber in order to retarget the AdV toward the selected receptor. We showed that the different ligands as well as the modified fibers could be produced and that both E-Coil and K-Coil expressing partners could interact together. We optimized the viral production by using an iodixanol purification protocol. More importantly, we clearly demonstrated that the ligand association with the fiber could increase the transduction efficiency between 2 to 21 fold against various tumour cells. The difficulty of adenovirus to infect muscle cells because of the lack of CAR expression brought us to evaluate the potential of our retargeted AdV to increase the transduction for the tissue. We showed that the use of IGF-E5 could increase the transduction efficiency in myoblasts as wells as in myotubes. We finally demonstrated that our retargeting system could increase the transduction efficiency for skeletal muscle by 1,6 fold in new born MDX mice. In conclusion, our results show that the retargeting system is indeed functional. This system could be assessed using vectors that express therapeutic genes.

High aerobic glycolytic capacity is correlated with poor prognosis and increased tumour aggressiveness. 6Phosphofructo-1-kinase catalyses the first irreversible step of glycolysis, and is activated by fructose-2,6-bisphosphate, a product of the kinase activity of four bifunctional isoenzymes, 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase (PFK-2/FBPase-2:PFKFB1-4). These are potential anti-tumour targets, but their individual and collective role requires further investigation. This thesis had three aims; to validate the PFK-2/FBPase-2 isoenzymes as anti-cancer targets, to investigate the requirement for isoenzyme-specific targeting, and to initiate assay development, enabling future identification of novel inhibitors. A panel of cancer cell lines was examined and PFKFB3 and PFKFB4 were confirmed to be the most strongly induced isoenzymes in hypoxia, regulated by HIF-1α. Basal and hypoxic relative PFKFB3/PFKFB4 expression varied markedly, and three cell lines with varying expression ratios (MCF-7, U87, PC3) were selected for further study. siRNA knockdown of each isoenzyme individually, markedly reduced 2D and 3D cell growth. The effect of PFKFB3 knockdown was consistently more pronounced, particularly in hypoxia. Double PFKFB3/PFKFB4 knockdown was significantly less effective than PFKFB3 knockdown alone. Direct antagonism of PFKFB3 and PFKFB4 on F-2,6-BP concentration was observed, with PFKFB3 exhibiting high kinase activity, as anticipated, and PFKFB4 exhibiting high bisphosphatase activity. The degree of antagonism was dependent on the relative PFKFB3/PFKFB4 expression ratio. Extensive efforts were made to examine the wider metabolic effect of PFKFB3/PFKFB4 on flux towards glycolysis or the pentose phosphate pathway (PPP), including using metabolite, lipid droplet, ¹³C NMR and mass spectrometry assays. No significant change in metabolic flux was detected, the evidence presented therefore suggesting the impact of the antagonistic effects of the isoenzymes on [F-2,6-BP] extends beyond regulation of metabolic flux alone. This study concluded that the most effective therapeutic strategy will be one that involves a PFKFB3-specific inhibitor, preferably hypoxia-targeted. Accordingly, steps were taken to validate and optimise a robust medium-throughput assay system.

Zunächst wurden mit Hilfe eines neuen Injektionssystems die Vorteile der Bolusgabe und der kontinuierlichen Applikation d-galaktosehaltiger Ultraschallsignalverstärker kombiniert und an einem klein- (Æ 0,86mm) und einem großlumigen (Æ 16 mm) Gefäßmodell die optimale Basis- und Bolusflußratenkombination für die Powerdopplersonographie evaluiert. Der Powerdopplersignalintensitätsverlauf verschiedener Infusionsprotokolle wurde subjektiv von drei Beobachtern einer sechsstufigen Skala zugeordnet. Objektive Intensitätsmeßdaten wurden mit einer CW-Dopplersonde und einem Computersystem gewonnen. Die 1 ml/min.-Basisinfusionsrate kam dem Optimalzustand am nächsten (Großlumenmodell: 70 %, Kleinlumenmodell: 100 % Grad-4-Plateau trotz geringer Standardabweichung der mittleren Spektraldopplerverstärkungsmeßwerte im Plateaubereich). Sie ermöglichte eine annähernd optimale Gefäßdarstellung mit ausreichendem Spielraum für mehrfache, optisch gut wahrnehmbare Bolusgaben (Optimalbolus: 300mg/ml, 2 ml/s, 1 s Injektionsdauer). Diese Ergebnisse lassen eine medizinische und ökonomische Optimierung des Signalverstärkereinsatzes in der Powerdopplersonographie erwarten. Anhand von tierexperimentellen Untersuchungen wurde die Zuverlässigkeit der nativen und der signalverstärkten Farbdopplersonographie bei der Visualisierung der intratumorösen Angioneogenese im Vergleich zur histologischen Vaskularisationsquantifizierung evaluiert. Zu diesem Zweck wurden Melanomzellen des Typs B16-F1 Mäusen intra- bzw. subkutan imjiziert und nach einer Wachstumsperiode in 54 Fällen sonographisch im B-Modus bezüglich Größe, Homogenität, Echogenität und Grenzechoschärfe und in der Farbdopplersonographie bezüglich intratumorös erkennbarer Gefäßzahl, Gefäßarchtektur und Gefäßanteil an der Tumorquerschnittsfläche (= percentage vessel area, PVA) analysiert. Die anschließende histologische Aufarbeitung erbrachte Vergleichsdaten hinsichtlich Größe, Nekrotisierung und Vaskularisation der Tumoren. Es fand sich eine signifikante Korrelation (p < 0,01) zwischen den makroskopisch und den sonographisch ermittelten Tumordurchmessern, jedoch zwischen Histologie und Sonographie bezüglich sonographisch erkannter Nekrosen nur, wenn diese mehr als 40 % des Tumors erfaßten. Nach Signalverstärkerapplikation stiegen die sonographisch erkennbare Tumorgefäßzahl, -architektur und die PVA signifikant an (p < 0,01), letztere bei den intrakutanen Tumoren um 483 % und bei den subkutanen um 373 %. Der histologische Vaskularisationsgrad korrelierte am stärksten (r = 0,686) von allen Farbdopplerparametern mit der signalverstärkten PVA (p < 0,01). Somit trug die Signalverstärkergabe zur Verbesserung der Korrelation der Ergebnisse der sonographischen und histologischen Vaskularisations- und Angioneogenesebeurteilung bei. Im klinisch-experimentellen Teil wurde prospektiv bei 83 malignitätssuspekten, kutan oder subkutan lokalisierten Raumforderungen unterschiedlichen, meist epithelialen Ursprungsgewebes mittels nativer und signalverstärkter Farbduplexsonographie eine Dignitätseinschätzung vorgenommen. Als Einstufungskriterien wurden diverse B-Modus- und Farbdopplerkriterien, u.a. intratumorös erkennbare Gefäßzahl und PVA, verwendet. Die Diagnosesicherung erfolgte durch Histologie oder Verlaufskontrolle. Während weder die B-Modus-Kriterien noch die Dopplerspektralanalyse für die Dignitätseinschätzung geeignet erschienen, trugen die Farbdopplerparameter und besonders die PVA nach Signalverstärkergabe zur Dignitätsbestimmung bei, wobei die erkennbare Gefäßzahl nach Signalverstärkergabe signifikant (p < 0,01) zunahm. Als ungeeignet erwiesen sich diese Kriterien jedoch bei entzündlichen und angiomatösen Raumforderungen und epithelialen Rezidivtumoren. Insgesamt liefert die signalverstärkte Farbdopplersonographie wesentliche zusätzliche Informationen bezüglich Angioneogenese und Dignität von Raumforderungen der Haut und ihrer Anhangsgebilde, insbesondere die signalverstärkte semiquantitative Vaskularisationsanalyse. Sie ist der B-Modus-Sonographie und der Spektraldoppleranalyse überlegen. Die Signalverstärkergabe führt zu einer deutlichen Sensitivitätserhöhung. / A new injection system combines the advantages of bolus and of continuous application of ultrasound contrast agents. This study evaluated the optimal combination of basic and bolus flow rates in power Doppler sonography using two different types of vitro vessel models. The flow of an in vitro circulation model consisting of a wide or small lumen vessels was visualized by power Doppler ultrasound. The intensity of colour Doppler signal was assessed subjectively by three observers using a six step scale (optimal: degree 5). The objective signal intensity was measured by a CW-Doppler probe and a computed sytem. Using a basic flow rate of 1 ml/min., approximately optimal results were reached. This basic flow rate enabled an almost optimal visualization of the vessel lumen with sufficient free range for repeated, well visible bolus injections. Thus, the use of the new injection system combining bolus and continous injection of contrast agent improves medical and economic use of signal enhancing agents in power Doppler sonography. The aim of the next study was to evaluate the reliability of plain and enhanced colour Doppler sonography in visualization of intratumoral vascularization as a sign of malignant angioneogenesis. Therefore, malignant melanomas of the histological type B16-F1 which had been implanted in mice were examined by sonography. The majority of these tumours was localized intracutaneously, the minority subcutaneously. Various B-mode aspects, colour Doppler criteria, and spectral Doppler parameter were evaluated before and after i.v.-application of an ultrasound signal enhancer. After sonographic examination, all tumors were analyzed histologically with semiquantitative grading of tumoral vascularization. Despite the higher mean volume of the subcutaneous tumours, the percentage of tumors with visible intratumoral vessels was not higher than in intracutaneous tumors on plain images. Enhanced, the sonographical vascularization of subcutaneous tumors seemed to be superior to this of the intracutaneous. The signal enhanced mode was definitely superior to plain Doppler in showing the intratumoral vessels as a sign of angioneogenesis. The intratumoral vascular structure could be sufficiently analyzed the minority of all tumors by plain Doppler, but in more than 90 % after application of the signal enhancing agent. Intracutaneous tumors had a more compact vascular structure than subcutaneous. Despite the missing direct correlation between the sonographically and the histologically determined degree of tumour vascularization the correlation was improved after application of the signal enhancer. Only the enhanced colour Doppler sonography provides valuable noninvasive information about angioneogenetic hypervascularization in experimental melanomas. The third study evaluated colour Doppler criteria to differentiate between malignant and benign skin tumors determining the extent of the intratumorous vascularization. The B-mode sonomorphology and the extent of the vascularization in color Doppler of clinically potentially malignant tumours of the cutaneous and subcutaneous structures were analyzed and quantified by different methods. After application of the signal enhancing agent, counting the intratumoral vessels visible on one ultrasound slice led to the highest sensitivity of all used criteria but the specificity was poor. The highest specificity and diagnostic accuracy of all used criteria were obtained using the criterion "percentage vessel area > 5,0 %" after excluding all inflamed lesions by clinical aspects. Plain colour Doppler increased the specificity but the sensitivity decreased to a not acceptable level. The analysis of the B-mode morphology and spectral Doppler parameter of intratumoral vessels did not contribute to differential diagnosis. Signal enhanced colour Doppler sonography is a valuable tool in pretherapeutic assessment of cutaneous lesions. This method can be relevant for therapy and prognosis. The application of the signal enhancing agent increases significantly (p < 0.01) the sensitivity. This method is not useful in assessing benignity or malignancy of inflamed lesions and angiomas.

Orientador: Antonio Carlos Alessi / Banca: Felipe Augusto Ruiz Sueiro / Banca: Rosemeri de Oliveira Vasconcelos / Resumo: As neoplasias mamárias caninas são as mais frequentes nessa espécie e também são comuns em mulheres. Um dos principais fatores prognósticos dessa enfermidade é a presença ou ausência de metástase em linfonodos. A metástase é um mecanismo complexo que envolve vários fatores. Em mulheres sabe-se que a molécula de adesão CD44 está relacionada com invasão e metástase. Este trabalho teve como objetivos: avaliar a imunomarcação de CD44 nas neoplasias mamárias malignas da cadela, com e sem metástase em linfonodos regionais; associá-la como fator prognóstico; na detecção precoce de metástase; relacioná-la com a imunomarcação de MMP-9, E-caderina e VEGF e associar com a sobrevida das cadelas. Compuseram os grupos experimentais, cadelas com tumor mamário, com (Grupo M) ou sem metástase (Grupo N) detectável em linfonodos e um grupo controle composto por tecido mamário normal. Não houve predileção por localização mamária, mas utilizou-se mais as mamas inguinais e linfonodos inguinais. As neoplasias mamárias foram classificadas de acordo com a Organização Mundial de Saúde. Para isso utilizou-se a técnica de imuno-histoquímica, em amostras incluídas em parafina. Para a determinação da porcentagem de imunomarcação considerou-se somente as células epiteliais neoplásicas. Para o anticorpo CD44 contou-se as marcações em linfócitos T nos linfonodos dos dois grupos Observou-se aumento significativo na marcação do CD44 do sítio primário do tumor para a metástase, assim como nas marcações de MMP-9 e E-caderina. As marcações em linfócitos T foram maiores no grupo N e menores no grupo M. O tipo histopatológico mais comum foi o carcinoma simples túbulo papilífero. A raça predominante no grupo das metástases foi Teckel, com idade média de 9,4 anos, e com tempo de sobrevida de sete meses. Concluiu-se... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Mammary neoplasia are the most frequently type of cancer in bitches and also in women. One of the main prognostic factors of this desease is the presence or absent of lymphonodes metastasis. Metastasis is a complex mechanism which involve multiple factors. At women, researchs have shown that the CD44, a adhesion molecule, is related with invasion and metastasis. This research looked for as objectives: Evaluation of CD44 in malignant mammary neoplasia at bitches with and without lymphonodes metastasis; link CD44 and prognosis; CD44 and early detection of metastasis; link CD44 with MMP-9; E-cadherin and VEGF; and associate with the survival of bitches. Experimental groups were arranged with bitches suffering from mammary neoplasia and divided into three groups: Group one(M) were compounded by bitches with visible metastasis in the lymphonodes; Group two(N) were compounded by bitches without visible metastasis in the lymphonodes;Group three or control compounded by bitches with normal mammary tissue. During the research did not have predilection about the mammary localization, despite inguinal breast and lymphonodes were more collected. Mammary neoplasias were classified according to the OMS norms. For this we used the technique of immunohistochemistry in paraffin sections and counted only epithelial cancer cells by method of percentage of labeled cells. Only antibody to CD44 told that the markings on T lymphocytes in lymph nodes of the two groups observed a significant increase in CD44 marking the site of the primary tumor to metastasis, as well as the markings of MMP-9 and E-cadherin. The markings on T lymphocytes were higher in group N and lower in group M. The most common pathological type was the simple tubular papillary carcinoma. The xiii predominant race in the group of metastasis was Daschshund, mean age 9,4 years, and survival... (Complete abstract click electronic access below) / Mestre

<p>The overall aim of this thesis is to investigate health-related quality of life (HRQoL), anxiety and depression in patients with endocrine gastrointestinal (GI) tumours. Patient as well as staff perceptions were assessed. HRQoL was studied with the EORTC QLQ-C30, and anxiety and depression with the Hospital Anxiety and Depression Scale. In addition, patient perceptions of the importance of and satisfaction with selected HRQoL aspects were investigated. Semi-structured interviews with open-ended questions were conducted to identify disease- and treatment-related distress, what constitutes a good quality of life and strategies to "keep a good mood" among these patients. Patients reported a relatively good HRQoL and low levels of anxiety and depression. However, they reported a lower HRQoL than could be expected for healthy people of similar age and gender. Staff gave a more pessimistic view of patient satisfaction with HRQoL aspects than did patients, and staff did not accurately judge individual patients' levels of anxiety and depression. Importance>satisfaction discrepancies for HRQoL aspects may identify patients with a low quality of life. HRQoL, anxiety and depression did not change substantially during the first year of treatment. Categories identified through content analysis of interview data concerning distress and quality of life were referred to physical, emotional or social dimensions. Identified strategies to "keep a good mood" were classified as Internal or External. Most categories of distress that were identified are covered by the EORTC QLQ-C30 and/or the HADS, but some additional emotional and social aspects of distress emerged from the interview data. Receiving good care was identified as a strategy to "keep a good mood". This result indicates a possible and potentially important relation between the quality of care and patient HRQoL.</p>

L'objectif de notre thèse est de contribuer à une meilleure délimitation de la forme et de l'extension de tumeurs intracrâniennes afin de pouvoir mieux les traiter par radiothérapie conformationnelle. Plusieurs approches ont été utilisées. Par une étude anatomo-pathologique autopsique, nous avons pu démontrer que les métastases cérébrales de plusieurs types de tumeurs s'étendent au moins 1 mm au-delà de leur bord macroscopiquement visible. Les métastases de tumeurs pulmonaires à petites cellules sont celles pour lesquelles nous observons la plus grande extension. En utilisant des techniques de spectroscopie et de l'imagerie par RMN, nous avons observé que des discordances existent dans 47% des voxels examinés. Le plus souvent, l'image apparaît pathologique en RMN et normale en spectroscopie, peut-être en raison d'un oedème périlésionnel important. Une troisième approche a été l'analyse comparative de l'extension de méningiomes intracrâniens par la RMN et par une nouvelle méthode d'imagerie métabolique (PET scan à un acide aminé marqué au fluor 18). Tous les méningiomes sont bien visualisés par le PET scan. Une concordance complète entre image de RMN et de PET scan est observée dans 54% des cas, l'image est plus étendue en PET scan dans 38 % des cas et la situation inverse est observée dans 8% des cas. Enfin, nous avons validé toute la chaîne de traitement en radiochirurgie sur des neurinomes de l'acoustique. Nous obtenons des résultats cliniques comparables à ceux de grandes séries publiées. En conclusion, nos travaux montrent que l'image anatomique seule (la RMN) est insuffisante pour délimiter la plupart des tumeurs intracrâniennes et que des méthodes complémentaires (spectroscopie, imagerie dite métabolique) sont nécessaires pour la préparation au traitement par radiothérapie de précision.

The overall aim of this thesis is to investigate health-related quality of life (HRQoL), anxiety and depression in patients with endocrine gastrointestinal (GI) tumours. Patient as well as staff perceptions were assessed. HRQoL was studied with the EORTC QLQ-C30, and anxiety and depression with the Hospital Anxiety and Depression Scale. In addition, patient perceptions of the importance of and satisfaction with selected HRQoL aspects were investigated. Semi-structured interviews with open-ended questions were conducted to identify disease- and treatment-related distress, what constitutes a good quality of life and strategies to "keep a good mood" among these patients. Patients reported a relatively good HRQoL and low levels of anxiety and depression. However, they reported a lower HRQoL than could be expected for healthy people of similar age and gender. Staff gave a more pessimistic view of patient satisfaction with HRQoL aspects than did patients, and staff did not accurately judge individual patients' levels of anxiety and depression. Importance&gt;satisfaction discrepancies for HRQoL aspects may identify patients with a low quality of life. HRQoL, anxiety and depression did not change substantially during the first year of treatment. Categories identified through content analysis of interview data concerning distress and quality of life were referred to physical, emotional or social dimensions. Identified strategies to "keep a good mood" were classified as Internal or External. Most categories of distress that were identified are covered by the EORTC QLQ-C30 and/or the HADS, but some additional emotional and social aspects of distress emerged from the interview data. Receiving good care was identified as a strategy to "keep a good mood". This result indicates a possible and potentially important relation between the quality of care and patient HRQoL.