Thesis (Ph.D. (Biochemistry))--North-West University, Potchefstroom Campus, 2009.

Thesis (Ph.D. (Biochemistry))--North-West University, Potchefstroom Campus, 2009.

Early diagnosis represents an effective way to improve patient prognosis in cancer. New opportunities for cancer diagnosis and screening may arise from identification of cancer-specific epigenetic alterations in the cell-free circulating DNA (cirDNA). This study investigated biomarkers at the level of DNA methylation in the plasma cirDNA of individuals affected with prostate cancer or colorectal cancer. A methylation-sensitive restriction enzyme-based method was used to enrich methylated DNA fractions, which were interrogated on CpG island and human genome tiling microarrays. A number of genes and non-coding loci exhibited differential methylation between prostate cancer patients and controls. The candidate loci identified from these microarray experiments underwent verification by bisulfite modification coupled with pyrosequencing. Our results suggest that microarray-based studies of DNA methylation in the cirDNA can be a promising avenue for the identification of epigenetic biomarkers in cancer.

Early diagnosis represents an effective way to improve patient prognosis in cancer. New opportunities for cancer diagnosis and screening may arise from identification of cancer-specific epigenetic alterations in the cell-free circulating DNA (cirDNA). This study investigated biomarkers at the level of DNA methylation in the plasma cirDNA of individuals affected with prostate cancer or colorectal cancer. A methylation-sensitive restriction enzyme-based method was used to enrich methylated DNA fractions, which were interrogated on CpG island and human genome tiling microarrays. A number of genes and non-coding loci exhibited differential methylation between prostate cancer patients and controls. The candidate loci identified from these microarray experiments underwent verification by bisulfite modification coupled with pyrosequencing. Our results suggest that microarray-based studies of DNA methylation in the cirDNA can be a promising avenue for the identification of epigenetic biomarkers in cancer.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20272号 / 医博第4231号 / 新制||医||1021(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 山田 泰広, 教授 藤渕 航, 教授 一山 智 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

O tratamento padrão para pacientes com câncer de reto localmente avançado consiste no uso de quimioradioterapia neoadjuvante (QRTn), seguida por cirurgia. Uma fração significativa dos pacientes responde completamente ao tratamento e no momento da reavaliação não apresenta evidência clínica nem radiológica de doença. Uma abordagem alternativa, Watch and Wait, propõe não operar imediatamente esses pacientes e submetê-los a um protocolo de observação frequente, a fim de evitar as morbidades associadas à cirurgia. No entanto, a avaliação da resposta ao tratamento ainda é um desafio, devido à subjetividade da avaliação clínica e a ausência de exames radiológicos suficientemente sensíveis e específicos para garantir a ausência de células tumorais residuais ou capazes de detectar a recorrência precoce da doença. DNA circulante contendo alterações genéticas específicas do tumor (ctDNA) pode ser encontrado na fração livre de células do sangue e tem sido utilizado para monitorar a dinâmica tumoral em tumores sólidos. Avanços recentes das tecnologias de sequenciamento permitem a identificação eficiente e rápida e a um custo relativamente baixo de alterações genéticas em tumores individuais, superando o problema imposto pela ausência de alterações genéticas recorrentes nesses tumores. Essas alterações podem ser utilizadas como biomarcadores personalizados para monitorar a resposta ao tratamento, detectar doença residual e a recidiva precoce do tumor. O objetivo deste trabalho foi identificar e estudar biomarcadores personalizados em pacientes com câncer de reto localmente avançado tratados com QRTn e avaliar a capacidade desses biomarcadores para monitorar a dinâmica tumoral, e auxiliar na definição da conduta cirúrgica e na detecção da recidiva precoce da doença. Biópsias de seis pacientes com adenocarcinoma de reto distal (cT2- 3N0-1M0), foram coletadas prospectivamente pré-tratamento. O DNA genômico extraído a partir das biópsias foi usado para construir bibliotecas tipo mate-pair para o sequenciamento do genoma completo, utilizando a plataforma SOLiD. Rearranjos inter e intracromossômicos foram identificados utilizando programas computacionais desenvolvidos pelo nosso grupo de pesquisa e em seguida foram validados utilizando PCR e sequenciamento Sanger. Foram validadas, pelo menos, três variações estruturais para cada paciente. Amostras de plasma foram coletadas no momento do diagnóstico, depois da QRTn e durante o seguimento. DNA circulante total foi extraído a partir das amostras de plasma e ensaios personalizados foram desenvolvidos para monitorar a presença de variações estruturais através de PCR Digital. ctDNA foi detectado em todas amostras de plasma pré-tratamento de pacientes com tumores T3. A detecção desses biomarcadores apresentou boa correlação com a resposta ao tratamento, no entanto, esta abordagem não foi sensível o suficiente para detectar doença residual. Para dois pacientes que desenvolveram doença metastática foi verificado um aumento nos níveis de ctDNA com pelo menos 36 semanas antes do diagnóstico clínico de doença metastática, sendo possível correlacionar os níveis de ctDNA detectados em coletas subsequentes com a resposta ao tratamento sistêmico de segunda linha. Este estudo, embora de caráter exploratório, gerou dados relevantes e suficientes para justificar a realização de estudos adicionais para avaliar a aplicação dos biomarcadores personalizados na definição da conduta cirúrgica e no acompanhamento de pacientes com câncer de reto tratados com QRTn. / The standard treatment for patients with locally advanced rectal cancer comprises in neoadjuvant chemo radiotherapy (nCRT), followed by surgery. A significant fraction of these patients show complete response to the treatment and at the time of reassessment, there are no clinical and nor radiological evidence of residual tumor. An alternative approach, Watch and Wait, proposes not to immediately operate these patients, but to submit them to a protocol of frequent observation in order to avoid the morbidities associated with radical surgery. However, assessment of treatment response remains a significant challenge due to the subjectivity of the clinical examination and to the lack of sufficiently sensitive tools to ensure the absence of tumor cells or to detect early disease recurrence. Circulating DNA carrying tumor-specific genetic alterations (circulating tumor DNA - ctDNA) can be found in the cell-free fraction of the blood and has been successfully used to monitor the tumor dynamics in solid tumors. Recent advances in sequencing technologies have enabled the rapid and cost effective identification of genetic alterations in individual tumors, overcoming the problem imposed by the absence of recurrent genetic alterations in these tumors. These alterations can be used as personalized biomarkers to monitor treatment response, detect residual disease and early tumor recurrence. The purpose of this work was to identify and validate the use of personalized biomarkers for patients with locally advanced rectal cancer treated with nCRT and to evaluate the ability of these biomarkers to monitor the tumor dynamics, to define surgical approach and to detect early recurrence of the disease. Pre-treatment biopsies from 6 patients with cT2-3N0-1M0 distal rectal adenocarcinoma were prospectively collected. Genomic DNA extracted from the biopsies was used to construct mate-pair libraries for whole genome sequencing using SOLiD platform. Inter and intrachromosomal rearrangements were identified using an in-house bioinformatics pipeline and validated using PCR amplification and Sanger sequencing. At least three structural variations were validated for each patient. Plasma samples were collect at diagnosis, after nCRT and follow-up. Circulating DNA was obtained from the plasma samples and personalized assays were designed to monitor the presence of structural variations using Droplet Digital PCR. ctDNA was detected in all pre-treatment plasma samples for patients with T3 tumors. The detection of these biomarkers showed a good correlation with the treatment response, nonetheless, the approach was not sensitive enough to detect residual disease. In two patients who developed metastatic disease, an increase in ctDNA levels was observed at least 36 weeks before clinical detection of metastatic disease, and it was possible to correlate the level of ctDNA in subsequent plasma samples with response to the second-line treatment. This study, although exploratory, generated relevant and sufficient data to support additional studies to evaluate the use of personalized biomarkers in the surgical management and follow-up of rectal cancer patients treated with nCRT.

L’analyse de l’ADN circulant dans le contexte de la tumorogenèse et comme outil diagnostic Le projet de thèse ici décrit est fondé sur la découverte remarquable qu'une quantité importante d’ADN circule dans le sang de patients atteints de cancer [1-5]. Le développement d'une technologie basée sur la détection de l'ADN circulant représente une avancée scientifique et médicale pour le diagnostic et le suivi dans la prise en charge thérapeutique des patients atteints de cancer. Malgré de nombreuses études menées au cours des dix dernières années [4,5] sur l'ADN circulant, les origines de la libération de l'ADN circulant dans les liquides biologiques sont hypothétiques et sa structure n'est pas élucidée. Ces données ne valident pas jusqu'à présent l'ADN circulant en tant que biomarqueur. Pour cette raison, les objectifs du groupe dirigé par Alain Thierry sont axés sur l'élucidation des formes structurelles de l'ADN circulant. Ainsi, en utilisant des souris nude xénogreffées avec des lignées cellulaires tumorales humaines de cancer colorectal ainsi que des échantillons sanguins cliniques provenant de patients atteints de cancer colorectal, l'équipe a montré que la concentration en ADN circulant était corrélée positivement avec la taille de la tumeur [6, 7] et ces résultats se sont révélés optimaux pour des tailles inférieures à 100 pb. Une discrimination significative entre les individus sains et les patients du cancer a été observée grâce à l'analyse de la fragmentation de l'ADN circulant. L'originalité de ces découvertes a donné naissance à la technologie Intplex récemment breveté par le CNRS [8]. L'objectif de la thèse est de valider la quantification et la fragmentation de l'ADN circulant comme un outil de diagnostic et de suivi de la maladie dans la prise en charge du cancer en analysant de près les facteurs qui peuvent influencer la quantification et la fragmentation de l'ADN circulant. Grâce au modèle animal développé par l’équipe et l’étroite collaboration avec les centres anti-cancéreux, différents paramètres seront analysés. Une partie de la thèse se concentrera sur la comparaison et la standardisation des résultats en fonction de nombreux facteurs spécifiques à la tumeur, comme son type, sa progression, sa différenciation et sa localisation tissulaire. Le travail de thèse portera également sur l'influence de facteurs individuels pouvant affecter la quantité et la fragmentation de l'ADN circulant: âge, sexe, antécédents médicaux, états physiologiques spécifiques, situations physiopathologiques. L'influence du traitement sera également explorée. Des études seront menées afin de standardiser l'analyse biologique: influence du rythme circadien, prise de nourriture .... Techniquement, la variation analytique et l'influence des facteurs pré-analytiques seront déterminées afin d’établir un guide de bonnes pratiques analytiques pour éliminer tout artefact susceptible d’affecter la quantité et l'intégrité de l'ADN circulant dans les échantillons. Ces deux paramètres seront testés dans une évaluation clinique prospective multicentrique sur une cohorte de 450 patients atteints de cancer colorectal. Ce travail garantit un impact considérable dans la littérature et dans la pratique clinique comme test non invasif de diagnostic et de suivi et comme un outil pour améliorer les connaissances de base sur l'ADN circulant et le cancer. / Analysis of circulating DNA circulating in the context of tumorigenesis and as a diagnostic tool The thesis project described here is based on the remarkable discovery that a significant amount of DNA circulates in blood of cancer patients [1-5]. The development of a technology based on the detection of circulating DNA represents a scientific and medical breakthrough for diagnosis and follow up in therapeutic care of cancer patients. Despite numerous studies conducted over the last decade [4,5] on circulating DNA, origins of release of circulating DNA in biological fluids are hypothetical and its structure is unclear. These data do not validate so far circulating DNA as a biomarker. For this reason, objectives of the group led by Alain Thierry are focused on elucidating structural forms of circulating DNA. Thus, using nude mice xenografted with human tumor cell lines of colorectal cancer as clinical samples from colorectal cancer patients, the team showed that the concentration was positively correlated with tumor size [6 , 7] and these results were optimal for sizes below 100 bp. A significative discrimination between healthy individuals and cancer patients was found by the analysis of circulating DNA fragmentation. The originality of these discoveries gave rise to the Intplex technology recently patented by the CNRS [8]. The aim of the thesis is to validate quantification and fragmentation of circulating DNA as a diagnostic and follow-up test in the management of cancer by closely analyzing the factors that may influence quantification and fragmentation of circulating DNA. Thanks to mouse model developed by the team and close collaboration with clinical cancer centers, different parameters will be analyzed. One part of the thesis will be focused on comparison and standardization of the different results depending on many factors specific to the tumor, such as its type, its progression, its differentiation and its tissue localization. The thesis work will also focus on the influence of individual factors that may affect the quantity and the fragmentation of circulating DNA: age, sex, medical history, specific physiological states, pathophysiological situations. The influence of treatment will also be explored. Studies will be undertaken in order to standardize the biological analysis: influence of circadian rhythm, food intake.... Technically, the analytical variation and the influence of pre-analytical factors will be determined to establish a good practice guide to eliminate any artifacts altering the amount and integrity of circulating DNA in the samples. These two parameters will be tested in a prospective multicentric clinical evaluation on a cohort including 450 patients with colorectal cancer. This work warrants a significant impact in the literature and in cancer clinical practice as a non invasive diagnostic and follow-up test and as a tool to improve the basic knowledge on circulating DNA and cancer.

Molecular analysis of free circulating (fc)DNA has the potential to change the face of medicine, specifically in cancer diagnostics and in monitoring the efficacy of cancer treatments. In this study, a microfluidic device using AC electrokinetics is developed for rapid concentration and detection of fcDNA from blood. The device concentrates fcDNA using a combination of AC electrothermal flow and dielectrophoresis. The electrothermal fluid motion drives fcDNA towards the center of the electrode where dielectrophoretic trapping occurs. Once fcDNA is collected at the center, the concentration in the sample can be determined by fluorescent analysis using an intercalating dye binding to the double-stranded DNA. Effects of operating parameters are investigated to optimize the device's design. The electrokinetic device isolates high molecular weight DNA and can distinguish from low molecular weight DNA. Quantitative detection of fcDNA in physiologically relevant concentrations is demonstrated toward rapid diagnostics of cancer and monitoring of treatment efficacy.

O tratamento padrão para pacientes com câncer de reto localmente avançado consiste no uso de quimioradioterapia neoadjuvante (QRTn), seguida por cirurgia. Uma fração significativa dos pacientes responde completamente ao tratamento e no momento da reavaliação não apresenta evidência clínica nem radiológica de doença. Uma abordagem alternativa, Watch and Wait, propõe não operar imediatamente esses pacientes e submetê-los a um protocolo de observação frequente, a fim de evitar as morbidades associadas à cirurgia. No entanto, a avaliação da resposta ao tratamento ainda é um desafio, devido à subjetividade da avaliação clínica e a ausência de exames radiológicos suficientemente sensíveis e específicos para garantir a ausência de células tumorais residuais ou capazes de detectar a recorrência precoce da doença. DNA circulante contendo alterações genéticas específicas do tumor (ctDNA) pode ser encontrado na fração livre de células do sangue e tem sido utilizado para monitorar a dinâmica tumoral em tumores sólidos. Avanços recentes das tecnologias de sequenciamento permitem a identificação eficiente e rápida e a um custo relativamente baixo de alterações genéticas em tumores individuais, superando o problema imposto pela ausência de alterações genéticas recorrentes nesses tumores. Essas alterações podem ser utilizadas como biomarcadores personalizados para monitorar a resposta ao tratamento, detectar doença residual e a recidiva precoce do tumor. O objetivo deste trabalho foi identificar e estudar biomarcadores personalizados em pacientes com câncer de reto localmente avançado tratados com QRTn e avaliar a capacidade desses biomarcadores para monitorar a dinâmica tumoral, e auxiliar na definição da conduta cirúrgica e na detecção da recidiva precoce da doença. Biópsias de seis pacientes com adenocarcinoma de reto distal (cT2- 3N0-1M0), foram coletadas prospectivamente pré-tratamento. O DNA genômico extraído a partir das biópsias foi usado para construir bibliotecas tipo mate-pair para o sequenciamento do genoma completo, utilizando a plataforma SOLiD. Rearranjos inter e intracromossômicos foram identificados utilizando programas computacionais desenvolvidos pelo nosso grupo de pesquisa e em seguida foram validados utilizando PCR e sequenciamento Sanger. Foram validadas, pelo menos, três variações estruturais para cada paciente. Amostras de plasma foram coletadas no momento do diagnóstico, depois da QRTn e durante o seguimento. DNA circulante total foi extraído a partir das amostras de plasma e ensaios personalizados foram desenvolvidos para monitorar a presença de variações estruturais através de PCR Digital. ctDNA foi detectado em todas amostras de plasma pré-tratamento de pacientes com tumores T3. A detecção desses biomarcadores apresentou boa correlação com a resposta ao tratamento, no entanto, esta abordagem não foi sensível o suficiente para detectar doença residual. Para dois pacientes que desenvolveram doença metastática foi verificado um aumento nos níveis de ctDNA com pelo menos 36 semanas antes do diagnóstico clínico de doença metastática, sendo possível correlacionar os níveis de ctDNA detectados em coletas subsequentes com a resposta ao tratamento sistêmico de segunda linha. Este estudo, embora de caráter exploratório, gerou dados relevantes e suficientes para justificar a realização de estudos adicionais para avaliar a aplicação dos biomarcadores personalizados na definição da conduta cirúrgica e no acompanhamento de pacientes com câncer de reto tratados com QRTn. / The standard treatment for patients with locally advanced rectal cancer comprises in neoadjuvant chemo radiotherapy (nCRT), followed by surgery. A significant fraction of these patients show complete response to the treatment and at the time of reassessment, there are no clinical and nor radiological evidence of residual tumor. An alternative approach, Watch and Wait, proposes not to immediately operate these patients, but to submit them to a protocol of frequent observation in order to avoid the morbidities associated with radical surgery. However, assessment of treatment response remains a significant challenge due to the subjectivity of the clinical examination and to the lack of sufficiently sensitive tools to ensure the absence of tumor cells or to detect early disease recurrence. Circulating DNA carrying tumor-specific genetic alterations (circulating tumor DNA - ctDNA) can be found in the cell-free fraction of the blood and has been successfully used to monitor the tumor dynamics in solid tumors. Recent advances in sequencing technologies have enabled the rapid and cost effective identification of genetic alterations in individual tumors, overcoming the problem imposed by the absence of recurrent genetic alterations in these tumors. These alterations can be used as personalized biomarkers to monitor treatment response, detect residual disease and early tumor recurrence. The purpose of this work was to identify and validate the use of personalized biomarkers for patients with locally advanced rectal cancer treated with nCRT and to evaluate the ability of these biomarkers to monitor the tumor dynamics, to define surgical approach and to detect early recurrence of the disease. Pre-treatment biopsies from 6 patients with cT2-3N0-1M0 distal rectal adenocarcinoma were prospectively collected. Genomic DNA extracted from the biopsies was used to construct mate-pair libraries for whole genome sequencing using SOLiD platform. Inter and intrachromosomal rearrangements were identified using an in-house bioinformatics pipeline and validated using PCR amplification and Sanger sequencing. At least three structural variations were validated for each patient. Plasma samples were collect at diagnosis, after nCRT and follow-up. Circulating DNA was obtained from the plasma samples and personalized assays were designed to monitor the presence of structural variations using Droplet Digital PCR. ctDNA was detected in all pre-treatment plasma samples for patients with T3 tumors. The detection of these biomarkers showed a good correlation with the treatment response, nonetheless, the approach was not sensitive enough to detect residual disease. In two patients who developed metastatic disease, an increase in ctDNA levels was observed at least 36 weeks before clinical detection of metastatic disease, and it was possible to correlate the level of ctDNA in subsequent plasma samples with response to the second-line treatment. This study, although exploratory, generated relevant and sufficient data to support additional studies to evaluate the use of personalized biomarkers in the surgical management and follow-up of rectal cancer patients treated with nCRT.

Les ADN circulants extracellulaires (ADNcf) sont considérés comme des biomarqueurs potentiels non invasifs de la progression tumorale. Ils présentent l'avantage d'être porteurs des altérations génétiques des tumeurs dont ils sont issus. Les connaissances sur les formes, les mécanismes de libération et les actions biologiques des ADNcf sont cependant encore peu caractérisées.Nous avons émis l'hypothèse que se focaliser sur l'étude de la structure et des origines des ADNcf issus des tumeurs permettrait d'ouvrir de nouvelles perspectives d'applications en génomique personnalisée.Nos travaux ont démontré à l'aide d'un animal modèle que les ADNcf issus des tumeurs de cancers colorectaux sont hautement fragmentés à des tailles inférieures à 145 bp. Cette observation a été confirmée sur plasma humain en réalisant par AFM la première image directe d'ADNcf issu de tumeurs. Nous avons déterminé que les proportions d'ADNcf mutés varient fortement dans la circulation sanguine, mais que près d'un tiers des individus présentaient des proportions d'ADNcf mutés supérieures à 25 % de tous les ADNcf retrouvés dans le sang. Ces découvertes nous ont permis de participer au développement d'une méthode d'analyse spécifique des ADNcf du plasma permettant de déterminer par Q-PCR la concentration en ADNcf, sa fragmentation ainsi que la présence des mutations KRAS et BRAF. Cette méthode a été validée cliniquement sur 79 échantillons de patients atteints de cancer colorectal métastatique en la comparant avec une concordance de 96 % à la technique de référence clinique utilisant l'ADN de tissu tumoral. L'utilisation des ADNcf en tant que « biopsie liquide » devrait être un biomarqueur central dans l'approche de génomique personnalisée des années à venir et les résultats de ces travaux de thèse participer au développement de cette nouvelle approche. / Cell-free circulating DNA (cfDNA) are considered as potentials non invasive biomarkers of tumor progression. They present the advantage to exhibit the genetic alterations from their tumor of origin. Knowledge on the forms, mechanism of release, and biological effect of cfDNA are however still less characterized. We have hypothesized that focalizing on the study of cfDNA structure and origin will open new perspectives of application in personalized genomic. Our works demonstrated, with an animal model, that cfDNA from colorectal cancer tumor are highly fragmented at size lower than 145 bp. This observation was confirmed on human plasma with AFM by realizing the first direct picture of tumor-derived cfDNA. We have determined that cfDNA proportion highly varied in bloodstream, but more than a third of individual exhibit proportions larger than 25 % of blood total cfDNA.These discoveries let us participate to the development of a specific analysis method of plasma cfDNA owing to determinate by Q-PCR the cfDNA concentration, its fragmentation and the presence of KRAS and BRAF mutation. This method has been clinically validated on 79 samples of metastatic colorectal cancer patients by comparing it, with a concordance of 96 %, with the technique of reference using DNA from tumoral tissue.cfDNA could be used as « liquid biospy » and could be a central biomarker in the personalized genomic for the future years, and this thesis work participate to the development of this new approach.