PURPOSE: This study was undertaken to compare HALO™ software image analysis measurements of cellularity with visual estimations from the pathologist and to outline a protocol for future experimental determinations of cellularity using HALO™. Secondly, this study investigated the clinically challenging prostate cancers of Gleason score 7 by analyzing a large database of radical prostatectomy (RP) specimens with regard to their Gleason grade composition and percentage tumor volume composition. The importance of these values of tumor cellularity, prostate volume, and tumor volume data were discussed in terms of future diagnostic endeavors. Finally, this study provided a brief background on prostate cancer, prostate cancer epidemiology, digital pathology, and the limitations and difficulties in the technological transition to digital pathology. All work for this study was done at Dana-Farber Cancer Institute (Boston, MA). METHODS: In the first part of this study, histological slides were acquired by radical prostatectomy (RP) and contained 12 tumor foci of varying degrees and sizes. These slides were scanned and imported into the HALO™ image analysis software. The tumor foci, previously demarcated by a pathologist, were annotated by hand in HALO™. An algorithm for image analysis was created by training classifiers to recognize and differentiate between epithelial tissue, stromal tissue, glass, and other. This process was accomplished by classifying 62 regions which were tested for accuracy before becoming the components of an algorithm to analyze the entire annotation layer. Each tumor focus was analyzed individually, and the results were exported into Microsoft® Excel from which relevant data were extracted. Cellularity was calculated by the percentage of tumor area that the algorithm characterized as epithelial. Cellularity values derived from HALO™ measurements for each tumor focus were compared with the visual estimations of cellularity provided by the pathologist using Pearson's correlation analysis. In the second part of this study, a database of 1386 slides containing tumors with Gleason scores between 6 and 9 was compiled from 140 RP cases. The average percentages of Gleason grades 3, 4, and 5 in each case were determined. The percentage of each slide that was occupied by the tumor was also averaged for each case, yielding an average percentage of tumor volume for each case. The average Gleason grade 3, 4, or 5 percentage for each case was plotted against the associated average tumor volume percentage of that case. The cases of Gleason score 7 (3+4, 4+3) were then isolated and plotted in a similar manner. Pearson’s correlation analysis was used to determine the degree of linear correlation between the two variables in each plot. Results: In the first part of this study, a statistically significant positive correlation between the cellularity estimations of the pathologist and the HALO™ cellularity measurements was found (r = 0.92, p < 0.01, n =12). In the second part of this study, there was a statistically significant negative correlation between average Gleason grade 3 percentage per case and average tumor volume percentage per case (r = -0.55, p <0.001, n = 140). There was also a statistically significant positive correlation between average Gleason grade 4 percentage per case and average tumor volume percentage per case (r = 0.55, p <0.001, n = 140). After slides containing Gleason score 6 (3+3) tumor were removed from the data, a statistically significant negative correlation remained between average Gleason grade 3 percentage per case and average tumor volume percentage per case (r = -0.51, p <0.001, n = 78), and a statistically significant positive correlation remained between average Gleason grade 4 percentage per case and average tumor volume percentage per case (r = 0.5, p <0.001, n = 101). A statistically significant relationship between average Gleason grade 5 percentage and average tumor volume percentage was not found (r = 0.32, p = 0.14, n = 23). CONCLUSIONS: In the first part of this study, the strong positive correlation between HALO™ cellularity values and visual estimations by the pathologist suggests that image analysis may be an effective tool for determining cellularity in digital histological images. More research using larger sample sizes is recommended to further validate the correlation between algorithm-derived cellularity from HALO™ and visual estimation by the pathologist. In the second part of this study, it appears that the volume of prostate tumors of Gleason score 7 may have prognostic power, considering that an increased percentage composition of Gleason grade 4 correlated with larger tumor volumes. Because this result may have significant clinical implications, further research specifically on tumors of Gleason score 7 is suggested to verify this relationship.

Les cancers de la prostate sont classés en deux catégories. Les cancers de haut grade se distinguent des cancers de bas grade par une plus forte agressivité et un pronostic plus mauvais. Lorsqu’ils deviennent résistants à l’hormonothérapie, les cancers de haut grade sont traités par une chimiothérapie basée sur les taxanes. Néanmoins, les taux de réponse restent faibles. Il existe donc un réel besoin quant à l'identification d'alternatives thérapeutiques qui soient spécifiques de ce type de tumeur. Dans cette optique, notre travail a été de proposer une telle alternative par une approche qui prenne en compte la génétique spécifique des cancers de haut grade. Nous avons exploité une signature de 86 gènes dont le niveau d’expression permet de discriminer entre les tumeurs de haut et de bas grade. Par une approche in silico originale utilisant la banque de données du NCI, nous avons identifié 382 corrélations entre le niveau d’expression de 50 gènes et la sensibilité à 139 agents antiprolifératifs. Parmi ces corrélations, nous avons identifié une signature de 9 gènes qui est spécifique de la réponse à l’oxaliplatine. Cette signature a été confirmée sur le plan fonctionnel dans les lignées cancéreuses prostatiques DU145 et LNCaP. Nous avons donc fourni la preuve de concept que notre approche permet d’identifier de nouvelles molécules pouvant être utilisées en alternative aux taxanes pour traiter spécifiquement les cancers de haut grade. Cette stratégie permet aussi d’identifier de nouveaux marqueurs (gènes) régulant la sensibilité à certains médicaments. Nos résultats démontrent par exemple le rôle des gènes SHMT, impliqués dans la régulation du métabolisme monocarboné, dans la sensibilité spécifique à l’oxaliplatine par un mécanisme qui fait intervenir, du moins en partie, une dérégulation du niveau de méthylation global de l’ADN. / Prostate cancers are classified in two categories. High grade cancers are distinguished from low grade cancers by their higher agressivity and worse prognostic. When they become refractory to hormone therapy, high grade cancers are treated with a taxane-based chemotherapy. However, response rates remain low. Therefore, there is a real need for the discovery of new therapeutic alternatives which are specific for this type of tumors. For that purpose, our work aimed at proposing such an alternative with a strategy that took into account the high grade genetic background. We exploited a signature of 86 genes for which expression level could distinguish between low grade and high grade tumours. With an original in silico approach, we searched the NCI databases and identified 382 correlations between 50 genes and the sensitivity to 139 antiproliferative agents. Among these, a signature of 9 genes was able to specifically predict cell response to oxaliplatin. This signature was validated at the functional level in two prostate cancer cell lines, DU145 and LNCaP. We have thus provided the proof-of-concept that our approach allows the identification of new drugs that can be used alternatively to taxanes in order to specifically treat high grade prostate cancers. This strategy also allows the identification of new markers (genes) regulating the sensitivity to various drugs. Our results demonstrate for example the implication of SHMT genes, which are involved in the regulation of the one-carbon metabolism, in the specific sensitivity to oxaliplatin, by a mechanism which involves, at least in part, the deregulation of the global level of DNA methylation.

At present, prostate cancer is a significant public health issue throughout the world and is the second leading cause of cancer deaths in older men. The prostate specific antigen or PSA (which is encoded by the kallikrein 3/KLK3 gene) test is the current most valuable tool for the diagnosis and management of prostate cancer. However, it is insufficiently sensitive and specific for early diagnosis, for staging of prostate cancer or for discriminating between benign prostatic hyperplasia (BPH) and prostate cancer. Recent research has revealed another potential tumour marker, glandular kallikrein 2 (KLK2 gene/hK2 protein), which may be used alone or in conjunction with PSA to overcome some of the limitations of the PSA test. Twelve new kallikrein gene family members have been recently identified and, like hK2 and PSA, many of these genes have been suggested to be involved in carcinogenesis. In this study, the cellular localisation and level of expression of several of these newer kallikreins (KLK4, KLK5, KLK7, KLK8 and KLK11) was examined in prostate tissue, to provide an understanding of the association of their expression with prostatic diseases and their potential as additional biomarkers. Like PSA and hK2, the present observation indicated that each of these proteins, hK4, hK5, hK7, hK8 and hK11, was detected within the cytoplasm of the secretory cells of the prostate glands. For the first time, all of these newly-identified proteins were shown to be expressed in prostatic intraepithelial neoplasia (PIN) lesions, in comparison to normal glands and cancer lesions. In addition to cytoplasmic secretory cell expression, the localisation of hK4 to the basal cells and nuclei in prostatic lesions was intriguing. The intensity of hK4 staining in prostate tissue was strongest in comparison to the other newly-identified kallikrein proteins (hK5, hK7, hK8 and hK11). Therefore, KLK4/hK4 expression was characterised further to define this cellular localisation and examined in non-prostatic tissue and also in a larger number of prostate tissues in an attempt to determine its potential value as a biomarker for prostate disease. Three hK4 antipeptide polyclonal antibodies, derived against N-terminal, mid-region and C-terminal hK4 amino acid sequences, were used. The hK4 N-terminal antipeptide antibody was used to demonstrate the cellular localisation of hK4 in kidney, salivary glands, liver, testis, colon carcinoma, heart, endometrium and ovarian cancer, for the first time. The presence of hK4 in these non-prostate tissues was consistent with the previous reports using RT-PCR. The dual cytoplasmic and nuclear localisation of hK4 observed in the prostate above was also seen in these tissues. Although hK4 was found widely expressed in many human tissue types, indicating that it is not prostate specific in its expression, the highest expression level of hK4 was seen in the prostate. Therefore, detailed expression patterns and levels of KLK4 mRNA and hK4 protein in the normal prostate and prostatic diseases and histopathological lesions were investigated and reported for the first time in this study. Twelve benign prostatic hyperplasia (BPH), 19 adenocarcinoma (Gleason grade 2-5) and 34 bone metastases from prostate cancer were analysed. Using in situ hybridisation, the expression of KLK4 mRNA was detected in the cytoplasm of the secretory cells of both normal and diseased prostate tissue. KLK4 mRNA was also noted in both secretory and basal cells of PIN lesions, but the basal cells of normal glands were negative. Using the hK4 N-terminal and mid-region antipeptide antibodies, hK4 was predominantly localised in the cytoplasm of the secretory cells. The intensity of hK4 staining appeared lowest in normal and BPH, and increased in PIN lesions, high Gleason grade prostate cancer and bone metastases indicating the potential of hK4 as a histopathological marker for prostatic neoplasias. Further studies are required with a larger cohort to determine its utility as a clinical biomarker. Small foci of atypical cells, which were found within normal glands, were also intensely stained. Surprisingly, hK4 protein was found in the nucleus of the secretory cells (but not the basal cells) of high grade PIN and Gleason grade 3 prostate cancer. The detection of KLK4 mRNA and hK4 protein in PIN lesions and small foci of atypical cells suggests that up-regulation of KLK4 expression occurs early in the pathology of prostate carcinogenesis. The finding of basal cell expression is not typical for the kallikreins and it is not clear what role hK4 would play in this cell type. With the use of the hK4 C-terminal antipeptide antibody, the staining was mainly localised in the nuclei of the secretory cells of the prostate glands. Although the nuclear localisation was readily noted in more than 90% of epithelial cells of the prostate gland with the C-terminal antibody, no difference in staining intensity was observed among the histopathological lesions of the prostate. The prominent nuclear localisation with the C-terminal antipeptide antibody was also shown to be distributed throughout the nucleus by using confocal microscopy. Further, by using gold-labelled particles for electron microscopy, the intracellular localisation of these hK4 antipeptide antibodies was reported here for the first time. Similar to the immunohistochemical results, the cytoplasm was the major site of localisation with the N-terminal and mid-region antipeptide antibodies. To further characterise the involvement of KLK4/hK4 in human prostate cancer progression, the transgenic adenocarcinoma mouse prostate (TRAMP) model was used in this study. In this study, mouse KLK4 (also known as enamel matrix serine protease -1, EMSP-1) was shown to be expressed in the TRAMP prostate for the first time. Previous studies had only shown the developing tooth as a site of expression for EMSP-1. The level of EMSP-1 mRNA expression was increased in PIN and prostate cancer lesions of the TRAMP model, while negative or low levels of EMSP-1 mRNA were seen in normal glands or in control mouse prostate tissue. The normal mouse prostate did not stain with any the three hK4 antipeptide antibodies. hK4 N-terminal and mid-region antipeptide antibodies showed positive staining in the cytoplasm of the epithelial cells of PIN and cancer lesions of the mouse prostate. The C-terminal antipeptide antibody showed distinctively nuclear staining and was predominantly localised in the nuclei of the glandular cells of PIN and cancer lesions of the mouse prostate. The expression patterns of both the mRNA and protein level for mouse KLK4 strongly supported the observations of KLK4/hK4 expression in the human prostate and further support the utility of the TRAMP model. Overall, the findings in this thesis indicate a clear association of KLK4/hK4 expression with prostate cancer progression. In addition, several intriguing findings were made in terms of cellular localisation (basal as well as secretory cells; nuclear and cytoplasmic) and high expression in atypical glandular cells and PIN, perhaps indicating an early involvement in prostate disease progression and, additionally, utility as basal cell and PIN histological markers. These findings provide the basis for future studies to confirm the utility of hK4 as a biomarker for prostate cancer progression and identify functional roles in the different cellular compartments.