Hepatocellular carcinoma (HCC) is the most common liver malignancy that usually develops in patients suffering from chronic liver diseases. One of the major problems faced in the treatment of HCC is severe chemoresistance. Endoplasmic reticulum (ER) stress and hepatic stellate cells play an important role in tumour survival and growth as well as fibrosis. This study further investigates the crosstalk between ER-stress and hepatic stellate cells in HCC resistant cells as well as their relation to chemoresistance markers expression. Mice with chemically induced HCC were divided in 3 different treatment group; one was only treated with doxorubicin, one only with pharmacological ER-stress inhibitor 4μ8C, and one was treated with a combination of doxorubicin and 4μ8C. Tumour burden, fibrosis and cell proliferation were assessed through histological analysis and ImageJ processing. Chemoresistance markers expression was evaluated through mRNAs determination using real-time qPCR. While the combined treatment consisting of doxorubicin and pharmacological ER-stress inhibitor (4μ8C) has shown to positively reduce tumour progression, ferroptosis and collagen deposition, consequently decreasing fibrosis, drug resistance markers’ expression, on the other hand, seems to be more intricate, thus indicating that further investigations are probably needed. / Hepatocellulärt karcinom (HCC) är den vanligaste maligniteten i levern som vanligtvis utvecklas hos patienter som lider av kroniska leversjukdomar. Ett av de största problemen vid behandling av HCC är svår kemoresistens. Stress i endoplasmatiska retikulum (ER) och hepatiska stellatceller spelar en viktig roll för tumörernas överlevnad och tillväxt samt för fibros. I denna studie undersöks vidare samspelet mellan ER-stress och hepatiska stellatceller i HCC-resistenta celler samt deras relation till uttryck av kemoresistensmarkörer. Möss med kemiskt inducerad HCC delades in i tre olika behandlingsgrupper; en behandlades enbart med doxorubicin, en enbart med den farmakologiska ER-stresshämmaren 4μ8C och en behandlades med en kombination av doxorubicin och 4μ8C. Tumörbörda, fibros och cellproliferation bedömdes genom histologisk analys och ImageJ-bearbetning. Kemoresistensmarkörernas uttryck utvärderades genom bestämning av mRNA med hjälp av qPCR i realtid. Medan kombinationsbehandlingen bestående av doxorubicin och farmakologisk ER-stresshämmare (4μ8C) har visat sig minska tumörprogressionen, ferroptos och kollagenavlagring och därmed minska fibros, verkar uttrycket av läkemedelsresistensmarkörer å andra sidan vara mer invecklat, vilket tyder på att det troligen behövs ytterligare undersökningar.

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In recent years laparoscopic liver surgery established itself into today’s standard of care regarding surgical liver treatment. It was a long way for minimally invasive liver resection to develop and popularize as it was accompanied by initial reservations and concerns. Some of these already had been clarified while other questions still remain and require further investigation in the complex field of laparoscopic liver surgery. Initial concerns with respect to oncological inferiority and technical inapplicability in contrast to open surgery treatment could have been disproved within the framework of retrospective studies. In contribution to that, the aim of the study was to compare the surgical results and postoperative outcomes of consecutive laparoscopic liver resections (LLR) and open liver resections (OLR) at the high-volume liver tumor center of Leipzig university hospital. Since common classification systems for open liver surgery cannot be applied for LLR, the introduction of specific difficulty scoring systems for LLR helps to assess and classify the complexity of minimal invasive liver resection. With an increase in experience, modification of hybrid surgery and the application of novel visualization techniques such as indocyanine green (ICG) staining or hyperspectral imaging (HSI), more challenging procedures were accomplished, that initially would have been contraindicated for the laparoscopic approach (e.g. perihilar cholangiocarcinoma (pCCA) requiring biliary reconstruction). During the years 2018 and 2019 42% of all liver resections were approached laparoscopically at the Leipzig University hospital. A retrospective data analysis of n=231 patients undergoing LLR or OLR for the years 2018 and 2019 was performed and previously determined variables were collected. As a primary outcome measure, the short-term surgical and postoperative outcome of patients receiving LLR (=LLR group) compared to the patient cohort being treated by open resection (=OLR group) was evaluated. All liver resections were executed or assisted by the same two surgeons. Prior to surgery, every case was reviewed in a multidisciplinary tumor-board meeting and primarily assessed for possible minimal invasive approach. Analysis for patient demographics, pathologic diagnosis, radiologic findings and peri- and intraoperative surgical data was carried out. For LLRs intraoperatively, ICG counter perfusion staining was used in anatomic liver resection and direct ICG tumor staining was employed for tumor demarcation. With respect to classification, the extent of OLR was graded according to the Brisbane 2000 terminology in minor and major resections, whereas LLRs were categorized by means of difficulty (in accordance with Ban et al. and Di Fabio et al.). For measurement of surgical complication and assessment of morbidity, the Clavien-Dindo classification was applied. OLR was performed in n=124 (57%) and LLR in n=93 (43%). From all minimally invasive treated patients, 79% were operated totally laparoscopic and 16% were laparoscopic-hand-assisted due to infeasible lesions in the posterosuperior segments 7, 8 and 4a. In 5 cases a conversion to open surgery was necessary because of inaccessibility, tumor infiltration or morbid obesity. 28% of patients had previous upper abdominal surgery, whereof 36% in the OLR group and 19% in the LLR group. Regarding patient demographics, the mean age was significantly higher in OLR and the sex ratio was in favor of men for both groups. Malignant tumor lesions comprised 77%, while 24% were benign lesions. In both groups this larger number of malignant oncologic operation remained valid. The most common benign indications comprised focal nodular hyperplasia (FNH) and liver adenomas. It was shown that patients with CCA and Colorectal liver metastases (CRLM) were predominantly treated by open surgery, while patients with HCC diagnosis received LLR to a greater extent. Concerning the type of liver resection, non-anatomical resections were the most frequent in the cohort with 47%, thereof 55% LLR and 40% OLR. Followed second most by anatomic right and left hemihepatectomies and third most by left lateral resections, which were predominantly performed in laparoscopic technique. On the other hand, extended resections and trisectionectomies were predominantly operated by OLR. Radical lymphadenectomy was performed to a greater extent during OLR. Results showed that the mean operative time was longer for OLR (341 minutes in median) compared to LLR (273 minutes in median). Also the mean length of hospital stay was shorter for LLR patients, as well as abdominal drains were placed to lesser extent in LLR compared to OLR. In regard to R0-resection, R0-rates were higher in LLR with 98% vs. 86% in OLR. Thereby being highest for CRLM resections, followed by HCC and CCA. Putting all liver resections into classification systems, it was found that of all open procedures, 52% had major and 48% underwent minor resection according to Brisbane 2000. From the LLR group, in accordance with Di Fabio et al. 39% were classified as laparoscopic major hepatectomies, comprising 44% laparoscopic traditional major hepatectomies (LTMH) and 56% laparoscopic posterosuperior major hepatectomies (LPMH), which were technically challenging. The difficulty index stated by Ban et al. was classified as low for 8% of all performed LLRs, intermediate for 45% and of high difficulty in even 47%. Relating to morbidity (=Clavien-Dindo 3b or greater), patients with LLR had significantly lower morbidity compared to OLR. The same applies for in-hospital mortality. Our data show that despite the high number of complex and high-difficulty-classified liver resections that were performed, morbidity and mortality rates were low. As mentioned before, R0 resection rate in the LLR group was better than in the OLR group, however, this was not a case matched study, so a direct comparison is not valid. But still the study could demonstrate that the high number of LLRs being performed at the Leipzig University hospital, did not impair R0-resection rates. With an overall hospital mortality rate of 5.9% in the cohort, good results were achieved. Particularly the low rate of 1% in the LLR group speaks for itself and confirms that the development of a minimal invasive liver resection program should be on the right track. The majority of patients in the LLR and OLR group received an oncologic resection, what also resembles the global attitude that minimally invasive techniques are not reserved for selected tumor entities. Still it should be emphasized, the indication for a liver resection should not be loosened just due to minimal invasive accessibility, especially in benign liver lesions. Nevertheless, in the study the majority of benign lesions was operated by LLR. A few patients diagnosed with CCA received LLR. Thereof predominantly iCCA cases were indicated for a minimal invasive approach without biliary duct reconstruction and satisfying short-term outcomes over OLR could be obtained. However, only one case of pCCA which required Roux-Y bile duct reconstruction was treated with LLR in the study group, so if laparoscopic surgery is capable to replace the open approach in terms of treatment strategies for pCCA remains questionable. Patients with CRLM represent the centerpiece of our study population, still only 13% received LLR. The main reason of applying OLR was the high tumor load requiring future liver remnant augmentation strategies. As liver resection is confirmed to be the approach of choice for patients with HCC in cirrhosis, it is not surprising that HCC diagnosis accounted for the major part of LLRS in our collective.:Vorbemerkung und Bibliographie, 3 Abkürzungsverzeichnis, 4 Einführung, 5 - 1. Development of minimal invasive liver surgery, 5 - 2. Prior concerns of LLR, 6 - 3. Benefits of laparoscopic surgery, 6 3.1 General advantages of minimal invasive surgery, 6 3.2 Specific benefits of applying LLR, 7 - 4. Indications for LLR, 7 4.1 Benign liver lesions, 8 4.2 Malignant liver lesions, 8 4.3 Liver transplantation, 9 - 5. Technical supplement, 9 5.1 Hybrid and hand-assisted techniques, 10 - 6. Classification systems, 11 6.1 Difficulty scoring, 11 6.2 Clavien-Dindo Classification ,12 - 7. Limitations of LLR, 12 - 8. Aim of the study, 13 Publikation, 14 Zusammenfassung, 26 Literaturverzeichnis, 30 Darstellung des eignen Beitrags, 34 Selbstständigkeitserklärung, 35

Inadequate metabolic conditions in solid tumors lead to the formation of quiescent cancer cells that are suspended in a transient cell cycle arrest. When conditions change, quiescent cancer cells can re-enter the cell cycle and cause recurrence. Drug screening efforts have revealed mitochondrial oxidative phosphorylation as a unique metabolic dependency in quiescent cancer cells. The anthelmintic drug nitazoxanide is an inhibitor of oxidative phosphorylation and preferentially active against quiescent cancer cells in multicellular tumor spheroids.  In this thesis, we employed current and developed new models of quiescent cancer cells and applied live cell imaging for improved preclinical evaluation of cancer drugs in hepatocellular and colorectal carcinoma cell lines. As part of this work, a new assay to measure mitochondrial membrane potential in three-dimensional cell models was developed, an application of the JC-1 assay, and we demonstrated that the preferential activity against quiescent cancer cells of nitazoxanide is shared by two kinase inhibitors: sorafenib and regorafenib. The sensitivity of quiescent cancer cells to nitazoxanide, sorafenib, and regorafenib correlated with the disruption of the mitochondrial membrane potential. Nitazoxanide and sorafenib, in combination, caused an additive decrease in viability, mitochondrial membrane potential, and colony regrowth capacity.  Furthermore, we developed a quiescent hollow fiber assay and implemented an improved analysis using live cell imaging and adenosine triphosphate analysis. Hypoxia and cancer cell quiescence were enriched in hollow fiber macrocapsules over time, and the culture conditions affected nitazoxanide sensitivity. Additionally, we used basement membrane extract gel to support cell growth in hollow fiber macrocapsules and implanted macrocapsules in mice. We observed that the in vivo environment was favorable to cell growth. Through this characterization of the quiescent hollow fiber assay, we were able to outline important paths for future research.

RNA-bindande proteiner (RBP:er) har framträtt som kritiska regulatorer i post-transkriptionell genreglering, och deras dysreglering bidrar till cancerpatogenes. CAPRIN1, ett cytoplasmiskt protein, har identifierats som ett onkofetalt RBP med potentiell betydelse i hepatocellulärt karcinom (HCC), en mycket malign form av levercancer med dålig prognos. Detta examensarbete syftade till att använda gensredigeringsteknologier som CRISPR-interferens (CRISPRi) och RNA-interferens (RNAi) för att störa CAPRIN1-uttryck i HCC-cellinjer och analysera dess effekter på cellproliferation och mängden av CAPRIN1:s främsta RNA-mål. CRISPRi-konstruktioner som riktade sig mot transkriptionsstartstället (TSS) av CAPRIN1 designades och validerades, men trots lyckad kloning och uttryck av guideRNA:er (gRNA:er) resulterade CRISPRi-medierad gensläckning (KD) inte i någon signifikant minskning av CAPRIN1-uttryck. Ineffektiviteten hos CRISPRi tillskrevs låg transfektionseffektivitet, vilket bekräftades av fluorescensmikroskopi med EGFP-expressande plasmider i HepG2- och Huh7-celler. Detta kräver ytterligare optimering av elektroporationsparametrar eller utforskning av alternativa leveransmetoder. I kontrast uppnådde RNAi-medierad KD en betydande minskning av CAPRIN1-uttryck, vilket visade hög KD-effektivitet (90%) enligt RT-qPCR. Denna nivå av gensläckning gav en robust modell för vidare analyser. Efterföljande RT-qPCR av sex topp-RNA-mål identifierade av RAPseq visade varierande svar, med oväntad uppreglering av MYC och Cyclin D2, vilket går emot litteratur som antyder att deras stabilitet beror på CAPRIN1. Denna diskrepans kan förklaras av betydande standardavvikelse i uttrycksnivåerna, vilket understryker behovet av att upprepa experimenten samt genomföra en transkriptomanalys med RNA-seq för att identifiera meningsfulla mål såsom långa icke-kodande RNA (lncRNA:er). Ytterligare, MTT-proliferationstester, visade ökad cellproliferation efter CAPRIN1-KD, även om experimentella inkonsekvenser såsom ojämna cellantal begränsade slutsatsernas pålitlighet. För att erhålla tillförlitliga resultat behöver dock MTT-testet upprepas för att säkerställa konsistens med den positiva kontrollen och samla in statistiskt signifikanta data.Sammanfattningsvis, trots att CRISPRi-försöket stötte på betydande utmaningar, kan gRNA-designen och klonade plasmider användas i framtida studier när elektroporationsprotokollet har optimerats. Dessutom visade den framgångsrika RNAi-medierade KD av CAPRIN1 en alternativ metod som kan antas för vidare studier med andra RBP-kandidater. Framtida studier bör syfta till att optimera elektroporationssystemet, validera KD på proteinnivå och använda RNA-seq för en omfattande analys av CAPRIN1:s inverkan på transkriptomet i HCC-cellinjer. Dessa ansträngningar kommer att förbättra förståelsen av CAPRIN1:s regulatoriska mekanismer och dess potential som terapeutiskt mål vid HCC. / RNA-binding proteins (RBPs) play a crucial role in post-transcriptional gene regulation, and their dysregulation is implicated in cancer pathogenesis. CAPRIN1, a cytoplasmic activation/proliferation-associated protein, identified as an oncofetal RBP with potential significance in hepatocellular carcinoma (HCC), is a worthy candidate to be studied. Objective: This project aimed to establish a protocol for silencing RBPs gene expression via CRISPR interference (CRISPRi) technology using CAPRIN1 as a case study, as the roles of CAPRIN1 in tumorigenesis remains unknown. Results: Despite successful cloning of the designed gRNAs, CRISPRi-mediated knockdown did not reduce CAPRIN1 expression, attributed to low transfection efficiency as indicated by fluorescence microscopy. RNAi-mediated knockdown, however, achieved substantial reduction in CAPRIN1 expression (90%). Subsequent analysis of CAPRIN1 top RNA interactors showed substantial standard deviations, highlighting the need for repeating the experiments. The MTT assay showed uneven initial seeding densities, necessitating further repetitions of the assay. Conclusions: The study highlights the challenges associated with CRISPi-mediated knockdown, especially in transfecting HepG2 cells with large plasmids using electroporation. However, the designed gRNAs and cloned plasmids have the potential to be used in future studies, provided that the transfection process is further optimized. RNAi proved to be an effective alternative for gene silencing, achieving high knockdown efficiency and enabling subsequent analysis of CAPRIN1 target RNAs. Prioritizing further optimization of CRISPRi transfection protocols in upcoming projects will facilitate the adoption of this workflow for investigating other RBP candidates. Additionally, performing a comprehensive RNA-seq analysis could provide a deeper understanding of CAPRIN1’s role in HCC.

No / Human aging involves a gradual decrease in cellular integrity that contributes to multiple complex disorders such as neurodegenerative disorders, cancer, diabetes, and cardiovascular diseases. Genome-wide association studies (GWAS) play a key role in discovering genetic variations that may contribute towards disease vulnerability. However, mostly disease-associated SNPs lie within non-coding part of the genome; majority of the variants are also present in linkage disequilibrium (LD) with the genome-wide significant SNPs (GWAS lead SNPs). Overall 600 SNPs were analyzed, out of which 291 returned RegulomeDB scores of 1-6. It was observed that just 4 out of those 291 SNPs show strong evidence of regulatory effects (RegulomeDB score < 3), while none of them includes any GWAS lead SNP. Nevertheless, this study demonstrates that by combining ENCODE project data along with GWAS reported information will provide important insights on the impact of a genetic variant-moving from GWAS towards understanding disease pathways. It is noteworthy that both genome-wide significant SNPs as well as the SNPs in LD must be considered for future studies; this may prove to be crucial in deciphering the potential regulatory elements involved in complex disorders and aging in particular.

Dissertation in der sich mit dem Thema der Selektiven Internen Radiotherapie auseinandergesetzt wurde. Der Titel der Doktorarbeit lautet: Langzeit-Follow-Up von Patienten mit malignen primären und sekundären Lebertumoren nach Selektiver Interner Radiotherapie, Ziel war es das Überleben der Patienten nach Selektiver Interner Radiotherapie zu untersuchen. Hierbei standen insbesondere Patienten mit hepatocellulärem Karzinom im Fokus. Interessant war, dass bei ca. 66% der Patienten mit hepatocellulärem Karzinom keine Vortherapien vor dem Verfahren durchgeführt wurden. Des Weiteren wurde auch das Ansprechen auf die Therapie näher betrachtet. Die Auswertung erfolgte mittels Vergleich von MRT Aufnahmen vor und nach der Selektiven Internen Radiotherapie.:Inhaltsverzeichnis Tabellenverzeichnis 6 Abbildungsverzeichnis 7 Abkürzungsverzeichnis 9 1 Einleitung 11 1.1 Die Selektive Interne Radiotherapie (SIRT) 11 1.1.1 Medizinhistorische Aspekte der SIRT 11 1.1.2 SIRT­Verfahren 12 1.1.2.1 Indikationen 14 1.1.2.2 Kontraindikationen 14 1.1.2.3 Erfordernisse und Vorgehen vor der Therapiedurchführung 14 1.1.2.4 Komplikationen 15 1.2 Das hepatozelluläre Karzinom (HCC) 16 1.2.1 Epidemiologie in Deutschland 16 1.2.2 Risikofaktoren 16 1.2.3 Therapie 16 1.2.4 Prognose 18 1.3 Das cholangiozelluläre Karzinom (CCC) 18 1.3.1 Epidemiologie 18 1.3.2 Risikofaktoren 19 1.3.3 Therapie 19 1.3.4 Prognose 19 1.4 Das hepatisch metastasierte kolorektale Karzinom (hmCRC) 21 1.4.1 Epidemiologie 21 1.4.2 Therapie 21 1.4.3 Prognose 23 1.5 Zum Forschungsstand der SIRT beim HCC 23 1.6 REILD und Betrachtung von Leberparametern im zeitlichen Verlauf 23 1.7 Fragestellungen und Ziele der vorliegenden Studie 24 2 Material und Methoden 25 2.1 Art, Ort und Zeitraum der Studie 25 2.2 Probanden/ Stichprobe 25 2.3 Durchführung der SIRT 28 2.3.1 Berechnungsmodell für die Therapieaktivität 28 2.4 Analyseparameter 30 3 Ergebnisse 32 3.1 Deskriptive Charakterisierung der Stichprobe 32 3.1.1 Deskriptive Charakterisierung der Studienteilnehmer 32 3.1.2 Deskriptive Charakterisierung der Tumorentitäten 33 3.1.3 Deskriptive Charakterisierung von Studienteilnehmern ohne SIRT 34 3.2 Tumorgrößen und Therapieaktivitäten 35 3.3 Zeitintervall zwischen der Diagnosestellung des Lebertumors und dem Therapiebeginn 37 3.4 Ansprechen auf SIRT 38 3.5 Überleben 43 3.5.1 Todesursachen 43 3.5.2 Überlebenszeit 45 3.5.3 Einflussfaktoren auf das Überleben (Korrelationen) 48 3.5.3.1 Zusammenhang von Tumorgröße und Überleben 48 3.5.3.2 Zusammenhang von Therapieaktivität und Überleben 52 3.5.3.3 Zusammenhang zwischen SIRT und Überleben bei Studienteilnehmern mit monolobärem und bilobärem Leberbefall 54 3.6 Auswertung der Leberwerte (Leberparameter) 57 4 Diskussion 63 4.1 Deskription der Studienteilnehmer 63 4.2 Diskussion und Interpretation der eigenen Ergebnisse 63 4.2.1 Tumorgrößen und Tumoraktivitäten 63 4.2.2 Zeitintervall zwischen Diagnosestellung des Lebertumors und dem Therapiebeginn 64 4.2.3 Ansprechen auf SIRT 65 4.2.4 Auswertung der Überlebenszeiten 66 4.2.4.1 Vergleich von Studienteilnehmern mit und ohne SIRT in Bezug auf die Überlebenszeit 66 4.2.4.2 Vergleich von Studienteilnehmern mit HCC und der Gruppe „anderer hepatisch metastasierter Tumor“ bezüglich der Ansprechrate nach SIRT und der Überlebenszeit 67 4.2.4.3 Vergleich von Überlebenszeiten bei den unterschiedlichen Tumorentitäten nach SIRT 67 4.2.4.4 Diskussion der Ergebnisse von Patienten mit HCC 69 4.2.4.5 Diskussion über den Einfluss des Tumorvolumens auf die Überlebenszeit 69 4.2.4.6 Zusammenhang zwischen Therapieaktivität und Überleben 69 4.2.4.7 Mono­ oder bilobäre Leberbeteiligung bei Studienteilnehmern mit HCC 70 4.2.4.8 Nähere Betrachtung der Studienteilnehmer mit geringerem Überleben und einem Tumorvolumen >0 bis 500 ml nach SIRT 70 4.2.4.9 Auswertung der Leberparameter 71 4.3 Vergleich der Daten mit anderen Studien 72 4.3.1 SARAH­Studie 72 4.3.2 SIRveNIB­Studie 73 4.3.3 LEGACY­ Studie 74 5 Zusammenfassung 76 6 Summary 79 7 Literaturverzeichnis 83 8 Anhang (Tabelle 2­5) 103 Anlage 1: Erklärungen zur Eröffnung des Promotionsverfahrens 115 Anlage 2: Erklärung über die Einhaltung der gesetzlichen Vorgaben 116