Ziel einer Definition der Resektabilität von Pankreaskarzinomen ist die Beschreibung von Kriterien, welche eine potentielle R0-Resektion ermöglichen. Wenngleich es zur Frage der Resektion bei positiven regionären Lymphknoten keine kontrollierten Studien gibt, ist weltweit die Resektion bei regionären Lymphknotenmetastasen Standard. Positive interaortokavale Lymphknoten stellen trotz Klassifikation als Fernmetastasen (M1) keine absolute Kontraindikation zur Resektion dar. Die mesenteriko-portale Venenresektion bei Verdacht auf Tumorinfiltration ist ein sicheres Verfahren. Sie hat keinen negativen Einfluss auf Morbidität, Mortalität und Überleben. Die En-bloc-Resektion der Arteria hepatica und der Arteria mesenterica superior wird sehr kontrovers diskutiert und sollte nur in Einzelfällen erwogen werden. Bei den meist fortgeschrittenen Karzinomen des Pankreaskorpus und -schwanzes kann durch eine En-bloc-Resektion des Truncus coeliacus eine höhere R0-Resektionsrate erreicht werden. / Pancreatic Cancer: Criteria and Limits of Resectability The aim of defining the resectability of pancreatic cancer is to determine the indication for potential R0 resection. Despite the absence of controlled trials, tumor resection in patients with regional lymph node involvement is a standard procedure worldwide. The involvement of interaortocaval lymph nodes is not an absolute contraindication for resection, although they are classified as distant metastasis (M1). Major pancreatic surgery can be safely combined with en-bloc resection of mesenteric, portal and splenic veins. Postoperative morbidity and mortality and long-term survival in patients with vein resection are comparable with those of patients without vein resection. The role of arterial en-bloc resection of the hepatic artery and the superior mesenteric artery is highly controversial and should be considered only in selected patients. For patients with locally advanced cancer of the body and tail of the pancreas distal pancreatectomy with en-bloc celiac axis resection offers an improved R0 resection rate. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Doctor of Philosophy / Department of Chemistry / Stefan H. Bossmann / Cancer is a group of diseases that are characterized by uncontrolled growth and spread of cells. In order to treat cancer successfully, it is important to diagnose cancers in their early stages, because survival often depends on the stage of cancer detection. For that purpose, highly sensitive and selective methods must be developed, taking advantage of suitable biomarkers. The expression levels of proteases differ from one cancer type to the other, because different cancers arise from different cell types. According to the literature, there are significant differences between the protease expression levels of cancer patients and healthy people, because solid tumors rely on proteases for survival, angiogenesis and metastasis. Development of fluorescence-based nanobiosensors for the early detection of pancreatic cancer and non-small-cell lung cancer is discussed in this thesis. The nanobiosensors are capable of detecting protease/arginase activities in serum samples over a broad range. The functionality of the nanobiosensor is based on Förster resonance energy transfer and surface energy transfer mechanisms. The nanobiosensors for protease detection feature dopamine-coated Fe/Fe₃O₄ nanoparticles, consensus (cleavage) peptide sequences, meso-tetra(4-carboxyphenyl)porphine (TCPP), and cyanine 5.5. The consensus peptide sequences were synthesized by solid-supported peptide synthesis. In this thesis, improved consensus sequences were used, which permit faster synthesis and higher signal intensities. TCPP, which is the fluorophore of the nanoplatform, was connected to the N-terminal end of the oligopeptides while it was still on the resin. After the addition of TCPP, the TCPP-oligopeptide was cleaved off the resin and linked to the primary amine groups of Fe/Fe₃O₄-bound via a stable amide bond. In the presence of a particular protease, the consensus sequences attached to the nanoparticle can be cleaved and release TCPP to the aqueous medium. Upon releasing the dye, the emission intensity increases significantly and can be detected by fluorescence spectroscopy or, similarly, by using a fluorescence plate reader. In sensing of arginase, posttranslational modification of the peptide sequence will occur, transforming arginine to ornithine. This changes the conformational dynamics of the oligopeptide tether, leading to the increase of the TCPP signal. This is a highly selective technology, which has a very low limit of detection (LOD) of 1 x 10⁻¹⁶ molL⁻¹ for proteases and arginase. The potential of this nanobiosensor technology to detect early pancreatic and lung cancer was demonstrated by using serum samples, which were collected from patients who have been diagnosed with pancreatic cancer and non-small cell lung cancer at the South Eastern Nebraska Cancer Center (lung cancer) and the University of Kansas Cancer Center (pancreatic cancer). As controls, serum samples collected from healthy volunteers were analyzed. In pancreatic cancer detection, the protease/arginase signature for the detection of pancreatic adenocarcinomas in serum was identified. It comprises arginase, MMPs -1, - 3, and -9, cathepsins -B and -E, urokinase plasminogen activator, and neutrophil elastase. For lung cancer detection, the specificity and sensitivity of the nanobiosensors permit the accurate measurements of the activities of nine signature proteases in serum samples. Cathepsin -L and MMPs-1, -3, and -7 permit detecting non-small-cell lung-cancer at stage 1.

TP53INP1 est un gène suppresseur de tumeur qui est inactivé dans les lésions pré-tumorales pancréatiques. Il est impliqué dans la régulation de la mort cellulaire notamment via l'activation de la voie p53. Cette thèse a pour objectif de mieux caractériser le mécanisme d'action de TP53INP1 afin de mieux comprendre son rôle suppresseur de tumeur dans le cancer pancréatique. Nous avons montré dans un premier temps que TP53INP1 est associé à une diminution de la migration cellulaire via l'inhibition de l'expression du gène SPARC. Dans un second temps, nous avons montré que la protéine TP53INP1 est impliquée dans l'autophagie, où elle interagit avec les protéines de la famille LC3/Atg8 au sein des autophagosomes, et favorise la mort cellulaire de manière dépendante de l'autophagie. Enfin, nous avons mis en évidence que TP53INP1 est régulée par le contexte de stress cellulaire via des modifications post-traductionnelles. En effet, nous avons montré que la SUMOylation de TP53INP1 est nécessaire à l'activation de la réponse au stress oxydatif de p53. Ces travaux ont donc permis de mieux caractériser le rôle de suppresseur de tumeur de TP53INP1 et son mécanisme de régulation. / TP53INP1 is a tumor suppressor gene which is inactivated in early pancreatic lesions. It is involved in regulation of cell death through the activation of the p53 pathway. The aim of this work is to better characterize the molecular mechanism of action of TP53INP1 in order to better understand its tumor suppressor role. Firstly, we have shown that TP53INP1 expression is associated with a decreased cell migration through the down-regulation of SPARC. Secondly, we have demonstrated that TP53INP1 is involved in autophagy, through its direct interaction with LC3/Atg8 family proteins into the autophagosomes, and induces autophagy-dependent cell death. Then, we have shown that TP53INP1 is regulated by cellular context, through its post-translational modifications. Indeed, the SUMOylation of TP53INP1 is required to activate the p53 oxidative stress response pathway. All these findings allow a better understanding of the tumor suppressor role of TP53INP1 and of its regulation mechanism.

La protéine de stress p8 fut découverte et caractérisée dans notre laboratoire. Cette protéine est surexprimée dans l'adénocarcinome pancréatique et possède un rôle dans la progression tumorale. Pendant ce travail de thèse, nous nous sommes focalisé sur le rôle de p8 dans les phases initiales de la tumorigénèse pancréatique et sur ses mécanismes d'action, impliqués dans la progression tumorale. Nous avons montré que p8 joue un rôle essentiel dans l'apparition des lésions PanINs suite à l'activation de l'oncogène Kras. Au niveau cellulaire, nous avons montré que la protéine p8 protège les cellules tumorales pancréatiques contre le stress de la privation en nutriments via la régulation de l'expression de RelB et IER3. La voie p8, RelB et IER3 est impliquée dans l'inhibition de l'apoptose suite au stress. De plus, nous avons observé que ces trois protéines sont co-exprimées dans les adénocarcinomes humains et leur expression corrèle avec l'évolution de la maladie. Dans un second lieu, nous avons démontré le rôle essentiel de la protéine p8 dans la résistance des cellules tumorales pancréatiques à l'hypoxie et à la privation en glucose. Nous avons identifié la voie p8/Aurora KinaseA, qui en réponse au stress métabolique, réduit l'apparition des dommages à l'ADN en contrôlant l'expression des gènes liés au cycle cellulaire et à la réparation de l'ADN. De plus, nos recherches ont montré que p8 protège les cellules tumorales du stress métabolique en inhibant la mort cellulaire dépendante de l'autophagie. Nous espérons que nos résultats aideront à mieux cibler les cellules tumorales pancréatiques et leur caractère résistant au stress micro-environnemental extrême. / The stress protein p8 was discovered and characterized in our laboratory. Over expressed in pancreatic adenocarcinoma, p8 is involved in tumor progression. During my PhD studies, we focused on the role of p8 in pancreatic cancer development and on its mechanisms of action. First, we demonstrated that p8 is essential for PanIN development following Kras oncogene activation. At the cellular level, we found that p8 protects pancreatic cancer cells upon nutrient starvation stress through the regulation of RelB and IER3 expression. p8, RelB and IER3-dependent cascade inhibits apoptosis after the starvation stress. Furthermore, we showed that these tree proteins are co expressed in human pancreatic adenocarcinoma. One the other hand, our study showed that p8 is involved in pancreatic cancer cells resistance to hypoxia and glucose starvation. We identified a p8/Aurora KinaseA pathway which, in response to such metabolic stress, reduces DNA damage by regulating cell cycle and DNA repair genes expression. Moreover, our studies demonstrated that p8/AURKA path protects cancer cells against metabolic stress by inhibiting autophagy-associated cell death. We expect that our data will help to get new therapeutics against pancreatic cancer.

Les récentes avancées dans notre compréhension de la tumorigenèse pancréatique ont montré que la présence d'un compartiment cellulaire non tumoral : le « stroma » ou « microenvironnement intra-tumoral », avait une incidence directe sur la progression de la maladie. Le but de ce travail était de déterminer le rôle du stroma dans la progression de l'adénocarcinome pancréatique. Pour cela, nous avons étudié le profil d'expression génique spécifique du stroma. Ceci nous a permis de mettre en évidence des gènes impliqués dans la régulation du système nerveux, dénommés « facteurs neurogéniques », pouvant être reliés aux phénomènes de remodelage neural observés dans les adénocarcinomes pancréatiques. Ceux-ci sont associés aux douleurs caractéristiques du cancer du pancréas, aux récidives locales, à l'extension locorégionale. Nous avons alors approfondi notre étude sur l'axe SLIT2/ROBO. Nos résultats montrent qu'au travers la sécrétion de Slit2, le stroma a un impact direct sur le remodelage neural. Ces données peuvent permettre d'ouvrir une nouvelle voie thérapeutique dans le cancer du pancréas, ayant pour but de cibler les conséquences du remodelage neural. / Recent progress in our understanding of pancreatic tumorigenesis had shed light on the non tumoral cell compartment of the tumor, so-called "stroma" or "intra-tumoral microenvironment", in the spread of the disease. The goal of our work was to decipher the role of stroma in the spread of this disease. We could analyze the specific gene expression profile of stroma, leading to the discovery of several genes plausibly linked to neural remodeling, called "neurogenic factors". This neural remodeling is clinically correlated with neuropathic pain and locoregional spread. We have next deepened our analysis on the axis SLIT2/ROBO. We could demonstrate that stromal compartment is able to impact on neural remodeling, through secretion of Slit2. These results provide rationale to investigate the disruption of stromal/neural compartment connexion with Slit2/ROBO inhibitors for treatment of pancreatic cancer reccurrence and pain.

<div>Pancreatic cancer is the present third leading cause of all cancer-associated deaths with a under 9% 5-year survival rate. Aggressive tumor progression and lack of early detection technique lead to the fact that most patients are diagnosed at terminal stage - pancreatic ductal adenocarcinoma (PDAC). Despite that numerous therapeutic approaches have been introduced, most options cannot advance to or fail at the clinical trials. It has been suggested that previous failure is due to insufficient understanding of PDAC tumor microenvironment (TME). Human PDAC is composed of severely fibrotic tissue (i.e., desmoplasia) that harbors a variety of malignant cells (e.g., pancreatic stellate cells, cancer-associated fibroblasts, macrophages, etc.), excessive extracellular matrices (ECM), as well as abnormal expression of growth factors, cytokines, and chemokines. Multiple cell-cell and cell-ECM interactions jointly result in a stiffened, hypoxic, and fluid pressure-elevated PDAC tissue. The resulting pancreatic TME not only physically hinders penetration of therapeutics, but also dynamically interacts with the residing cells, regulating their behaviors.</div><div><br></div><div>Increasing tumor tissue stiffness in PDAC is not only a passive outcome from desmoplasia, but an active environmental factor that promotes tumor survival, growth, and invasion. However, traditional in vitro cell culture systems such as two-dimensional (2D) culture plate and animal models are not ideal for mechanistic understanding of specific cell-matrix interactions. Therefore, dynamic hydrogels have been introduced as a category of advanced biomaterials that exhibit biomimetic, adaptable, and modularly tunable physiochemical property. Dynamic hydrogels can be precisely engineered to recapitulate a variety of aspects in TME, from which to investigate the role of dynamic tumor-stroma interaction in PDAC progression. The goal of this dissertation was to exploit synthetic polymers (i.e., poly(ethylene glycol) (PEG)) or natural ECM (i.e., gelatin and hyaluronic acid (HA)) as precursors to prepare the dynamic cancer-cell laden gels. The design utilized the orthogonal thiol-norbornene photopolymerization to prepare the primary homogenous xxvi</div><div><br></div><div>gel network. Next, through further functionalizing gel precursors with phenolic derivatives, enzymatic reaction (i.e., tyrosinase) or flavin mononucleotide (FMN)-mediated photochemistry could be harnessed to manipulate the dynamic changes of substrate mechanics. Experimentally, a computational model and the associated validation were presented to investigate the process of gel stiffening. Finally, these techniques were integrated to prepare cell-laden gels with spatial-temporally tunable properties that were instrumental in exploring the synergistic effects of dynamical matrix stiffening and presence of HA in promoting epithelial-mesenchymal transition (EMT) in PDAC cancer and stromal cells.</div>

INTRODUCTION: Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive form of cancer with a high mortality rate, primarily due to lack of effective treatment options. Current therapeutic approaches are limited to surgical resection of the pancreas during early stages of the disease and to the use of non-specific chemotherapeutic drugs such as gemcitabine, neither of which has successfully improved the 5-year survival rate of PDAC. Both the lack of effective treatments and the high mortality of the disease call for the urgent need to develop new therapeutic options. OBJECTIVES: This thesis project focuses on an endogenous inhibitor of the neuropilin 2 receptor (NRP2) called semaphorin 3F (SEMA3F) and its use as a potential new drug in the fight against pancreatic cancer. By binding the transmembrane receptor neuropilin 2 (NRP2), SEMA3F can inhibit angiogenesis and cellular proliferation. Interestingly, given its role as a guidance molecule, it is also a potent mediator of cellular repulsion. All three of these effects will be analyzed in the context of this study. METHODS: Syngeneic pancreatic cancer cells were injected orthotopically in two separate groups of mice. One group involved the use of transgenic Nrp2-/- mice, and served as a way to analyze the absence of the receptor on the vasculature and how that affects the growth of the primary tumor and the formation of metastases in the liver. The other group received intravenous injections of SEMA3F-expressing and control adenovirus, and served to explore the effect of SEMA3F as a potential therapy against the growth of the primary tumor in the pancreas and distant metastases in the liver. RESULTS: We observed a decrease in pancreatic tumor and metastatic growth in the absence of Nrp2 in our transgenic mouse model compared to the WT control. Mice injected with SEMA3F-expressing adenovirus also showed a decrease in primary tumor growth as well as a reduction in the formation of metastases in the liver compared to the control. CONCLUSION: Nrp2 mediates angiogenesis in pancreatic cancer, which facilitates the growth of the primary tumor as well as the formation of metastases. Our results indicate that the anti-angiogenic, anti-proliferative and repulsive actions of SEMA3F could be used to develop an effective treatment option for PDACpancreatic ductal adenocarcinoma. / 2020-07-24T00:00:00Z

O adenocarcinoma de ducto pancreático (PDAC) é a quarta causa de morte em decorrência de neoplasias nos países ocidentais. Atualmente, a cirurgia ressectiva é a única possibilidade de cura para a doença, porém, a recidiva tumoral acontece em menos de um ano após a intervenção cirúrgica, mesmo com a quimioterapia adjuvante. A terapia fotodinâmica (PDT) é uma alternativa promissora no tratamento do câncer. No entanto, pouco se sabe sobre o uso da PDT em tumores pancreáticos. Portanto, o objetivo deste trabalho foi avaliar a eficiência da PDT com o azul de metileno (MB) como fotossensibilizador (MB-PDT) em induzir a morte de linhagens de PDAC humanas (AsPC-1, Panc-1, MIAPaCa-2 e BxPC-3) e estudar a contribuição de vias de necrose regulada nos efeitos citotóxicos da terapia sobre estes modelos. Os resultados obtidos mostraram que a MB-PDT foi capaz de induzir a morte massiva das células de PDAC. Além disso, eles indicaram que há dois perfis de susceptibilidade entre as quatro linhagens estudadas quando submetidas a MBPDT com 4,5 J/cm2 de energia e 6min de irradiação. De acordo com os dados apresentados, a diferença nas sensibilidades das linhagens à terapia não está associada à diferenças na capacidade de incorporação do MB ou na localização sub-celular do fotossensibilizador nas diferentes células, uma vez que a localização é, predominantemente, lisossomal em todas elas. Adicionalmente, mostrou-se que as linhagens menos susceptíveis ao tratamento, MIAPaCa-2 e Panc-1, apresentam níveis significativamente menores de RIPK3 e MLKL, dois dos componentes do necrossomo, essenciais para a execução da necroptose. Além disso, foi visto que a MB-PDT induz um aumento de fosforilação de MLKL em AsPC-1, demonstrando a ativação da necroptose após a terapia nestas células, mas não em MIAPaCa-2 (menos responsiva à terapia com 4,5 J/cm2 deenergia e 6min de tempo de irradiação). Ainda, a inibição da via de sinalização necroptótica diminuiu significativamente as porcentagens de morte das células mais susceptíveis (BxPC-3 e AsPC-1), não alterando a resposta de Panc-1 e MIAPaCa-2, corroborando a ativação e importância da necroptose para a citotoxicidade da MB-PDT. Finalmente, neste trabalho foi mostrado que o aumento do tempo de irradiação, mantendo-se a quantidade total de energia aplicada no tratamento, melhora a eficiência da MB-PDT em induzir a morte das células que apresentam limitações para executar a necroptose, sugerindo que mais de uma via de morte esteja sendo ativada após a terapia e que o tempo de irradiação atuaria modulando esta ativação. Complementarmente, foi mostrado que os tempos maiores de irradiação aumentam o estresse oxidativo intracelular que é acompanhado por uma diminuição significativa do conteúdo intracelular de glutationa reduzida (GSH), indicando, preliminarmente, que a ferroptose pode estar sendo acionada após os protocolos mais longos de irradiação. Coletivamente, os resultados apresentados neste trabalho confirmam a eficiência da MB-PDT no tratamento de diferentes linhagens de PDAC, indicando que a necroptose está sendo ativada e contribuindo para a citotoxicidade da terapia sobre as células que não apresentam resistência à esta via de morte. Ainda, eles demonstram que o aumento do tempo de irradiação pode transpor a barreira de resistência de algumas linhagens à terapia, provavelmente por induzir a ativação de outras vias de necrose regulada, mostrando a importância da otimização do protocolo de tratamento no aumento da eficiência da MB-PDT sobre os tumores de pâncreas. Finalmente, os resultados confirmam a MB-PDT como alternativa eficaz no tratamento do PDAC, apresentando um amplo espectro de atuação sobre subtipos tumorais resistentes à vias clássicas de morte celular, uma característica importante no contexto de uma terapia anti-cancer. / Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of death due to neoplasms in western countries. Currently, resective surgery is the only therapetical approach to cure this disease, but tumor´s recurrence occurs less than one year after the surgery, even with adjuvant chemotherapy. Photodynamic therapy (PDT) is a promising alternative for the cancer treatment. However, the efficacy of PDT to treat pancreatic tumors as well as the mechanisms involved in the induction of tumorigenic cell death remain unclear. For this purpose, in this study, we set out to evaluate the efficacy of PDT using methylene blue (MB) as a photosensitizer (MB-PDT), in inducing death of human PDAC derived cell lines (AsPC-1, Panc-1, MIAPaCa-2 and BxPC-3) and to deeper investigate the contribution of necroptosis to the cytotoxic effects of the therapy. We observed that MB-PDT was able to induce massive death of PDAC cells. Moreover, our results indicated that upon MB-PDT (4.5 J/cm2 energy and 6min of irradiation time), there were two susceptibility profiles among the four cell lines studied. Data also showed that this differential profile of cell response was neither associated with the differences in the MB incorporation capacity nor with the subcellular location of the photosensitizer, since the localization was predominantly lysosomal in all of tested cell lines. In addition, less susceptible cells, MIAPaCa-2 and Panc-1, showed significantly lower levels of RIPK3 and MLKL, two of the necrosome components, essential for triggering necroptosis. Furthermore, while MB-PDT (4.5 J/cm2 and 6min of irradiation) has been able to increase MLKL´s phosphorylation levels, an essential step in necroptosis induction, in AsPC-1cells, less responsive MIAPaCa-2 cells presented no variations on the phosphorylation state of this pseudokinase. Moreover, pharmacological inhibition of the necroptotic signaling pathway significantly decreased cell death percentages of the most susceptible cells (BxPC-3 andAsPC-1), without altering the response of Panc-1 and MIAPaCa-2, corroborating that activation of necroptosis was strongly involved in the cytotoxicity of MB-PDT. Finally, this work showed that increasing the irradiation time improved the efficacy of MB-PDT in killing cells which display limitations to perform necroptosis, suggesting that the irradiation time would be modulating the degree of oxidative stress generated and this stimuli would in turn, be responsible for triggering other regulated cell death pathways in a RIKP3 and MLKL independent way. Indeed, this increase in oxidative stress was accompanied by a significant decrease in GSH, a global indicatior of less antioxidant cell capacity, preliminarily pointing at the induction of ferroptosis by longer irradiation protocols. In summary, we demonstrated that MB-PDT is able to induce cell death in different PDAC cell lines and that different regulated cell death mechanisms are being activated upon MB-PDT induction. Furthermore, it was demonstrated that increased irradiation time may overcome the resistance barrier of some cell lines, probably inducing the activation of other regulated cell death pathways, showing the importance of optimizing the irradiation protocol in order to maximize the efficacy of the therapy. Finally, our observations point MB-PDT as an alternative and effective therapy for pancreatic cancer treatment, displaying a broad-spectrum action on tumors displaying different resistance mechanisms to classic cell death pathways, a desired property for improving an anticancer therapy.

O adenocarcinoma de ducto pancreático (PDAC) é a quarta causa de morte em decorrência de neoplasias nos países ocidentais. Atualmente, a cirurgia ressectiva é a única possibilidade de cura para a doença, porém, a recidiva tumoral acontece em menos de um ano após a intervenção cirúrgica, mesmo com a quimioterapia adjuvante. A terapia fotodinâmica (PDT) é uma alternativa promissora no tratamento do câncer. No entanto, pouco se sabe sobre o uso da PDT em tumores pancreáticos. Portanto, o objetivo deste trabalho foi avaliar a eficiência da PDT com o azul de metileno (MB) como fotossensibilizador (MB-PDT) em induzir a morte de linhagens de PDAC humanas (AsPC-1, Panc-1, MIAPaCa-2 e BxPC-3) e estudar a contribuição de vias de necrose regulada nos efeitos citotóxicos da terapia sobre estes modelos. Os resultados obtidos mostraram que a MB-PDT foi capaz de induzir a morte massiva das células de PDAC. Além disso, eles indicaram que há dois perfis de susceptibilidade entre as quatro linhagens estudadas quando submetidas a MBPDT com 4,5 J/cm2 de energia e 6min de irradiação. De acordo com os dados apresentados, a diferença nas sensibilidades das linhagens à terapia não está associada à diferenças na capacidade de incorporação do MB ou na localização sub-celular do fotossensibilizador nas diferentes células, uma vez que a localização é, predominantemente, lisossomal em todas elas. Adicionalmente, mostrou-se que as linhagens menos susceptíveis ao tratamento, MIAPaCa-2 e Panc-1, apresentam níveis significativamente menores de RIPK3 e MLKL, dois dos componentes do necrossomo, essenciais para a execução da necroptose. Além disso, foi visto que a MB-PDT induz um aumento de fosforilação de MLKL em AsPC-1, demonstrando a ativação da necroptose após a terapia nestas células, mas não em MIAPaCa-2 (menos responsiva à terapia com 4,5 J/cm2 deenergia e 6min de tempo de irradiação). Ainda, a inibição da via de sinalização necroptótica diminuiu significativamente as porcentagens de morte das células mais susceptíveis (BxPC-3 e AsPC-1), não alterando a resposta de Panc-1 e MIAPaCa-2, corroborando a ativação e importância da necroptose para a citotoxicidade da MB-PDT. Finalmente, neste trabalho foi mostrado que o aumento do tempo de irradiação, mantendo-se a quantidade total de energia aplicada no tratamento, melhora a eficiência da MB-PDT em induzir a morte das células que apresentam limitações para executar a necroptose, sugerindo que mais de uma via de morte esteja sendo ativada após a terapia e que o tempo de irradiação atuaria modulando esta ativação. Complementarmente, foi mostrado que os tempos maiores de irradiação aumentam o estresse oxidativo intracelular que é acompanhado por uma diminuição significativa do conteúdo intracelular de glutationa reduzida (GSH), indicando, preliminarmente, que a ferroptose pode estar sendo acionada após os protocolos mais longos de irradiação. Coletivamente, os resultados apresentados neste trabalho confirmam a eficiência da MB-PDT no tratamento de diferentes linhagens de PDAC, indicando que a necroptose está sendo ativada e contribuindo para a citotoxicidade da terapia sobre as células que não apresentam resistência à esta via de morte. Ainda, eles demonstram que o aumento do tempo de irradiação pode transpor a barreira de resistência de algumas linhagens à terapia, provavelmente por induzir a ativação de outras vias de necrose regulada, mostrando a importância da otimização do protocolo de tratamento no aumento da eficiência da MB-PDT sobre os tumores de pâncreas. Finalmente, os resultados confirmam a MB-PDT como alternativa eficaz no tratamento do PDAC, apresentando um amplo espectro de atuação sobre subtipos tumorais resistentes à vias clássicas de morte celular, uma característica importante no contexto de uma terapia anti-cancer. / Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of death due to neoplasms in western countries. Currently, resective surgery is the only therapetical approach to cure this disease, but tumor´s recurrence occurs less than one year after the surgery, even with adjuvant chemotherapy. Photodynamic therapy (PDT) is a promising alternative for the cancer treatment. However, the efficacy of PDT to treat pancreatic tumors as well as the mechanisms involved in the induction of tumorigenic cell death remain unclear. For this purpose, in this study, we set out to evaluate the efficacy of PDT using methylene blue (MB) as a photosensitizer (MB-PDT), in inducing death of human PDAC derived cell lines (AsPC-1, Panc-1, MIAPaCa-2 and BxPC-3) and to deeper investigate the contribution of necroptosis to the cytotoxic effects of the therapy. We observed that MB-PDT was able to induce massive death of PDAC cells. Moreover, our results indicated that upon MB-PDT (4.5 J/cm2 energy and 6min of irradiation time), there were two susceptibility profiles among the four cell lines studied. Data also showed that this differential profile of cell response was neither associated with the differences in the MB incorporation capacity nor with the subcellular location of the photosensitizer, since the localization was predominantly lysosomal in all of tested cell lines. In addition, less susceptible cells, MIAPaCa-2 and Panc-1, showed significantly lower levels of RIPK3 and MLKL, two of the necrosome components, essential for triggering necroptosis. Furthermore, while MB-PDT (4.5 J/cm2 and 6min of irradiation) has been able to increase MLKL´s phosphorylation levels, an essential step in necroptosis induction, in AsPC-1cells, less responsive MIAPaCa-2 cells presented no variations on the phosphorylation state of this pseudokinase. Moreover, pharmacological inhibition of the necroptotic signaling pathway significantly decreased cell death percentages of the most susceptible cells (BxPC-3 andAsPC-1), without altering the response of Panc-1 and MIAPaCa-2, corroborating that activation of necroptosis was strongly involved in the cytotoxicity of MB-PDT. Finally, this work showed that increasing the irradiation time improved the efficacy of MB-PDT in killing cells which display limitations to perform necroptosis, suggesting that the irradiation time would be modulating the degree of oxidative stress generated and this stimuli would in turn, be responsible for triggering other regulated cell death pathways in a RIKP3 and MLKL independent way. Indeed, this increase in oxidative stress was accompanied by a significant decrease in GSH, a global indicatior of less antioxidant cell capacity, preliminarily pointing at the induction of ferroptosis by longer irradiation protocols. In summary, we demonstrated that MB-PDT is able to induce cell death in different PDAC cell lines and that different regulated cell death mechanisms are being activated upon MB-PDT induction. Furthermore, it was demonstrated that increased irradiation time may overcome the resistance barrier of some cell lines, probably inducing the activation of other regulated cell death pathways, showing the importance of optimizing the irradiation protocol in order to maximize the efficacy of the therapy. Finally, our observations point MB-PDT as an alternative and effective therapy for pancreatic cancer treatment, displaying a broad-spectrum action on tumors displaying different resistance mechanisms to classic cell death pathways, a desired property for improving an anticancer therapy.

Malignancy within the pancreatic head can arise from pancreatic duct, distal bile duct, ampulla or duodenum. Since September 2000, surgery for all pancreatic head malignancy (PHM) has been centralised into regional pancreatic centres where assessment of preoperative imaging and subsequent surgery is undertaken. As part of this guidance, surgery must be performed within 62-days of referral. This project will assess four aspects of the pre-operative pathway in PHM: 1) Potential variation in outcome of patients referred from different sites within a Cancer Network 2) Potential variation in outcome associated with different intervals to surgery within the 62 day guideline 3) The ability of interpretation of heterogeneous pre-operative CT scans from different hospitals to determine the resectability of PHM 4) The ability of CT scan to distinguish the different tumour types of PHM Images of a consecutive series of patients were re-reported and compared with final pathology reports. Good agreement was noted in determining the tumour origin of PHM (observed agreement = 0.758, Kappa= 0.6 (0.51-0.68)). In the assessment surgical outcomes, geographical isolation from the regional centre was not associated with delay to surgery. Variation in outcome between referral centres was however noted but this was not associated with travel distance. Although little association was noted between delay to surgery and outcome overall, a paradoxical improvement in survival was noted however for the small group of patients with ampullary tumours who waited longer than the median interval to surgery.