Stimulating lymphocytes with Ifn-γ, anti-CD3, and interleukin-2 promotes the proliferation of a cell population coexpressing T-lymphocyte surface antigens such as CD3, CD8a, and CD25 as well as natural killer cell markers such as NK1.1, CD49, and CD69. These cells, referred to as cytokine-induced killer cells (CIKs), display cytotoxic activity against tumour cells, even without prior antigen presentation, and offer a new cell-based approach to the treatment of malignant diseases. Because CIKs are limited in vivo, strategies to optimize in vitro culture yield are required. In the last 10 years, mesenchymal stem cells (MSCs) have gathered considerable attention. Aside from their uses in tissue engineering and as support in haematopoietic stem cell transplantations, MSCs show notable immunomodulatory characteristics, providing further possibilities for therapeutic applications. In this study, we investigated the influence of murine MSCs on proliferation, phenotype, vitality, and cytotoxicity of murine CIKs in a coculture system. We found that CIKs in coculture proliferated within 7 days, with an average growth factor of 18.84, whereas controls grew with an average factor of 3.7 in the same period. Furthermore, higher vitality was noted in cocultured CIKs than in controls. Cell phenotype was unaffected by coculture with MSCs and, notably, coculture did not impact cytotoxicity against the tumour cells analysed. The findings suggest that cell–cell contact is primarily responsible for these effects. Humoral interactions play only a minor role. Furthermore, no phenotypical MSCs were detected after coculture for 4 h, suggesting the occurrence of immune reactions between CIKs and MSCs. Further investigations with DiD-labelled MSCs revealed that the observed disappearance of MSCs appears not to be due to differentiation processes.

The most promising applications for targeted alpha-therapy with astatine-211 (At-211) include treatments of disseminated microscopic disease, the major medical problem for cancer treatment. The primary advantages of targeted alpha-therapy with At-211 are that the alpha-particle radiation is densely ionizing, translating to high relative biological effectiveness (RBE), and short-range, minimizing damage to surrounding healthy tissues. In addition, theranostic imaging with I-123 surrogates has shown promise for developing new therapies with At-211 and translating them to the clinic. Currently, Canada does not have a way of producing At-211 by conventional methods because it lacks alpha-particle accelerators with necessary beam energy and intensity. The work presented here was aimed at studying the Rn-211/At-211 generator system as an alternative production strategy by leveraging TRIUMF's ability to produce rare isotopes. Recognizing that TRIUMF provided production opportunities for a variety of astatine isotopes, this work also originally hypothesized and evaluated the use of At-209 as a novel isotope for preclinical Single Photon Emission Computed Tomography (SPECT) with applications to At-211 therapy research. At TRIUMF's Isotope Separator and Accelerator (ISAC) facility, mass separated ion beams of short­-lived francium isotopes were implanted into NaCl targets where Rn-211 or At-209 were produced by radioactive decay, in situ. This effort required methodological developments for safely relocating the implanted radioactivity to the radiochemistry laboratory for recovery in solution. For multiple production runs, Rn-211 was quantitatively transferred from solid NaCl to solution (dodecane) from which At-211 was efficiently extracted and evaluated for clinical applicability. This validated the use of dodecane for capturing Rn-211 as an elegant approach to storing and shipping Rn-211/At-211 in the future. Po-207 contamination (also produced by Rn-211 decay) was removed using a granular tellurium (Te) column before proceeding with biomolecule labelling. Although the produced quantities were small, the pure At-211 samples demonstrated these efforts to have a clear path of translation to animal studies. For the first time in history, SPECT/CT was evaluated for measuring At-209 radioactivity distributions using high energy collimation. The spectrum detected for At-209 by the SPECT camera presented several photopeaks (energy windows) for reconstruction. The 77-90 Po X­-ray photopeak reconstructions were found to provide the best images overall, in terms of resolution/contrast and uniformity. Collectively, these experiments helped establish guidelines for determining the optimal injected radioactivity, depending on scan parameters. Moreover, At-209-based SPECT demonstrated potential for pursuing image-­based dosimetry in mouse tumour models, in the future. Simultaneous SPECT imaging with At-209 and I-123 was demonstrated to be feasible, supporting the future evaluation of At-209 for studying/validating I-123 surrogates for clinical image-based At-211 dosimetry. This work also pursued a novel strategy for labelling cancer targeting peptides with At-211, using octreotate (TATE, a somatostatin analogue for targeting tumour cells, mostly neuroendocrine tumours) prepared with or without N-terminus PEGylation (PEG2), followed by conjugation with a closo-decaborate linking moiety (B10) for attaching At-211. Binding affinity and in vivo biodistributions for the modified peptides were determined using iodine surrogates. The results indicated that B10-PEG2-TATE retained target binding affinity but that the labelling reaction with iodine degraded this binding affinity significantly, and although having high in vivo stability, no I-123-B10-PEG2-TATE tumour uptake was observed by SPECT in a mouse tumour model positive for the somatostatin receptor (sstr2a). This suggested that further improvements are required for labelling. A new method for producing At-211 at TRIUMF is established, and At-209-­based SPECT imaging is now demonstrated as a new preclinical technology to measure astatine biodistributions in vivo for developing new radiopharmaceuticals with At-211. Combined with the theranostic peptide labelling efforts with iodine, these efforts provide a foundation for future endeavours with At-211-­based alpha-therapy at TRIUMF. All procedures were performed safely and rapidly, suitable for preclinical evaluations. All animal studies received institutional ethics approval from the University of British Columbia (UBC). / Graduate

In order to associate with the cytoplasmic leaflet of the plasma membrane, many cytosolic signalling proteins possess a distinct lipid binding domain as part of their overall fold. Here, a multiscale simulation approach has been used to investigate three membrane-binding proteins involved in cellular processes such as growth and proliferation. The pleckstrin homology (PH) domain from the general receptor for phosphoinositides 1 (GRP1-PH) binds phosphatidylinositol (3,4,5)-trisphosphate (PI(3,4,5)P₃) with high affinity and specificity. To investigate how this peripheral protein is able to locate its target lipid in the complex membrane environment, Brownian dynamics (BD) simulations were employed to explore association pathways for GRP1-PH binding to PI(3,4,5)P₃ embedded in membranes with different surface charge densities and distributions. The results indicated that non-PI(3,4,5)P₃ lipids can act as decoys to disrupt PI(3,4,5)P₃ binding, but that at approximately physiological anionic lipid concentrations steering towards PI(3,4,5)P₃ is actually enhanced. Atomistic molecular dynamics (MD) simulations revealed substantial membrane penetration of membrane-bound GRP1-PH, evident when non-equilibrium, steered MD simulations were used to forcibly dissociate the protein from the membrane surface. Atomistic and coarse grained (CG) MD simulations of the phosphatase and tensin homologue deleted on chromosome ten (PTEN) tumour suppressor, which also binds PI(3,4,5)P₃, detected numerous non-specific protein-lipid contacts and anionic lipid clustering around PTEN that can be modulated by selective in silico mutagenesis. These results suggested a dual recognition model of membrane binding, with non-specific membrane interactions complementing the protein-ligand interaction. Molecular docking and MD simulations were used to characterise the lipid binding properties of kindlin-1 PH. Simulations demonstrated that a dynamic salt bridge was responsible for controlling the accessibility of the binding site. Electrostatics calculations applied to a variety of PH domains suggested that their molecular dipole moments are typically aligned with their ligand binding sites, which has implications for steering and ligand electrostatic funnelling.

In this thesis, two algorithms are introduced for use in ultrasound elastography. Ultrasound elastography is a technique developed in the last 20 years by which anomalous regions in soft tissue are located and diagnosed without the need for biopsy. Due to this, the relativity cheap cost of ultrasound imaging and the high level of accuracy in the methods, ultrasound elastography methods have shown great potential for the diagnosis of cancer in soft tissues. The algorithms introduced in this thesis represent an advance in this field. The first algorithm is a two-step iteration procedure consisting of two minimization problems - displacement estimation and elastic parameter calculation that allow for diagnosis of any anomalous regions within soft tissue. The algorithm represents an improvement on existing methods in several ways. A weighting factor is introduced for each different point in the tissue dependent on the confidence in the accuracy of the data at that point, an exponential substitution is made for the elasticity modulus, an adjoint method is used for efficient calculation of the gradient vector and a total variation regularization technique is used. Most importantly, an adaptive mesh refinement strategy is introduced that allows highly efficient calculation of the elasticity distribution of the tissue though using a number of degrees of freedom several orders lower than methods that use a uniform mesh refinement strategy. Results are presented that show the algorithm is robust even in the presence of significant noise and that it can locate a tumour of 4mm in diameter within a 5cm square region of tissue. Also, the algorithm is extended into 3 dimensions and results are presented that show that it can calculate a 3 dimensional elasticity distribution efficiently. This extension into 3-d is a significant advance in the field. The second algorithm is a one-step algorithm that seeks to combine the two problems of elasticity distribution and displacement calculation into one. As in the two-step algorithm, a weighting factor, exponential substitution for the elasticity parameter, adjoint method for calculation of the gradient vector, total variation regularization and adaptive mesh refinement strategy are incorporated. Results are presented that show that this original approach can locate tumours of varying sizes and shapes in the presence of varying levels of added artificial noise and that it can determine the presence of a tumour in images taken from breast tissue in vivo.

L’immunothérapie tumorale à médiation cellulaire est un traitement qui utilise le système immunitaire des patients afin d’induire une réponse des lymphocytes T CD8+ (T CD8+) contre la tumeur. Cette réponse est produite suite à la reconnaissance des antigènes par les T CD8+. Ces cibles sont appelées antigènes tumoraux (TAA) et définies comme des protéines exprimées par les cellules cancéreuses mais absentes des tissus normaux. Par une approche bio-informatique, notre laboratoire a identifié Dickkopf-1 (DKK1), une protéine inhibitrice de la voie de Wnt, comme un TAA potentiel. Une immunothérapie à médiation cellulaire efficace requiert l’identification de TAA candidats pertinents. Le traitement de patients par immunothérapie pourrait également être améliorées par l’augmentation de la puissance d’action anti-tumorale ainsi que la persistante des T CD8+ spécifiques aux TAA. Ce projet de doctorat se divise en deux parties : 1- La caractérisation de l’expression de DKK1 dans les cancers communs et la détermination de son immunogénicité afin de valider sa candidature comme TAA. 2- La reprogrammation des T CD8+, de patients atteints d’un cancer commun, vers un phénotype moins différentié afin d’augmenter leur potentiel anti-tumoral et leur persistance. Dans le premier objectif, nous avons caractérisé l’expression de DKK1 dans le cancer du sein et dans d’autres cancers communs. Le profil d’expression de DKK1 a été étudié par RT-PCR et par ELISA dans plusieurs lignées cellulaires de cancer et dans les tissus normaux. L’expression de DKK1 a aussi été étudiée dans des échantillons cliniques provenant de cancers du sein, du poumon et du rein. Trente pourcents (30%) des tumeurs provenant d’un cancer du sein exprimaient DKK1. La moitié des tumeurs DKK1(+) était triple négative, donc pas de récepteurs d’œstrogène et de progestérone et était Her-2/neu(-) (ces patientes ont des possibilités de traitements très restreintes). De plus, 50% des échantillons cliniques de tumeurs du poumon et 30% des tumeurs de rein exprimaient DKK1. Les observations effectuées dans le cancer du poumon ont été, par la suite, corroborées par d'autres groupes qui ont montré une corrélation entre l'expression de DKK1 et un mauvais pronostic. Après avoir confirmée l’expression de DKK1 dans les cancers communs, justifiant ainsi sa candidature comme TAA, nous avons évalué l’immunogénicité de DKK1. Pour ce faire, nous avons effectué des stimulations in vitro de cellules mononucléées du sang périphérique (PBMC) de patient(e)s atteint(e)s d’un cancer du sein ou du poumon avec des peptides dérivés de DKK1 pouvant être présentés par les complexes majeurs d’histocompatibilité (CMH) HLA-A*0201. Des clones de T CD8+ reconnaissant un peptide de DKK1 ont été identifiés et isolés. Par essai multiplex et cytométrie de flux intracellulaire, la polyfonctionnalité d’un ces clones T CD8+ spécifiques à DKK1 a été étudiée et a révélée un profil effecteur, renforçant ainsi la candidature de DKK1 comme TAA. Dans l’ensemble, les résultats obtenus dans cette première partie de thèse suggèrent une possible utilisation de DKK1 en immunothérapie contre les cancers communs, attribuable à son expression dans ces cancers et la possibilité de faire proliférer des T CD8+ effecteurs spécifiques à DKK1 à partir de sang de patients. Dans la seconde partie de cette thèse, je décrirai la manipulation in vitro des T CD8+ de patients atteints d’un cancer commun, afin d’augmenter la force et la durée de leurs fonctions anti-tumorales. Il a été démontré que des lymphocytes moins différentiés sont capables d’une réponse immunologique plus efficace et durable. Nous avons basé ce projet sur l’utilisation d’un inhibiteur pharmacologique de la GSK-3, pour activer de la voie de Wnt chez les T CD8+ et ainsi leur conférer un phénotype moins différentié, partageant des caractéristiques de la cellule naïve et de la cellule mémoire. Des cultures de T CD8+, spécifiques à des antigènes viraux, en présence de l’inhibiteur ont permis d’augmenter la sécrétion d’interféron (IFN)- et leur activité cytotoxique. Ces résultats indiquent un effet de l’activation de la voie de Wnt sur la fonction des T CD8+. Ces observations sont rapportées pour la première fois chez les T CD8+ humains et suggèrent une nouvelle stratégie, applicables à l’immunothérapie du cancer, afin de prolonger la persistance des cellules ainsi que leur activité anti-tumorale. En conclusion, ces travaux de recherche ont mené à la réalisation d’une étape très importante dans la validation de la candidature de DKK1 comme TAA pour les cancers communs, soit la démonstration de son expression dans ces cancers et son absence dans les tissus normaux dérivés d’organes importants. Ces travaux ont également mené à la démonstration de l’immunogénicité de DKK1, par l’identification d’un peptide de DKK1 reconnu par les T CD8+. De plus, l’étude de la polyfonctionnalité des T CD8+ spécifiques à DKK1 a révélée un profil effecteur favorable pour l’obtention d’une réponse anti-tumorale efficace. Ces découvertes pourraient servir à l’élaboration d’une stratégie d’immunothérapie à médiation cellulaire pour les cancers communs. Pour sa part, l’étude phénotypique et fonctionnelle de la modulation de la voie de Wnt dans les T CD8+ a donné lieu à l’observation d’un phénotype encore jamais rapporté chez l’humain, conférant aux T CD8+ un aspect moins différentié avec des caractéristiques propre à un phénotype mémoire. Ces résultats sont pertinents dans l’amélioration de l’immunothérapie du cancer, passant par l’augmentation de la persistance des lymphocytes. En résumé, les résultats présentés dans cette thèse de doctorat fournissent des évidences indéniables quant à la validation de DKK1 comme TAA pour une immunothérapie à médiation cellulaire des cancers communs. Ces résultats fournissent également des preuves quant à la pertinence de la reprogrammation des T CD8+ par l’activation de la voie de la voie de Wnt, afin de générer des lymphocytes médiateurs plus efficaces pour ce type de thérapie. / Cell-mediated cancer immunotherapy is based on the priming of the patient’s CD8+ T lymphocytes (CD8+ T cells) to mediate an immune response directed against the tumour. This anti-tumour response is antigen-specific and directed against tumour associated antigens (TAA), which are defined as proteins expressed principally by cancer cells and absent from non-malignant tissues. By utilizing a bio-informatic approach, we identified the gene DKK1, a Wnt pathway inhibitor, as a potential TAA. This was an important novel finding as the identification of a new TAA is one of the key elements to enhance cell-mediated cancer immunotherapy. Furthermore, patient treatment options may also be improved through the amplification of the force and duration of the anti-tumour immune response mediated by TAA specific T cells. This thesis is divided in two parts: 1- The characterization of DKK1 expression and immunogenicity in common cancers as validation of TAA candidate. 2- The reprogrammation of CD8+ T cells from patient with common cancers to restore a less-differentiated phenotype in an attempt to improve their anti-tumour response. We first characterized DKK1 expression in breast cancer and other common cancers. In order to prove its specificity to malignant tissues, the DKK1 expression profile was initially established by RT-PCR and ELISA assay using cancer cell lines and in RNA panels from normal tissues. DKK1 expression was also described using clinical samples from breast, lung and kidney cancers. We found that 30% of breast cancer clinical samples were positive for DKK1 expression. Interestingly, half of the triple negative breast cancer tumours (negative for the expression of progesterone and estrogen receptors and Her-2/neu) were DKK1 (+). Moreover, 50% of the lung cancer and 30% of the kidney cancer clinical samples were also DKK1 (+). These results have been corroborated by other groups who recently reported similar observations in lung cancer with a correlation with poor prognosis. After confirming that the DKK1 gene expression profile in common cancer qualifies DKK1 as a relevant TAA, we then explored its immunogenicity. To do so, we performed in vitro stimulations of peripheral blood mononuclear cells (PBMC) from lung and breast cancer patients with DKK1-derived synthetic peptides, which were selected for their capacity to be presented by the major histocompatibility complex (MHC) HLA-A*0201. With this method, we identified and isolated CD8+ T cell clones with a specificity unique for one DKK1 peptide. Cytokine secretion profile of anti-DKK1 T cells was established by cytokine mutiplex assay and flow cytometry. This study revealed that DKK1-specitfic CD8+ T cells had an effector profile with polyfunctionality proprieties, thereby reinforcing DKK1 as a TAA candidate. Altogether, the results obtained in this first part of this thesis suggest the possible use of DKK1 in common cancer immunotherapy as it is principally expressed by malignant tissues and can generate the activation of effector CD8+ T cells. In the second part of this thesis, I will describe in vitro manipulations of patients’ CD8+ T cells in the goal of augmenting their longevity and the strength of the anti-tumour response. Previous research revealed that a less-differentiated phenotype correlated with an augmented capacity of persistence and the intensity of the T cell response. For this project, we generated less-differentiated CD8+ T cells by activating the Wnt pathway with a pharmalogical inhibitor of GSK-3. These less-differentiated T cells shared a phenotype of both naive and memory T cells. As for their immune functions, viral antigen specific CD8+ T cells cultured with the inhibtitor showed an elevation in interferon (IFN)-γ production and cytotoxic activity. This represent the first report of such observations in humans CD8+ T cells and suggest a new stategy to prolonge the persistence of T cells in a cancer immunotherapy setting. In conclusion, this work has strongly contributed to the validation of DKK1 as a TAA for common cancers, as it is expressed in malignant tissues and relatively absent in form normal tissues. It demonstrated the immunogenicity of DKK1 with the identification of a DKK1 peptide recognized by CD8+ T cells. Moreover, these DKK1-specific CD8+ T cells appear to be polyfunctional with an effector profil, which is favorable to mount a potent anti-tumour response. These findings could serve in novel strategies to be exploited in cell-mediated immunotherapy against common cancers. Furthermore, the phenotypic and functional study of the Wnt pathway activation resulting in a less-differentiated CD8+ T cells, generated observations that had never been reported in humans. These findings are relevant for cancer immunotherapy because they could help generate less-differentiated cells with augmented persistance and anti-tumorale capacities. Altogether, the results presented in this doctoral thesis provide significant evidence that DKK1 may serve as a TAA in cell-mediated immunotherapy for patients affected by common cancers and that reprogramming of CD8+ T cells through activation of the Wnt pathway could generate more effective mediator for this type of treatment.

Le gène TP53 est extrêmement polymorphique avec 85 polymorphismes décrits. Certains de ces polymorphismes sont associés à une augmentation du risque de cancer, par exemple rs10425222 peut moduler les fonctions de p53. Cependant, pour d’autres, comme le rs17878362 qui est le polymorphisme intronique le plus étudié, leur association avec une augmentation du riques au cancer est controversée.Pour analyser l’association entre le polymorphisme rs17878362 et la susceptibilité au cancer, nous avons analysé son rôle dans des contextes de cancers sporadiques et familiaux. Les résultats obtenus pour le polymorphisme rs17878362 sont paradoxaux avec une augmentation des cancers sporadiques associée avec le génotype A2A2 alors que l’allèle A2 est associé avec un effet « protectif » chez les patients atteints du syndrome de Li-Fraumeni porteurs d’une mutation germinale de TP53 situé sur l’haplotype A1. Ces observations suggèrent que des haplotypes spécifiques de TP53 pourraient moduler les capacités suppressives de p53. Une hypothèse possible est que les différents haplotypes de TP53 présenteraienrt des mutations somatiques à des fréquences différentes dans la population.De plus, le gène TP53 exprime différentes isoformes, comme le D40p53, inhibant l’activité suppressive de p53. Le D40p53 peut être produite par le maintien de l’intron 2 par épissage alternatif. Nous avons montré que les G-quadruplexes, des structures tridimensionnelles formées dans des régions riches en G, sont formés dans l’intron 3 et régulent la rétention de l’intron 2 et la formation du transcrit p53I2. Nous avons aussi observé que le polymorphisme rs1652785 (localisé dans l’intron 2) semble réguler la stabilité du p53I2. Ces résultats suggèrent que les polymorphismes de TP53 localisés dans une région de 412 pb située entre l’exon 2 et l’exon 4 régulent l’expression des isoformes de p53 dans une séquence temporelle d’évènements en modulant la formation des pré-ARNm (rs17878362), la stabilité des ARNm (rs1642785) et les fonctions protéiques (rs10425222).L’expression des isoformes de p53 est donc finement régulée par des mécanismes impliquant les polymorphismes de TP53 qui sont aussi associés avec une altération dans la susceptibilité au cancer. / The TP53 gene is a highly polymorphic gene with 85 polymorphisms described. Some of these have been associated with an increase of cancer susceptibility, for example rs10425222 that can modulate certain p53 activities. However for others such as rs17878362, the most studied intronic polymorphism, the association with cancer risk is more controversial. To investigate the influence of rs17878362 on cancer susceptibility, we analysed its role in sporadic and familial contexts. The results are paradoxical with an increase of sporadic cancer associated with the rs17878362 A2A2 genotype whereas the rs17878362 A2 allele is associated with a “protective” effect in the context of Li-Fraumeni patients carrying a TP53 germline mutation on an A1 haplotype. These observations suggest that specific TP53 haplotypes could modulate p53’s tumour suppression capacities. A possible hypothesis to explain this could be that somatic mutations are carried on different haplotypes of TP53 present at different allele frequencies in the population. In addition, TP53 is expressed as several protein isoforms, such as D40p53, which inhibits p53’s suppressive activity. D40p53 can be produced from an alternative spliced transcript that retains intron 2. We have shown that G-quadruplexes, tri-dimensional structures formed in G-rich sequences, are formed in intron 3 and regulate the retention of intron 2 and the formation of the p53I2 transcript. We also observed that rs1642785 (located in intron 2) could regulate p53I2’s stability. These results suggest that the TP53 polymorphisms located in a 412 bp region located between exon 2 and exon 4 regulate the expression of p53 isoforms in a temporal sequence of events by modulating the pre-mRNA formation (rs17878362), mRNA stability (rs1642785) and protein functions (rs1042522).p53 isoforms’ expression is thus finely regulated by mechanisms involving TP53 polymorphisms, which are also associated with altered cancer susceptibility.

<p>Colorectal cancer is one of the most common malignancies in Sweden, with more than 5000 new cases annually. Median age at time of diagnosis is approximately 75 years. Owing to the ageing population, the incidence of colorectal cancer is increasing. The improvement in surgical technique and the introduction of adjuvant radio- and chemotherapy increased the 5-year survival rate from approximately 30-40% in the early 1960s to almost 60% in the late 1990s. The cost of public health care has risen considerably, and case-costing systems are increasingly demanded. Linked to clinical guidelines and quality registers, such control systems form a proper basis for quality assurance projects and improvement. The aim of this thesis is to describe the efficiency and cost effectiveness of colorectal cancer treatment in a defined Swedish population. Emergency surgery for colon cancer, constituting 25% of the cases, increased both mortality and cost. Among emergency cases there was not only an increase in postoperative mortality but also a stage specific decrease in long-term survival rate. Correct staging is decisive for further treatment of patients after colon cancer surgery and influences long-term survival. The number of lymph nodes examined varied between different pathology departments and could be used as a quality measurement. The proportion of tumour stage III increased the more nodes examined. A prognostic estimation of stage III cases that is less sensitive to the number of nodes examined is proposed. A case-control study aimed at identifying risk factors for anastomotic leakage after rectal cancer surgery confirmed previously known risk factors but failed to identify further steps during the perioperative course that were amenable to improvement. This research has confirmed that population-based quality and case-costing registers, linked to clinical guidelines, constitute a proper source for projects of quality improvement and decisions about distribution of resources in health care.</p>

Colorectal cancer is one of the most common malignancies in Sweden, with more than 5000 new cases annually. Median age at time of diagnosis is approximately 75 years. Owing to the ageing population, the incidence of colorectal cancer is increasing. The improvement in surgical technique and the introduction of adjuvant radio- and chemotherapy increased the 5-year survival rate from approximately 30-40% in the early 1960s to almost 60% in the late 1990s. The cost of public health care has risen considerably, and case-costing systems are increasingly demanded. Linked to clinical guidelines and quality registers, such control systems form a proper basis for quality assurance projects and improvement. The aim of this thesis is to describe the efficiency and cost effectiveness of colorectal cancer treatment in a defined Swedish population. Emergency surgery for colon cancer, constituting 25% of the cases, increased both mortality and cost. Among emergency cases there was not only an increase in postoperative mortality but also a stage specific decrease in long-term survival rate. Correct staging is decisive for further treatment of patients after colon cancer surgery and influences long-term survival. The number of lymph nodes examined varied between different pathology departments and could be used as a quality measurement. The proportion of tumour stage III increased the more nodes examined. A prognostic estimation of stage III cases that is less sensitive to the number of nodes examined is proposed. A case-control study aimed at identifying risk factors for anastomotic leakage after rectal cancer surgery confirmed previously known risk factors but failed to identify further steps during the perioperative course that were amenable to improvement. This research has confirmed that population-based quality and case-costing registers, linked to clinical guidelines, constitute a proper source for projects of quality improvement and decisions about distribution of resources in health care.

The aim of the study was to examine the immune response and different immunoprotective strategies in experimental type 1 diabetes mellitus. The autoimmune destruction of the insulin-producing pancreatic β-cells that leads to type 1 diabetes is complex and incompletely understood. Activated immune cells infiltrate the pancreatic islets at an early stage of the disease, and they produce and release cytokines, which may contribute to β-cell dysfunction and death. Several immunomodulatory agents with different mechanisms have recently been developed in order to suppress cytokine function such as MDL 201, 449A, a novel transcriptional inhibitor of TNF-α. At least in rodent β-cells, many of the toxic actions of cytokines depend on the synthesis of nitric oxide (NO). Aminoguanidine (AG), an inhibitor of NO formation, might therefore be an interesting compound for prevention of type 1 diabetes. Another substance that could influence the course of events leading to this disease is the pituitary hormone prolactin (PRL), since it has the ability to activate different immune cells. We have studied the effects of AG, PRL and MDL 201, 449A on the development of hyperglycaemia and pancreatic insulitis in multiple low dose streptozotocin induced autoimmune diabetes in mice. The natural course after syngeneic islet transplantation of pancreatic islets in NOD mice, a model of type 1 diabetes mellitus was also investigated. AG and PRL were also studied in vitro on cultured isolated rodent pancreatic islets. We suggest that the insulin-producing cells are specifically targeted by the inflammatory response after syngeneic islet transplantation in type 1 diabetic mice. Our data do not exclude a role for NO in type 1 diabetes, but it raises concerns about the use of AG as a therapeutic agent since an increased mortality and no decline in diabetes frequency was observed. AG did not seem to be directly harmful to β-cell function, but it could affect pancreatic and islet blood flows. PRL and MDL 201, 449A could both counteract hyperglycaemia and insulitis in the early phase of autoimmune diabetes.

This thesis concerns the investigation of novel immunotherapies for cancer eradication. CpG therapy was used in order to target antigen-presenting cells (APCs), facilitating antigen presentation and activation of T cells. Blockade of the two major immune checkpoint regulators (CTLA-4 and PD-1) was also studied to ensure proper and sustained T cell activation. The therapies were investigated alone and compared to BCG, the standard immunotherapy in the clinic today for bladder cancer. In addition, CpG as well as BCG was combined with CTLA-4 or PD-1 blockade to examine if the combination could improve therapy. Single and combination strategies were assessed in an experimental bladder cancer model. In addition, one of the therapies (local aCTLA-4 administration) was evaluated in an experimental pancreatic cancer model. To be able to study the effects of CpG in humans, a human whole blood loop system has been used. This allowed us to dissect the potential interplay between CpG and complement. CpG was found to be superior to the conventional therapy, BCG, in our experimental model and T cells were required in order for effective therapy to occur. Used as a monotherapy, CTLA-4 blockade but not PD-1 blockade, prolonged survival of mice. When CTLA-4 or PD-1 blockade was combined with CpG, survival was enhanced and elevated levels of activated T cells were found in treated mice. In addition, Treg levels were decreased in the tumor area compared to tumors in control treated mice. CTLA-4 blockade was also effective when administrated locally, in proximity to the tumor. Compared to systemic CTLA-4 blockade, local administration gave less adverse events and sustained therapeutic success. When CpG was investigated in a human whole blood loop system it was found to tightly interact with complement proteins. This is an interesting finding which warrants further investigation into the role of TLRs in complement biology. Tumor therapy could be affected either negatively or positively by this interaction. The results presented herein are a foundation for incorporating these combination therapies into the clinic, specifically for bladder cancer but in a broader perspective, also for other solid tumors such as pancreatic cancer.