Haematological malignancies and their treatment lead to prolonged periods of severe thrombocytopenia (platelet count ≤ 50 x 10⁹/l). Despite the use of prophylactic platelet transfusions, haemorrhage remains an important complication during this thrombocytopenic period. Within a 30 day period up to 70% of patients have clinically significant haemorrhage (World Health Organization (WHO) grade 2 or above bleeding) and up to 10% have severe or life-threatening haemorrhage (WHO grade 3 or 4 bleeding). Hence our current management of these patients to prevent haemorrhage is sub-optimal. The aim of this thesis was to identify clinical and laboratory factors that may predict the risk of haemorrhage in patients with haematological malignancies and severe thrombocytopenia. This was achieved via several different study designs and assessed the effect of clinical and laboratory factors on any or clinically significant haemorrhage and their effect on intracranial haemorrhage. This thesis has demonstrated that there is no consensus on how bleeding is assessed and graded in this patient group. Also it showed that the absolute immature platelet number may be a better alternative to the total platelet count to guide administration of platelet transfusions. Female sex, a previous history of a fungal infection, a high C-reactive protein, a high white cell count, a low platelet count, anaemia, impaired renal function, and recent clinically significant haemorrhage were all found to be independent risk factors for haemorrhage. Patients who were in complete remission from their haematological malignancy had a much lower risk of bleeding.

As our understanding of cancer biology increases and novel therapies are developed, an increasing number of predictive biomarkers are becoming clinically available. Aberrant acetylation has been strongly linked to tumourigenesis and the modulation of acetylation through targeting histone deacetylase (HDAC) has led to the introduction of many HDAC inhibitors. To date, two have had regulatory approval for the treatment of cutaneous T cell lymphoma (CTCL). Modifications in chromatin control underpin the mechanism of action of HDAC inhibitors. A genome wide loss-of-function screen identified HR23B as a gene that governs sensitivity to HDAC inhibitors. HR23B shuttles ubiquitinated cargo proteins to the proteasome and elevated levels may contribute to cell death mediated by this pathway. It also governs cell sensitivity to drugs that act directly on the proteasome. HDAC inhibitors influence proteasome activity and there may be a synergistic interaction with proteasome inhibitors. HR23B and HDAC6 interact and HDAC6 may be a negative regulator of apoptosis and a positive regulator of autophagy and through its ability to down-regulate HR23B, may impact on the cellular outcome of HDAC inhibitor treatment. Expression of HR23B has been correlated with clinical response to HDAC inhibitors in a retrospective analysis of CTCL patients. The tissue expression of HR23B and the autophagy marker LC3 has been investigated and there may be a reciprocal relationship in their expression in some tumours which may provide prognostic information and patients with low HR23B expression but high levels of autophagy appear to have a particularly poor prognosis. Well designed, biomarker-driven prospective clinical trials are needed to clarify the predictive and prognostic roles of HR23B.

Background: Brain metastasis is a leading cause of cancer mortality and affects 20-40% of all cancer patients. The BBB is responsible for isolation and protection of the brain parenchyma from many diagnostic and therapeutic agents. New molecular agents that target tumour-associated VCAM-1 expression on the brain endothelium show improvements in the early diagnosis of brain metastasis. The vascular endothelium of the CNS plays an important role in the maintenance of the brain microenvironment and possibly aids the extravasation of tumour cells via expression of CAMs. Aims: Using the breast carcinoma-derived 4T1 cell line, syngeneic to BALB/c mice, this work aimed (i) to determine the level of colocalisation between VCAM-1 expression at sites of brain metastasis and the presence of VCAM-MPIO-induced hypointensities in MR datasets; (ii) to describe the normal developmental characteristics of the intracardial BALB/c-4T1 brain metastatic model in the absence of overt inflammation; (iii) to test the effects of an adenovirus-induced systemic inflammatory challenge on metastatic uptake and development in the brain. Results: The level of correspondence of VCAM-MPIO-derived hypointensities with VCAM-1 expression at the tumour site was found to be dependent on the size of metastasis. An improved method for detection of VCAM-MPIO hypointensities using an automated method has been presented. Tumours were found to develop preferentially on venous rather than arteriolar blood vessels, and showed greater and lesser abundance in different anatomical brain regions. Adenovirus injection was found to cause an upregulation of a range of peripheral pro-inflammatory cytokines, and expression of VCAM-1 on cerebral vasculature, preferentially on arteriolar blood vessels. Both pre- and post-treatment with adenovirus caused a two-fold reduction in tumour numbers and altered developmental characteristics of established tumours, although no significant differences were observed in VCAM-MPIO hypointensities in MR datasets. Conclusions: The development of molecular MRI approaches to target VCAM-1 expression at the site of brain metastases has improved the sensitivity of tumour detection. 4T1-GFP metastasis to the brain is specific both to anatomical sites and to regions of the vascular bed, suggesting differences in vascular morphology and/or signalling dynamics in these locations. The changes in tumour number and morphology as a result of systemic inflammation suggest an anti-tumour effect of adenoviral treatment and, given the role of the systemic immune system and its importance in the development of immunotherapies, possible future directions for research.

Antal cancerfall ökar ständigt. Samtidigt ses en ökning av antalet cancerpatienter som lever längre tack vare tidig diagnostisering och bättre behandlingsmetoder. Neuroendokrina tumörsjukdomar diagnostiseras med hjälp av tumörmarkören chromogranin A. Syftet med studien var att redogöra för och jämföra kliniskt biokemiska metoder för analys av chromogranin A i plasma och serum. I samband med detta gjordes verifiering av KRYPTOR, BRAHMS automated immunofluorescent assay (KRYPTOR) för chromogranin A. Förekomst av analysmetoder undersöktes genom fördjupad litteraturgenomgång. Metodverifieringen innefattade smittöverföringstest mellan prover, mellanliggande precision, inomserieprecision samt jämförelse med samma metod respektive radioimmunoassay-metoden. I litteraturgenomgången erhölls analysmetoderna radioimmunoassay, immunoradiometric assay, enzymed linked immunosorbent assay och KRYPTOR/immunochemiluminometric assay. Metodverifieringens smittöverföringsrisk blev 0.04%, mellanliggande precision gav total CV på 1.96% respektive 2.33%, inomserieprecisions total CV 2.85%. Fem av sex analysresultat överrensstämde vid jämförelse med radioimmunoassay, medan jämförelse med samma metod gav en genomsnittlig skillnad på 17.6%. Sammanfattningsvis konstaterades att inom forskning används fyra immunologiska metoder för analys av chromogranin A i plasma och serum. Dess utveckling har gått från radioaktiv manuell till icke-radioaktiv automatiserad analysmetod med förkortad analystid. Metodverifieringen med KRYPTOR visade god mellanliggande- och inomserieprecision, men otillräckligt provunderlag resulterade i låg reliabilitet. / Title: Verification on KRYPTOR compact PLUS and an in-depth literature overview of clinical biochemical assays for the detection of Chromogranin A in plasma and serum.   Cancer is constantly increasing. Simultaneously, there is an increase in survival for cancer patients due to early diagnosis and better treatment.  Neuroendocrine tumour disease is diagnosed with help of tumour marker chromogranin A. The aim of this study was to narrate and compare clinical biochemical methods for the detection of chromogranin A in plasma and serum. In addition, a verification of KRYPTOR, BRAHMS automated immunofluorescent assay (KRYPTOR) for chromogranin A was performed. Occurring methods for analysis was investigated by in-depth literature overview. Verification contained tests for carry over, intra- and inter-assay, comparison with same method and radioimmunoassay method respectively. The literature overview resulted in radioimmunoassay, immunoradiometric assay, enzyme linked immunosorbent assay and KRYPTOR/immunochemiluminometric assay. Verification gave carry over 0.04%, inter-assay CV 1.96% and 2.33%, intra-assay CV 2.85%. Comparison with the same method gave a mean difference of 17.6% and five samples out of six correlated for comparison with radioimmunoassay. In summary, four immunological methods are used for analysis of chromogranin A, within research. Their development ranges from radioactive manual to non-radioactive automated method with shortened analysis times. Verification for KRYPTOR showed god intra- and inter-assay but an insufficient number of samples resulted in low reliability.

<p>Enterochromaffin-like (ECL) and ghrelin cells, in the human gastric mucosa and in gastric endocrine tumours (GETs), were subclassified with respect to immunohistochemical reaction <i>vs.</i> vesicular monoamine transporter 2 (VMAT-2), ghrelin/obestatin, and histidine decarboxylase (HDC). The immunohistochemical expression of ghrelin/obestatin and HDC in GETs was related/correlated to plasma ghrelin/obestatin and urinary methyl imidazole acetic acid (U-MeImAA) excretion respectively, with the intention of identifying markers for these tumour types. </p><p>ECL cells in the gastric mucosa appear either with VMAT-2 only, or with HDC immunoreactivity only, or they can express both proteins; but in GETs the transporter protein and the enzyme were almost always co-expressed in the same cells. Furthermore, ghrelin and obestatin were co-localized in the same cells in the gastric mucosa and in the tumours. In the gastric mucosa, occasional ghrelin/obestatin cells expressed VMAT-2, but in GETs these proteins were always co-localized. Ghrelin expressing cells were non-immunoreactive to HDC. Plasma ghrelin/obestatin concentrations remained low in patients with GETs, irrespective of the relative incidence of these cells in the mucosa and in tumours. The plasma values were not related/correlated to various clinico-pathological parameters. A malignant ghrelinoma was however an exception. The tumour released high total and active ghrelin concentrations into the blood circulation. The patient suffered from diarrhoea, hypothyroidism and diabetes mellitus, but it is not clear if these conditions were due to hyperghrelinaemia. The excretion U-MeImAA was increased in a few patients with GETs, but this increase was not always related to clinical symptoms.</p><p>In conclusion, ECL cells are an heterogeneous group according to VMAT-2 and HDC immunoreactivity. Ghrelin and obestatin are expressed in the same cells in the gastric mucosa, and a few of these cells display VMAT-2 immunoreactivity. Ghrelinoma is a new gastric tumour entity.</p>

Phthalates are industrial plasticizers with a wide range of applications. Di-(2-ethylhexyl) phthalate (DEHP) is one of the most highly produced and frequently studied phthalates. Its metabolite, mono-(2-ethylhexyl) phthalate (MEHP) is known as a testicular toxicant. The objective of this study was to examine expression of the genes of interest in testicular germ cells exposed to MEHP in a dose- and time-dependent manner at concentrations of 1µM, 10µM, and 100µM at 24, 48, 72 and 96hr time points. The genes consisted of Testisin, GSPT1, and MGMT genes which are a tumor suppressors, phase II xenobiotic metabolizing enzyme and DNA repair gene respectively. These genes were analyzed by Quantitative Real Time PCR (RT-PCR). The results revealed an overall down-regulation for each gene as the concentration and/or time increased. Testisin was the focus of the gene expression analysis. Testisin is epigenetically silenced in testicular germ cell tumors (TGCT) by DNA methylation at the 5’CpG island of the gene. To investigate if MEHP is capable of DNA hypermethylation, a co-exposure with 5-azacytidine (demethylating agent) was conducted. Compared with the 5-azacytidine treatment alone, there was a significant down-regulation of the Testisin gene in the co-exposure. This suggests that MEHP may down-regulate Testisin gene expression by DNA methylation. These findings provide evidence that MEHP can alter the expression of Testisin, GSTP1 and MGMT, genes that are associated in the risk of developing testicular germ cell tumors. In addition, results indicated that MEHP may cause DNA methylation leading to the down-regulation/silencing of genes such as Testisin.

Due to its selectivity in killing cancer cells, Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) has provided a potential new agent for cancer treatment. However, despite promising pre-clinical results, it appears that TRAIL therapies will be most effective when used in combination with a sensitizing agent. In light of previous evidence suggesting that cell adhesion could influence sensitivity to Tumour necrosis factor family ligands, this thesis presents a study of the effects of disrupting matrix adhesion on the sensitivity of human MDA-MB-231 breast and 1205Lu melanoma cell lines to TRAIL-induced apoptosis. This was investigated using a number of models including i) culturing cells on normal and low attachment plates; ii) disrupting the transcription of genes involved in cell attachment and spreading in MDA-MB-231 cells using shRNA to Myocardin-related transcription factors-A and B (MRTF-A/B); iii) disrupting the integrin signalling pathway using inhibitors or siRNA to β integrin subunits, talin, integrin-linked kinase (ILK), focal adhesion kinase (FAK) and SRC. With the exception of ILK depletion, disruption of cell adhesion and spreading in all models resulted in sensitisation to TRAIL-induced apoptosis. Cells under these conditions also showed alterations in death receptor signalling and amplification of intrinsic apoptosis pathway signalling through caspase-9. Both MRTF-A/B depleted cells and those treated with the SRC family kinase inhibitor PP2 showed alterations in signalling through ERK1/2. When investigated in an experimental model of metastasis in mice, FAK and SRC inhibitors increased the clearance of MDA-MB-231 cells from the mouse lung when used in combination with recombinant human TRAIL therapy. By utilizing these models, the work in this thesis has shown that disrupting cell adhesion could provide a new combination strategy to sensitise tumour cells to TRAIL therapy.

Angiogenesis, the growth of new blood vessels, is vital to tumour growth. Prevailing dogma has been that tumours cannot grow without angiogenesis. Based on this premise, anti-angiogenic drugs are used clinically. However, the principle of angiogenesis as an absolute requirement for tumour growth has been challenged with reports that many tumours are entirely or partially non-angiogenic. This study describes and quantifies characteristics of non-angiogenic non-small cell lung tumours, demonstrates non-angiogenic growth in small-cell/neuroendocrine lung tumours and investigates the underlying pathogenetic processes by comparison with angiogenic lung tumours. Hypoxia is an important stimulus for angiogenesis. Differences in response to hypoxia may determine whether a tumour produces new vessels. In order to test this, levels of. necrosis, often considered a surrogate marker of hypoxic stress, were quantified but no difference in quantity of necrosis was found Moreover, immunohistochemical investigation of hypoxia and angiogenesis factors provided no unambiguous explanation for the differences in angiogenesis. Significant differences were seen, however, in fibrosis and inflammation, which were both greater in angiogenic tumours. Differences were greater for lymphocytes rather than cells of the ‘innate’ immune system. This provided an alternative hypothesis: angiogenesis occurs during wound healing and in the growth of granulation tissue, so it is possible that tumour angiogenesis is a response to factors produced by immune cells rather than the tumour itself. A tumour’s angiogenic status may, therefore, be determined by the response it provokes from the immune system. Further work to test this theory would compare levels of immunogenic factors such as Tumour Necrosis Factor and tumour cell surface antigens such as the HLA class I molecules. The study concludes with an investigation into the molecular basis of non-angiogenic growth using the technique of comparative genomic hybridisation (CGH) which allows amplifications and deletions of areas of DNA to be calculated. High-resolution array CGH was evaluated against conventional CGH, and the results compared with previous RNA studies from our laboratory. These revealed a set of genes with consistent changes in both RNA and DNA, several of which form part of known angiogenic and inflammatory pathways.

<strong>Background:</strong> Malignant transformation of cells is typically characterised by aerobic glycolysis, resulting in supressed mitochondrial function, a state that helps resistance to apoptosis. This characteristic has been widely accepted as a hallmark of cancer and has been shown to be of critical importance in tumour development. The bioenergetic differences between normal and malignant cells are being exploited to identify potential cancer specific therapeutics. Improved in-vitro models are required to aid the identification and assessment of candidate drugs. In this project, we investigated the bioenergetic phenotypes of a panel of adult and paediatric cancer cell lines and evaluated the potential of 3D models as a platform for testing drugs that target cancer metabolism. We also investigated a novel method to assess mitochondrial function that enables the quantification of the level of oxygenation within the cell. <strong>Results:</strong> The results presented in this thesis show that not all cancers display this aerobic glycolytic phenotype. We found that while some cell lines displayed the Warburg phenotype others displayed high levels of oxidative metabolism. These bioenergetic profiles need to be considered when deciding which anti-cancer drugs to use in a chemotherapeutic regime. If a bioenergetic pattern can be identified it may one day form the basis of a screening strategy for tumours. Dichloroacetate (DCA) is a small molecule PDK inhibitor that was investigated in this study. It was found to be relatively non-toxic to cells cultured in 2D but had improved toxicity when the cells were cultured in a 3D environment. Lastly, we evaluated a new oxygen sensing nanoprobe, Mito-Xpress Intra, and the results demonstrate its potential as a non-invasive means of measuring oxygen concentrations within the cell in real time as well as highlighting some striking differences between applied ambient and measured intracellular oxygen concentrations. <strong>Conclusion:</strong> The findings suggest that not all cancers display the characteristic glycolytic phenotype. They also highlight the importance of controlling oxygen and glucose levels when evaluating metabolism and when drug testing.

This thesis describes the design of a virotherapy strategy capable of destroying both breast cancer vasculature and tumour cells, using an oncolytic adenovirus expressing angiogenesis-regulating proteins. Five oncolytic adenoviruses were compared to identify the best virotherapy agent for breast cancer, including measurement of cytotoxicity in vitro, and replication, intra-tumoural spread and anticancer efficacy in vivo. The viruses tested were Ad-dl922-947 (targets G1-S checkpoint defects); Ad-Onyx-015 and Ad-Onyx-017 (target p53/mRNA nuclear export defects); Ad-vKH1 (targets Wnt pathway defects) and AdEHE2F (targets estrogen receptor/G1-S checkpoint/hypoxia signalling defects). AdEHE2F demonstrated optimal oncolytic activity and selectivity against breast cancer, accordingly this virus was engineered to express potent regulatory angiogenic proteins, namely soluble Flt1 and soluble Delta like-4 (Dll4). sFlt1 is the soluble extra-cellular domain of VEGFR1 and binds to and sequesters VEGF-A, thereby preventing VEGFR2 stimulation which is crucial to trigger angiogenesis. sDll4 is the soluble extracellular domain of Dll4 and has been previously shown to block Dll4/Notch signalling. Dll4/Notch signalling increases a chaotic and non-functional angiogenesis which ultimately delays tumour growth. Importantly, VEGF and Dll4 are the only angiogenesis genes reported to be haploinsufficient in vascular development and both have been shown to have a good anti-tumour effect. sFlt1 and sDll4 genes were substituted for the viral genes E3 6.7K/gp19K of AdEHE2F, thereby using endogenous adenoviral machinery to drive production. The activities of AdEHE2F viruses expressing either sFlt1 or sDll4 were compared in vitro and in vivo. sFlt1 (expressed from AdEHE2F) inhibited endothelial cell proliferation and sprouting whereas sDll4 increased proliferation and branching in vitro. In vivo AdEHE2F expressing sFlt1 or sDll4 both showed superior anticancer activity compared to parental AdEHE2F, indicating at least additive efficacy between virotherapy and regulatory angiogenic approaches.