Targeted therapy using EGFR inhibitors cetuximab and panitumumab has anti-tumor efficacy in colorectal cancer, though only in patients without a KRAS mutation in their tumor. This thesis aims to... Show moreTargeted therapy using EGFR inhibitors cetuximab and panitumumab has anti-tumor efficacy in colorectal cancer, though only in patients without a KRAS mutation in their tumor. This thesis aims to give insight on several aspects of EGFR inhibitors en RAS mutations in colorectal cancer. It reviews aspects of mutational analysis, aims to find ways to restore sensitivity to EGFR inhibitors in patients with KRAS mutated colorectal cancer and discusses the distinctive skin toxicity of cetuximab en pantiumumab. Show less
Approximately 35% of colorectal cancer (CRC) risk is attributed to heritable factors, with 5 to 10% linked to dominant or recessive inherited syndromes. Known high-risk genes like POLE, POLD1,... Show moreApproximately 35% of colorectal cancer (CRC) risk is attributed to heritable factors, with 5 to 10% linked to dominant or recessive inherited syndromes. Known high-risk genes like POLE, POLD1, NTHL1 and APC contribute to a portion of this risk. However, the genetic basis for 20%-30% of inherited CRC remains unclear. This thesis explores the roles of POLE, POLD1, APC and NTHL1 in CRC and polyposis. While screening for pathogenic variants in POLE and POLD1, remarkably POLE L424V variants were found to induce Lynch syndrome-like features due to somatic mismatch repair gene mutations. Biallelic NTHL1 variants predisposing to CRC and polyposis were studied in a collaborative effort, describing a broad tumor spectrum and a high risk of extracolonic cancers associated with NTHL1 deficiency. For monoallelic NTHL1 variant carriers, no significant evidence link was found with increased polyposis or CRC risk, as supported by mutational signature analysis on colorectal tumors. Show less
In prostate (PCa) and colorectal (CRC) cancer, there is a need to improve patient stratification techniques that aid diagnostic and prognostic decision-making. To fulfill this unmet clinical need,... Show moreIn prostate (PCa) and colorectal (CRC) cancer, there is a need to improve patient stratification techniques that aid diagnostic and prognostic decision-making. To fulfill this unmet clinical need, the measurement of disease-related biological parameters known as “biomarkers” from biofluids is an approach with the potential to develop noninvasive tests as well as achieve greater clinical accuracy and personalized medicine. Thus, this thesis focused on developing a better understanding of biomarkers relevant to PCa and CRC as well as advancing analytical methodology and achieving methodological advancements for the purpose of biomarker discovery. In chapters two and three, a large diversity of prostate-specific antigen (PSA) cleaved and non-cleaved proteoforms (PCa) with different N-glycosylation patterns were determined in urine and seminal fluid using capillary electrophoresis-electrospray ionization-mass spectrometry (CE-ESI-MS), some of which are relevant for PCa patient stratification. In addition, the data processing workflow was improved in chapter three in order to enable larger studies of intact proteoforms to be performed. Furthermore, chapter four developed a reversed phase-liquid chromatography (RPLC)-MS method whereby it was possible to determine sialic acid linkages and positional isomers in released N-glycans following fluorescent labeling and sialic acid derivatization. This method was applied in chapter five to study serum N-glycosylation profiles in CRC and it was demonstrated that specific N-glycan isomers are implicated in the disease and differences between histological types were eradicated following surgery. Show less
Colorectal cancer (CRC) is often treated with chemotherapy. However, it is well known that treatment with chemotherapy comes with challenges, such as (severe) adverse events leading to loss of... Show moreColorectal cancer (CRC) is often treated with chemotherapy. However, it is well known that treatment with chemotherapy comes with challenges, such as (severe) adverse events leading to loss of quality of life, treatment discontinuation and sometimes even death. Moreover, chances for curation in the metastatic setting are low. Therefore, a large window of opportunity to improve both safety as well as efficacy of chemotherapeutic treatment for the individual patient exists. A possible approach to improve chemotherapeutic treatment for CRC patients could be the discovery, validation and implementation of new genetic biomarkers. The use of genetic biomarkers allows to identify patients that are at higher risk for severe adverse drug events and to select patients which will benefit the most from chemotherapy. The aim of this thesis was therefore to improve the safety and efficacy of chemotherapeutic drugs in patients with colorectal cancer by individualising drug dosing and choice of drug based on germline genetic biomarkers. The described studies in this thesis brought us a few steps closer to safe and effective use of chemotherapeutic drugs in the individual colorectal cancer patient. Irinotecan should no longer be administered without a UGT1A1 genotype test and a start has been made towards personalised medicine for colorectal cancer patients with peritoneal metastases. Show less
For part I population-based data from the national cancer registries of Belgium, the Netherlands, Norway, and Sweden was used. In all countries, the use of chemotherapy increased with stage and... Show moreFor part I population-based data from the national cancer registries of Belgium, the Netherlands, Norway, and Sweden was used. In all countries, the use of chemotherapy increased with stage and decreased with age. Also, 30-day and one-year excess mortality decreased over the years for colon and rectal cancer. After surviving the first postoperative year, the survival of surgically treated older patients aligned with their younger counterparts, except for patients with stage III disease. Part II describes the results of the analyses of the RAPIDO trial. DRTF decreased from 30% in the standard-care group to 24% in the experimental group at 3 years after randomisation, mainly due to a decrease in DM, which is probably due to better compliance preoperatively and perhaps due the earlier treatment of micrometastases in the treatment process. Although patients with DM in the experimental group had worse survival compared to patients in the standard-care group, the cumulative probability of overall survival remained comparable for both treatment groups. If the patients with a complete response can be identified during reassessment after neoadjuvant therapy, surgery may be omitted, a W&W after a cCR with an appropriate follow-up has no additional oncological risk in young patients compared to older patients (part III). This opens the door for potential organ preservation. Show less
Glycosylation is a widely occurring and complex modification found on lipids and proteins and is involved in the recognition, signaling and interaction events within the cell and between cells.... Show moreGlycosylation is a widely occurring and complex modification found on lipids and proteins and is involved in the recognition, signaling and interaction events within the cell and between cells. These events based on glycan structures result in adhesion, cell-matrix interaction and immune recognition. Alterations in the glycomic profile are considered a hallmark of various diseases, including cancer where it contributes to the development and progression of cancer, affecting cell-cell communication, cell-matrix interactions, tumor angiogenesis, invasion and metastasis. These functions are governed by different glycans and their terminal structures. In order to further explore these structures with regard to their potential as biomarkers and specific targets for diagnostic applications and therapeutical strategies for various diseases, in-depth glycomic analysis is needed. It is further noted that aberrant glycosylation not only results from the altered expression of glycosyltransferases (GTs) but also from the changed activity of GTs and glycosidases as well as the availability and abundance of sugar nucleotide donors. The aim of the research described in this thesis was to explore the glycomic signatures of colorectal cancer (CRC) in cell lines and tissues as well as of acute myeloid leukemia (AML) cell lines. Show less
Colorectal cancer is one of the most diagnosed cancer types worldwide and incidence remains on the rise, especially in patients under 50. The prognosis for patients with CRC differs greatly and... Show moreColorectal cancer is one of the most diagnosed cancer types worldwide and incidence remains on the rise, especially in patients under 50. The prognosis for patients with CRC differs greatly and although immunotherapy has shown promising results in a number of cancer types, not all CRC patients respond well to these treatments. This can in part be attributed to the differences in T cell infiltration between cancers but does not one on one translate to clinical response. Moreover, the activity of specific immune cells can directly influence other immune cells, both in an activating and inhibitory manner. This highlights the complexity of the tumour immune microenvironment and requires an comprehensive multiplex approach to simultaneously investigate all the players of the tumour immune microenvironment. Furthermore, the interaction between different immune cells and between those and cancer cells is essential to take into account, hence the need for an approach that combines multiplex immunophenotyping with spatial cell context. This will provide hints into the behaviour of the players of the tumour immune microenvironment and aid the understanding of CRC, but potentially of other cancer types as well. In this work we developed and applied multispectral immunophenotyping methodologies to strengthen our understanding of CRC Show less
Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the western world and an improved understanding of the molecular pathways involved in CRC could potentially allow... Show moreColorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the western world and an improved understanding of the molecular pathways involved in CRC could potentially allow improved prediction and personalized therapy. The BMP pathway is known to be crucial for the maintenance of intestinal homeostasis and deregulation of this pathway is known to contribute to colorectal cancer formation. The studies presented in this thesis provide evidence that the BMP pathway is an important homeostatic pathway and that, both in normal tissue and in cancer, BMP signaling is influenced by (cancer-associated) fibroblasts. The outcome of BMP signaling on the epithelial cells appears to be dependent on the bioavailability of BMPs and, importantly, on the presence of a functional intracellular BMP pathway. Show less
Integrins play an essential role in multicellular life by connecting cells to the extracellular matrix. This thesis provides an overview of the distinct types of integrin-containing cell adhesion... Show moreIntegrins play an essential role in multicellular life by connecting cells to the extracellular matrix. This thesis provides an overview of the distinct types of integrin-containing cell adhesion complexes present in epithelial cells. By employing BioID we succesfully characterized the composition of focal adhesions, flat clathrin lattices, and hemidesmosomes. In addition, we investigated the role of different adhesion complexes in (cancer) cell adhesion, migration, polarity, and proliferation and in mechanotransduction. Show less
Immunotherapy is a highly promising treatment option for cancer. At present, only a small proportion of cancer patients benefits from immunotherapeutic interventions. There is an unmet need to... Show moreImmunotherapy is a highly promising treatment option for cancer. At present, only a small proportion of cancer patients benefits from immunotherapeutic interventions. There is an unmet need to understand which factors determine a patient’s response to immunotherapy as well as to develop novel immunotherapeutic approaches that address shortcomings of current immunotherapies.In this thesis, we have performed an unprecedented characterization of immune cell subsets participating in anti-tumor responses in colorectal cancer and pancreatic ductal adenocarcinoma with different single-cell technologies. Most cancer immunology research studied the role of cytotoxic T cells in both cancer types, while a comprehensive analysis of both innate and adaptive components of cancer immunity was largely lacking. With such an approach, we demonstrated an important involvement of understudied unconventional (γδ T cells) and innate (innate lymphoid cells (ILCs)) immune effector cells in anti-tumor immunity. These immune subsets displayed cytotoxic activity and showed potential for therapeutic exploitation. Further studies will focus on their functional characterization and potential reconversion into a therapeutic agent.This thesis resulted from the collaboration between research groups led by Noel de Miranda (Pathology, LUMC) and Frits Koning (Immunology, LUMC), and underscores the relevance of applying single-cell technologies for the study of complex biological systems. Show less
This thesis focused on risk factors and outcomes based on colorectal cancer auditing and aimed to provide new insights into outcome indicators, treatment modalities, and outcomes in high-risk... Show moreThis thesis focused on risk factors and outcomes based on colorectal cancer auditing and aimed to provide new insights into outcome indicators, treatment modalities, and outcomes in high-risk patients, and to monitor outcomes after implementation of minimally invasive surgery. Nationwide population-based studies with data of the Dutch ColoRectal Audit (DCRA) were used to provide information regarding colorectal cancer care on different levels (hospital, national, and international level) and in specific high-risk subpopulations. Show less
This thesis highlights, firstly, the importance of early CRC detection by presenting results of a CRC diagnostic proteomic biomarker signature with high discriminative power. Secondly, a strong... Show moreThis thesis highlights, firstly, the importance of early CRC detection by presenting results of a CRC diagnostic proteomic biomarker signature with high discriminative power. Secondly, a strong robust, independent prognostic tumor stroma ratio (TSR) biomarker, which confirms to be of important clinical value. The TSR has the ability to stratify colon cancer patients according to their prognostic outcome in a highly reproducible and low-cost manner. It has shown to link patients with a high intra tumor stromal content and a worse prognosis. Literature shows a wealth of evidence that supports this prognostic value in CRC as well as in other cancers. This PhD research therefore concludes that it should be implemented in the official guidelines of the TNM classification to improve stratification for CRC patients in daily routine pathological evaluation. The prospective, international, multicentre UNITED study will hopefully overcome the last hurdle for this clinical implementation. Lastly, this thesis offers more insight in the elusiveness of the tumor microenvironment and stromatogenesis that contributes to the aggressiveness of some CRC tumors. The biological differences, interconnections and changes in the microenvironment presented give multiple leads for further research and new personalized treatment possibilities. Show less
The surface of eukaryotic cells contains a very dense layer of oligosaccharides called glycans that are linked to protein and lipid carriers and play an important role in cell-cell and cell... Show moreThe surface of eukaryotic cells contains a very dense layer of oligosaccharides called glycans that are linked to protein and lipid carriers and play an important role in cell-cell and cell-extracellular matrix interactions. Cancer-induced changes in glycosylation have an impact on the function of major glycoproteins in the human colon, therefore studies focused on colorectal cancer (CRC)-specific glycosylation signatures can provide novel insights into onset and progression of this disease. The major focus of this thesis was to investigate mucin type O-glycosylation signatures of CRC. For this purpose, a protocol for in-depth analysis of N- and O-glycans obtained from cell lines was developed (Chapter 2) using nanoscale porous graphitized carbon liquid chromatography coupled to mass spectrometry (PGC-nano-LC-MS). In Chapter 3 additional conditions were optimized in the MS methodology by using polar protic dopant (methanol and isopropanol) enriched nitrogen gas to increase sensitivity on the MS and tandem MS level. In Chapter 4 we applied the methodology developed in Chapter 2 to the analysis of O-glycosylation signatures of 26 different CRC cell lines. This analysis resulted in the characterization of more than 150 O-glycan structures and increased our understanding of glycan expression in the analyzed cell lines. To gain further understanding in the mechanisms underlying glycomic changes with colon cell differentiation, we explored changes in the cell line glycome and proteome upon spontaneous and butyrate-stimulated differentiation in in vitro cell culture (Chapter 5). By performing an integrative approach, we generated hypotheses about glycosylation signatures of specific cell adhesion proteins, which may play an important role in cancer progression. The localization of glycans on the cell surface and their role in biological processes are important in cancer pathogenesis, making them potential candidates for glycan targeting immunotherapy. Therefore, we further optimized the methodology to enable comprehensive analysis of N- and O-glycans from specific regions of formalin-fixed, paraffin-embedded tissues using laser capture microdissections and applied it for the analysis of selected regions of CRC tissues and their patient-matched colon mucosa controls (Chapter 6). We identified specific tumor-associated carbohydrate antigens (TACAs) that show expression only in the tumor samples, with no or limited expression in the normal colon mucosa. Since TACAs are present in high abundance on the surface of cancer cells which are linked to many different proteins, these are very promising targets for the development of tumor-specific immunotherapy. Show less
The interaction between tumor and immune cells in the microenvironment plays a key role in oncogenesis. This recognition can be mediated by changes in glycosylation on tumor cells which are sensed... Show moreThe interaction between tumor and immune cells in the microenvironment plays a key role in oncogenesis. This recognition can be mediated by changes in glycosylation on tumor cells which are sensed by lectins, such as the Macrophage Galactose-type Lectin (MGL), expressed on immune cells, resulting in immunosuppressive responses. MGL binding to the Tn-epitope on MUC1 triggers DCs to stimulate T-regulatory responses and tolerance against the tumor, while suppressing T-effector cells responsible for tumor eradication. This undesirable consequence in cancer led to interest in the characterization of targets of MGL. This thesis dealt with the analysis of glycoproteins binding to MGL expressed by different tumor cell models. For this purpose, a robust method to enrich MGL binding proteins, in combination with their mass spectrometry-based identification was established. Because of the high level of the Tn-antigen, due to a Cosmc mutation, the Jurkat cell line was initially used for this purpose (Chapter 2) but a slightly adjusted method was later applied to high- and low-MGL binding CRC cell lines as well (Chapter 3 and 5). These analyses led to the identification of hitherto unknown MGL binders. In Chapter 4, we focused on to the contribution of N-glycan MGL binding glycotopes in CRC cell lines, most probably corresponding to LacdiNAc structures, by implementing overall N-glycan release in our workflows. With this, we were able to show that N-glycoproteins represent a hitherto underestimated group of MGL binding protein in these cell lines. Also several secreted proteins from the CRC cell lines could bind to MGL (Chapter 5), indicating that the interaction with immune cells can also be mediated by this group of proteins. The results from previously published transcriptomics and N-/O-glycomic analyses could not explain the different expression of MGL binding proteins on the CRC cell lines used. For this reason, in Chapter 4, we extended our research with full comparative quantitative proteomics analyses, in an attempt to explain the differences in MGL binding, for example by different levels of MGL binding proteins or proteins involved in glycosylation pathways. Additionally, in Chapter 6, we used such a quantitative proteomics dataset also to test the suitability of a previously suggested mass spectrometry-based method to discriminate O-GalNAc (Tn) versus O-GlcNAc, which led to the first site-specific identification of O-glycosylation of both intracellular and secreted anterior gradient protein 2 (AGR2). Show less
Fluorescence guided surgery is a technique that has widely been implemented and investigated over the last decade, and has repetitively revealed to be a vital tool during surgery. However, the... Show moreFluorescence guided surgery is a technique that has widely been implemented and investigated over the last decade, and has repetitively revealed to be a vital tool during surgery. However, the process of adopting this technique into standard of care along with developing and translating novel fluorescent agents into the clinic has proven to take time. Preclinical studies that have been validated several years ago have now slowly been making the transition into the surgical field to be appraised in patients.This thesis mainly focused on the clinical translation of ZW800-1 and cRGDZW800-1 which were developed for the intraoperative imaging of the ureters and colon cancer, respectively. Furthermore, this thesis focused on the further appraisal of a previously studied tumor-targeted fluorescent antibody (SGM-101) for the intraoperative imaging of primary, recurrent and metastasized colorectal cancer. Show less
There is a pending need for prognostic and predictive biomarkers in the treatment of patients with colorectal cancer.This thesis describes the prognostic and predictive application of the tumor... Show moreThere is a pending need for prognostic and predictive biomarkers in the treatment of patients with colorectal cancer.This thesis describes the prognostic and predictive application of the tumor-stroma ratio (TSR) in colorectal cancer, focusing on expanding current clinical-pathological standards and combining TSR with other diagnostic parameters. The TSR is a microscopy scoring method performed on hematoxylin-eosin stained tissue slides used for routine pathology assessment, and has proven to be a robust prognostic maker. Here, we investigate whether the TSR also exhibits predictive value with regard to adjuvant targeted therapy in stage II and III colon cancer. Moreover, exploring the value of collagen fiber organization in the intratumoral stroma, as well as combining this parameter with the TSR. Finally, expanding the application of the TSR with radiological diagnostics in rectal cancer. Assessing is there is a correlation between TSR and apparent diffusion coefficient values obtained from diagnostically performed MRI-DWI scans, in order to determine if there is potential with regards to neoadjuvant treatment choices or patient follow-up. Show less
The aim of this thesis was to better understand the underlying biology of tumor-immune interactions, especially in the circulation of CRC patients. The focus was primarily on the innate immune... Show moreThe aim of this thesis was to better understand the underlying biology of tumor-immune interactions, especially in the circulation of CRC patients. The focus was primarily on the innate immune system including NK cells, NKT cells, and macrophages. Show less
As with all cancer screening programmes, the expected reduction in cancer cases and deaths must be weighed against the burden of screening and possible side effects. The aim of this thesis is to... Show moreAs with all cancer screening programmes, the expected reduction in cancer cases and deaths must be weighed against the burden of screening and possible side effects. The aim of this thesis is to provide insights in consequences of colorectal cancer screening participation from a surgical perspective. We investigated potential harm in terms of serious morbidity from colonoscopy, additional findings on imaging, and psychological impacts following a positive faecal immunochemical test (FIT) result. Second, studies were performed to gain more in-depth insight into surgical referral patterns for benign colorectal lesions and CRC lesions with only submucosal invasion (pT1), thereby contributing to the understanding of whether early diagnosis following CRC screening results in better surgical outcomes. Third, surgical outcomes of screen-detected patients were compared with symptomatic patients. Show less
We set out the get a better understanding of the role of Bone Morphogenetic Protein(BMP) signalling in normal intestine and in carcinogenesis. The BMP pathway isknown to be a major player in the... Show moreWe set out the get a better understanding of the role of Bone Morphogenetic Protein(BMP) signalling in normal intestine and in carcinogenesis. The BMP pathway isknown to be a major player in the development of colorectal cancer (CRC). CRC isone of the leading causes of cancer-related deaths in the western world. Althoughsurvival and recurrence of CRC have improved, 5-year survival is low at only 65%(https://seer.cancer.gov – US data). Improving our understanding of the molecularpathways involved in CRC will potentially allow earlier detection, better predictionand personalized therapy. To briefly summarise the research we have done, we startedby investigating the function of BMP in the normal intestine. We then went on tostudy the role of BMP signalling in carcinogenesis, mainly the role of non canonicalBMP signalling in the development of metastasis. We ended with a focus on patientsby explaining how we can improve estimation of prognosis using expression levelsof several BMP components and how targeting the BMP pathway can be used forpersonalized treatment of patients. Show less
Colorectal tumours with high stromal content have a poor prognosis. In part 1, I investigated, at the protein and gene expression levels, the composition of these tumours in comparison to stroma... Show moreColorectal tumours with high stromal content have a poor prognosis. In part 1, I investigated, at the protein and gene expression levels, the composition of these tumours in comparison to stroma-low tumours. In part 2, KRAS mutant colorectal cancer cell lines had a different metabolism compared to KRAS wild type after inhibition of mTORC1. This may contribute to therapeutic resistance. Show less
