Surgery (St Vincent's) - Theses

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    Assessing the suitability of Australian general practice electronic health record data for clinical prediction model development: A case study in Osteoarthritis
    Thuraisingam, Sharmala ( 2022)
    Australian general practice electronic health records contain a wealth of patient information. However, the suitability of these data for developing clinical prediction tools is unclear. This research focussed on determining the suitability of these data for prediction model development using osteoarthritis as a case-study. A comprehensive data quality assessment was conducted and a prediction model for total knee replacement surgery developed. The thesis demonstrated that suitability of Australian general practice electronic health record data for prediction model development should be assessed on a case-by-case basis. A decision aid was developed to assist researchers in determining whether their electronic health record data are fit for prediction model development.
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    Bio-engineering vascularised liver organoids
    Yap, Kiryu Kee Loong ( 2022)
    Liver organoids are bioengineered constructs that recapitulate native liver tissue, and are used to study liver development, test drugs, and as replacement tissue that can be transplanted to treat liver disease. This thesis focusses on the specific application of liver organoids for use as a cell-based treatment for liver disease via organoid transplantation. It places a particular emphasis on the addition of vascularisation to liver organoids to enhance structure and function, and improve engraftment during in vivo transplantation. Initially, the effect of the addition of endothelial cells to create vascularised liver organoids was assessed using mouse cells. The addition of mouse liver sinusoidal endothelial cells (LSECs) to mouse liver progenitor cells (LPCs) resulted in a striking change in organoid morphology, with the development of hepatobiliary ductular structures and clusters of polygonal hepatocyte-like cells which did not appear when LPCs were cultured alone as organoids. Furthermore, in vitro hepatobiliary gene expression, hepatic synthetic functions (albumin and apolipoprotein E production) and organoid viability was significantly increased by the addition of LSECs. Upon transplantation into vascularised chambers established in Fah-/- Rag2-/- Il2rg-/- (FRG knockout) mice, LPC only organoids had almost zero survival at 2 weeks, whereas LPC/LSEC organoids developed robust hepatobiliary ductular structures with a 115-fold increase in HNF4a+ cells and 42-fold increase in Sox9+ cells. To translate the mouse findings into a humanised platform, human LPCs and LSECs and their human induced pluripotent stem cell (hiPSC)-derived counterparts were characterised. The hepatic differentiation of human primary adult LPCs and hiPSC derived LPCs into hepatocyte-like cells was confirmed based on cell morphology, marker expression, and function (albumin production), and transcriptomic profiling using bulk and single cell RNA sequencing. Concurrently, human primary adult LSECs were compared to hiPSC-derived endothelial cells(iECs). Although in vitro iECs had a generic endothelial phenotype very different to LSECs, when iECs were transplanted into mouse liver they underwent tissue specification to approximate LSECs, highlighting the importance of the liver microenvironment in this process. Subsequently, three types of vascularised human liver organoids were explored using primary human and hiPSC-derived cells. First, primary LPCs, LSECs and adipose-derived mesenchymal stem cells were combined in a human liver-derived extracellular matrix (ECM) hydrogel and seeded into bioabsorbable porous polyurethane scaffolds. Second, iECs were aggregated with hiPSC-derived hepatocyte (iHep) organoids to coat the surface of the iHep organoids. Third, single cell-type organoids were integrated to form a combination organoid created from hepatocyte, cholangiocyte, and vascular organoids. Of the three models, combining organoids of different cell types to create a combination organoid was deemed the best approach to derive complex liver organoids containing well-organised tissue structures such as polarised hepatocytes with bile canaliculi, bile ducts, and blood vessel networks. An overarching theme is that vascularisation is pivotal in the development of transplantable liver organoids. Adding endothelial cells promotes hepatobiliary differentiation, and pre-formed vasculature can significantly enhance the survival of transplanted liver organoids by hastening connection to the host’s blood supply. However, this is not easy to achieve and remains a challenge in the liver organoid field, and the production of well-vascularised liver organoids with sustained development of blood vessels over time in culture remains elusive. Nevertheless, the limitations and challenges identified in this thesis point towards future directions in addressing the issue of vascularisation. For clinical translation of liver organoid transplantation, hiPSC-derived cells are a more reliable source of personalised cells, and the ECM additive should be bio-synthetic and chemically-defined, rather than Matrigel. Ultimately, the results in this thesis support the exciting prospect of stem-cell derived liver organoids being used as a regenerative treatment for liver disease.
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    ‘Every bone in my body aches’: A culturally secure exploration of osteoarthritis among Aboriginal and Torres Strait Islander People
    O'Brien, Penny ( 2022)
    Background As a leading cause of pain and disability worldwide, osteoarthritis is associated with considerable personal, economic and societal toll. Osteoarthritis commonly coexists with chronic diseases such as heart disease, diabetes and mental health challenges and can exacerbate the morbidity and mortality associated with these conditions. The health and social disparities experienced by Aboriginal and Torres Strait Islander people in Australia are well documented and include a greater burden of chronic disease, poorer self-assessed health status and lower life expectancy. Osteoarthritis and the burden of illness among Aboriginal and Torres Strait Islander people represent two substantial public health challenges today, however there is a dearth of research which bring the two together. The limited research available suggests that Aboriginal and Torres Strait Islander people experience a higher prevalence and greater burden of osteoarthritis, yet access health care for osteoarthritis at substantially lower rates than non-Aboriginal people. With no culturally adapted models of osteoarthritis care for Aboriginal and Torres Strait Islander people, osteoarthritis is an unmet health need. This thesis responds to these gaps by exploring osteoarthritis among Aboriginal and Torres Strait Islander people and laying the foundations of culturally secure osteoarthritis research for Aboriginal and Torres Strait Islander people. Cultural security in research occurs when the research is conducted in a way that will not compromise the cultural rights, values, beliefs, knowledge systems and expectations of Aboriginal and Torres Strait Islander people. Objectives To explore osteoarthritis among Aboriginal and Torres Strait Islander people and lay the foundations of culturally secure osteoarthritis research for Aboriginal and Torres Strait Islander people, the aims of this PhD were to; 1) Establish an Aboriginal and Torres Strait Islander community reference group to inform, guide and enable community engagement throughout the research; 2) Examine the access, utilisation and surgical outcomes among Aboriginal and Torres Strait Islander people with hip and knee osteoarthritis undergoing total joint replacement surgery and; 3) Inform and guide the development of culturally secure osteoarthritis care for Aboriginal and Torres Strait Islander people based on their lived experience. Methods To achieve these aims, a mixed-methods approach, situated within methodological pluralism and a pragmatic epistemology was employed. Predominantly qualitative methods were chosen to prioritise the stories and cultural context of Aboriginal and Torres Strait Islander participants. This PhD was also conducted within a culturally secure research framework, which prioritised relationships, community engagement and Aboriginal and Torres Strait Islander cultural values and voices throughout. Four phases of research were conducted: 1. In Phase 1, a review of the literature describing osteoarthritis and health care access, including access to total joint replacement among Aboriginal and Torres Strait Islander people was performed. 2. In Phase 2, a qualitative key informant study was conducted. Research yarning interviews with Aboriginal health stakeholders and Aboriginal and Torres Strait Islander people with lived experience of osteoarthritis were conducted to inform the establishment of a community reference group and terms of reference. 3. In Phase 3, a qualitative dominant mixed-methods study was conducted. First, a retrospective cohort study was conducted to explore the uptake and utilisation of total joint replacement by Aboriginal and Torres Strait Islander people and characteristics of Aboriginal and Torres Strait Islander people undergoing total joint replacement. This was followed by a qualitative exploration of the lived experience of osteoarthritis from the perspective of Aboriginal and Torres Strait Islander people, and; 4. In Phase 4, data collected in Phase 3 were integrated to inform and guide the development of culturally secure osteoarthritis care and to develop the discussion chapter of this thesis. Findings The review of the literature conducted in Phase 1 highlighted a lack of evidence describing osteoarthritis among Aboriginal and Torres Strait Islander people, particularly from a person-centred perspective. Two published manuscripts addressed the paucity of research directed towards this unmet health need. The first publication ‘Tackling the burden of osteoarthritis as a health care opportunity in Indigenous communities – A call to action’ raises the profile of osteoarthritis as an unmet health need for Indigenous communities around the world, placing this public health issue on the research agenda. The second narrative review and call to action titled ‘Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia’s universal health care system: A call to action’ highlights that Aboriginal and Torres Strait Islander people experience significant barriers to accessing care along the whole of the patient journey to surgical care by drawing examples from the field of osteoarthritis and total joint replacement. The process of establishing an Aboriginal and Torres Strait Islander community reference group and terms of reference in Phase 2 was described in the manuscript (under review) ‘Laying the foundations of community engagement in Aboriginal health research: Establishing a community reference group and terms of reference in a novel research field’. Trust and relationships were considered the most important factors in successfully recruiting ‘the right people’ to an Aboriginal and Torres Strait Islander community reference group. Key informants recommended that representatives of a broad spectrum of expertise should have a seat at the table, including both health service providers and Aboriginal and Torres Strait Islander people with lived experience of osteoarthritis. Community engagement, research steering, knowledge dissemination and advocacy were identified as essential functions of a community reference group. Emphasis was placed on the importance of self-determination, ownership and the decision-making power of the group to negotiate their own terms and conditions. The findings from this study informed the establishment of an Aboriginal and Torres Strait Islander community reference group (comprised of six members) and terms of reference who provided significant input in all subsequent studies in this PhD. The uptake and characteristics of Aboriginal and Torres Strait Islander people undergoing total joint replacement explored in Phase 3 was presented in the manuscript (under review) ‘Total joint replacement may be a valuable treatment for Aboriginal and Torres Strait Islander people with osteoarthritis, but uptake is low’. This manuscript describes the findings from a registry-based retrospective cohort study which compared the sociodemographic, clinical characteristics and surgical outcomes of all Aboriginal and Torres Strait Islander patients and non-Aboriginal patients who underwent primary hip and knee replacement at St Vincent’s Hospital Melbourne between 1996-2019. This exploratory study identified that in the 23-year study period, 49 (0.5%) of procedures were conducted in patients who identified as Aboriginal, Torres Strait Islander or Aboriginal and Torres Strait Islander. St Vincent’s Hospital Melbourne is the largest metropolitan provider of care to Victoria’s Aboriginal community, with over 5000 occasions of care to Aboriginal adults annually. Based on hospital data from the Decision Support Unit, approximately 2.2% of acute hospital admissions at SVHM are patients who identify as Aboriginal, Aboriginal and Torres Strait Islander or Torres Strait Islander. Aboriginal people make up approximately 1.6% of the population in Victoria, excluding metropolitan Melbourne, and 0.5% of the population of Melbourne. The study also found that although Aboriginal and Torres Strait Islander people undergoing total joint replacement were younger, more likely to be overweight and more likely to have a diagnosis of diabetes or multiple chronic diseases, they experienced comparable post-operative quality of life improvements 12-months post-surgery to non-Aboriginal people. The lived experience of osteoarthritis from the perspective of Aboriginal and Torres Strait Islander people, also investigated in Phase 3, was described in the manuscript (accepted for publication) ‘Understanding the impact and tackling the burden of osteoarthritis for Aboriginal and Torres Strait Islander people’. This study identified that osteoarthritis is a multidimensional issue for Aboriginal and Torres Strait Islander people which permeates all aspects of life. Many participants experienced significant psychosocial impacts of osteoarthritis which often occurred within already stressful or complex health or life circumstances. Participants also described multiple negative health care experiences whilst seeking care for their osteoarthritis, which were often characterised by ineffective communication by health care providers. Conclusions As the first in-depth person-centred exploration of osteoarthritis among Aboriginal people and Torres Strait Islander people, this research highlighted the impact of osteoarthritis as a significant health concern which permeates all aspects of life for those affected and validates the importance of addressing the impacts of osteoarthritis within a multidimensional framework. Integrated, multidisciplinary care which is evidence based, culturally secure, individualised to patient need and accessible is required to address the burden of osteoarthritis among Aboriginal and Torres Strait Islander people. By addressing the burden of osteoarthritis among Aboriginal and Torres Strait Islander people, there is an opportunity to improve the health and wellbeing of Aboriginal and Torres Strait Islander communities.
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    Tackling regulation “In situ”: A model for approaching regulation during a 3D bioprinting pre-clinical research translation program
    Mladenovska, Tajanka ( 2021)
    3D bioprinting uses the techniques of additive manufacturing, but includes living cells, with the goal of creating living 3D tissues for modelling disease or for patient implantation. This ongoing technological revolution presents a major challenge for regulators as the current regulatory frameworks are designed for mass manufactured, standardised devices, and as such are not suited to 3D bioprinted, individual-specific devices, often using the patient’s own cells. The aims of the project were to identify and highlight the challenges of regulating 3D bioprinting technologies, and to develop an approach and the relevant tools that researchers could use for integrating regulatory considerations into the development pipeline for a 3D bioprinting device during a research translation program. By using the Axcelda (formerly known as the Biopen) project example and associated publications, this research highlighted several areas of commonly missed opportunity to consider and integrate relevant regulatory requirements into the initial academic study design. These included both general and specific considerations such as the generation of technical and regulatory documentation to better outline the existing product and components, initial critical ingredient identification and safety profiling, risks and regulatory strategy, as well as to incorporate additional specific biocompatibility testing into early pre-clinical studies, among other considerations. Doing so demonstrated the potential of this process to lead to better designed, faster and more efficient studies (from a regulatory perspective), thus increasing the potential for successful translation into a commercial product.
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    Multiparametric MRI in Prostate Cancer Diagnosis and Management
    Whish-Wilson, Thomas Ian ( 2021)
    Prostate canceris the most common cancer affecting men in Australia. Detection has previously relied upon clinical examination and prostate specific antigen (PSA) screening. Addition of MRI of the prostate prior to prostate biopsy has increased our ability to accurately diagnose prostate cancer. This thesis examines the implementation of multiparametric MRI of the prostate in Australia and the impact it has had on prostate cancer diagnosis.
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    Biofabrication of articular cartilage: Development of an efficient in vivo repair technique using autologous stem cells
    Francis, Sam ( 2020)
    Articular cartilage defects represent a major clinical challenge due to the lack of long-term management options available for young patients who present with a symptomatic and functional burden. Microfracture is the traditional standard treatment of care and has no long-term benefit demonstrated beyond 2 years, with patients reporting symptom relapse and functional compromise. Other techniques used to treat chondral defects include Autologous Chondrocyte Implantation and Matrix-induced Autologous Chondrocyte Implantation, both of which are not superior in comparison to the cheap and easily performed microfracture technique. Cartilage tissue engineering approaches using stem cells and bioscaffolds have become of significant research focus; additionally, the emergence of bioprinting technology has opened up the ability to efficiently and accurately deliver engineered tissue constructs. Biological tissue can be generated by printing cells and scaffolds together in a ‘bioink’ composition rather than using prefabricated scaffold constructs; this approach is coined ‘Biofabrication’, which is a rapidly growing field. Biofabrication approaches show promise in treating chondral defects; however, we are no closer today to a human clinical trial. Several hurdles currently prevent the progression of such research; a significant barrier is the use of long periods of laboratory-based cell culture and expansion. This increased culture duration leads to concerns with the use of animal serum-based media, sterility, senescence, loss of differentiation potential, and tumorigenic transformation. To overcome these issues, human tissue harvest, cell isolation and reimplantation should be performed efficiently, thereby reducing the exposure to the risks mentioned above. Furthermore, by establishing a specific timeframe in which a biofabrication procedure can be achieved, surgical planning and patient preparation can be structured and adequately performed. This thesis aimed to develop an efficient biofabrication procedure for cartilage repair using an autologous cell population, which could produce neocartilage in clinically relevant defects. The chapters in this work present several critical developments concerning the overall aim. First, the most chondrogenic cell source from those tested within the knee joint was identified to be the human Adipose-Derived Stem Cell (hADSC). A rapid 85-minute hADSCs isolation protocol from the Infrapatellar Fat Pad (IFP) was then developed by optimising the time-consuming aspects of the standard IFP-derived hADSCs isolation protocol (>27 hours) and shown to be comparable. Secondly, the minimum chondrogenic requirements of rapidly isolated hADSCs before reimplantation were established. It was determined that 5 days is the earliest time point during cellular expansion in which hADSCs could be driven into chondrogenesis. Therefore, the minimum biofabrication turnaround time is roughly 1-week (5 days and 85 minutes to be precise). Next, 5.0 million hADSCs/mL of a biocompatible hydrogel was shown to be the minimum concentration required to produce in vitro neocartilage. Finally, the maximum defect volume treatable in a 1-week turnaround was shown to be 380 uL (mm3) or 760 uL (mm3) using one or two IFPs respectively, representing clinically significant defect volumes. The next section of this thesis aimed to establish a biofabrication model that could be adapted for surgical use and be implemented in an animal model. In this chapter, a safe, efficient and user-friendly procedure was designed and validated in vitro. First a representative cell source was selected and validated. Next, suitable hydrogel compositions and gelation times were identified, and finally, a safe intraoperative crosslinking set-up was developed. The final element of this work was a proof of concept study, where the newly devised biofabrication approach was performed on a rabbit model to evaluate chondral repair. This procedure was successfully implemented, and the associated degree of cartilage repair was superior compared to the microfracture (clinical standard) and empty control groups. In conclusion, an efficient 1-week biofabrication approach was established for chondral repair, and this approach was shown to treat clinically significant defect volumes. The newly developed procedure has been validated for short term repair in vivo and is superior to the existing standard treatment. The next step is to provide mid-long-term efficacy of therapy in vivo using a large animal model, which if successful, paves the way to human translation. This work presents promise in the future management of chondral defects in young patients with a low-risk strategy that could one day treat/halt the progression to early-onset osteoarthritis.
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    Colorectal cancer in rural regional Australia
    Ng, Suat Chin ( 2017)
    Colorectal cancer (CRC) is the second commonest cancer in Australia. The survival outcome of colorectal cancer patients within Australia is reported to vary with population density and between health services, with some literature showing poorer prognosis in rural regional and remote patients. Chapter one aims to outline some key issues in CRC such as epidemiology, diagnosis, treatment, surveillance, and outcome whilst chapter two aims to present a systematic review of how geographical disparity influences CRC survival. There are many potential factors that contribute to a poorer prognosis in rural regional CRC patients though the literature is limited, and at times, inconsistent. Thus, there is a need for regular audit, reporting and benchmarking of outcomes in CRC patients against agreed standards. I reviewed the long-term outcomes of CRC at Barwon Health, which serves the South West Victoria, a region with a population of some 500,000. My aim was to determine whether changes introduced to the management of CRC translated into improved survival after surgery. The literature to date has suggested that patients living in rural and regional Australia (grouped together) have worse colorectal cancer survival rates than those living in metropolitan Australia. This thesis was based on a prospectively maintained registry kept over a period of thirteen years from 2002 to 2014, that had accumulated 1079 patients who had undergone surgery at the University Hospital Geelong for CRC (744 colon cancers and 335 rectal cancers). The overall number of operations per year increased over time (p=0.037) but with similar proportions of elective and emergency surgery (p=0.75) and tumour stage (P=0.21). This lack of change in the proportion of elective cases was in spite of the Federal Government introducing a National Bowel Cancer Screening Program in 2006. The proportion of patients with severe comorbidities did increase (p=0.015) over the study period. The median survival after surgery by stage was 123 months, 141 months, 76 months and 17 months for stages I to IV CRC respectively. Overall, there were improvements observed in both peri-operative mortality (POMR) (p=0.028) and long- term survival (p=0.0025) of CRC patients in this major regional centre. I then reviewed the outcome of patients with metastatic disease. The Geelong database included 843 patients who had undergone resection and primary anastomosis for their primary tumour (661 colon cancers, 182 rectal cancers). Metastatic disease was present in 16% (135 patients) and was associated with an increased risk of anastomotic leakage (13% vs. 5%, p=0.003) and a higher peri- operative mortality rate (9.6% vs. 2.8%, p=0.0003). Patients with anastomotic leakage had a reduction in the overall survival (121 months vs. 66 months, p=0.02). The fifth chapter aimed to perform a regional study to identify patients with colorectal cancer at higher risk of developing metastatic disease. There were 503 patients (345 colon and 158 rectal) with non-metastatic (stage I-III) CRC who had resections and were followed up for at least five years. Metastatic progression was, as expected, significantly higher for patients with stage III disease (aHR 4.42 for colon cancer 95% CI 1.74 to 11.23, aHR 3.34 for rectal cancer 95% CI 1.36 to 8.22), and those with lymphovascular invasion (aHR 2.94 95% CI 1.70 to 5.06). Metastatic disease was also more likely to eventuate in those with severe comorbidities (aHR 2.18, 95% CI 0.26 to 0.86), and in colon cancer patients with the lowest socioeconomic status (aHR 2.03 95% CI 1.23 to 3.34). Gender, tumour location and geographical location (rural or regional) was not associated with metastatic progression. Before determining surveillance strategies targeting higher-risk patient groups in regional Victoria, these findings would require confirmation from similar studies in other regions of rural/regional Victoria, such as Bendigo, Albury / Wodonga, Latrobe Valley, or Shepparton.
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    Pre-mRNA alternative splicing in the epithelial to mesenchymal transition of breast cancer cells
    Widodo, Edwin ( 2018)
    Pre-mRNA alternative splicing in the epithelial to mesenchymal transition of breast cancer cells Edwin Widodo, Eva Tomaskovic-Crook, Bryce van Denderen, Erik W. Thompson Summary Alternative pre-messenger RNA splicing is a process that generates multiple variants of a single gene by virtue of the alternative exons that are transcribed. In breast cancer progression and metastasis, alternative splice events (ASE) are regulated during epithelial to mesenchymal transition (EMT). EMT occurs naturally during embryonic development as epithelial-derived cells become transiently mesenchymal and move around the embryo to generate the body plan. EMT status can be determined by expression of specific markers for EMT. E-cadherin is recognized as the archetypical marker for the epithelial phenotype. During carcinoma EMT, E-Cadherin is reduced by transcriptional repression and/or translocation away from the membrane junctions, and the cytokeratin intermediate filament network is reduced or lost while vimentin expression is enhanced. EMT manipulation can be implemented by inducing overexpression of EMT-regulating driver genes, including Twist1 and Snail1 (Mani et al., 2008), and is prominently driven by transforming growth factor beta (TGFbeta). These genes act by transcriptional repression of E-Cadherin. The nuclear factor kappa B (NF-kB) pathway has also been shown to be involved in EMT in MCF10A breast cancer cells. Human breast cancer cell lines are mostly divided into 5 categories based on their characteristics defined in clinical breast cancer datasets. The categories are Luminal A, Luminal B, Basal A, Basal B, and HER2+ types. Hierarchical clustering of high throughput array studies conducted on 34 (Charafe-Jauffret et al., 2006) and 51 (Neve et al., 2006) measuring RNA expression on human breast cancer cell lines grouped those cell lines into Luminal and Basal subgroups. Luminal cells often express estrogen receptor (ER+) and progesterone receptor (PR+) while Basal cell lines lack expression of ER, PR and HER2 (triple negative) and are more resistant to adjuvant chemotherapy. The Luminal group was further divided into Luminal A with low Ki67, a marker of proliferating cells, and Luminal B with high Ki67. The Basal group of cell lines was further divided into 2 groups, Basal A and Basal B (Neve et al., 2006). Most cell lines in the Basal B group have a more invasive phenotype and exhibit a mesenchymal gene signature. We applied a panel of cell lines from those different molecular subgroups: Luminal (MCF7, which has epithelial features), Basal A (MDA-MB-468) and Basal B (MDA-MB-231, which has mesenchymal properties). The EMT features in the PMC42 system include down-regulation of CDH1 and up-regulation of Vimentin for PMC42-ET and PMC42-LA cell lines (Ackland et al., 2001, Ackland et al., 2003). PMC42 system consists of the parental PMC42-ET and the epithelial subtype, PMC42-LA, the PMC42 system provides us with a spectrum of EMT associated changes. The PMC42-LA cell line contains a low number (10-15%) of Vimentin-positive cells, whereas the PMC42-ET cells are 100% Vimentin positive, with commensurate CDH1 differences (Hugo et al., 2007). Further, in response to EGF PMC42-LA cells undergo EMT-like changes (Ackland et al., 2003). ASE in the PMC42 human breast cancer EMT were investigated by (i) comparisons between the more mesenchymal parental PMC42-ET (ET) cells and the more epithelial PMC42-LA (LA) subline, and (ii) in response to epidermal growth factor (EGF), which stimulates EMT-like changes at the mRNA and protein level in both PMC42 variants. We assessed these effects in 2D monolayer culture as well as 3D cultures in Matrigel or Collagen (Vitrogen) and found very similar results in all three culture conditions. ASE are regulated by Epithelial Splice Regulatory Proteins (ESRP) 1 and 2. The expression of both, ESRP1 and ESRP2, was found to be suppressed in Basal B but not in Luminal or Basal A cell lines (Warzecha et al., 2009a). This suggests that their suppression could be involved in EMT-related events. ESRP1 and 2 mRNA levels were constitutively lower in the mesenchymal ET cells compared to LA, but showed little EGF regulation. ESRP1 mRNA levels in epithelial MCF-7 cells were similar to LA, while mesenchymal MDA-MB-231 cells were similar to ET. For ESRP2, MCF-7 levels were higher than LA. Mammalian Ena Homolog (MENA) levels in both PMC42 variants resembled MCF-7 cells, however both variants predominantly expressed the mesenchymal-associated form, as was the case with Cluster of Differentiation 44 (CD44), Ral GEF with PH Domain and SH3 Binding Motif 2 (RALGPS2) and Membrane-associated guanylate kinase, WW and PDZ domain-containing protein 1 (MAGI1). Thus, EMT-associated-ASE revealed predominantly mesenchymal-specific splicing patterns despite the ESRP1 differential, perhaps due to a lack of ESRP2. The results confirm an ESRP1/2-related mesenchymal shift from PMC42-LA to ET cells. In general, we also confirmed a high level of ESRP1 and Fibroblast growth factor receptor 2 – exon IIIb (FGFR2 IIIb) in Luminal and Basal A cells, and reduced level of ESRP1 and higher Fibroblast growth factor receptor 2 – exon IIIc (FGFR2 IIIc) in Basal B cells. The shift from FGFR2-IIIb to FGFR2-IIIc in EMT showed alternatively spliced variants from the same gene, FGFR2. Expression of FGFR2-IIIb measured by splice-specific RT-PCR followed the same pattern as ESRP1, while both PMC42 variants were higher than MCF-7 cells for mesenchymal-associated FGFR2-IIIc. Zinc finger E-box-binding homeobox 1 (ZEB1) mRNA levels, a transcription factor that binds E-box motifs in promoters, were reduced by expression of a short hairpin RNA (shZEB1) in PMC42-ET cells. Lack of ZEB1 resulted in a significant reduction (p=0.0018) of ESRP1, but not ESRP2, consistent with the E-box in the ESRP1 proximal promoter. Although FGFR2 IIIb was upregulated after ZEB1 silencing (p=0.058), FGFR2 IIIc, which was supposed to be alternatively spliced, remained at the same level after ZEB1 silencing (p=0.6263). This suggests a direct role of ZEB1 in ESRP1 expression. Total Enabled Homolog (ENAH) was not reduced significantly after ZEB1 knockdown, (p=0.366). In summary, ZEB1-knockdown in PMC42-ET cells caused enhanced levels of ESRP1 and FGFR2 IIIb expression. Partek Genomic Suite analysis of the Affymetrix data indicated a selective upregulation of a 3’-truncated isoform of Laminin subunit alpha 3 (LAMA3 variant 2 or LAMA3v2) by EGF. qRT-PCR analysis revealed that both the long variant (LAMA3v1) and shorter variant (LAMA3v2) showed enhanced levels along the Luminal to Basal B spectrum (as explained in Chapter 1.1.3.), although the Basal B MDA-MB-231 cells appeared to under-express LAMA3v2. LAMA3v2 was particularly highly expressed in the PMC42 variants and was upregulated by EGF in PMC42-LA cells but not in the PMC42-ET cells. LAMA3v1 levels in PMC42-LA and –ET cells both resembled the MDA-MB-231. In the MDA-MB-468 model of EGF-induced EMT, LAMA3v1 was stimulated by EGF treatment (7 days) but not hypoxia (3 days), whereas LAMA3v2 expression was stimulated by either EGF (7 days) or hypoxia (3 days) treatments. Our group has conducted an experiment by xenografting MDA-MB-468 in mice. In MDA-MB-468 xenografted tumours, LAMA3v2 was expressed significantly higher than LAMA3v1. Gene silencing using small interference RNA (siRNA) techniques provide a sight on the short term effects of knocking down gene(s) in cells. In assessing the effectiveness of silencing subunit alpha 3, subunit beta 3 and subunit gamma 2 of Laminin (LAMA3, LAMB3 and LAMC2), we used short interference RNA (siRNA) targeting LAMA3 (siLAMA3), LAMB3 (siLAMB3) and LAMC2 (siLAMC2) and combination of those three siRNAs (siLAMA3B3C2). On the one hand, inhibition of LAM using the siLAMs, as confirmed with inhibition of LAMB3 LAMC2, and laminin v2, inhibited the expression of EMT markers: Vimentin. On the other hand, siLAM increased expression of Zeb1, ENAH and laminin v1. This may suggest that targeting Laminins using siRNA could reduce the EMT properties of PMC42 cell lines. RNA Seq results showed several top genes as potential candidates for EMT in PMC42 breast cancer cells. We applied Multivariate Analysis of Transcript Splicing (MATS) and Differential Exon Usage in RNASeq (DEXSeq) to identify several top candidates, which have upregulated transcript variants during EMT in the PMC42 system. Those top candidates were inspected using SeqMonk to visualize RNASeq reads. Several transcripts were listed on MATS and DEXSeq results as having one of their exon upregulated after EGF treatment in PMC42-LA, including Ladinin-1 (LAD1), Tenascin-C (TNC), Cleft Lip and Palate Transmembrane Protein-1 Like (CLPTM1L), Serine / Arginin-rich Splicing Factor 1 (SRSF1). In this investigation, only LAD1 showed a pronounced up-regulated transcript variant in SeqMonk visualization. Thus, LAD1 is a good candidate as a target for inhibiting EMT in PMC42 breast cancer cell line.
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    Combining TIL and CAR for adoptive cell therapy in metastatic melanoma
    Mills, Jane Kathleen ( 2019)
    Background Metastatic melanoma is a highly lethal disease, and until recently patients had limited therapeutic options. Knowledge and understanding of the role the immune system plays in tumour development and its therapeutic potential has recently gained momentum and immunotherapeutic agents have emerged as the gold standard of therapy in treating this cancer. Adoptive cell therapy (ACT) has been shown to have high rates of tumour regression with durable, complete responses and potential 'cure'. Tumour-infiltrating Lymphocytes (TIL) and Chimeric Antigen Receptor (CAR) therapies are examples of ACT. Each has their own advantages, limitations and toxicities. As the complexity of the immune system and its targets is increasingly appreciated, combining immunotherapies is emerging as a promising avenue for improving patient oncological outcomes. This project explores the efficacy of dual specific T cells by combining TIL and CAR therapies. Aim To establish a model system transducing TIL with anti-Her2 CAR (TIL-CAR) and assessing function against autologous melanoma tumour cells that express Her2 antigen. Method TIL were generated from patient derived metastatic melanoma tumours and tumour cell lines were established in a biobank. TIL were thawed and activated using CD3/28 beads and transduced with second generation anti-Her2 CAR (scFv-erbB2-CD28-zeta) using a retronectin protocol. Patient matched PBMCs were transduced for functional comparison. Melanoma tumour lines in the biobank were found to innately express Her2 antigen to varying degrees. Some melanoma tumour lines were transduced and sorted to create higher expressing Her2 antigen lines for functional comparison. Flow cytometry was used to confirm cell phenotype and antigen/CAR expression. Functional testing was performed using ELISA and chromium release assays. An in vivo ACT model in NSG mice was performed comparing TIL and TIL-CAR. Results TIL were successfully cultured from metastatic melanoma tumour pieces. Despite TIL proliferating at lower rates than PBMCs, both were successfully transduced to express anti-Her2 CAR. When TIL were transduced to express anti-Her2 CAR they were functionally active through both TCR and CAR and produced greater amounts of interferon gamma against Her2 expressing tumour lines. TIL-CAR had greater cytotoxic activity when cultured against autologous melanoma tumour lines, but the benefit transduced TIL over PBMCs varied in response between tested patients. The advantage of TIL-CAR over PBMC-CAR did not demonstrate consistent trends across this limited group of patients. The functional activity may be influenced by the level of Her2 expression in the co-cultured tumour cells as well as by the phenotype of T cell populations. Results of an in vivo pilot study in mice demonstrated reduction in tumour size when TIL-CAR were used in an ACT protocol. The primary limitation of this study was the low proliferation rate of TIL following transduction which required extended periods in culture. Conclusions Combination of TIL-CAR is a novel concept. TIL can be transduced to express anti-Her2 CAR. Metastatic melanoma cells in our biobank constitutively express Her2 antigen. TIL-CAR tend to show greater activity in interferon gamma and cytotoxic functions compared to parental (non-transduced) TIL when cultured against Her2 expressing tumour lines. When compared to the activity of PBMCs transduced with the same CAR the additional benefit conferred by TIL-CAR is inconsistent. Protocols would benefit from further optimisation to generate a 'younger' phenotype capable of more rapid and sustainable proliferative potential and facilitate earlier delivery of therapy if used in a clinical setting.
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    Strategies for engineering skeletal muscle: an important link in the neuroprosthetic interface of bionic limbs
    Ngan, Catherine G. Y. ( 2019)
    Limb amputation is a major cause of disability in our community, for which motorised prosthetic devices offer a return to function and independence. Advanced robotic limb technology utilises a range of mind-prosthetic interfacing strategies to intuitively drive the limb. These approaches include direct recording of peripheral nerves, brain-recording interfaces, or the transposition of transected nerves to remaining muscle groups for myoelectric recording. All of the current methods are hampered by delicate neural biology, either leading to premature device failure or introducing unnecessary surgical risk. As an alternative, this thesis proposes a new solution: to develop a bioelectrode using tissue engineered skeletal muscle as a signal amplifier of activity from residual nerves for intuitive prosthetic control. Conceptually, the fabrication of such a device would begin with a tissue biopsy from the patient from which a pool of myogenic stem cells would be derived and expanded. These autologous cells would be used for the tissue engineering of skeletal muscle fibres, primed with neurotrophic biofactors to optimise the tissue for innervation. Flexible recording wires could be incorporated into this fabrication step, thus eliminating the trauma of electrode insertion and also optimising its biocompatibility. The bioelectrode device could also be designed to patient or prosthetic anatomy as required. This thesis developed key elements of the above proposal. Firstly, a bioprinting technique was established to tissue engineer functional skeletal muscle using a gelatin methacryloyl (GelMA) bioink. Bioprinting enabled the rapid deposition of muscle progenitor cells (primary mouse myoblasts) in layered fibres, reminiscent of native muscle architecture. Fabrication parameters were optimised to produce fibres with high cell viability and print resolution. These bioprinted constructs were then able to support advanced maturation of cells into multinucleated muscle fibres, as evidenced by molecular analysis and functional testing. There was a significantly greater upregulation of genetic markers of myogenesis when compared to monolayer myotube cultures, and this result was complemented with functional testing that demonstrated mature patterns of calcium handling and electrical activity. The bioprinted muscle was then implanted in the nude rat to assess its capacity for innervation and vascularisation. The tissue construct was implanted in an in vivo chamber, which was supplied by a surgically formed arteriovenous loop and transected nerve. After only two weeks, independent bundles of mature muscle fibres had developed, with histological evidence of neural integration and vascularisation. In vivo electrophysiological studies confirmed the presence of innervation by demonstrating muscle activity in response to neural stimulation. Lastly, the triad of bioprinted muscle, vasculature and nerve was housed in a customised 3D printed chamber as a prototype for a bioelectrode that could be surgically grafted onto transected peripheral nerves after limb amputation. To conclude, this thesis developed the principle elements of designing a bioelectrode for neuroprosthetic interfacing and provides the foundation for further tissue optimisation and integration of electrodes. Although the work presented is in the frontier stages of development, it offers an exciting glimpse into the future of modern medicine and brings the dream of mind-controlled motorised prosthetic limbs closer to everyday reality.