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The incidence of cancer cases is rising steadily, while improved early detection and new cancer-specific therapies are reducing the mortality rate. In addition to curing cancer or prolonging life, increasing the quality of life is thus an important goal of oncology, which is why the burdens of cancer and treatment are becoming more important. A common side effect of cancer and its therapy is cancer-related fatigue, a tiredness that manifests itself on physical, emotional and cognitive levels and is not in proportion to previous physical efforts. Since the etiology of fatigue has not yet been fully clarified, symptom-oriented therapy is preferable to cause-specific therapy. In addition to activity management, sleep hygiene, and cognitive behavioral therapy, mind-body interventions such as yoga are recommended for reducing fatigue.
Previous studies with small sample sizes were able to examine the efficacy of yoga regarding fatigue predominantly in patients with breast cancer. Long-term effects of yoga have rarely been studied and there have been no attempts to increase long-term effects through interventions such as reminder e-mails. This dissertation takes a closer look at these mentioned aspects of the study sample and long-term effects. An 8-week randomized controlled yoga intervention was conducted, including patients with different cancer types reporting mild to severe fatigue. Following the 8-week yoga therapy, a randomized group of participants received weekly reminder e-mails for 6 months for regular yoga practice, whereas the control group did not receive reminder e-mails.
The first paper is a protocol article, which addresses the design and planned implementation of the research project this dissertation is based upon. This serves to ensure better replicability and comparability with other yoga studies. Due to a very low consent rate of patients in the pilot phase, it was necessary to deviate from the protocol article in the actual implementation and the planned inclusion criterion of fatigue >5 was reduced to fatigue >1.
The second paper examines the efficacy of the eight-week yoga intervention. Patients in the intervention group who participated in the yoga classes seven times or more showed a significantly greater reduction in general and physical fatigue than those who participated less often. The efficacy of yoga was related to the number of attended yoga sessions. Women with breast cancer who participated in yoga reported greater reductions in fatigue than women with other cancer types. There was also an improvement for depression and quality of life after eight weeks of yoga therapy compared to no yoga therapy. These results imply that yoga is helpful in reducing depression and cancer-related fatigue, especially in terms of physical aspects and improving quality of life.
The third paper focuses on the efficacy of reminder e-mails in terms of fatigue and practice frequency. Patients who received reminder e-mails reported greater reductions in general and emotional fatigue, as well as significant increases in practice frequency, compared to patients who did not receive reminder e-mails. Compared to fatigue scores before yoga, significantly lower fatigue and depression scores and higher quality of life were reported after yoga therapy and at follow-up six months later. Weekly e-mail reminders after yoga therapy may have positive effects on general and emotional fatigue and help cancer patients with fatigue establish a regular yoga practice at home. However, higher practice frequency did not lead to higher improvement in physical fatigue as found in Paper 2. This may indicate other factors that influence the efficacy of yoga practice on physical fatigue, such as mindfulness or side effects of therapy.
This research project provides insight into the efficacy of yoga therapy for oncology patients with fatigue. It is important that such interventions be offered early, while fatigue symptoms are not too severe. Regular guided yoga practice can reduce physical fatigue, but subsequent yoga practice at home does not further reduce physical fatigue. Reminder emails after completed yoga therapy could only reduce patients' emotional fatigue. It may be that physical fatigue was reduced as much as possible by the previous yoga therapy and that there was a floor effect, or it may be that reminder emails are not suitable as an intervention to reduce physical fatigue at all. Further research is needed to examine the mechanisms of the different interventions in more detail and to find appropriate interventions that reduce all levels of fatigue equally.
BAD (Bcl-2 antagonist of cell death, Bcl-2 associated death promoter) is a pro-apoptotic member of the Bcl-2 protein family that is regulated by phosphorylation in response to survival factors. Although much attention has been devoted to the identification of phosphorylation sites in murine BAD (mBAD), little data are available with respect to phosphorylation of human BAD (hBAD) protein. In this work, we investigated the quantitative contribution of BAD targeting kinases in phosphorylating serines 75, 99 and 118 of hBAD (Chapter 3.1). Our results indicate that RAF kinases phosphorylate hBAD in vivo at these established serine residues. RAF-induced phosphorylation of hBAD was not prevented by MEK inhibitors but could be reduced to control levels by use of the RAF inhibitor Sorafenib (BAY 43-9006). Consistently, expression of active RAF suppressed apoptosis induced by hBAD and the inhibition of colony formation caused by hBAD could be prevented by RAF. In addition, using surface plasmon resonance technique we analyzed the direct consequences of hBAD phosphorylation by RAF with respect to complex formation of BAD with 14-3-3 proteins and Bcl-XL. Phosphorylation of hBAD by active RAF promotes 14-3-3 protein association, whereby the phosphoserine 99 represents the major binding site. Furthermore, we demonstrate in this work that hBAD forms channels in planar bilayer membranes in vitro. This pore-forming capacity is dependent on phosphorylation status and interaction with 14-3-3 proteins. Additionally, we show that hBAD pores possess a funnel-shaped geometry that can be entered by ions and non-charged molecules up to 200 Da (Chapter 3.2). Since both lipid binding domains of hBAD (LBD1 and LBD2) are located within the C-terminal region, we investigated this part of the protein with respect to its structural properties (Chapter 3.3). Our results demonstrate that the C-terminus of hBAD possesses an ordered β-sheet structure in aqueous solution that adopts helical disposition upon interaction with lipid membranes. Additionally, we show that the interaction of the C-terminal segment of hBAD with the BH3 domain results in the formation of permanently open pores, whereby the phosphorylation of serine 118 proved to be necessary for effective pore-formation. In contrast, phosphorylation of serine 99 in combination with 14-3-3 association suppresses formation of channels. These results indicate that the C-terminal part of hBAD controls hBAD function by structural transitions, lipid binding and phosphorylation. Using mass spectrometry we identified in this work, besides the established in vivo phosphorylation sites at serines 75, 99 and 118, several novel hBAD phosphorylation sites (serines 25, 32/34, 97, 124 and 134, Chapter 3.1). To further analyze the regulation of hBAD function, we investigated the role of these newly identified phosphorylation sites on BAD-mediated apoptosis. We found that in contrast to the N-terminal phosphorylation sites, the C-terminal serines 124 and 134 act in an anti-apoptotic manner (Chapter 3.4). Our results further indicate that RAF kinases and PAK1 effectively phosphorylate BAD at serine 134. Notably, in the presence of wild type hBAD, co-expression of survival kinases, such as RAF and PAK1, leads to a strongly increased proliferation, whereas substitution of serine 134 by alanine abolishes this process. Furthermore, we identified hBAD serine 134 to be strongly involved in survival signaling in B-RAF-V600E containing tumor cells and found phosphorylation of this residue to be crucial for efficient proliferation in these cells. Collectively, our findings provide new insights into the regulation of hBAD function by phosphorylation and its role in cancer signaling.
Bispecific T cell engager (BiTE) display a novel design among the class of bispecific antibodies and hold great promise to fight diverse cancers. BiTE molecules consist of two different binding entities derived from two human IgG antibodies connected by a short peptide linker. Their binding arms are directed against the CD3e chain of the T cell receptor on T cells and against an antigen that is specific for (e.g., CD19 for lymphoma in MT103) or over-expressed on (e.g., EpCAM for epithelial cancer in MT110) tumor cells. Without requirement for pre- or co-stimulation, BiTE molecules efficiently redirect CD3+ T cells towards tumor cells expressing the relevant target antigen. Only a BiTE molecule simultaneously bound to both tumor cell and T cell activates the T cell to exert its cytolytic function resulting in tumor cell death. In T cells stimulated with both BiTE and target cells, elevated levels of caspase activation and increased expression of cytotoxic and signaling proteins are observed. These include cytolytic proteins granzyme B and perforin, activation markers CD69 and CD25 and adhesion molecules CD2 and LFA-1. Activated T cells secrete the usual mix of cytokines, among them pro-inflammatory cytokines IFN-g and TNF-a. The membrane of tumor cells expressing the relevant target antigen is perforated during the attack of BiTE-stimulated effector cells as can be concluded from adenylate kinase release from the cytosol of tumor cells. Ca2+-chelator EGTA completely blocked BiTE-mediated activation of caspases and tumor cell lysis. As perforin is strictly Ca2+-dependent, a major role for this pore-forming protein is assumed for the elimination of tumor cells via BiTE-stimulated T cells. Granzyme B and caspases are main players in BiTE-mediated elimination of tumor cells. Inhibitors of granzyme B or caspases reduce or block, respectively the activation of caspases. However, other signals of apoptosis (cleavage of PARP and fragmentation of DNA) were only reduced by granzyme B inhibitor or caspase inhibitor. Most interestingly, the lytic capacity of BiTE molecules was not impaired by granzyme B inhibitor or caspase inhibitor. It seems that there is no requirement for granzyme B and caspases to be present simultaneously. Instead the data presented provide evidence that they can be replaced one at a time by related proteins. Pre-incubation of effector cells with the glucocorticoids dexamethasone or methylprednisolone resulted in markedly decreased secretion of cytokines by T cells yet only a small reduction in the expression of activation markers and adhesion molecules on T cells and specific lysis of tumor cells upon BiTE stimulation. Soluble factors secreted in an undirected manner by BiTE-stimulated T cells do not mediate tumor cell death by themselves. Bystander cells negative for the antigen that is recognized by the BiTE molecule will not be compromised by BiTE activity. The cytokine TGF-b reduced proliferation as well as granzyme B and perforin expression of BiTE-stimulated T cells. Redirected lysis by BiTE-activated T cells was also decreased under the influence of TGF-b, however lysis was still performed at a reasonable rate (72 % of target cells). TGF-b does not exert a deleterious effect on lytic potential of BiTE-stimulated T cells. The minimal anticipated biological effect level for the BiTE MT110 was determined for the entry of MT110 into phase I clinical studies. Experiments analyzing redirected lysis of tumor cells, expression of activation marker CD25 and cytokine release by T cells revealed a MABEL value of 50 pg/ml for MT110.
Melanotic melanoma (MM) of Xiphophorus (Teleostei: Poeciliidae) was studied by conventional preparations and freeze-etch preparations for electron microscopy. MM of Xiphophorus exhibits tightly packed pigment cells with prominent dendritic processes and interdigitations of their plasma membranes. The most impressive feature of MM cells is the occurrence of Iarge lobulated nuclei with numerous nuclear pores and some nuclear pockets. Abundant spheroidal or ellipsoidal melanosomes (diameter 200-650 nm) and vesicular structures are distributed throughout the cellular dendrites, whereas the perinucJear cytoplasm is free of melanosomes.
A further characteristic feature of melanoma cells in fish is the occurrence of melanosome complexes (i.e., "compound melanosomes"). These melanosome complexes consist of a few to numerous melanosomes, which are enveloped by a separate rnembrane. Pinocytotic vesicles couJd be demonstrated with distinct differences in frequency and distribution patterns, indicating differences in the metabolic activities of the cells in the same melanoma. Intercellular junctions are lacking in the MM cells.
The conventional TEM technique showed clear advantages in the demonstration of intemal architecture of organelles, whereas FE bad considerable potential in respect to the visualization of membrane surface specializations.