During stress conditions, glucocorticoids are secreted and exert most of their physiological responses by binding to and modulating the transcriptional activity of the glucocorticoid receptor (GR). Once activated, GR can regulate numerous cellular processes including inflammation, development, growth, metabolism and apoptosis. Although glucocorticoids have been used in the treatment of leukaemia for over 50 years, with the molecular mechanisms by which steroids exert their pro-apoptotic effect, the pathways responsible for the development of resistance to glucocorticoid treatment, as well as their role in the programmed cell death in other tissue types have not been precisely defined. Research has demonstrated that glucocorticoid-induced apoptosis requires a transcriptionally active form of GR and is executed by the induction of the intrinsic pathway of apoptosis. In addition, GR is regulated by diverse types of cytotoxic stress; including UV irradiation and hypoxia, which alter the receptor’s transcriptional activity through multiple mechanisms. These include post-translational modifications, subcellular localisation and interaction of the receptor with co-regulator proteins. The aims of this study are to identify novel members of the Bcl-2 family that are regulated at the transcriptional level by GR in both leukaemia and other tissue types where glucocorticoids promote cell survival. In addition, the molecular crosstalk between signalling pathways activated by cytotoxic stress conditions and the mechanisms by which they differentially modulate the apoptotic response will be investigated. Results obtained in this study have identified putative glucocorticoid response elements in the promoters of the BH3-only pro-apoptotic gene NOXA and the anti-apoptotic gene Mcl-1 and confirmed that both NOXA and Mcl-1 are direct GR transcriptional targets. The glucocorticoid-mediated expression of NOXA and Mcl-1 alters their protein-protein interaction pattern, leading to the subsequent destabilisation of Mcl-1 in cell lines that undergo glucocorticoid-induced apoptosis. Investigation into the effects that other cytotoxic stress pathways have on GR function have revealed that serine 226 phosphorylation of GR by JNK occurs in a rapid and transient manner. Phosphorylation has inhibitory effects on the transcription of GR targets in a gene-specific manner, including the differential regulation of NOXA gene expression. During hypoxia, glucocorticoids differentially regulate the GR and HIF-1 target genes, NOXA and Mcl-1, altering the apoptotic response. This study has provided additional insight into the molecular mechanisms that govern glucocorticoid-induced programmed cell death and revealed mechanisms by which glucocorticoids and cytotoxic stress pathways crosstalk, regulating apoptosis.

T-cell acute lymphocytic leukemia (T-ALL) affects approximately 1,500 people per year in the United States, many of them children. The overall survival rate of children with T-ALL is greater than 80%. However, patients in a newly identified subtype called early T-cell progenitor acute lymphocytic leukemia (ETP-ALL), have a survival rate of only 19%. We have used the Sleeping Beauty (SB) transposon/transposase system in mice to model the T-ALL subtypes and identify cancer-causing mutations in the diseases. We have also developed three strains of NOTCH1 transgenic mice. NOTCH1 is a gene that is mutated in over 60% of cases of T-ALL, and these NOTCH1 transgenic mice could be used to better understand the role NOTCH1 plays in T-cell transformation. In order to model T-ALL subtypes we crossed SB mice to Vav-iCre mice, Lck-Cre mice, and CD4-Cre mice. This causes activation of SB in hematopoietic stem cells (HSCs), double negative (DN) thymocytes, and double positive (DP) T-cells, respectively. The Vav/SB tumors were characterized by mutations in Notch1, Ikzf1, and Rasgrp1. The predominant mutations found in the Lck/SB and CD4/SB models were Stat5b, Myc, Gfi1, Whsc1, and Jak1. Microarray was performed on a subset of samples. It was found that the CD4/SB tumors had expression profiles very similar to human ETP-ALL samples, and the Vav/SB tumors had expression profiles very similar to typical T-ALL samples. This data indicates that the cell-of-origin for ETP-ALL may not be an early T-cell progenitor, but instead may be a double positive or single positive T-cell. It also indicates that the cell-of-origin for typical T-ALL may be a stem/progenitor cell of the T-lineage. In order to better study the oncogenic potential of mutant NOTCH1 in T- ALL, we produced three NOTCH1 transgenic mouse strains that mimic the most common NOTCH1 mutations found in human T-ALL patients. These mutations are found in two distinct regions of the gene, the heterodimerization (HD) domain and the PEST domain and can occur alone or in combination. The strains also contain a lox-stop-lox (LSL) cassette in the first exon of NOTCH1, making expression Cre-dependent. Preliminary results from NOTCH1-HD-PEST (NHDP) transgenic mice indicate that, when crossed to Lck-Cre mice, offspring do not develop T- cell lymphoma. However, when NHDP/Lck-Cre mice are crossed to SB mice, the mutant NOTCH1 transgene accelerates a SB-induced model of T-cell lymphoma.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / A Leucemia LinfocÃtica Aguda (LLA) e o Linfoma nÃo-Hodgkin (LNH) estÃo entre os mais frequentes tipos de neoplasias em crianÃas. A prevenÃÃo e controle do cÃncer devem ser priorizados, tendo em vista sua alta prevalÃncia e crescente relevÃncia como causa de morte em muitos paÃses, alÃm do grande volume de recursos financeiros consumidos. O nordeste brasileiro à pobre em estudos epidemiolÃgicos sobre o cÃncer infantil. O objetivo deste estudo foi traÃar o perfil dos pacientes portadores de LLA e LNH admitidos no perÃodo de 2001 a 2005 no Hospital Infantil Albert Sabin. Estudo observacional, descritivo e retrospectivo. 325 prontuÃrios (254 casos de LLA e 71 de LNH) de pacientes entre 0 e 18 anos e 11 meses foram revisados. Os dados foram inseridos em bancos de dados dos programas SPSS 14.0, Epi Info 3.3.2 e Microsoft Excel 2007. O ponto de corte para desnutriÃÃo foi o escore Z igual a -2 desvios-padrÃo. Na anÃlise estatÃstica foram utilizados o teste exato de Fisher, Qui-quadrado, Student (t), Mann-Whitney, Shapiro-Wilk, Levene, Log-rank, modelo de regressÃo de Cox e mÃtodo de Kaplan Meier para anÃlise de sobrevida. O nÃvel de significÃncia foi p<0,05. A populaÃÃo deste estudo constituiu-se predominantemente por pacientes do sexo masculino (63,4%), faixa etÃria de 02 a 06 anos (49,8%), cor nÃo-branca (62,5%); provenientes da capital e regiÃo metropolitana (56,9%) e com prognÃstico de alto risco (59,1%). 38,3% evoluÃram a Ãbito. As principais manifestaÃÃes clÃnicas iniciais foram febre, anemia, emagrecimento e cansaÃo nos casos de LLA; e febre, massa tumoral palpÃvel, anemia e dor abdominal nos casos de LNH. O tempo mÃdio de duraÃÃo das queixas foi de 3,9 meses. CrianÃas de 0-1 e de 13-18 anos apresentaram pior prognÃstico. A cor da pele, o prognÃstico, o protocolo de tratamento e os sintomas/sinais iniciais febre, cansaÃo e vÃmito mostraram associaÃÃo significativa em relaÃÃo aos Ãbitos. Os protocolos terapÃuticos mais utilizados foram adaptados do LLA 93 e LNH 95. 31% dos pacientes em uso do LLA 93 e 49,2% em uso do LNH 95 evoluÃram a Ãbito. Maior percentual de Ãbito ocorreu no grupo de alto risco (56,94%) e durante a fase de induÃÃo (36,11%) do protocolo LLA 93. Entre os pacientes de baixo risco, 39,28% faleceram durante a fase de manutenÃÃo e 17,85% apÃs o fim do protocolo. 48,78% dos pacientes de alto risco faleceram durante a fase de induÃÃo. Entre os 25 casos que utilizavam o protocolo LNH 95 e faleceram, 4% correspondiam a Linfoma de alto risco oriundos de cÃlulas T e 96% de cÃlulas B. 53,31% (n=15) dos pacientes com Linfoma de cÃlulas B e risco intermediÃrio para recaÃda faleceram durante o Ciclo A do tratamento. Nove pacientes apresentavam alto risco para recaÃda e 33,34% faleceram na fase de CitorreduÃÃo. O Ãndice de desnutriÃÃo para os pacientes com LLA foi de 8,3%, 6,0% e 5,6% e para LNH foi 12,3%, 14,1% e 15,9% em relaÃÃo a peso/estatura, peso/idade e estatura/idade, respectivamente. Pacientes com LLA apresentaram dÃficit maior no Ãndice peso/estatura, indicativo de um processo de desnutriÃÃo aguda. Maior dÃficit no Ãndice estatura/idade entre os pacientes com LNH indica um processo de desnutriÃÃo crÃnica. Os resultados acerca da frequÃncia dessas patologias, faixa etÃria e sexo foram equivalentes aos encontrados na maioria dos estudos. O prognÃstico inicial e o protocolo terapÃutico indicam uma possÃvel influÃncia sobre o desfecho do tratamento. Estudos adicionais sÃo necessÃrios para avaliar a influÃncia da quimioterapia, cor da pele, estado nutricional e outros fatores sobre o tempo de sobrevida do paciente com cÃncer. Os profissionais de saÃde e a populaÃÃo leiga precisam conhecer melhor e estar atentos Ãs manifestaÃÃes clÃnicas iniciais das neoplasias a fim de facilitar o diagnÃstico precoce. / The Acute Lymphocytic Leukemia (ALL) and the Non-Hodgkin Lymphoma (NHL) are among the most frequent types of cancer in children. The prevention and control of the cancer must be prioritized, in view of its high prevalence and increasing relevance as cause of death in many countries, beyond the great sum of consumed financial resources. The Brazilian northeast is poor in epidemiological studies about cancer in the children. The objective of this paper was to set the profile of the patients with LLA and LNH admitted in the Hospital Infantil Albert Sabin between 2001 and 2005. Observational descriptive and retrospective study. 325 medical registers (254 cases of LLA and 71 of LNH) of patients among 0 and 18 years and 11 months had been revised. The data had been inserted in data bases of the programs SPSS 14.0, Epi 3.3.2 Info and Microsoft Excel 2007. A Z-score cut-off point of <-2 SD was used to classify the malnutrition. The Fisherâs Exact Test, Qui-square, Student (t), Mann-Whitney, Shapiro-Wilk, Levene, Log-rank, Cox regression and Kaplan Meier Survival Probability Estimates were used in the statistical analyses. The level of significance was p<0,05. The population of this study was predominantly male (63.4%), 02 to 06 years age-group (49.8%), non-white (62.5%), from the capital and metropolitan region (56.9%) and with prognostic of high risk (59.1%). 38.3% died. The main clinical manifestations had been fever, anaemia, loss of weight and fatigue in the LLA cases; and fever, anaemia, palpable tumor mass and abdominal pain in the LNH cases. The mean duration time of the complaints was 3.9 months. Children with 0 to 1 and 13 to 18 years had presented worse prognosis. The color of the skin, the prognosis, the treatment protocol and the initial clinical manifestations (fever, fatigue and vomit) had shown significant association in relation to the deaths. The therapeutical protocols more used were adapted of the LLA 93 and LNH 95. 31% of the patients in use of LLA 93 and 49.2% in use of LNH 95 died. The largest percent of deaths were in the group of high risk (56.94%) and in the induction phase (36.11%) of protocol LLA 93. Between the patients of low risk, 39.28% died during the maintenance phase and 17.85% after the end of the protocol. 48.78% of the patients of high risk died during the induction phase. Among the 25 cases that used protocol LNH 95 and died, 4% corresponded to lymphoma of high risk deriving of the cells T and 96% of the cells B. 53.31% (n=15) of the patients with lymphoma of the cells B and intermediate risk to fallen died during the Cycle A of the treatment. Nine patients presented high risk for fallen and 33.34% died in the cytoreduction phase. The malnutrition indices to the LLA patients were of 8.3%, 6.0% and 5.6% and to LNH were 12.3%, 14.1% and 15.9% in relation the weight/height, weight/age and height/age, respectively. Patients with LLA had presented larger deficit in the index weight/height, indicative of a process of acute malnutrition. Larger deficit in the height/age index between the patients with LNH indicates a process of chronic malnutrition. The results about the frequency of these disease, age-group and gender were equivalents to those encountered in the majority of studies. The initial prognosis and the therapeutical protocol indicate an influence on the outcome of the treatment. Other studies are necessary to evaluate the influence of the chemotherapy, color of the skin, nutritional status and other factors on the survival time of the patient with cancer. The professionals of health and the laypeople need to know better and to be intent to the initial clinical manifestations of the neoplasm disease in order to facilitate the precocious diagnosis.

Magister Scientiae (Nutrition Management) - MSc(NM) / Acute lymphocytic leukemia (ALL) is the most common type of childhood cancer accounting for approximately 25% of cancers diagnosed in children less than 20 years of age. It originates in the bone marrow and prevents the normal manufacture of red blood cells, white blood cells and platelets. A poor nutritional status is frequently observed in children with ALL at the time of diagnosis and during treatment which may result in protein energy malnutrition if nutrition intervention is delayed. This retrospective study aims to assess the nutritional status of children newly diagnosed with Acute Lymphoblastic Leukemia (ALL) using 20 case studies between 1 January 2013 and 31 December 2014 from Sheikh Khalifa Medical City (Abu Dhabi, UAE), in order to develop an appropriate nutritional support protocol for pediatric ALL patients treated at this institution. Study Design: A retrospective descriptive case study design was used. The study population consisted of 20 electronic medical records of patients aged between 1-14 years who were newly diagnosed with Acute Lymphoblastic Leukemia (ALL) and admitted to Sheikh Khalifa Medical City for treatment during the period 1 January 2012 and 31 Dec 2014. Data Collection: Identification of suitable participants began through a review of each potential study participant`s electronic medical record. Data was collected and recorded on a data collection form (Appendix III) from the electronic medical record for each suitable participant for the following at admission and during the full duration of all phases of cancer treatment namely induction, consolidation, interim maintenance, delayed intensification and maintenance. The data collected comprised of the following: age, gender, date of diagnosis, symptoms on diagnosis, the cancer diagnosis (type and subtype), anthropometric measurements (weight, length/ height, head circumference), biochemical values (visceral proteins, blood glucose levels, hemoglobin, hematocrit, lymphocyte count), clinical assessment (stomatitis, anemia, mucositis), diet history (home feeding regimes; consumption of daily requirements; food preferences – types, textures; food allergies, food intolerances; food aversions; use of oral nutritional supplements; treatment-related side-effects; systemic related side-effects (nausea; vomiting; diarrhea; anorexia; appetite changes; taste changes; physical activity level; depression), dietary requirements (age and gender related nutritional requirements for energy, protein, fat and fluids) and indications for nutritional support (oral feeding; enteral feeding; parenteral feeding). Analysis of Results: The weights and length/ heights of participants recorded in the electronic medical records were converted to z-scores on the World Health Organization growth charts. The diet prescription of nutritional intervention was interpreted in comparison to the biochemical indices, anthropometric status and dietary intake of each participant. All the data involving changes in anthropometrics, biochemistry, diet history and nutritional interventions from each case study (from diagnosis and through all stages of treatment) was screened and compared with reference values in the context of the age and sex of the child. Evidence based nutritional guidelines were used to document the outcomes of the medical nutrition treatment provided in order to develop a nutrition support protocol for children with Acute Lymphoblastic Leukemia at Sheikh Khalifa Medical City. Results: The results showed that weight loss expressed as a percentage of body weight provided a more accurate estimate of the true significance of weight loss in subjects undergoing cancer treatment (chemotherapy) for ALL. A weight loss of greater than 5% of body weight over a period of one month is considered a sign of nutritional deprivation even if the subject is not classified as undernourished by anthropometric parameters. Subjects experienced the highest weight loss during the consolidation phase and interim maintenance phases of treatment. Conclusion: It can therefore be concluded that pediatric subjects on cancer treatment for ALL at SKMC and receiving nutritional support underwent changes in nutritional status as manifest by a reduction in more than 5% of their body weight during three phases of treatment namely induction, consolidation and interim maintenance. An appropriate nutrition support protocol was developed based on the results and experience obtained from this study for pediatric ALL patients treated at SKMC.

A leucemia linfóide aguda nos adultos apresenta prognóstico reservado. Os objetivos deste estudo são descrição e análise de parâmetros clínicos, laboratoriais e fatores prognósticos em 102 pacientes tratados com diferentes protocolos de quimioterapia no período de 1990 a 2005, no Serviço de Hematologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Em estudo de coorte retrospectivo, com exclusão de LLA subtipo L3 (FAB) ou B-IV (EGIL), foram analisadas a taxa de remissão completa (RC), sobrevida global (SG) e sobrevida livre de doença (SLD) para a população geral e para os dois principais protocolos de tratamento. A análise estatística foi feita pelo programa SPSS 10.0. Associação entre variáveis, fatores prognósticos e resposta foram observados através do teste ?2 de Person. Curvas de SG e SLD foram construídas pelo método de Kaplan-Meier e as diferenças analisadas pelo teste de log-rank. A idade média foi de 30,6 anos (12 a 82 anos) e predominou o sexo masculino (55,9%). Ao diagnóstico, os achados clínicos foram: fadiga (58,2%), esplenomegalia (59,7%), hepatomegalia (54,6%), linfadenopatia (52,6), febre (38,8%), dor óssea(28,6%), sangramento (27,5%) e cefaléia (15,3%). Envolvimento do sistema nervoso central (SNC) foi detectado em 11 (11,8%) pacientes, enquanto envolvimento testicular acometeu um paciente. O valor médio de hemoglobina, leucócitos e plaquetas foram 8,5g/dl, 84.341/mm3 e 76.275/mm3, respectivamente. 98,7% dos pacientes apresentaram linfoblastos no sangue periférico. A classificação FAB foi igualmente observada entre os tipos L1 e L2. As LLA B e T foram observadas em 69,7% e 30,2%, respectivamente. O cariótipo foi realizado em 40 pacientes, e t (9;22) foi identificada em 20% (8/40) dos casos. Os pacientes foram tratados com quatro diferentes protocolos: BFM 86 modificado (BFM 86M) em 47,15% (48/102), Linker et al em 39,2% (40/102), Lister et al em 5,9% (6/102) e CHOP em 7,8% (8/102). Na análise para a população geral, na fase de indução, 70,6% (65/92) dos pacientes entraram em RC. Idade inferior a 18 anos e ausência de infiltração de SNC foram fatores preditores positivos de resposta em análise multivariada (p=0,03). Com mediana de seguimento de 49 meses, observamos taxa de 30,5% e 27% para SG e SLD em 4 anos. Ausência de sangramento e hepatomegalia, ao diagnóstico, e idade < 35 anos estiveram associados à maior SG através de análise multivariada (p=0,01). Os dois protocolos com maior número de pacientes, apresentaram distribuição semelhante de parâmetros clínicos e laboratoriais, a exceção da variável FAB. RC foi obtida em 76,7% e 63,9% dos pacientes tratados respectivamente com os protocolos BFM 86M e Linker (p=0,21). A SG foi de 49,5% com o BFM 86M em 4 anos Vs 16% com o protocolo Linker (p=0,004). Observou-se que o protocolo BFM86M teve melhor SG para pacientes com idade <35 anos (p=0,01), sem sangramento e hepatomegalia ao diagnóstico (p=0,03 e p=0,01) e sem leucocitose (B <30.000mm3 e T <100.000mm) (p=0,04); enquanto que pacientes com LLA T tratados com o protocolo Linker apresentaram SG inferior (p=0,05). A diferença de SLD entre os dois protocolos não foi significativa (p=0,58), entretanto na faixa etária entre 21-35 anos, o protocolo BFM se mostrou superior (p=0,03). Verificamos que o BFM 86M é superior ao Linker et al, sendo um bom protocolo para tratamento de LLA em pacientes adolescentes e adultos jovens sem fatores de risco. / Acute lymphoblastic leukemia in adults has a poor outcome. The aim of this study is to describe and evaluate clinical, laboratory and prognostic factors in 102 patients reated with different protocols of chemotherapy from 1990 to 2005. Adult ALLsubtype L3 (FAB) or B-IV (EGIL) was excluded. We evaluated complete remission (CR), overall survival (OS) and disease free survival (DFS) rates for the whole population and for the two principal treatment protocols. This retrospective cohort was done in hematology department of the FMUSP. Statistical analysis was done by SPSS 10.0. The association of features and prognosis was assessed by Person\'s chi-square. OS and DFS curves were constructed by Kaplan-Meier method and the differences were calculated by the log-rank test. Mean age was 30,6 (12 to 82) years and 55,9% was male. Clinical findings, at diagnosis, were fatigue (58,2%), splenomegaly (59,7%), hepatomegaly (54,6%), ymphadenopathy (52,6%), fever (38,8%), bone pain (28,6%), bleeding (27,5%) and headache (15,3%). Involvement of central nervous system (CNS) was detected in 11 (11,8%) patients and testicular involvement was observed in one patient. Mean blood values were 8,5g/dl, 84.341/mm3 and 76.275/mm3 for hemoglobin, leucocytes and platelets respectively. 98,7% of the patients presented with lymphoblasts in peripheral blood. FAB classification was equally observed between L1 and L2. B and T ALL was noted in 69,7% and 30,2% respectively. Karyotype analysis was performed in 40 cases, where Philadelphia chromosome (ph) was identified in 20% (8/40) of them. Patients were treated with four different protocols: BFM 86 modified (BFM 86M) in 47,1% (48/102), Linker et al in 39,2% (40/102), Lister et al in 5,9% (6/102) and CHOP in 7,8% (8/102) of the patients. In the judgment for the entire population, in induction treatment, 70,6% (65/92) of the patients had CR. Age below 18 years and no infiltration in CNS were positive factors for CR in multivariate analyses (p=0,03). In a median follow up of 49 months, we have observed a 4 years OS and DFS of 30,5% and 27% respectively. No bleeding and hepatomegaly, at diagnosis, and age less than 35 years were factors associated a better OS in multivariate analyses (p=0, 01). Protocols with highest number of patients (BFM and Linker) showed the same distribution of clinical and laboratory factors; exception FAB classification. CR were seen in 76,7% and 63,9% of the patients treated with BFM 86M and Linker respectively. (p=0,21). OS was 49,5% with BFM protocol in 4 years Vs 16% with Linker (p=0,004). We observed a better OS for patients with age below 35 years (p=0,01), no bleeding and no hepatomegaly at diagnosis (p=0,03 ; p=0,01) and no leucocytosis ( B < 30000/mm3 and T < 100000/mm3) treated with BFM 86M; however ALL - T treated with Linker protocols had inferior OS (p=0,05). DFS between protocols wasn\'t significant (p=0,58), but with age between 21 and 35 years BFM was better (p=0,03). We conclude that BFM 86M is superior than Linker et al and it is a good treatment for childhood / young adults without risk factors

A leucemia linfóide aguda nos adultos apresenta prognóstico reservado. Os objetivos deste estudo são descrição e análise de parâmetros clínicos, laboratoriais e fatores prognósticos em 102 pacientes tratados com diferentes protocolos de quimioterapia no período de 1990 a 2005, no Serviço de Hematologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Em estudo de coorte retrospectivo, com exclusão de LLA subtipo L3 (FAB) ou B-IV (EGIL), foram analisadas a taxa de remissão completa (RC), sobrevida global (SG) e sobrevida livre de doença (SLD) para a população geral e para os dois principais protocolos de tratamento. A análise estatística foi feita pelo programa SPSS 10.0. Associação entre variáveis, fatores prognósticos e resposta foram observados através do teste ?2 de Person. Curvas de SG e SLD foram construídas pelo método de Kaplan-Meier e as diferenças analisadas pelo teste de log-rank. A idade média foi de 30,6 anos (12 a 82 anos) e predominou o sexo masculino (55,9%). Ao diagnóstico, os achados clínicos foram: fadiga (58,2%), esplenomegalia (59,7%), hepatomegalia (54,6%), linfadenopatia (52,6), febre (38,8%), dor óssea(28,6%), sangramento (27,5%) e cefaléia (15,3%). Envolvimento do sistema nervoso central (SNC) foi detectado em 11 (11,8%) pacientes, enquanto envolvimento testicular acometeu um paciente. O valor médio de hemoglobina, leucócitos e plaquetas foram 8,5g/dl, 84.341/mm3 e 76.275/mm3, respectivamente. 98,7% dos pacientes apresentaram linfoblastos no sangue periférico. A classificação FAB foi igualmente observada entre os tipos L1 e L2. As LLA B e T foram observadas em 69,7% e 30,2%, respectivamente. O cariótipo foi realizado em 40 pacientes, e t (9;22) foi identificada em 20% (8/40) dos casos. Os pacientes foram tratados com quatro diferentes protocolos: BFM 86 modificado (BFM 86M) em 47,15% (48/102), Linker et al em 39,2% (40/102), Lister et al em 5,9% (6/102) e CHOP em 7,8% (8/102). Na análise para a população geral, na fase de indução, 70,6% (65/92) dos pacientes entraram em RC. Idade inferior a 18 anos e ausência de infiltração de SNC foram fatores preditores positivos de resposta em análise multivariada (p=0,03). Com mediana de seguimento de 49 meses, observamos taxa de 30,5% e 27% para SG e SLD em 4 anos. Ausência de sangramento e hepatomegalia, ao diagnóstico, e idade < 35 anos estiveram associados à maior SG através de análise multivariada (p=0,01). Os dois protocolos com maior número de pacientes, apresentaram distribuição semelhante de parâmetros clínicos e laboratoriais, a exceção da variável FAB. RC foi obtida em 76,7% e 63,9% dos pacientes tratados respectivamente com os protocolos BFM 86M e Linker (p=0,21). A SG foi de 49,5% com o BFM 86M em 4 anos Vs 16% com o protocolo Linker (p=0,004). Observou-se que o protocolo BFM86M teve melhor SG para pacientes com idade <35 anos (p=0,01), sem sangramento e hepatomegalia ao diagnóstico (p=0,03 e p=0,01) e sem leucocitose (B <30.000mm3 e T <100.000mm) (p=0,04); enquanto que pacientes com LLA T tratados com o protocolo Linker apresentaram SG inferior (p=0,05). A diferença de SLD entre os dois protocolos não foi significativa (p=0,58), entretanto na faixa etária entre 21-35 anos, o protocolo BFM se mostrou superior (p=0,03). Verificamos que o BFM 86M é superior ao Linker et al, sendo um bom protocolo para tratamento de LLA em pacientes adolescentes e adultos jovens sem fatores de risco. / Acute lymphoblastic leukemia in adults has a poor outcome. The aim of this study is to describe and evaluate clinical, laboratory and prognostic factors in 102 patients reated with different protocols of chemotherapy from 1990 to 2005. Adult ALLsubtype L3 (FAB) or B-IV (EGIL) was excluded. We evaluated complete remission (CR), overall survival (OS) and disease free survival (DFS) rates for the whole population and for the two principal treatment protocols. This retrospective cohort was done in hematology department of the FMUSP. Statistical analysis was done by SPSS 10.0. The association of features and prognosis was assessed by Person\'s chi-square. OS and DFS curves were constructed by Kaplan-Meier method and the differences were calculated by the log-rank test. Mean age was 30,6 (12 to 82) years and 55,9% was male. Clinical findings, at diagnosis, were fatigue (58,2%), splenomegaly (59,7%), hepatomegaly (54,6%), ymphadenopathy (52,6%), fever (38,8%), bone pain (28,6%), bleeding (27,5%) and headache (15,3%). Involvement of central nervous system (CNS) was detected in 11 (11,8%) patients and testicular involvement was observed in one patient. Mean blood values were 8,5g/dl, 84.341/mm3 and 76.275/mm3 for hemoglobin, leucocytes and platelets respectively. 98,7% of the patients presented with lymphoblasts in peripheral blood. FAB classification was equally observed between L1 and L2. B and T ALL was noted in 69,7% and 30,2% respectively. Karyotype analysis was performed in 40 cases, where Philadelphia chromosome (ph) was identified in 20% (8/40) of them. Patients were treated with four different protocols: BFM 86 modified (BFM 86M) in 47,1% (48/102), Linker et al in 39,2% (40/102), Lister et al in 5,9% (6/102) and CHOP in 7,8% (8/102) of the patients. In the judgment for the entire population, in induction treatment, 70,6% (65/92) of the patients had CR. Age below 18 years and no infiltration in CNS were positive factors for CR in multivariate analyses (p=0,03). In a median follow up of 49 months, we have observed a 4 years OS and DFS of 30,5% and 27% respectively. No bleeding and hepatomegaly, at diagnosis, and age less than 35 years were factors associated a better OS in multivariate analyses (p=0, 01). Protocols with highest number of patients (BFM and Linker) showed the same distribution of clinical and laboratory factors; exception FAB classification. CR were seen in 76,7% and 63,9% of the patients treated with BFM 86M and Linker respectively. (p=0,21). OS was 49,5% with BFM protocol in 4 years Vs 16% with Linker (p=0,004). We observed a better OS for patients with age below 35 years (p=0,01), no bleeding and no hepatomegaly at diagnosis (p=0,03 ; p=0,01) and no leucocytosis ( B < 30000/mm3 and T < 100000/mm3) treated with BFM 86M; however ALL - T treated with Linker protocols had inferior OS (p=0,05). DFS between protocols wasn\'t significant (p=0,58), but with age between 21 and 35 years BFM was better (p=0,03). We conclude that BFM 86M is superior than Linker et al and it is a good treatment for childhood / young adults without risk factors

Submitted by Maike Costa (maiksebas@gmail.com) on 2017-03-16T14:10:50Z No. of bitstreams: 1 arquivototal.pdf: 1122971 bytes, checksum: 96c05223167558b53c43c710feee4238 (MD5) / Made available in DSpace on 2017-03-16T14:10:50Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 1122971 bytes, checksum: 96c05223167558b53c43c710feee4238 (MD5) Previous issue date: 2015-12-14 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / Introduction: Acute lymphocytic leukemia (ALL) is the most common malignancy in childreen accounting for 75% of all diagnosed leukemias and being 25% of all malignancies in childhood. There are few studies that deal directly with the understanding of the clinical profile and other variables associated with oral Candida colonization in pediatric patients with ALL, especially in developing countries. Objective: The aim of this study was to evaluate antifungal resistance and Candida colonization in oral cavity of infant juvenile ALL patients. Material and Methods: This was a cross sectioned design, controlled, with dual observational and descriptive characteristics. To carry out this study, two groups were formed: a ALL group with 40 patients diagnosed with ALL and a control group, formed by 40 healthy individuals matched by age and gender. All these individuals were clinically evaluated and submitted to salivary collection with sterile swab. The saliva was seeded onto CHROMagar CandidaTM, incubed for 48hs at 37oC, and the obtained colony formation unities (CFU) were counted and presumptively identified. Variable data of the participants were collected and stored in individual files. The found species was submitted to microdilution for Nystatin and Amphotericin B, widely used treating candidosis, to establish their susceptibility/resistance. Results: Of 40 patients evaluated in case group, 13 (32.5%) were positive to Candida and only 1 (2.5%) was positive in control group (p<0.001). Candida albicans was the most prevalent strain (87.5%). All patients who had 10³ CFU/mL counts were on induction phase of chemotherapy. Of analysed variables, only mucositis was directly associated with Candida positiveness (p=0.017) on ALL group. Five out 14 strains of C. albicans (35.7%) were resistant to Nystatin and all species were not susceptible to Ampothericin B. Conclusion: Candida colonization was associated with ALL probably vinculated to mucositis events being the higher counts found on induction phase of chemotherapy. C. albicans was the prevalent strain and resistance and lack of susceptibility to Nystatin and Amphotericin B was found. / Introdução: Leucemia linfocítica aguda (LLA) é a neoplasia maligna mais comum em crianças, representando 75% de todas as leucemias diagnosticados e sendo 25% de todas as neoplasias malignas na infância. Existem poucos estudos que lidam diretamente com o entendimento do perfil clínico e outras variáveis associadas com a colonização por Candida em pacientes oncológicos infanto-juvenis, especialmente nos países em desenvolvimento. Objetivo: O objetivo deste estudo foi avaliar a colonização e resistência antifúngica de Candida spp. na cavidade bucal de pacientes infanto-juvenis com LLA. Material e Métodos: Este foi um estudo transversal, controlado, com características observacionais e descritivas. Para realizar este estudo, foram formados dois grupos: um grupo LLA com 40 pacientes diagnosticados com LLA e um grupo controle, formado por 40 indivíduos saudáveis pareados por idade e sexo. Todos esses indivíduos foram avaliados clinicamente e submetidos à coleta de saliva com cotonete estéril. A saliva foi semeada em CHROMagar CandidaTM, incubada por 48 hs a 37ºC, e as unidades formadoras de colônias (UFC) obtidas foram contadas e identificadas presuntivamente. Dados variáveis dos participantes foram coletados e armazenados em arquivos individuais. As espécies encontradas foram submetidas a teste de susceptibilidade antifúngica por ensaio de microdiluição para nistatina e anfotericina B, amplamente utilizadas no tratamento de candidose, para estabelecer a sua susceptibilidade/resistência. Resultados: Dos 40 pacientes avaliados no grupo LLA, 13 (32,5%) foram positivos para Candida e apenas 1 (2,5%) foi positivo no grupo controle (p <0,001). Candida albicans foi a espécie mais prevalente (87,5% ). Todos os pacientes que tiveram 10³ UFC/ml de quantificação estavam em fase de indução da quimioterapia. Das variáveis analisadas, apenas a presença de mucosite esteve diretamente associada com a Candida (p = 0,017) no grupo LLA. Das 14 cepas de C.albicans, 5 cepas (35,7%) eram resistentes à Nistatina e todas as espécies não foram suscetíveis ao Anfotericina B. Conclusão: A colonização por Candida foi associada a LLA e vinculadas a mucosite sendo as contagens mais elevadas encontradas em fase de indução da quimioterapia. C. albicans foi a cepa predominante e a resistência e falta de susceptibilidade à Nistatina e Anfotericina B foram observadas.

[pt] Esta tese propõe uma metodologia, baseada em procedimentos quantitativos, para estimação do risco de evento adverso (recaída ou morte) em crianças portadoras de Leucemia Linfoblástica Aguda (LLA). A metodologia proposta foi implementada e analisada utilizando dados de grupo de crianças diagnosticadas no Setor de Hematologia do Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG) da UFRJ e no Serviço de Hematologia Hospital Universitário Pedro Ernesto (HUPE) da UERJ que constituem uma considerável parcela dos casos de LLA na infância registrados no Rio de Janeiro nos últimos anos. A estimação do risco de recaída foi realizada através de um modelo de Redes Neurais após uma seqüência de procedimentos de pré- tratamento de variáveis e de refinamentos do método no que concerne a saída alvo da rede. O tratamento das variáveis é fundamental uma vez que o número reduzido de amostras é uma característica intrínseca deste problema. Embora a LLA seja o câncer mais freqüente a infância, sua incidência é de aproximadamente 1 caso por 100 mil habitantes por ano. Os resultados encontrados foram satisfatórios obtendo-se um percentual de acerto de 93% (fora da amostra) para os pacientes que recaíram quando comparados com o método classicamente utilizado na clínica médica para a avaliação do risco de recidiva (método do grupo BFM). Espera-se que os resultados obtidos possam vir a dar subsídios às condutas médicas em relação à estimativa do risco de recidiva dos pacientes, portanto, podendo vir a ser útil na modulação da intensidade da terapêutica. / [en] In this it is proposed a methodology, based on quantitative procedure, to estimate the adverse event risk (relapse or death) in Acute Lymphoblastic Leukemia (ALL) in children. This methodology was implemented and analyzed in a dataset composed by children diagnosed and treated at the hematology service of the Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG) in the Federal University of Rio de Janeiro and of the Hospital Universitário Pedro Ernesto (HUPE) in the University of state of Rio de Janeiro. This group constitutes a considerable fraction of the ALL cases in childhood registered in the last few years in Rio de Janeiro. The relapse risk was estimated by a Neural Networks model after a sequence of variable pre-treatment procedures. This treatment has a fundamental importance due to the small number of cases (an intrinsic characteristic of this problem). Although, the ALL is the most frequent cancer in childhood, it incidence is approximately just 1 case for 100 000 inhabitants by year. The obtained results may be considered excellent when compared with the classical risk estimative method used in the medical clinics (BFM risk). A perceptual of successes of 93% (out-of-sample) in no- relapse patients was achieved. We expect that the obtained results may subsidize medical conduct concerning the risk of adverse event and so it could be useful in the treatment intensity modulation.

Les protéines de choc thermiques (HSP) sont des chaperons moléculaires qui stabilisent le pliage et la conformation de protéines normales et oncogéniques, prévenant la formation d'agrégats protéiques. Elles sont impliquées dans la régulation de l'apoptose, de la survie cellulaire et dans la cancérogénèse. HSP90 est la protéine chaperone majeure de stabilisation d'oncogènes impliqués dans les hémopathies malignes. L'objectif de notre travail était de déterminer l'implication de HSP90 dans différents types d'hémopathies malignes, les Leucémies Aiguës Myéloïdes (LAM), les Syndromes Myélodysplasiques (SMD) et les Leucémies Aiguës Lymphoblastiques (LAL), et de tester son inhibition par un inhibiteur spécifique, la tanespimycine (17- AAG). Dans les LAM, nous avons évalué l'implication des différentes isoformes de la protéine dans la résistance aux chimiothérapies et aux inhibiteurs de HSP90. Ce travail met en évidence la valeur péjorative de l'expression de HSP90 dans les différents sous types d'hémopathies, corrélant avec un risque de rechute élevé ou d'évolution vers des formes plus agressives. L'utilisation de la tanespimycine a permis de déclencher l'apoptose dans les cellules immatures impliquées dans ces pathologies. HSP90 constitue donc une protéine majeure de la cellule leucémique, et son ciblage offre des perspectives intéressantes dans le traitement des hémopathies malignes / Heat shock proteins (HSP) are molecular chaperones that stabilize the folding and conformation of normal and oncogenic proteins, preventing the formation of protein aggregates. They are involved in the regulation of apoptosis, cell survival and carcinogenesis. HSP90 is the major chaperone implicated in stabilization of oncogenes involved in hematologic malignancies. The aim of our study was to determine the involvement of HSP90 in various types of malignancies, Acute Myeloid Leukemia (AML), Myelodysplastic Syndromes (MDS) and Acute Lymphoblastic Leukemia (ALL) and to test its inhibition by a specific inhibitor, the tanespimycine (17-AAG). In acute myeloid leukemia, we evaluated the involvement of different isoforms of the protein in resistance to chemotherapy and inhibitors of HSP90. This work highlights the pejorative value of HSP90 expression in different subtypes of malignancies, correlated with a high risk of relapse or progression to more aggressive forms. Use of tanespimycine has triggered apoptosis in immature cells involved in these diseases. HSP90 is therefore a major protein of the leukemic cell and its targeting offers interesting perspectives in the treatment of hematologic malignancies

Orientador: Jose Andres Yunes / Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-10T05:42:02Z (GMT). No. of bitstreams: 1 Laranjeira_AngeloBrunelliAlbertoni_M.pdf: 2767287 bytes, checksum: 8b66a1e06cad088fa256103c24e955a7 (MD5) Previous issue date: 2007 / Resumo: A resistência intrínseca ou adquirida aos compostos quimioterápicos é uma das mais importantes causas dos insucessos no tratamento das LLAs pediátricas. A interação da LLA com o microambiente da medula óssea contribui para a proliferação e resistência ao regime quimioterápico das células leucêmicas através de uma grande variedade de mecanismos celulares que provavelmente incluem: aumento da expressão de transportadores celulares, aumento no processo de reparo do DNA, diminuição na regulação dos alvos das drogas, mudanças na regulação do ciclo celular e alteração nas vias apoptóticas. No presente estudo observou-se que a interação estabelecida entre células estromais e células de LLA-B, promoveu a ativação destas como avaliado pela análise das moléculas de superfície das células leucêmicas ao longo dos períodos de cultivo, além da sobrevivência e/ou proliferação em mais de 60% dos casos in vitro. A comunicação entre os dois tipos celulares também mostrou a influência do estroma na modulação da expressão transcricional de 17 genes relacionados com a resistência e sensibilidade a quimioterápicos em células de LLA-B. A modulação teve como conseqüência o aumento nos níveis de expressão da maioria dos genes de resistência e a queda de expressão da maioria dos genes de sensibilidade. Sendo assim, a LLA, pela interação com as células estromais, apresentaram uma alteração que as levou a um fenótipo característico de células resistentes. Essa alteração de expressão mediada pelo contato com o estroma foi confirmada por estudos funcionais de dois genes relacionados com a resistência. O gene KCNN4 em linhagens celulares, que quando submetidas à ação do clotrimazol apresentaram maior viabilidade na presença do que na ausência do estroma; e a adição da proteína recombinante IGFBP-7 no sistema de co-cultura promoveu a resistência e até mesmo proliferação na presença da L-asparaginase. Esta proteína também se mostrou atuante na proliferação das células estromais. Estes resultados mostram dois genes de LLA, que quando modulados pelo contato com o estroma podem contribuir com a maior resistência ao regime quimioterápico, podendo vir a ser usados como alvo para posteriores terapias / Abstract: The intrinsic or acquired chemotherapy resistance composites one of the most important causes of failures in the treatment of pediatric ALL. The ALL and bone marrow microenvironment nteraction contributes for the proliferation and resistance to the chemotherapy regimen of leukemic cells probably through a great variety of cellular mechanisms, including increase of the expression of cellular transporters, increase in the process of DNA repair, downregulation of drugs targets, changes in the regulation of cellular cycle and alteration in the apoptotic ways. In the present study it was observed that the interaction established between stromal cells and pre-B ALL, evaluated through analysis of surface molecules in leukemic cells throughout the periods of culture, were important for the survival and/or proliferation in more than 50% of the cases in vitro. This interaction also showed the influence of stroma in the transcriptional profile of 17 genes related with the resistance and sensitivity to chemotherapeutic agents in pre-B ALL cells. The modulation had as consequence the increase in the levels of expression of the majority of the resistance genes and the decrease of expression of the majority of the sensitivity genes. Being thus, these cellular types, for the interaction with the stromal cells, had presented an alteration that took them to one phenotype characteristic of resistant cells. This stroma-mediated alteration was confirmed by functional studies of two genes related with the resistance. Gene KCNN4 three leukemic cell lines, that when submitted to the action of clotrimazole they had presented greater viability in the presence than in the absence of stroma; and the addition of recombinant protein IGFBP-7 in the co-culture system promoted the resistance and proliferation of primary ALL cells in the presence of the L-asparaginase. This protein also induced proliferation of stromal cells. These results show two genes of ALL, that when modulated for the contact with stroma, can contribute with a resistance to the chemotherapic regimen, becoming possible targets for posterior therapies / Mestrado / Genetica Animal e Evolução / Mestre em Genética e Biologia Molecular