OBJETIVOS: Caracterizar o perfil de imunoexpressão de MLH1, MSH2, MSH6 e PMS2 em adenocarcinomas gástricos, explorando seu desempenho na identificação de características clínicas e patológicas, bem como sua influência prognóstica isolada e em relação aos demais parâmetros. MÉTODOS: Cento e trinta e três casos de adenocarcinomas gástricos esporádicos localmente avançados (pT2a ou mais) operados no Hospital das Clínicas/FMUSP foram incluídos pela ausência de metástases a distância ao diagnóstico (M0) e caracterizados clínica (idade, sexo e sobrevida) e patologicamente (tamanho, local, tipo de Borrmann, tipo histológico, infiltração vascular, perineural e variáveis de estadiamento locorregional). Amostras de 1,0 mm foram dispostas em micromatrizes teciduais (TMA) para pesquisa imuno-histoquímica das enzimas MLH1, MSH2, MSH6 e PMS2, com detecção por sistema de polímeros curtos conjugados a peroxidase. Casos com resultados negativos ou incertos nas amostras de TMA tiveram repetidas as reações em secções convencionais. A associação entre o estado de expressão dos marcadores com variáveis clínicopatológicas foi avaliada através do teste do qui-quadrado ou exato de Fisher. O impacto dos parâmetros clínico-patológicos e estado de expressão das enzimas na sobrevida foi explorado em modelos uni e multivariados de Cox, com construção de curvas de Kaplan-Meyer. Todas as análises estatísticas foram consideradas significativas ao nível de p<0,05. RESULTADOS: Quarenta e cinco casos (33,6%) exibiram perda de expressão de ao menos uma enzima, sendo frequente a perda de duas (9/45: 20%), três (14/45:31,2%) ou quatro enzimas (7/45:15,5%). Anormalidade mais frequente ocorreu com o MLH1 (26,7%), seguida de MSH6 (23%), PMS2 (21%) e MSH2 (20,8%). Quando avaliadas em conjunto, houve correlação entre o estado de expressão de todos os possíveis pares, com destaque para MLH1/PMS2 (rho=0,467, p<0,001) e MSH2/MSH6 (rho=0,666, p<0,001). Perda de MLH1 associou-se a tipos I/II de Borrmann (p<0,001), fenótipo intestinal de Lauren (p=0,005), tubular/túbulo-papilífero (p=0,009), expansivo de Ming (p=0,027) e infiltração em muscular própria (p=0,011). Com relação a perda de MSH2, tipos I/II de Borrmann (p<0,001), padrões tubular/túbulo-papilífero (p=0,008), intestinal (p=0,001), expansivo (p=0,001), infiltração da muscular própria (p=0,025), reação desmoplásica ausente a discreta (p=0,021) e ausência de infiltração perineural (p=0,016) foram mais frequentes. Perda de MSH6 associou-se aos tipos macroscópicos de Borrmann e histológicos de Lauren, OMS e Ming (p<0,001) e ausência de infiltração perineural (p=0,036). Idade mais avançada (p=0,046), tipos I/II de Borrmann (p=0,002), padrão intestinal de Lauren (p=0,021) e menos frequente infiltração perineural (p=0,035) foram identificados nos casos com perda de PMS2. A co-negatividade para os pares MLH1/PMS2 e MSH2/MSH6, além de reproduzir as associações mencionadas, identificou infiltrado linfoplasmocitário intra/peritumoral acentuado (p=0,011 e p=0,013), reação estromal desmoplásica ausente a leve para MSH2/MSH6 (p=0,037) e tamanho maior do tumor primário para MLH1/PMS2 (p=0,021). Pior sobrevida associou-se ao sexo masculino (LogRank: 5,11, p=0,024), tamanho do tumor (3,98, p=0,046), tipos III/IV de Borrmann (4,75, p=0,029), histologia mucinosa/anel-de-sinete da OMS (8,61, p=0,003) e difuso (11,62, p=0,003), infiltração perineural (12,62, p<0,001), metástase linfonodal (23,25, p<0,001) e estadio TNM (35,60, p<0,001) em análises univariadas. Melhor sobrevida associou-se a perda de MLH1, MSH6 e PMS2 isoladamente (5,46, p=0,019; 6,08, p=0,014; 7,46, p=0,006) e dos pares MLH1/PMS2 (7,89, p=0,005) e MSH2/MSH6 (5,29, p=0,021). Em modelos multivariados compostos pelos parâmetros clínicopatológicos, apenas o sexo masculino (HR=2,42, p=0,047), tipo histológico difuso (4,94, p=0,037) e estadios II, IIIA e IV (2,23, p=0,088; 3,12, p=0,022; 33,24, p=0,005), constituíram variáveis independentes de determinação prognóstica. Nas análises multivariadas incluindo o estado de expressão das enzimas, evidenciou-se que as perdas de PMS2 e do par MLH1/PMS2 associaram-se significativamente a maior sobrevida (3,84, p=0,029 e 9,82, p=0,028).CONCLUSÕES: O presente estudo demonstra o valor da imunohistoquímica na identificação de alterações na expressão de enzimas MMR, sendo a mais frequentemente negativa a MLH1. A frequente co-negatividade aponta para a importância da dimerização na funcionalidade do sistema de reparo. A perda isolada destes marcadores, e especialmente do par MLH1/PMS2, define perfil clínico-patológico característico, permitindo avanços no conhecimento previamente atribuído a fenótipo microssatélite instável conforme determinado em métodos moleculares. Em análises multivariadas, o estado de expressão de PMS2 isoladamente ou do par MLH1/PMS2 constitui fator independente de determinação prognóstica / OBJECTIVES: To characterize immunoexpression profile of MLH1, MSH2, MSH6 e PMS2 in gastric adenocarcinomas, exploring its performance to identify distinctive clinico-pathological features, as well as their prognostic implications in univariate and multivariate analyses. METHODS: A hundred and thirty three cases of locally advanced (pT2a or higher) sporadic gastric adenocarcinomas operated on Hospital das Clínicas/FMUSP were included due to absence of distant metastases at diagnosis (M0). Clinical (age, gender and survival) and pathological features (size, local, Borrmann´s type, histological type, vascular and perineural infiltration and locorregional staging parameters) were characterized. One millimeter samples were placed on tissue microarray blocks (TMA) and immunohistochemical detection of MLH1, MSH2, MSH6 and PMS2 performed on obtained sections, with revelation developed by peroxidase conjugated short-polymer based reagents. Negative or equivocal results obtained with TMA samples were repeated on conventional sections. Association between expression status for these markers and clinico-pathological features were evaluated by chisquare or Fisher´s exact test when appropriate. Impact of clinico-pathological features and expression status on disease specific survival were explored by Cox uni and multivariate models, with Kaplan-Meyer curves being fitted to illustrate these. All statistical results were considered significant at p<0,05. RESULTS: Forty five cases (33.6%) showed loss of at least one mismatchrepair enzyme, being frequent loss of two (9/45: 20%), three (14/45:31.2%) or even the four evaluated enzymes (7/45:15.5%). The most frequent abnormality addressed MLH1 (26.7%), followed by MSH6 (23%), PMS2 (21%) and MSH2 (20.8%). When analyses were performed in conjunction, correlation was identified for the expression status of all possible pairs, mainly the functional heterodimers MLH1/PMS2 (rho=0.467, p<0.001) and MSH2/MSH6 (rho=0.666, p<0.001). MLH1 loss was associated to Borrmann´s types I/I (p<0.001), Lauren´s intestinal phenotype (p=0.005), tubular/tubulo-papillary architecture (p=0.009), Ming´s expansile type (p=0.027) and infiltration limited by muscular propria (p=0.011). Among cases showing MSH2 loss, Borrmann´s I/I (p<0.001), tubular/tubulo-papillary (p=0.008), intestinal (p=0.001), expansile (p=0.001), muscular propria infiltration (p=0.025), absent to mild stromal desmoplasia (p=0.021) and absent perineural infiltration (p=0.016) were more frequent. MSH6 loss was associated to Borrmann´s gross type and Lauren, WHO and Ming´s histological types (p<0.001), as well as absent perineural infiltration (p=0.036). More advanced age (p=0.046), Borrmann´s types I/I (p=0.002), Lauren´s intestinal morphology (p=0.021) and less frequent perineural infiltration (p=0.035) were identified as associated to PMS2 loss. Conegativity for MLH1/PMS2 and MSH2/MSH6 pairs resumed all the above mentioned associations and additionally identified heavy lymphoplasmacytic infiltrate (p=0.011 e p=0.013), absent to mild stromal desmoplasia for MSH2/MSH6 (p=0.037) and increased primary tumor size for MLH1/PMS2 (p=0.021). In univariate analyses, decreased disease-specific survival was associated to male gender (LogRank: 5.11, p=0.024), tumor size (3.98, p=0.046), Borrmann´s types III/IV (4.75, p=0.029), mucinous/signet-ring cell morphology according to WHO (8.61, p=0.003) and Lauren´s diffuse morphology (11.62, p=0.003), perineural infiltration (12.62, p<0.001), lymph node metastases (23.25, p<0.001) and TNM staging (35.60, p<0.001). Better survival was seen in cases showing loss of MLH1, MSH6 and PMS2 when individually analyzed (5.46, p=0.019; 6.08, p=0.014; 7.46, p=0.006), as well as MLH1/PMS2 (7.89, p=0.005) and MSH2/MSH6 heterodimeric pairs (5.29, p=0.021). In multivariate models addressing clinico-pathological features, only male gender (HR=2.42, p=0.047), diffuse histological type (4.94, p=0.037) and stages II, IIIA and IV (2.23, p=0.088; 3.12, p=0.022; 33.24, p=0.005, respectively) were independent prognostic features. Multivariate analyses including status of MMR enzymes and the most significant clinicopathological features disclosed that PMS2 and MLH1/PMS2 losses were independent predictors of increased disease-specific survival (3.84, p=0.029 e 9.82, p=0.028). CONCLUSIONS: The present study demonstrates immunohistochemical detection of mismatch-repair enzymes as a tool to identify losses of these markers, being the most frequently negative MLH1. The frequently observed co-negativity points toward the importance of heterodimerization of these proteins in functional activity of mismatch-repair system. Losses of these markers, mainly MLH1/PMS2 pair, define a distinctive clinico-pathological profile and add knowledge to the previously reported associations with microsatellite instability as defined by molecular approach. In multivariate analyses, expression status of PMS2, as well as MLH1/PMS2 pair, revealed independent prognostic impact on diseasespecific survival

No description available.

published_or_final_version / abstract / Pathology / Doctoral / Doctor of Philosophy

<p>Malignant tumours of the small intestine are rare. Age-standardised incidence in Europe is between 0.5-1.5 per 100 000. As the small intestine represents more than 90 % of the gastrointestinal mucosal surface, it is surprising that it gives rise to less than 2 % of gastrointestinal malignancies. The dominating histological subtypes are carcinoids and adenocarcinomas. </p><p>We used three population-based registries in Sweden to study survival, second malignant tumours, causes of death, and Crohn’s disease as a risk factor for small intestinal adenocarcinoma and carcinoid.</p><p>We evaluated tumour site, sex, age, and year of diagnosis as prognostic factors. For adenocarcinomas there was no difference in survival between duodenal and jejunal/ileal tumours. Women with jejunal/ileal adenocarcinomas showed higher probabilities of survival than men, while no such relation was found for duodenal tumours. Old age correlated with poor survival for duodenal tumours, and prognosis has improved in later years. For carcinoids, duodenal tumours had a more favourable prognosis than jejunal/ileal tumours. There was no difference in survival between sexes. Old age correlated with poor survival, and survival has improved in recent years.</p><p>Female patients with adenocarcinoma had increased risk of acquiring cancer in the genital organs and breasts, and both sexes had increased risks of second tumours in the gastrointestinal tract and skin. Men with carcinoid tumours had increased risk of prostate cancer. Both sexes had increased risk of malignant melanoma and malignancies of endocrine organs.</p><p>Patients with adenocarcinoma had increased risk of dying from malignant diseases other than the primary small intestinal cancer and from gastrointestinal disease. The cohort with carcinoid had higher than expected risk of dying from malignant disease, gastrointestinal disease, and cardiovascular disease.</p><p>Patients with Crohn’s disease had increased risk of small intestinal adenocarcinoma and carcinoid, and the risk has increased for patients diagnosed in recent years.</p>

The impact of Ad.mda-7 on the survival of renal cell carcinoma lines (RCC), primary renal epithelial cells, glioblastoma multiforme lines (GBM), and primary rodent astrocytes is unknown. The present studies examine whether the GST fusion protein, GST-MDA-7, and the adenovirus, Ad.mda-7, altered the growth and survival of the A498 and UOK121N RCC lines or radiosensitized GBM, respectively. Due to previous findings that the RCC lines, but not primary renal epithelial cells, were resistant to type 5 adenoviral infection, we used purified GST-MDA-7 protein to show that GST-MDA-7, but not GST, caused a dose-dependent reduction in A498 and UOK121N proliferation but not that of primary renal epithelial cells. Free radical species, generated by clinically relevant concentrations of arsenic trioxide, synergized with subnanomolar concentrations of GST-MDA-7 to inhibit the proliferation, viability, and long-term survival of RCC. We also found that MDA-7 (IL-24), when expressed via a recombinant replication defective adenovirus, Ad.mda-7, exerted anti-proliferative effects on GBM cells, an effect found to be enhanced in a greater than additive fashion when combined with ionizing radiation. These findings argue that MDA-7, in combination with agents that generate free radicals, such as arsenic trioxide and ionizing radiation, may have potential in the treatment of RCC and GBM. Geldanamycins are currently being used in a number of clinical trials in different tumor cell types, such as hepatocellular carcinoma (HCC), targeting the inhibition of the heat shock protein and molecular chaperone Hsp90. Previous studies have demonstrated that geldanamycins have dose limiting toxicity in vivo due to their actions in promoting normal liver dysfunction. These studies show that the geldanamycin derivative, 17-allylamino-17-demethoxygeldanamycin (17-AAG), interacts with the secondary bile acid, deoxycholic acid (DCA), to kill primary rat hepatocytes and HuH7 human hepatoma cells. An effect abolished by the addition of the ROS-quenchers, NAC and Trolox. Collectively, these findings argue that geldanamycins may not be a viable therapy for HCC treatment and that 17-AAG toxicity in primary hepatocytes may be, at least upon initial drug exposure, due to ROS generation and mechanisms independent of Hsp9O inhibition and the down-regulation of "classical" Hsp90 client proteins.

Depuis sa découverte, le gène TP63 a soulevé un intérêt considérable grâce à son rôle majeur dans la morphogenèse des épithélia. La quasi-totalité de nos connaissances dérive de l’observation des phénotypes des souris déficientes qui présentent une absence d’épithélia pluristratifiés, due à un défaut d'expression des complexes d'adhérence cellule-matrice extra cellulaire et cellules-cellules. De plus, TP63 est amplifié et surexprimé dans environ 25% des carcinomes épidermoïdes de l’œsophage et est quasi absent des adénocarcinomes du même organe. Dans ce travail nous avons étudié l’expression de p63 dans la muqueuse œsophagienne, et nous avons montré que p63 exerce un rôle de régulateur de l’expression des complexes d’adhérence intra-épithéliaux lors de la transition entre les cellules basales/suprabasales hautement prolifératives et les couches les plus différenciées incapables de proliférer. Puis, nous avons étudié le rôle possible de p63 dans la formation de la métaplasie intestinale, une lésion précurseur de l’adénocarcinome. Dans ce contexte, nous avons établi qu’un traitement reconstituant le stress acido-biliaire induit une perte d’expression de p63 secondaire à une dégradation par le protéasome dans des cellules primaires et des lignées dérivées de carcinomes œsophagiens. Enfin, à l’aide d’un modèle de peau reconstruite, nous avons montré l’implication de p63 dans la stratification épithéliale, dans la prolifération, la différenciation et les interactions épithélium-mésenchyme. Ces réstultats clarifient le rôle de TP63 comme un ongène potentiel dans le carcinome épidermoïde de l’œsophage et comme potentiel suppresseur dans l’adénocarcinome / Since its discovery in 1998, the TP63 gene has raised considerable interest due to its major role in epithelial morphogenesis. The vast majority of our current knowledge is based on the phenotypes of TP63 deficient mice, which show a lack of stratified epithelia associated with defects in the expression of cell-cell and cell-matrix adhesion complexes. In addition, TP63 systematically overexpressed in squamous cell carcinomas and amplified in about 25% of œsophageal squamous cell carcinomas, whereas it is barely detectable in adenocarcinomas that arise in the same organ. This work analyzes the expression of p63 in normal œsophageal mucosa and demonstrates its regulatory role in the expression of cell-cell adhesion complexes at the transition between highly proliferative basal/suprabasal layers and more differentiated, non-proliferative superficial layers. Next, the role of p63 in the formation of intestinal metaplasia, a precursor of adenocarcinoma, is addressed in experiments reconstituting in vtro the effects of acid-bile gastro-oesophageal reflux. We show that this form of stress induces a loss of p63 in cell lines derived from oesophageal cancers, due to its rapid proteasome-dependent degradation. Finally, we have used an in vitro skin reconstruction model to demonstrate the involvement of p63 in the process of epidermal stratification, proliferation, differentiation, and epithelium-mesenchyme interactions. These results clarify the role of TP63 as a potential oncogene in œsophageal squamous cell carcinoma, and as a potential suppressor in adenocarcinoma

L’infection par Helicobacter pylori touche environ la moitié de la population mondiale et est responsable de plusieurs pathologies gastro-intestinales incluant l’adénocarcinome gastrique. Les mécanismes de la carcinogénèse induite par H. pylori ne sont pas clairement élucidés. Mais, l’oncoprotéine CagA que possèdent certaines souches est très impliquée dans la carcinogénèse gastrique ; elle induit l’apparition d’un phénotype particulier, dit colibri, qui mime une transition épithélio-mésenchymateuse (EMT). De plus, CagA déstabilise les jonctions cellulaires en perturbant la E-cadhérine. Les objectifs de ces travaux ont été de déterminer si H. pylori induit une véritable EMT et si cette EMT est à l’origine de l’émergence de cellules souches cancéreuses (CSC). De plus, nous avons étudié le rôle joué par la protéine IQGAP1, protéine assurant le maintien des jonctions cellulaires, dans la carcinogénèse gastrique induite par H. pylori. Ces travaux ont montré que H. pylori induit une EMT in vitro. Cette EMT est à l’origine de l’émergence de cellules CD44high présentant les caractéristiques de CSC. L’étude du rôle de IQGAP1 au cours de la carcinogénèse gastrique liée à H. pylori a permis de déterminer son implication dans l’apparition de lésions néoplasiques dans un modèle de souris transgéniques hétérozygotes pour IQGAP1. En outre, IQGAP1 apparaît comme une protéine dont l’expression est modifiée par l’infection à H. pylori et par l’EMT induite par cette bactérie in vitro. Nos résultats permettent de mieux comprendre le mécanisme physiopathologique de l’adénocarcinome gastrique et seront potentiellement utiles au développement de nouvelles thérapeutiques anti-cancéreuses. / Helicobacter pylori infection is found in about half of the world population and is responsible for several gastrointestinal pathologies, including gastric adenocarcinoma. The mechanisms of the carcinogenesis due to H. pylori remain unclear. However, the link with gastric adenocarcinoma is partly due to the H. pylori CagA oncoprotein. CagA is responsible for a particular cell phenotype in vitro, the “hummingbird” phenotype which corresponds to an elongation of the cells, mimicking an epithelial to mesenchymal transition (EMT). EMT participates to carcinogenesis, and is involved in the generation of cancer stem cells (CSC). Moreover, CagA destabilize the cell junctions. This study aimed to determine wether H. pylori induces a true EMT, and if so, wether this EMT can generate CSCs. The role of IQGAP1, which is a scaffold protein involved in cell adhesion, was also studied in cases of gastric carcinogenesis due to H. pylori. We demonstrated that H. pylori induces an EMT in vitro. Moreover, we showed that this EMT is responsible for the emergence of CD44high cells which have the same characteristics as the CSCs. IQGAP1 has been identified as a protein implicated in neoplastic lesion development in a transgenic mouse model heterozygous for IQGAP1. Moreover, in vitro, the expression of IQGAP1 was modified by H. pylori infection and more specifically by the EMT induced by H. pylori. Our results allow a better understanding of gastric adenocarcinoma pathophysiology and will be helpful in developing new cancer chemotherapies.

Orientador: Agnaldo Lopes da Silva Filho / Resumo: Introdução: O câncer de endométrio (CE) é a neoplasia ginecológica mais comum em países desenvolvidos, e tem um comportamento heterogêneo sob o aspecto clínico, biológico, e morfológico, com taxas de recorrência de 15 a 20% após a cirurgia. Este estudo avaliou, a associação entre a proteína 3 de ligação ao mRNA com fator de crescimento insulina símile II (IMP3), e fatores prognósticos e morfológicos do CE. Métodos: Realizou-se um estudo retrospectivo tipo transversal analítico, com avaliação anátomo-clínica em 79 pacientes com CE, com 70 casos de adenocarcinoma-endometrióide (ACEE) e 9 casos de carcinoma seroso, entre 1992 e 2010. Setenta e quatro amostras de endométrio benigno, obtidas de pacientes com patologias benignas (mioma e pólipo), foram utilizadas como controle. A expressão da IMP3 foi avaliada por imunohistoquímica e quantificada em intensidade e extensão, e então associada a fatores morfológicos e prognósticos, e claudinas (CLDNs) 3 e 4, receptor de estrogênio (ER) e receptores de progesterona (PR), p53 e KI-67. Resultados: Foi evidenciada associação entre a expressão da IMP3 no carcinoma seroso, em comparação com o ACEE, tanto em intensidade (p=0,044) quanto em extensão (p<0,001), bem como nos seguintes fatores prognósticos: grau de diferenciação (p =0,024; p<0,010), estadiamento (p<0,001; p<0,001), metástase (p=0,002; p<0,001). A expressão de IMP3 foi significativa em extensão (p=0,002), nos tumores de endométrio quando comparados aos controles. Houve associação... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

Objetivo: Describir la asociación entre la mortalidad por adenocarcinoma gástrico y el tipo de seguro de salud en el Perú. Métodos: Estudio de cohorte retrospectivo realizado en un hospital público de referencia en Lima, Perú. La variable resultado fue el tiempo hasta evento, definida como la cantidad de días transcurridos entre la fecha de diagnós-tico y la fecha de muerte o fecha de censura; y la variable de exposición fue el tipo de seguro de salud del paciente. Se usó la regresión de Cox para evaluar la asociación de interés, reportándose Hazard Ratios (HR) e intervalos de confianza al 95% (IC95%). Resultados: Se incluyeron a 429 pacientes, edad promedio de 57,6 años (DE 13,8), y 256 pacientes mujeres (48,4%). De acuerdo al tipo de seguro de salud, 311 pacientes (77,7%) tuvieron Seguro Integral de salud (SIS), brindado por el Ministerio de Salud; 63 (11,9%), no tuvieron seguro de salud; y 65 (10,4%), tuvieron otro tipo de seguro de sa-lud. Durante el seguimiento, fallecieron 408 (77%) pacientes; la mediana de tiempo de sobrevida fue de 336 (RIQ: 131-651) días y la mortalidad estuvo asociada a presencia metástasis al diagnóstico, tipo histológico, grado de diferenciación y tipo de tratamiento recibido. En el análisis ajustado, aquellos que fueron atendidos mediante el SIS tuvieron mayor probabilidad de morir (HR = 1,63, IC: 1,08-2,45) que aquellos con otro tipo de seguro de salud. Conclusión: Los pacientes con adenocarcinoma gástrico con SIS tie-nen 63% mayor probabilidad de morir que aquellos con otro tipo de seguro de salud, mientras que no se encontró asociación en aquellos sin seguro de salud. / Objective: To describe the association between mortality due to gastric adenocarcinoma and type of health insurance in Peru. Methods: Retrospective cohort study performed in a referral public hospital in Lima, Peru. The outcome was time until event, from the date of diagnosis to the date of death or the date of censorship, whereas the exposure was the type of health insurance of the patient. Cox regression was used to evaluate associa-tions of interest reporting Hazard Ratios (HR) and 95% confidence intervals. Results: A total of 429 patients were enrolled. The age mean was 57.6 years (SD 13.8), 256 pa-tients were women (48.4%). According to the type of health insurance 311 (77.7%) pa-tients had “Seguro Integral de Salud” (SIS), provided by the Health Ministry; 63 (11.9%), had no health insurance; and 65 (10.4%), had other health insurance. During follow-up, 408 (77%) patients died, mean of survival was 336 (IQR: 131-651) days and mortality was associated with the presence of metastasis at diagnosis, type of histology, degree of differentiation, and type of treatment. In adjusted model, those with SIS were at higher risk of mortality (HR = 1.63, CI: 1.08-2.45) compared to those with contributory insur-ance. Conclusions: Patients with gastric adenocarcinoma with SIS health insurance had 63% more probability of dying than those with other health insurance; while there was no association in those without health insurance. / Tesis

The high incidence of gastrointestinal cancers in the general population and the presence of premalignant dysplastic precursor lesions in the gastrointestinal tract make the gastrointestinal tract an ideal environment to study cancer clonality and clonal expansion. Background: Intestinal metaplastic (IM) glands in the human stomach are clonal, contain multiple stem cells and spread by fission. This mechanism of gland fission causes field cancerisation. We hypothesised that gastric adenocarcinoma (GA) progresses through a series of genetic events arising from a founder mutation. A process analogous to niche succession may also take place in the normal oesophagus. We hypothesise that oesophageal squamous cell cancer occurs by a process of field cancerisation of the oesophagus. RHBDF2 has been identified as the gene responsible for tylosis with oesophageal carcinoma (TOC). We hypothesise that RHBDF2 germline gain of function mutations might be lost during tumour progression in TOC and this might affect iRhom2 localisation in the cell. Methods and results: A cohort of 23 patients with dysplasia and a cohort of 51 GA patients were screened for genes accounting for 75% of all somatic mutations previously reported in GA. Only 13% of dysplastic patients and 31.4% of GA patients had mutations. Three dysplastic patients and six GA patients were analysed by microdissection. Small gastric cancer foci in a cohort of hereditary diffuse gastric cancer (HDGC) patients (n=5) were also screened by laser-capture microdissection (LCM) for mutations in TP53. A cohort of 30 patients was screened for common mutations in OSCC and for RHBDF2 mutations. 36.36% of the patients presented mutations. Three patients with mutations were randomly selected and areas of oesophageal squamous cell dysplasia and OSCC were analysed by LCM. Three TOC patients were also analysed by LCM and immunohistochemistry was performed for iRhom2 and ADAM17. Conclusions: The usual mutational events established for GA development during the metaplasiadysplasia- carcinoma sequence (MCS) do not fit the results from either of our two LCM mutation studies in the human stomach. Dysplasia was shown to be clonal and GA demonstrates genetic heterogeneity through clonal evolution. Field cancerisation could not be detected in HDGC using TP53 as a clonal marker. The low incidence of OSCC patients with mutations implies that other genes may be involved in the premalignant pathway leading to OSCC. Oesophageal squamous cell dysplasia and OSCC demonstrate clonal expansion through tumour progression. RHBDF2 mutations do not occur in sporadic OSCC but germline RHBDF2 mutations can be lost during tumour progression in TOC patients with LOH in 17q. Overall, the somatic mutation theory of carcinogenesis seems to hold true for both the progression to GA and OSCC, as both carcinomas seem to evolve from a single mutated stem cell and acquire genetic heterogeneity as the tumours evolve.