A endometriose, caracterizada por crescimento de tecido endometrial fora da cavidade uterina, é responsável por sintomas álgicos com grande impacto na qualidade de vida da paciente. Várias linhas de medicações têm sido estudadas para essa o tratamento da endometriose, já que a cirurgia não é o tratamento de escolha sempre e, quando realizado, não é um tratamento definitivo. O conhecimento da patogenia da endometriose é fundamental para o estudo de novas classes de medicações. Uma delas, os fatores inibitórios da angiogênese, tem papel fundamental no estabelecimento e crescimento de lesões de endometriose. Neste estudo, buscamos a influência da Bevacizumab, droga anti-fator de crescimento endotelial (anti-VEGF), utilizada em duas dosagens diferentes, em endometriose peritoneal induzida em ratas, modelo animal já bem estabelecido para o estudo de endometriose. As ratas permaneceram sob tratamento durante 4 semanas, após as quais foram sacrificadas, sendo as lesões e o corno uterino remanescente retirados para posterior avaliação. Foi realizada avaliação da área das lesões de cada rata, da presença de tecido endometrial à microscopia, da positividade para o anticorpo antiVEGF na imunohistoquímica e da expressão gênica de PCNA, MMP9, Tp63 e VEGFA. O bevacizumab atuou reduzindo a área das lesões nos grupos que receberam medicação (p=0,002) e reduzindo a expressão gênica para Tp63 nas lesões (p=0,04). Não houve resultado significativo nas outras avaliações / Endometriosis, characterized by growth of endometrial tissue outside the uterine cavity, is responsible for painful symptoms with great impact on the quality of life of women. Several lines of medications have been studied for endometriosis\'s treatment, since surgery is not always the treatment of choice and, when done, it is not a definitive treatment. Knowing the pathogenesis of this disease is fundamental for the study of new classes of medications. One of them, the inhibitory factors of angiogenesis, plays a fundamental role in the establishment and growth of endometriosis lesions. In this study, we sought the influence of Bevacizumab, an anti-endothelial growth factor (anti-VEGF) drug, used in two different dosages, in peritoneal endometriosis induced in rats, an animal model well established for the study of endometriosis. The rats remained under treatment for 4 weeks, after which they were sacrificed, with the remaining lesions and uterine horn being removed for further evaluation. An evaluation of the lesion area of each rat, the presence of endometrial tissue under microscopy, the positivity of the anti-VEGF antibody in immunohistochemistry and the gene expression of PCNA, MMP9, Tp63 and VEGFA were performed. Bevacizumab worked by reducing the area of the lesions in the groups receiving medication (p = 0.002) and reducing the gene expression for Tp63 in the lesions (p = 0.04). There was no significant result in the other evaluations

A endometriose, caracterizada por crescimento de tecido endometrial fora da cavidade uterina, é responsável por sintomas álgicos com grande impacto na qualidade de vida da paciente. Várias linhas de medicações têm sido estudadas para essa o tratamento da endometriose, já que a cirurgia não é o tratamento de escolha sempre e, quando realizado, não é um tratamento definitivo. O conhecimento da patogenia da endometriose é fundamental para o estudo de novas classes de medicações. Uma delas, os fatores inibitórios da angiogênese, tem papel fundamental no estabelecimento e crescimento de lesões de endometriose. Neste estudo, buscamos a influência da Bevacizumab, droga anti-fator de crescimento endotelial (anti-VEGF), utilizada em duas dosagens diferentes, em endometriose peritoneal induzida em ratas, modelo animal já bem estabelecido para o estudo de endometriose. As ratas permaneceram sob tratamento durante 4 semanas, após as quais foram sacrificadas, sendo as lesões e o corno uterino remanescente retirados para posterior avaliação. Foi realizada avaliação da área das lesões de cada rata, da presença de tecido endometrial à microscopia, da positividade para o anticorpo antiVEGF na imunohistoquímica e da expressão gênica de PCNA, MMP9, Tp63 e VEGFA. O bevacizumab atuou reduzindo a área das lesões nos grupos que receberam medicação (p=0,002) e reduzindo a expressão gênica para Tp63 nas lesões (p=0,04). Não houve resultado significativo nas outras avaliações / Endometriosis, characterized by growth of endometrial tissue outside the uterine cavity, is responsible for painful symptoms with great impact on the quality of life of women. Several lines of medications have been studied for endometriosis\'s treatment, since surgery is not always the treatment of choice and, when done, it is not a definitive treatment. Knowing the pathogenesis of this disease is fundamental for the study of new classes of medications. One of them, the inhibitory factors of angiogenesis, plays a fundamental role in the establishment and growth of endometriosis lesions. In this study, we sought the influence of Bevacizumab, an anti-endothelial growth factor (anti-VEGF) drug, used in two different dosages, in peritoneal endometriosis induced in rats, an animal model well established for the study of endometriosis. The rats remained under treatment for 4 weeks, after which they were sacrificed, with the remaining lesions and uterine horn being removed for further evaluation. An evaluation of the lesion area of each rat, the presence of endometrial tissue under microscopy, the positivity of the anti-VEGF antibody in immunohistochemistry and the gene expression of PCNA, MMP9, Tp63 and VEGFA were performed. Bevacizumab worked by reducing the area of the lesions in the groups receiving medication (p = 0.002) and reducing the gene expression for Tp63 in the lesions (p = 0.04). There was no significant result in the other evaluations

Angiogenese ist an physiologischen Vorgängen wie der Embryogenese und der Wundheilung, aber auch bei pathologischen Abläufen wie bei Neoplasien und der Makula Degeneration beteiligt. Im Bereich des Tissue Engineering ist sie ebenfalls unersetzlich und ausschlaggebend für den Erfolg einer Gewebetransplantation. In dieser Studie wurde an 40 männliche Charles Lewis-Ratten das arteriovenöse (AV-) Loop-Modell angewandt, um spontane Angiogenese unter Einfluss wachstumshemmender Faktoren in vivo zu untersuchen. Der AV-Loop wurde in einer mit Fibrin gefüllten Teflonkammer gebettet. Für die statistische Auswertung wurde der Student t-Test mit ungepaarten Stichproben angewandt und das Signifkanzniveau betrug α=0,05. Multiple Testungen wurden nach der Bonferroni-Holm-Methode angepasst. In der Anfangsphase der Studie wurde der zeitliche Verlauf der AV-Loop assoziierten Angiogenese an 16 Tieren untersucht. Es wurde ein signifikanter Anstieg der Gefäßfläche über einen Zeitraum von 5 (n=2), 10 (n=3) und 15 Tagen (n=3) beobachtet und ebenfalls eine signifikant höhere Gefäßanzahl an Tag 15 im Vergleich zu Tag 5. Acht Tiere konnten nicht in die Studie miteingeschlossen werden infolge von Thrombosierungen des Loops. Diese erwartete Verlustrate trat aufgrund Lernkurve dieses komplexen mikrochirurgischen Modells, insbesondere zu Beginn des Projektes, auf. In der zweiten Phase der Studie wurde die Neoangiogenese auf drei unterschiedliche Verfahren gehemmt. Die Implantationszeit betrug bei allen Gruppen 15 Tage. In der ersten Gruppe (n = 6) wurde ein Inhibitor des Wachstumfaktors VEGF (vascular endothelial growth factor) intravenös appliziert, nämlich der monoklonale Antikörper Bevacizumab. Hier konnte ein signifikanter Unterschied zur Kontrollgruppe (n = 6) bei der Gefäßfläche (94 432 ± 17 903 μm2 gegenüber 268 682 ± 63 575 μm2) und ebenfalls bei der Gefäßdichte (18 ± 5 Gefäße pro mm2 versus 40 ± 9 Gefäße pro mm2 in der Kontrollgruppe) gemessen werden. Dieser Befund ließ darauf schließen, dass die Neovaskularisation durch VEGF vermittelt wurde. Die direkte Bestrahlung von 2 Gy auf den venösen Graft in der zweiten Versuchsgruppe (n = 7) löste eine signifikante Verringerung von Gefäßanzahl (311 ± 73), -fläche (43 137 ± 10 225 μm2) und –dichte (15 ± 7 Gefäße pro mm2) im Vergleich zur Kontrollgruppe (776 ± 123, 268 682 ± 63 575 μm2 und 40 ± 9 Gefäße pro mm2) aus. Dieses Verfahren hatte somit starken Einfluss auf den Reifeprozess der Neoangiogenese. Bei der Kombinationsgruppe (Bevacizumab und Bestrahlung, n = 5) konnte nur bei der Gefäßfläche ein signifikant geringerer Unterschied in der Angiogenese erhoben werden. Dies ließ vermuten, dass das hier zu findende physiologische und somit geordnete Gefäßwachstum nicht auf diese hemmende Methode anspricht, wie es bei chaotischen Tumorgefäßsystemen der Fall ist und der vermutete Synergismus ausbleibt. Zusätzlich wurde im Zuge dieser Studie ein standardisiertes Auswertungsprogramm etabliert. Dabei handelt es sich um ein selbstentwickeltes Computerprogramm, das nicht nur die hier gesammelten aber auch 2-D-Aufnahmen anderer Angiogenese-Modelle benutzerunabhängig und standardisiert evaluieren kann. Zusammenfassend kann gesagt werden, dass das AV-Loop-Modell sich ausgezeichnet für die Untersuchung der Angiogenese im gesunden Gewebe eignet. Es bietet die Möglichkeit verschiedene angiogene und anti-angiogene Faktoren zu applizieren sowie deren Einfluss auf eine physiologische Neovaskularisation zu beobachten.:1 EINLEITUNG 1 1.1 ZIELSETZUNG DIESER ARBEIT 3 2 LITERATURÜBERSICHT 5 2.1. ANGIOGENESE 5 2.1.1 PHYSIOLOGIE 5 2.1.1.1 Bildung von Blutgefäßen 5 2.1.1.2 Embryogenese 8 2.1.1.3 Angiogenese und Wundheilung 9 2.1.2 TUMOR-ASSOZIIERTE ANGIOGENESE 11 2.2 TISSUE ENGINEERING 22 2.3 DAS ARTERIOVENÖSE (AV) LOOP-MODELL 22 2.4 AUSWERTUNG VON ANGIOGENESEPROZESSEN 23 3 MATERIAL UND METHODEN 24 3.1 TIERE UND HALTUNG 24 3.2 OPERATIVE EINGRIFFE 24 3.2.1 KAMMER UND MATRIX 24 3.2.2 HERSTELLUNG DES AV-LOOPS 25 3.2.3 BESTRAHLUNG 29 3.3 EXPLANTATION 29 3.3.1 PERFUSION MIT INDIA INK 29 3.3.2 PERFUSION MIT MICROFIL® 31 3.4. HISTOLOGISCHE UND IMMUNHISTOLOGISCHE METHODEN 32 3.4.1 VORBEREITUNG DER SCHNITTE 32 3.4.2 HÄMATOXYLIN-EOSIN-FÄRBUNG 33 3.4.3 LEKTINFÄRBUNG 34 3.5 DATENVERARBEITUNG 36 3.5.1 MIKROSKOPISCHE AUFZEICHNUNGEN 36 3.5.2 AUSWERTUNG DER HISTOLOGISCHEN SCHNITTE 36 3.5.3 AUFNAHMEN DER MIKRO-CT-BILDER 41 3.5.4 AUSWERTUNG DER MIKRO-CT-BILDER 42 3.5.5 POWER ANALYSE 43 3.5.6 STATISTISCHE AUSWERTUNGEN 43 3.6 VERWENDETES MATERIAL 44 4 ERGEBNISSE 47 4.1 AV-LOOP-ASSOZIIERTE ANGIOGENESE 48 4.2 ZEITLICHER VERLAUF DER AV-LOOP-ASSOZIIERTEN ANGIOGENESE 50 4.3 HISTOMORPHOMETRISCHE ANGIOGENESE-CHARAKTERISIERUNG MITTELS HE- UND LEKTINFÄRBUNG 52 4.4 AUTOMATISCHE, COMPUTERGESTÜTZTE UND UNTERSUCHERUNABHÄNGIGE ANGIOGENESE- QUANTIFIZIERUNG 53 4.5 EINFLUSS VON VEGF AUF AV-LOOP-ANGIOGENESE 58 4.6 EINFLUSS VON BESTRAHLUNG AUF DIE NEOVASKULARISATION IM AV-LOOP-MODELL 62 4.7 WECHSELWIRKUNG VON VEGF UND IONISIERENDER BESTRAHLUNG AUF DIE ANGIOGENESE IM AV-LOOP-MODELL 65 5 DISKUSSION 71 6 ZUSAMMENFASSUNG 81 7 SUMMARY 83 8 LITERATURVERZEICHNIS 85 9 ANHANG 95 9.1 PROTOKOLL ZUR HERSTELLUNG DER PUFFER 95 9.1.1 CITRATPUFFER 95 9.1.2 TRISPUFFER 95 9.2 TABELLEN 95 9.3 ABBILDUNGEN 95 10 DANKSAGUNG 98 / Angiogenesis is evident in both physiological and pathological processes in the body. It is involved in events of embryogenesis and in wound healing as well as in neoplastic growth and macula degeneration. In the field of Tissue Engineering neovascularisation plays an irreplaceable role and determines the result of the transplantation. Here, an arterio-venous loop (AV-loop) model embedded in fibrin- filled teflon chambers in 40 Charles Lewis rats was applied to conduct in vivo investigations of the physiological processes of vessel growth in healthy tissue and to understand neovascularisation under the impact of anti-angiogenic factors such as monoclonal anti-bodies and ionizing radiation (IR). For statistical analysis the unpaired t-test was applied with a significance level of α = 0,05. Multiple testing was adapted according to the Bonferroni-Holm method. At the beginning of the study the AV-loop induced angiogenesis was examined on 16 animals and consecutively characterized. A significant increase in vessel area was observed over a time frame of 5 (n=2), 10 (n=3) and 15 days (n=3). Additionally the vessel count has increased significantly at day 15 in comparison to day 5. Eight of the animals had to be excluded due to thrombosis of the loop, which was expected due to the complex microsurgical model, especially at the onset of the project. In the second phase of the study three different anti-angiogenic procedures were investigated. Time of implantation was 15 days. In group one (n = 6) the monoclonal antibody of VEGF (vascular endothelial growth factor) named Bevacizumab was applied intravenously. As a result a significant lower vessel area (94 432 ± 17 903 μm2) and density (18 ± 5 vessels per mm2) could be measured in comparison to the control group (n = 6; 268 682 ± 63 575 μm2 respectively 40 ± 9 vessels per mm2). We concluded from these results that angiogenesis was mediated by VEGF. In comparison to the controlgroup direct IR of 2 Gy led in group two (n = 7) to a significant decrease in vessel number (311 ± 73 versus 776 ± 123), area (43137±10225μm2 versus 268682±63575μm2) and density (15±7 versus 40±9 vessels per mm2). Therefore this procedure has an obvious impact on the vessel maturation. In the combined group (n = 5) of both anti-angiogenic procedures (anti- VEGF and IR) a significant decrease was only evident in the vessel area. We assumed that this physiological and accordingly organized angiogenesis does not respond to the applied inhibiting methods, as it is observed in tumor vessel growth. Additionally, an evaluation program was established with the goal of designing a user-independent and standardized computer program to measure 2-D-images of both this and other angiogenesis models. In summary the AV-loop presents a proficient model to investigate angiogenesis in healthy tissue. It offers a variety of possibilities to apply pro- and anti-angiogenic factors and to examine their impact in vivo.:1 EINLEITUNG 1 1.1 ZIELSETZUNG DIESER ARBEIT 3 2 LITERATURÜBERSICHT 5 2.1. ANGIOGENESE 5 2.1.1 PHYSIOLOGIE 5 2.1.1.1 Bildung von Blutgefäßen 5 2.1.1.2 Embryogenese 8 2.1.1.3 Angiogenese und Wundheilung 9 2.1.2 TUMOR-ASSOZIIERTE ANGIOGENESE 11 2.2 TISSUE ENGINEERING 22 2.3 DAS ARTERIOVENÖSE (AV) LOOP-MODELL 22 2.4 AUSWERTUNG VON ANGIOGENESEPROZESSEN 23 3 MATERIAL UND METHODEN 24 3.1 TIERE UND HALTUNG 24 3.2 OPERATIVE EINGRIFFE 24 3.2.1 KAMMER UND MATRIX 24 3.2.2 HERSTELLUNG DES AV-LOOPS 25 3.2.3 BESTRAHLUNG 29 3.3 EXPLANTATION 29 3.3.1 PERFUSION MIT INDIA INK 29 3.3.2 PERFUSION MIT MICROFIL® 31 3.4. HISTOLOGISCHE UND IMMUNHISTOLOGISCHE METHODEN 32 3.4.1 VORBEREITUNG DER SCHNITTE 32 3.4.2 HÄMATOXYLIN-EOSIN-FÄRBUNG 33 3.4.3 LEKTINFÄRBUNG 34 3.5 DATENVERARBEITUNG 36 3.5.1 MIKROSKOPISCHE AUFZEICHNUNGEN 36 3.5.2 AUSWERTUNG DER HISTOLOGISCHEN SCHNITTE 36 3.5.3 AUFNAHMEN DER MIKRO-CT-BILDER 41 3.5.4 AUSWERTUNG DER MIKRO-CT-BILDER 42 3.5.5 POWER ANALYSE 43 3.5.6 STATISTISCHE AUSWERTUNGEN 43 3.6 VERWENDETES MATERIAL 44 4 ERGEBNISSE 47 4.1 AV-LOOP-ASSOZIIERTE ANGIOGENESE 48 4.2 ZEITLICHER VERLAUF DER AV-LOOP-ASSOZIIERTEN ANGIOGENESE 50 4.3 HISTOMORPHOMETRISCHE ANGIOGENESE-CHARAKTERISIERUNG MITTELS HE- UND LEKTINFÄRBUNG 52 4.4 AUTOMATISCHE, COMPUTERGESTÜTZTE UND UNTERSUCHERUNABHÄNGIGE ANGIOGENESE- QUANTIFIZIERUNG 53 4.5 EINFLUSS VON VEGF AUF AV-LOOP-ANGIOGENESE 58 4.6 EINFLUSS VON BESTRAHLUNG AUF DIE NEOVASKULARISATION IM AV-LOOP-MODELL 62 4.7 WECHSELWIRKUNG VON VEGF UND IONISIERENDER BESTRAHLUNG AUF DIE ANGIOGENESE IM AV-LOOP-MODELL 65 5 DISKUSSION 71 6 ZUSAMMENFASSUNG 81 7 SUMMARY 83 8 LITERATURVERZEICHNIS 85 9 ANHANG 95 9.1 PROTOKOLL ZUR HERSTELLUNG DER PUFFER 95 9.1.1 CITRATPUFFER 95 9.1.2 TRISPUFFER 95 9.2 TABELLEN 95 9.3 ABBILDUNGEN 95 10 DANKSAGUNG 98

Objetivos: Avaliar as alterações retinianas em modelo experimental de hipóxia em coelhos aclimatizados em ambiente hipóxico-normobárico e investigar os efeitos do tratamento com bevacizumabe intravítreo (IV). Métodos: Vinte e dois coelhos New Zealand, com pesos entre 2,4 a 3,8 kg, foram divididos em quatro grupos. Os grupos S12% (n=5) e B12% (n=5) foram aclimatizados durante três dias consecutivos em concentrações de oxigênio (O2) a 12%. Os grupos S8% (n=5) e B8% (n=7) foram aclimatizados durante três dias consecutivos, com reduções graduais da concentração de O2, até atingir o nadir de 8%. Os olhos direitos (OD) foram mantidos como controle e os olhos esquerdos (OE) dos animais dos grupos S12% e S8% receberam injeção IV de 0,05 ml de solução salina balanceada (SSB), enquanto os OE dos grupos B12% e B8% receberam 0,05 ml (1,25 mg) de bevacizumabe IV. Foram realizados exames de tomografia de coerência óptica (OCT) para avaliação da espessura dos segmentos retinianos (SR) e coroidianos (SC), angiografia por fluoresceína sódica (AF) para observação da presença ou ausência de vasodilatação e tortuosidade da vasculatura retiniana e quantificação do Vascular Endothelial Growth Factor (VEGF) do humor aquoso e soro no primeiro dia (D0), antes do tratamento, no terceiro dia de hipóxia (D7) e no décimo primeiro dia (D11), utilizando-se a técnica do Luminex®. Após, os animais foram sacrificados e amostras do tecido retiniano foram avaliadas por histologia e imuno-histoquímica (IHQ). Resultados: Comparando-se os cortes horizontais dos OD (controle) nos períodos D0 e D7, notou-se redução de 8% (p<0,0001) e 10% (p<0,0001) da espessura do SR nas concentrações de O2 a 12% e 8%, respectivamente. Comparando-se os cortes verticais nos mesmos períodos, verificou-se redução da espessura do SR de 7%, tanto nas concentrações a 12% (p<0,0001) como a 8% (p<0,0001). Nos olhos tratados com bevacizumabe, a redução das médias das espessuras do SR para os cortes horizontais entre os períodos D0 e D7 foi de 6% (<0,0001) e 9% (<0,0001), para as concentrações de O2 a 12 e 8%, respectivamente. Enquanto que nos olhos tratados com SSB no mesmo período, observou-se redução de 8% (<0,0001) e 6% (<0,0001) para as concentrações de O2 a 12 e 8%, respectivamente, nos cortes horizontais. Nos cortes verticais, para os olhos tratados com bevacizumabe, houve redução de 5% (p=0,0005) e 8% (<0,0001) para concentrações de O2 a 12% e 8%, respectivamente; e para os olhos tratados com SSB foi encontrada redução de 7% (<0,0001) e 8% (<0,0001) nas concentrações de O2 a 12% e 8%, respectivamente. As espessuras dos SC não apresentaram alterações. O grupo B8 apresentou diferença estatisticamente significativa na análise da proporção dos olhos que não evidenciaram vasodilatação e tortuosidade dos vasos retinianos durante o período hipoxêmico, e não foram observados neovasos retinianos. A histologia e IHQ dos olhos tratados com SSB e bevacizumabe não demonstraram alterações quando comparados com os controles. Conclusões: A aclimatização de coelhos em ambiente hipóxico-normobárico resultou na redução da espessura do SR no terceiro dia de hipóxia. Notou-se, ainda, aumento da tortuosidade e vasodilatação. O bevacizumabe IV não inibiu a redução da espessura retiniana, mas sim a vasodilatação e tortuosidade vascular. / Objectives: Evaluate retinal changes in experimental model of hypoxia in rabbits acclimatized in normobaric-hypoxic environment and to investigate the effects of the treatment by intravitreal (IV) bevacizumab drug. Methods: Twenty two New Zealand rabbits weighing between 2,4 to 3,8 kg were divided into 4 groups. The groups S12 (n=5) and B12 (n=5) were acclimatized for 3 consecutive days in oxygen concentration (O2) to 12%. The groups S8 (n=5) and B8 (n=7) were acclimatized for 3 consecutive days with gradual reductions in O2 concentration until the nadir of 8%. The right eye (RE) were kept as controls and the left eye (LE) of the animals belonging to S12 and S8 groups received IV injection of 0,05 ml of balanced salt solution (BSS), while the LE belonging to groups B12 and B8 received 0,05 ml (1,25 mg) of bevacizumab IV. Optical coherence tomography (OCT) to evaluate the thickness of the retinal segments (RS) and choroidalsegments (CS), sodium fluorescein angiography (FA) for evaluation of the presence or absence of vasodilation and tortuosity of the retinal vasculature and quantification of VEGF in the aqueous fluid and peripheral blood sample were conducted at the first day (D0) before treatment, on the third day of hypoxia (D7) and day 11 (D11) using the Luminex® technique. After the animals were sacrificed, the retinal tissue samples were evaluated by histology and immunohistochemistry (IHC). Results: Comparing the horizontal sections of the RE (control) in D0 and D7 periods, a reduction of 8% (p<0,0001) and 10% (p<0,0001) the thickness of the RS in O2 concentration at 12% and 8%, respectively. Comparing the vertical cuts in the same period, there was reduced RS thickness of 7% in both concentrations to 12% (p<0,0001) and 8% (p<0,0001). In the eyes treated with bevacizumab, to reduce the average thickness of the retinal segment for horizontal cuts between D0 and D7 periods were 6% (<0,0001) and 9% (<0,0001) for O2 concentrations to 12 and 8%, respectively. While in the eyes treated with BSS in the same period, there was an 8% reduction (<0,0001) and 6% (<0,0001) for the O2 concentration at the 12% and 8%, respectively, in the horizontal cuts. In the vertical sections is observed for the eyes treated with bevacizumab, 5% reduction (p=0.0005) and 8% (<0,0001) O2 concentration at 12% and 8%, respectively; and BSS treated eyes was reduced by 7% (<0,0001) and 8% (<0,0001) in the O2 concentrations of 12% and 8%, respectively. The thickness of the CS did not show changes. The B8 group showed statistical difference in the analysis of the eyes that did not have vasodilation and tortuosity of the retinal vessels during the hypoxic period. Retinal neovascularization were not observed. Histology and IHC of the eyes treated with BSS and bevacizumab showed no changes compared to the control eyes. Conclusions: The acclimatization of the rabbits in normobaric-hypoxic environment has the effect of reducing the thickness RS on the third day of hypoxia. It is observed also increased tortuosity and vasodilation. The intravitreal bevacizumab does not inhibit retinal thickness decrease, but inhibits vasodilation and vascular tortuosity.

Objetivos: Avaliar as alterações retinianas em modelo experimental de hipóxia em coelhos aclimatizados em ambiente hipóxico-normobárico e investigar os efeitos do tratamento com bevacizumabe intravítreo (IV). Métodos: Vinte e dois coelhos New Zealand, com pesos entre 2,4 a 3,8 kg, foram divididos em quatro grupos. Os grupos S12% (n=5) e B12% (n=5) foram aclimatizados durante três dias consecutivos em concentrações de oxigênio (O2) a 12%. Os grupos S8% (n=5) e B8% (n=7) foram aclimatizados durante três dias consecutivos, com reduções graduais da concentração de O2, até atingir o nadir de 8%. Os olhos direitos (OD) foram mantidos como controle e os olhos esquerdos (OE) dos animais dos grupos S12% e S8% receberam injeção IV de 0,05 ml de solução salina balanceada (SSB), enquanto os OE dos grupos B12% e B8% receberam 0,05 ml (1,25 mg) de bevacizumabe IV. Foram realizados exames de tomografia de coerência óptica (OCT) para avaliação da espessura dos segmentos retinianos (SR) e coroidianos (SC), angiografia por fluoresceína sódica (AF) para observação da presença ou ausência de vasodilatação e tortuosidade da vasculatura retiniana e quantificação do Vascular Endothelial Growth Factor (VEGF) do humor aquoso e soro no primeiro dia (D0), antes do tratamento, no terceiro dia de hipóxia (D7) e no décimo primeiro dia (D11), utilizando-se a técnica do Luminex®. Após, os animais foram sacrificados e amostras do tecido retiniano foram avaliadas por histologia e imuno-histoquímica (IHQ). Resultados: Comparando-se os cortes horizontais dos OD (controle) nos períodos D0 e D7, notou-se redução de 8% (p<0,0001) e 10% (p<0,0001) da espessura do SR nas concentrações de O2 a 12% e 8%, respectivamente. Comparando-se os cortes verticais nos mesmos períodos, verificou-se redução da espessura do SR de 7%, tanto nas concentrações a 12% (p<0,0001) como a 8% (p<0,0001). Nos olhos tratados com bevacizumabe, a redução das médias das espessuras do SR para os cortes horizontais entre os períodos D0 e D7 foi de 6% (<0,0001) e 9% (<0,0001), para as concentrações de O2 a 12 e 8%, respectivamente. Enquanto que nos olhos tratados com SSB no mesmo período, observou-se redução de 8% (<0,0001) e 6% (<0,0001) para as concentrações de O2 a 12 e 8%, respectivamente, nos cortes horizontais. Nos cortes verticais, para os olhos tratados com bevacizumabe, houve redução de 5% (p=0,0005) e 8% (<0,0001) para concentrações de O2 a 12% e 8%, respectivamente; e para os olhos tratados com SSB foi encontrada redução de 7% (<0,0001) e 8% (<0,0001) nas concentrações de O2 a 12% e 8%, respectivamente. As espessuras dos SC não apresentaram alterações. O grupo B8 apresentou diferença estatisticamente significativa na análise da proporção dos olhos que não evidenciaram vasodilatação e tortuosidade dos vasos retinianos durante o período hipoxêmico, e não foram observados neovasos retinianos. A histologia e IHQ dos olhos tratados com SSB e bevacizumabe não demonstraram alterações quando comparados com os controles. Conclusões: A aclimatização de coelhos em ambiente hipóxico-normobárico resultou na redução da espessura do SR no terceiro dia de hipóxia. Notou-se, ainda, aumento da tortuosidade e vasodilatação. O bevacizumabe IV não inibiu a redução da espessura retiniana, mas sim a vasodilatação e tortuosidade vascular. / Objectives: Evaluate retinal changes in experimental model of hypoxia in rabbits acclimatized in normobaric-hypoxic environment and to investigate the effects of the treatment by intravitreal (IV) bevacizumab drug. Methods: Twenty two New Zealand rabbits weighing between 2,4 to 3,8 kg were divided into 4 groups. The groups S12 (n=5) and B12 (n=5) were acclimatized for 3 consecutive days in oxygen concentration (O2) to 12%. The groups S8 (n=5) and B8 (n=7) were acclimatized for 3 consecutive days with gradual reductions in O2 concentration until the nadir of 8%. The right eye (RE) were kept as controls and the left eye (LE) of the animals belonging to S12 and S8 groups received IV injection of 0,05 ml of balanced salt solution (BSS), while the LE belonging to groups B12 and B8 received 0,05 ml (1,25 mg) of bevacizumab IV. Optical coherence tomography (OCT) to evaluate the thickness of the retinal segments (RS) and choroidalsegments (CS), sodium fluorescein angiography (FA) for evaluation of the presence or absence of vasodilation and tortuosity of the retinal vasculature and quantification of VEGF in the aqueous fluid and peripheral blood sample were conducted at the first day (D0) before treatment, on the third day of hypoxia (D7) and day 11 (D11) using the Luminex® technique. After the animals were sacrificed, the retinal tissue samples were evaluated by histology and immunohistochemistry (IHC). Results: Comparing the horizontal sections of the RE (control) in D0 and D7 periods, a reduction of 8% (p<0,0001) and 10% (p<0,0001) the thickness of the RS in O2 concentration at 12% and 8%, respectively. Comparing the vertical cuts in the same period, there was reduced RS thickness of 7% in both concentrations to 12% (p<0,0001) and 8% (p<0,0001). In the eyes treated with bevacizumab, to reduce the average thickness of the retinal segment for horizontal cuts between D0 and D7 periods were 6% (<0,0001) and 9% (<0,0001) for O2 concentrations to 12 and 8%, respectively. While in the eyes treated with BSS in the same period, there was an 8% reduction (<0,0001) and 6% (<0,0001) for the O2 concentration at the 12% and 8%, respectively, in the horizontal cuts. In the vertical sections is observed for the eyes treated with bevacizumab, 5% reduction (p=0.0005) and 8% (<0,0001) O2 concentration at 12% and 8%, respectively; and BSS treated eyes was reduced by 7% (<0,0001) and 8% (<0,0001) in the O2 concentrations of 12% and 8%, respectively. The thickness of the CS did not show changes. The B8 group showed statistical difference in the analysis of the eyes that did not have vasodilation and tortuosity of the retinal vessels during the hypoxic period. Retinal neovascularization were not observed. Histology and IHC of the eyes treated with BSS and bevacizumab showed no changes compared to the control eyes. Conclusions: The acclimatization of the rabbits in normobaric-hypoxic environment has the effect of reducing the thickness RS on the third day of hypoxia. It is observed also increased tortuosity and vasodilation. The intravitreal bevacizumab does not inhibit retinal thickness decrease, but inhibits vasodilation and vascular tortuosity.

Η ανάγκη εξατομίκευσης της θεραπείας ασθενών που πάσχουν από καρκίνο κρίνεται επιτακτική, λόγω του στενού θεραπευτικού εύρους των αντινεοπλασματικών φαρμάκων και των παρατηρούμενων δια-ατομικών διαφορών στη φαρμακοκινητική και στην κλινική ανταπόκριση. Ένα πολύ χρήσιμο εργαλείο στην εξατομίκευση της θεραπείας θεωρείται ότι είναι η πληθυσμιακή φαρμακοκινητική-φαρμακοδυναμική μοντελοποίηση, καθώς μπορεί να περιγράψει τις σχέσεις δόσης-ανταπόκρισης, να εξηγήσει την παρατηρούμενη μεταβλητότητα στην έκθεση στο φάρμακο ή στην κλινική ανταπόκριση και να καθοδηγήσει την επιλογή της δόσης βάσει της βέλτιστης αναλογίας οφέλους-κινδύνου για τη δεδομένη θεραπεία. Η παρούσα διδακτορική διατριβή επικεντρώθηκε στην μπεβασιζουμάμπη, ένα σχετικά καινούριο φάρμακο στοχευμένης θεραπείας για το οποίο δεν υπάρχουν αρκετά διαθέσιμα στοιχεία που αφορούν στη φαρμακοκινητική και φαρμακοδυναμική συμπεριφορά του. Σκοπός της συγκεκριμένης μελέτης ήταν ο χαρακτηρισμός της αλληλεπίδρασης της μπεβασιζουμάμπης με τον μοριακό της στόχο, VEGF165, σε ενήλικες ασθενείς με μεταστατικό ορθοκολικό καρκίνο που λαμβάνουν το φάρμακο σε συνδυασμό με χημειοθεραπεία (FOLFIRI, FOLFOX ή CAPIRI). Για αυτόν τον λόγο, προσδιορίστηκαν αρχικά οι συγκεντρώσεις της ολικής μπεβασιζουμάμπης και του ελεύθερου VEGF165 σε διάφορους κύκλους θεραπείας και στη συνέχεια, εφαρμόζοντας τη μη γραμμική μικτών επιδράσεων μοντελοποίηση με το υπολογιστικό πρόγραμμα NONMEM 7.3, αναπτύχθηκε ένα φαρμακοκινητικό μοντέλο σύνδεσης της μπεβασιζουμάμπης με τον VEGF165. Επιπλέον, διερευνήθηκε η επίδραση των δημογραφικών δεδομένων και των VEGF μονονουκλεοτιδικών πολυμορφισμών στην αλληλεπίδραση μεταξύ της φαρμακοκινητικής της μπεβασιζουμάμπης και των συγκεντρώσεων του VEGF165. Είναι η πρώτη φορά που χρησιμοποιήθηκε η TMDD προσέγγιση για τον χαρακτηρισμό της in vivo αλληλεπίδρασης μπεβασιζουμάμπης-VEGF165. Σύμφωνα με αυτή την προσέγγιση, η φαρμακοκινητική ενός φαρμάκου επηρεάζεται από την υψηλής συγγένειας δέσμευση με τον μοριακό του στόχο και την επακόλουθη αποικοδόμηση του σχηματιζόμενου συμπλόκου μέσω ενδοκυττάρωσης. Το αναπτυχθέν μοντέλο επέτρεψε την ικανοποιητική περιγραφή της φαρμακοκινητικής της μπεβασιζουμάμπης και των ιδιοτήτων σύνδεσής της με τον VEGF165. Η κάθαρση της μπεβασιζουμάμπης βρέθηκε να είναι 0.18 L/day, η τιμή αναφοράς της συγκέντρωσης του ελεύθερου VEGF165 ήταν 212 ng/L, η σταθερά του ρυθμού απομάκρυνσης του ελεύθερου VEGF165 ήταν 0.401 day-1 και η Kss ήταν 267 nM. Η επίδραση του πραγματικού σωματικού βάρους συνυπολογίστηκε στην εκτίμηση όλων των φαρμακοκινητικών παραμέτρων του μοντέλου. Κάποιες στατιστικά μη σημαντικές συσχετίσεις παρατηρήθηκαν μεταξύ της συγγένειας δέσμευσης του φαρμάκου και των VEGF-2578C/A και VEGF-634G/C πολυμορφισμών. Το αναπτυχθέν μοντέλο θα μπορούσε να αποτελέσει ένα χρήσιμο εργαλείο στην εξατομίκευση της θεραπείας και στην αξιολόγηση της κλινικής ανταπόκρισης ασθενών που λαμβάνουν μπεβασιζουμάμπη σε συνδυασμό με χημειοθεραπεία. / The need for individualized treatment in cancer patients is considered crucial due to the narrow therapeutic range of antineoplastic drugs and the observed inter-individual differences in pharmacokinetics and clinical response. Population pharmacokinetic-pharmacodynamic modeling has been recognized as a beneficial tool for personalizing treatment, as it can describe the dose-response relationships, explain the observed variability in drug exposure or response and guide dose selection based on the optimal benefit-risk ratio for a given treatment. The current doctoral thesis was focused on bevacizumab, a relatively new targeted therapy drug for which no sufficient data are available regarding its pharmacokinetic and pharmacodynamic behavior. The aim of the present study was to characterize the interaction of bevacizumab with its molecular target, VEGF165, in adult patients with metastatic colorectal cancer who receive the drug in combination with chemotherapy (FOLFIRI, FOLFOX or CAPIRI). For this reason, the concentrations of total bevacizumab and free VEGF165 were first determined in different cycles of treatment and then, a pharmacokinetic model for bevacizumab binding to VEGF165 was developed by using nonlinear mixed-effects modeling implemented in NONMEM 7.3 software. Moreover, the effect of demographic data and VEGF single nucleotide polymorphisms on the interplay between bevacizumab pharmacokinetics and VEGF165 concen-trations was investigated. This is the first time the TMDD approach was applied to characterize the in vivo bevacizumab-VEGF165 interaction. According to this approach, the pharmacokinetics of a drug is affected by its high affinity binding to its molecular target and subsequent degradation of the formed complex via endocytosis. The developed model allowed an adequate description of bevacizumab pharmacokinetics and its binding properties to VEGF165. Bevacizumab clearance was found to be 0.18 L/day, the free VEGF165 concentration at baseline was 212 ng/L, the elimination rate constant of free VEGF165 was 0.401 day-1, and Kss was 267 nM. The effect of actual body weight was taken into account in the estimation of all pharmacokinetic model parameters. Correlations, which were not statistically significant, were noticed between the binding affinity of the drug and the VEGF-2578C/A and VEGF-634G/C polymorphisms. The developed model could become a useful tool for individualizing treatment and evaluating clinical response of patients receiving bevacizumab in combination with chemotherapy.

Background: Although Bevacizumab (BVZ) and Sunitinib (SNT) prolong survival in cancer patients, an unanticipated side-effect is cardiotoxicity. Early indices of left ventricular (LV) systolic dysfunction would be useful to address the cardiac safety of anti-cancer drugs. Objective: Whether cardiac biomarkers, tissue velocity imaging (TVI), and/or strain rate (SR) can detect early cardiac dysfunction. Methods: A total of 95 C57Bl/6 mice received one of the following drug regimens: i) 0.9% saline; ii) BVZ; or iii) SNT and followed for 14 days. Serial blood pressure, high sensitivity troponin I (hsTnI), and echocardiography were performed. Results: BVZ- and SNT-treated mice demonstrated an increase in mean arterial blood pressure, hsTnI, cardiac apoptosis, and loss of cell integrity. TVI and SR values confirmed early LV systolic dysfunction at day 8, compared to conventional LVEF at day 13. Conclusions: Novel imaging techniques can detect early LV systolic dysfunction in a model of drug-mediated cardiomyopathy.

Angiogeneseinhibitoren haben innerhalb weniger Jahre die Medizin revolutioniert. Auf dem Gebiet der Augenheilkunde ist es v.a. das Bevacizumab (Avastin ®), welches bei verschiedenen Krankheitsbildern eingesetzt wird, um den Verlust an Sehschärfe zu bekämpfen, der u.a. durch eine Vergrößerung der Netzhautdicke zustande kommt. Diese Arbeit untersucht die Veränderungen von Visus und Netzhautdicke (Makulaödem) an Patienten mit diabetischer Retinopathie (DR) und retinalem Venenverschluss (RVO). Verschiedene Studien zeigen, dass nicht alle Patienten von dieser neuen Therapieform profitieren. Mit dem Ziel herauszufinden, welche Patienten auf die Bevacizumabbehandlung ansprechen, werden Einflussfaktoren analysiert, die mit einer Visusverbesserung und einer Verringerung der Netzhautdicke in Verbindung gebracht werden können. Zu diesen Einflussfaktoren zählen: der Untersuchungszeitpunkt, die Art und Ausprägung der Erkrankung und der Visus vor einer Behandlung. Ein zusätzlich untersuchter Einflussfaktor bei Patienten mit RVO ist die Verschlussdauer. Die Arbeit weist nach, dass sowohl Patienten mit DR als auch Patienten mit RVO auf die Behandlung ansprechen. Subgruppenanalysen können diese Ergebnisse auch für die Entitäten nicht proliferative DR (NPDR), Astvenen- (BRVO) und Zentralvenenverschluss (CRVO) belegen. Die Analyse der Einflussfaktoren zeigt, dass Patienten mit einer geringen Sehschärfe vor der Behandlung größere Verbesserungen der Sehschärfe nach der Behandlung aufweisen als Patienten mit initial guter Sehschärfe. Die Verschlussdauer hingegen erweist sich nur bedingt als signifikanter Einflussfaktor auf die Bevacizumabtherapie. Die Ergebnise dieser Arbeit können eine Entscheidungshilfe für den Einsatz der Bevacizumabbehandlung bei Patienten mit DR und RVO darstellen.

Orientador: José Paulo Cabral de Vasconcellos / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T03:32:34Z (GMT). No. of bitstreams: 1 Medina_FlavioMacCord_D.pdf: 2571030 bytes, checksum: 442e6e86f7bd3a0d6fae088740a1e85e (MD5) Previous issue date: 2013 / Resumo: Introdução: O fator de complemento H (CFH) é um componente do sistema imunológico que possui ação imunomoduladora sobre a resposta inflamatória. A gravidade da degeneração macular relacionada à idade (DMRI) é determinada em parte por um estado inflamatório sustentado por atividade aberrante da via alternativa do complemento. As evidências na literatura da relação entre o polimorfismo Y402H do gene CFH e a resposta ao tratamento da DMRI exsudativa permanecem controversas. Objetivo: Avaliar a associação entre as variantes do polimorfismo Y402H do gene CFH e os efeitos funcional e morfológico a curto prazo, assim como a evolução a longo prazo, dos antiangiogênicos em pacientes com DMRI exsudativa. Métodos: Vinte e cinco pacientes recém diagnosticados com DMRI exsudativa foram avaliados em um estudo de curto prazo com acuidade visual medida pela tabela do ETDRS e espessura retiniana central por tomografia de coerência óptica (OCT) de alta resolução, submetidos a injeção intravítrea de bevacizumabe e prospectivamente reexaminados em 7 e 28 dias. Quarenta e seis pacientes previamente submetidos ao tratamento com antiangiogênicos tiveram seus prontuários e exames retrospectivamente avaliados em um estudo de longo prazo quanto às evoluções funcional e morfológica ao longo de um ano. Esses parâmetros foram comparados com o genótipo do CFH, cuja análise molecular do polimorfismo Y402H foi realizada por meio da reação em cadeia da polimerase (PCR) e sequenciamento direto. Resultados: No estudo de curto prazo, houve melhora da acuidade visual no dia 28 em relação ao valor inicial (D0 vs. D28) em todos os genótipos. Entretanto, no grupo homozigoto para o alelo de risco (CC), ocorreu diferença apenas no dia 28 em relação ao dia 7 (D7 vs. D28), enquanto nos grupos CT e TT, a acuidade visual melhorou mais precocemente, no dia 7 em relação ao valor inicial (D0 vs. D7). A espessura retiniana central apresentou redução nos grupos CT (D0 vs. D7 e D0 vs. D28) e TT (D0 vs. D28), enquanto não houve mudança significativa no grupo CC. No estudo de longo prazo, foi evidenciada melhora da acuidade visual ao longo de um ano de acompanhamento apenas no grupo de pacientes sem o alelo C, sem diferença significativa no grupo de pacientes com o alelo de risco. A espessura retiniana central apresentou redução nos genótipos CT e TT, enquanto que no grupo CC não houve significância. Número de injeções, persistência de atividade neovascular e percepção subjetiva de melhora não diferiram entre os genótipos. Conclusão: O perfil de genótipo do CFH parece influenciar o efeito funcional e morfológico da injeção intravítrea de bevacizumabe com uma ação mais precoce em pacientes sem o genótipo de risco. A presença do alelo de risco parece estar relacionada à ausência de melhora visual ao longo de um ano de tratamento com inibidores do VEGF. Esses resultados sugerem que o perfil do genótipo do CFH possa exercer efeito farmacogenético nesse grupo de pacientes brasileiros, influenciando negativamente a resposta ao tratamento da DMRI exsudativa com antiangiogênicos / Abstract: Introduction: The complement factor H (CFH) is a component of the immune system that has immunomodulatory action on the inflammatory response. The severity of age-related macular degeneration (AMD) is determined in part by an inflammatory state sustained by aberrant activity of the alternative complement pathway. Evidences in the literature of the relationship between the Y402H polymorphism of CFH gene and response to treatment of wet AMD remain controversial. Purpose: To evaluate the association between variants of the Y402H polymorphism of CFH gene polymorphism and the short-term functional and morphological effects, as well as long-term evolution, of antiangiogenic drugs in patients with exudative AMD. Methods: Twenty-five patients with newly diagnosed exudative AMD were evaluated in a short-term study with visual acuity on ETDRS chart and central retinal thickness measured with high resolution optical coherence tomography (OCT), underwent intravitreal injection of bevacizumab and were prospectively reviewed in 7 and 28 days. Forty-six patients previously submitted to treatment with VEGF inhibitors had their medical charts retrospectively evaluated in a long-term study about the functional and morphological evolutions over one year. These parameters were compared with the CFH genotype, whose molecular analysis of Y402H polymorphism was performed by polymerase chain reaction (PCR) and direct sequencing. Results: In the short-term study, there was improvement in visual acuity at day 28 compared to baseline (D0 vs. D28) in all genotypes. However, in the group homozygous for the risk allele (CC), differences occurred only on day 28 compared to day 7 (D7 vs. D28), while the CT and TT groups, visual acuity improved earlier in the day 7 compared the initial value (D0 vs. D7). The central retinal thickness decreased in groups CT (D0 vs. D7, D0 vs. D28) and TT (D0 vs. D28), while there was no significant change in group CC. In the long-term study, it was noticed improvement in visual acuity over one year of follow-up in the group of patients without the C allele and no significant difference in the group of patients with the risk allele. The central retinal thickness decreased in the CT and TT genotypes, whereas in the CC group the difference was not significant. Number of injections, persistent neovascular activity and subjective perception of improvement did not differ between genotypes. Conclusion: The profile of the CFH genotype seems to influence the functional and morphological effect of intravitreal injection of bevacizumab with an earlier action in patients without the risk genotype. The presence of the risk allele seems to be related to the lack of visual improvement over one year of treatment with inhibitors of VEGF. These results suggest that the profile of the CFH genotype may present pharmacogenetic effect in this group of Brazilian patients, negatively influencing the response to treatment of exudative AMD with antiangiogenic drugs / Doutorado / Oftalmologia / Doutor em Ciências Médicas

Access to bevacizumab, an important component of oncology treatment regimens, may be limited. This survey of oncologists in the US (n = 150), Europe (n = 230), and emerging markets (EM: Brazil, Mexico, and Turkey; n = 130) examined use of and barriers to accessing bevacizumab as treatment of advanced solid tumors. We also assessed the likelihood that physicians would prescribe a bevacizumab biosimilar, if available. Bevacizumab was frequently used as early-line therapy in metastatic colorectal cancer, metastatic non-squamous non-small-cell lung cancer, and metastatic ovarian cancer (all markets), and as a second-line therapy in glioblastoma multiforme (US, EM). A greater percentage of EM-based physicians cited access-related issues as a barrier to prescribing bevacizumab versus US and EU physicians. Lack of reimbursement and high out-of-pocket costs were cited as predominant barriers to prescribing and common reasons for reducing the number of planned cycles. Overall, similar to 50% of physicians reported they "definitely" or "probably" would prescribe a bevacizumab biosimilar, if available. Efficacy and safety data in specific tumor types and lower cost were factors cited that would increase likelihood to prescribe a bevacizumab biosimilar. A lower cost bevacizumab biosimilar could address the unmet needs of patients and physicians worldwide, and may have the greatest impact on patient outcomes in EM.