Introdução: A expectativa global para 2030 é uma incidência de 26,4 milhões de casos e 17 milhões de mortes causadas pelo câncer. O câncer colorretal (CCR) já é terceiro tumor mais incidente no mundo. No Brasil, o CCR é o terceiro tumor mais incidente em homens e o segundo em mulheres na região sul. Neste cenário pessimista, é importante avaliar a relação entre o custo e o benefício de tecnologias para o tratamento quimioterápico, sobretudo na gestão dos gastos na saúde pública. Objetivo: O presente trabalho objetivou avaliar as alternativas para o CCR, XELOX e mFOLFOX6, sob o aspecto econômico. Metodologia: As informações sobre a efetividade foram obtidas através de uma revisão narrativa da literatura. Realizou-se também uma revisão narrativa de estudos farmacoeconômicos e por fim uma análise de custo minimização (ACM) sob a perspectiva de um hospital de caráter público. O microcusteio foi utilizado como método para estimar o custo de cada componente que incluiu medicamentos, materiais, exames laboratorial e de imagem, atendimentos ambulatoriais, diárias de internação e recursos humanos e administrativos, permitindo identificar o custo individual por paciente, com cada alternativa. O sistema informatizado do hospital foi utilizado para a coleta dos dados. Resultados: Foram encontrados 14 estudos farmacoeconômicos, dentre os quais apenas 2 estudos nacionais, ambos em cenário metastático da doença. A ACM revelou um custo por paciente de R$ 9.925,98 (adjuvância) e R$ 8.036,95 (paliativo) para mFOLFOX6, e R$ 8.407,13 (adjuvância) e R$ 6.946,47 (paliativo) para tratamento com XELOX. Os custos de materiais e medicamentos representam cerca de 85% do custo total de XELOX; para mFOLFOX6 esse custo é menor, em torno de 36%. Por outro lado, os custos com internação e colocação de cateter ocorrem exclusivamente para mFOLFOX6, que também apresenta maior custo com recursos humanos. Conclusão: O número de pacientes e a falta de dados no sistema informatizado da instituição reforçam a necessidade de mais estudos para se afirmar que XELOX é menos oneroso que mFOLFOX6 no sistema público. O estudo é inédito por se tratar de uma ACM utilizando o método de microcusteio para comparar as alternativas em um hospital público e universitário do país, especialmente na adjuvância do CCR. / Introduction: The global expectation for 2030 is an incidence of 26.4 million cases and 17 million deaths caused by cancer. Colorectal cancer (CRC) is already the third most incident tumor in the world. In Brazil, CRC is the third most incident tumor in men and the second in women in the southern region. In this pessimistic scenario, it is important to evaluate the relationship between the cost and the benefit of technologies for chemotherapy treatment, especially in the management of public health expenditures. Objective: The present study aimed to evaluate the alternatives for CRC, XELOX and mFOLFOX6, under the economic aspect. Methodology: Information on effectiveness was obtained through a narrative review of the literature. A narrative review of pharmacoeconomic studies was also conducted, and finally, a cost minimization analysis (CMA) from a public hospital perspective was carried out. The micro-costing was used as a method to estimate the cost of each component that included medicines, materials, laboratory and imaging exams, outpatient visits, hospital stay and human and administrative resources, allowing the individual cost per patient to be identified for each alternative. The computerized system of the hospital was used to collect the data. Results: We found 14 pharmacoeconomic studies, of which only 2 national studies, both in the metastatic setting of the disease. The CMA revealed a cost per patient of BRL$ 9,925.98 (adjuvant) and BRL$ 8,036.95 (palliative) for mFOLFOX6, and BRL$ 8,407.13 (adjuvant) and BRL$ 6,946.47 (palliative) for treatment with XELOX. Material and drug costs account for about 85% of the total cost of XELOX; For mFOLFOX6 this cost is lower, around 36%. On the other hand, costs with hospitalization and catheter placement occur exclusively for mFOLFOX6, which also presents higher cost with human resources. Conclusion: The number of patients and the lack of data in the computerized system of the institution reinforce the need for further studies to assert that XELOX is less costly than mFOLFOX6 in the public system. The study is notorious because it is a CMA using the micro-costing method to compare the alternatives in a public and university hospital in the country, especially in the adjuvant treatment of CRC.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A junção aderente (JA) é um dos principais componentes do complexo juncional apical. Esta juncão é um complexo multiprotéico em que a E-caderina, uma glicoproteína transmembrana, atua como principal mediadora da adesão célula-célula. Sua ancoragem ao citoesqueleto de actina ocorre via proteínas da família das cateninas. Modificações pós-traducionais da E-caderina, como fosforilação e glicosilação, podem modular a estabilidade e organização das JAs. Muitos estudos têm sugerido que no câncer a invasão e a metástase podem estar associadas a arranjos de glicanos na superfície celular. Em câncer colo-retal, o papel de alterações na expressão de glicanos sobre a estabilidade da adesão mediada por Ecaderina ainda não está claro. Neste estudo, investigamos a relação entre estas alterações e a estabilidade das JAs em células de câncer colo-retal. Nós utilizamos duas linhagens celulares com diferentes potenciais metastáticos, Caco-2 and HCT- 116, que constituem dois modelos de JAs: estáveis e instáveis, respectivamente. Ensaios de precipitação de lectinas e immunoblotting demonstraram que em HCT- 116, a linhagem mais invasiva, a E-caderina apresenta uma diminuição de glicanos reconhecidos pelas lectinas HPA e WGA, que reconhecem resíduos de Nacetilgalactosamina e, _-N-acetilhexosaminas e ácido siálico, respectivamente. Concomitantemente, em HCT-116 também foi observado um aumento de glicanos reconhecidos pelas lectinas L-PHA e E-PHA, que reconhecem respectivamente: acetilglicosamina_1,6-ligada formando N-glicanos tri- e tetraantenados e, Nacetilglicosamina bisectante _1,4-ligada formando N-glicanos biantenados. Ensaios de imunofluorescência mostraram que a presença desses glicanos reconhecidos por L-PHA, em HCT-116, é intensa na região de contato célula-célula quando comparada com células Caco-2, em que a marcação foi observada, predominantemente, na região apical. Além disso, a inibição completa da Nglicosilação por tunicamicina ou a inibição da síntese de N-glicanos complexos por swainsonina, aumentou a associação da E-caderina com o citoesquleto de actina em células HCT-116, mas não em Caco-2. Em células HCT-116, a inibição de Nglicosilação por tunicamicina produziu uma diminuição da atividade de ERK1/2 e a formação de adesão célula-célula foi mais evidente. Estes dados sugerem que alterações na expressão e localização subcelular de diferentes glicanos podem ser importantes eventos associados à perda da estabilidade das JAs em câncer coloretal. / The adherent junction (AJ) is one of the main components of the apical junctional complex. It is a multiprotein complex where E-cadherin, a transmembrane glycoprotein, acts as the main mediator of cell-cell adhesion in epithelium. This protein is anchored to the actin cytoskeleton via proteins of the catenin family. Posttranslational modifications of E-cadherin, such as phosphorylation and glycosylation, can modulate the assembly of AJs. Various studies have suggested that invasion and metastasis is associated to glycan patterns on the cell surface of tumor cells. In colorectal cancer the role of altered glycans expression and stability of E-cadherin-mediated adhesion is not clear. In this study we investigated the relation between changes of the glycans expression and AJs stability in colorectal cancer cells. We used two colon adenocarcinoma cell lines with different metastatic potential, Caco-2 and HCT-116, both models of stable and unstable AJs, respectively. Lectin binding assays demonstrated that in HCT-116, the more invasive cell line, E-cadherin presents a decrease of the glycans recognized by HPA and WGA lectins, which recognize N-acetylgalactosamine and, _-N-acetylhexosamines and sialic acid, respectively. Conversely, in HCT-116, there was an increase of glycans recognized by E-PHA and L-PHA lectins, which recognize bisecting _1,4- branched and _1,6-branched N-acetylglucosamine, respectively. Immunofluorescence assays showed a stronger L-PHA binding on cell-cell contact regions of HCT-116 cells when compared with Caco-2. Furthermore, in HCT-116 cells a complete inhibition of N-glycosylation by tunicamycin or inhibition of complex N-glycans synthesis by swainsonine increased the association of E-cadherin with the actin cytoskeleton. Finally, it was possible to observe that the inhibition of N-linked glycosylation by tunicamycin, leaded to a decreasing of ERK1/2 phosphorylation concomitantly with the formation of more intimate cell-cell contacts. These findings suggest that altered expression and subcellular localization of different glycans can be important events associated to loss of AJs stability in colorectal cancer.

Understanding the mechanisms and nature of tumour heterogeneity is a key focus of current cancer research. Tumour heterogeneity can arise from clonal evolution and/or differentiation. This thesis investigated the role of methylation in dynamic regulation of CD24 based heterogeneity in colorectal cancer cell lines. First, E-Cadherin variation between the cell lines LS174T and LS180 was investigated to find out whether E-Cadherin had any causal role in the difference in lumen formation between these two cell lines derived from the same tumour. These studies found no evidence of a causal role of E-Cadherin. However, morphological heterogeneity in LS174T was observed during the E-Cadherin study, suggesting that this cell line might be a mixture of two different clones. Single cell sorting by FACS allowed to isolate and establish these clones which were stable in the culture for long enough (until passage ~30) to allow their characterisations. Between the two clones, the CD24⁺ clone (named the LS174T_Clone 1^CD24+) was found to have shorter doubling time (23 hours) than the CD24- clone (named the LS174T_Clone 2CD24-; 30 hours). When cultured in matrigel, the LS174T_Clone 1^CD24+ showed higher clonogenicity (Chapter 4). Microarray analysis further revealed differences in gene expression including LAPTM4B, CXCR4, TGFIB and IL8 between these clones. Interestingly, when maintained for a long time in culture (around passage 50, which is equivalent to ~7 months), CD24 expression went through a gradual change in these clones, which became more evident from subclones of LS174T_Clone 2^CD24- (Chapter 6) and clones from another CRC cell line SW480 (chapter 5 and 6). To understand the mechanism of this dynamic change in the expression of CD24, it was first shown that no mutation could be responsible for this phenomenon. This suggested that promoter methylation of CD24 might be the mechanism of the observed dynamic changes in CD24 expression. Bisulfite (BS) modification of DNA from the LS174T clones and CD24 differentially expressing CRC cell lines (such as CD24- cell lines: CC20, RKO vs CD24+ cell lines: DLD1, NCIH716) followed by Sanger sequencing showed that direct methylation of seven CpG positions in the CD24 promoter region Chr6:106975560-106975834 is strongly correlated with the expression of CD24. Further subcloning and sequencing revealed that changes in the methylation of only two out of the seven CpG positions might be the main contributor to the CD24 expression differences. This is the first evidence of direct methylation-mediated regulation of CD24, showing, more broadly, how methylation can contribute to and maintain dynamic heterogeneity in cancer cells. Finally, a mixed culture experiment with the CD24+ and CD24- clones was conducted to test a simple mathematical model, which aimed to explain the interaction between the clones that are stably present in the LS174T cell line (Chapter 7). Altogether, these experiments suggest that genes such as REG1A (an inducer of angiogenesis) might be expressed because of synergistic interactions between the clones, whereas CXCR4 and TFF2 might be involved in a receptor-ligand complementary relationship. These findings have set a ground for future studies to confirm such interactions between co-existing subpopulations within a heterogeneous milieu of cancer cells.

Chez l’adulte, le facteur de transcription homéotique Cdx2 est spécifiquement exprimé dans l’intestin dont il maintient l’identité et contrôle l’homéostasie. Des études récentes menées chez l’homme ont identifié des formes de cancer colorectal de mauvais pronostic dans lesquelles l’expression de Cdx2 est très fortement réduite. Ce travail de thèse visait à étudier les conséquences physiopathologiques de la perte de fonction de Cdx2 dans l’intestin adulte. A partir d’un modèle murin d’invalidation conditionnelle et mosaïque de Cdx2, nos résultats montrent que la perte de Cdx2 conduit au développement de lésions caecales de type gastrique qui n’évoluent pas spontanément en cancer. Ces lésions créent cependant un microenvironnement inflammatoire qui favorise la transformation maligne de cellules épithéliales voisines intactes pour Cdx2 et prédisposées à la tumorigénèse. Globalement, ces résultats montrent que Cdx2 exerce une fonction suppresseur de tumeurs « cellule non-autonome » dans l’intestin. / The intestine-specific transcription factor Cdx2 is required throughout life for intestinal homeostasis and for the maintenance of intestinal identity. Several recent studies showed that Cdx2 expression is dramatically reduced in some human colon cancers of poor prognosis. This work aimed to investigate the pathophysiological consequences of the loss of Cdx2 in the adult gut. Conditional mosaic ablation of Cdx2 in mice causes gastric-type metaplasia in the cecum which do not spontaneously evolve to cancer. However, these lesions strongly modify the inflammatory microenvironment which facilitates the malignant transformation of adjacent Cdx2-intact and cancer-prone epithelial cells. Collectively, these results unravel a novel and original function of Cdx2, namely its non-cell autonomous tumor suppressor activity in the gut.

Gene expression analysis can be performed by a number of methods. One of the most common methods is using relative qPCR  to assess the relative expression of a determined set of genes compared to a reference gene. Analysis methods benefits from an as homogeneous sample set as possible, as great variety in original sample disease status, quality, type, or distribution may yield an uneven base expression between replicates. Additionally normalization of qPCR data will not work if there are missing values in the data. There are methods for handling non-detects (i.e. missing values) in the data, where most of them are only recommended to use when there is a single, or very few, value missing. By integrating microarray expression data with qPCR data, the data quality could be improved on, eradicating the need to redo an entire experiment when too much data is missing or sample data too is heterogeneous. In this project, publically available microarray data, with similar sample status of a given qPCR dataset, was downloaded and processed. The qPCR dataset included 51 genes, where a set of four DLG genes has been chosen for in-depth analysis. For handling missing values, mean imputation and inserting Cq value 40 were used, as well as a novel method initialized where microarray data was used to replace missing values. In summary replacing missing values with microarray data did not show any significant difference to the other two methods in three of the four DLG genes. From this project, it is also suggested an initialized approach towards testing the possibility of qPCR and microarray data integration.

Submitted by Raquel Bester Liszbinski (raquelb.biomed@gmail.com) on 2018-06-12T15:27:51Z No. of bitstreams: 1 Dissertação Raquel Bester Liszbinski 04.2018 .pdf: 2684297 bytes, checksum: 39e14fcba58d472dfe21ab816c211c29 (MD5) / Approved for entry into archive by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br) on 2018-06-13T16:59:06Z (GMT) No. of bitstreams: 1 liszbinski_rb_me_bot.pdf: 2684297 bytes, checksum: 39e14fcba58d472dfe21ab816c211c29 (MD5) / Made available in DSpace on 2018-06-13T16:59:06Z (GMT). No. of bitstreams: 1 liszbinski_rb_me_bot.pdf: 2684297 bytes, checksum: 39e14fcba58d472dfe21ab816c211c29 (MD5) Previous issue date: 2018-04-26 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O câncer colorretal (CCR) é o terceiro tipo mais prevalente de câncer no mundo, com frequentes complicações metastáticas muitas vezes associadas ao desenvolvimento de resistência adquirida aos fármacos. Uma das estratégias terapêuticas utilizadas no tratamento de pacientes que não respondem bem à quimioterapia convencional é a imunoterapia baseada na aplicação de anticorpos monoclonais cetuximab ou panitumumab, ambos dirigidos ao receptor do fator de crescimento epidérmico (EGFR). Em alguns casos observa-se associação da resistência aos anticorpos com a superexpressão de HER2, outro membro da família do EGFR. Assim, esta dissertação foi elaborada para testar a hipótese de que o uso conjunto de anticorpos anti-EGFR e anti-HER será capaz de reduzir o escape das células tumorais e que a associação com fármacos antitumorais tornará mais efetiva sua eliminação. Com esse propósito, nosso objetivo foi utilizar nanopartículas ouro (AuNP) para o transporte de 5-fluorouracil (5FU), endereçando esses nanocarreadores para as células de câncer colorretal recobrindo-os com anticorpos contra os receptores para fator de crescimento epidérmico EGFR (ErbB-1) e HER2 (ErbB-2). Os nanocarreadores foram testados in vitro quanto a sua interação por células de câncer colorretal HCT-116 e Caco-2 por citometria de fluxo, sua capacidade de induzir apoptose/necrose e seu efeito sobre a atividade proliferativa das células testadas. Nossos dados indicam que as AuNP produzidas e funcionalizadas com as moléculas de interesse possuem estrutura esférica, no entanto, algumas formulações apresentaram aglomeração devido a incorporação das moléculas orgânicas. Os ensaios biológicos mostraram que a AuNP 5FU EGFR teve efeito significativo na atividade citotóxica pela via apoptótica recente quando as células foram expostas à maior concentração testada, independentemente do tempo de exposição. Consequentemente, a proliferação celular foi cessada neste mesmo tratamentos e ambos os fenômenos foram observados de forma mais evidente na linhagem Caco-2, inclusive demonstrando efeito superior ao quimioterápico na forma livre. / Colorectal cancer (CRC) is the third most prevalent type of cancer in worldwide and is frequently associated with metastatic complications. Therapeutic strategies to treat those patients who do not respond to conventional chemotherapy is based on the application of monoclonal antibodies cetuximab or panitumumab, both directed targeting the epidermal growth factor receptor (EGFR). However, in some cases resistance is associated with an overexpression of HER2, another receptor belonging to the EGFR family. Therefore, this dissertation was designed to test the hypothesis that the combination of anti-EGFR and anti-HER antibodies will be able to reduce the escape of tumor cells, and that their association with antitumor drugs could improve the elimination of tumor cells. Then, our goal was to use gold nanoparticles (AuNP) for transporting 5-fluorouracil (5FU), addressing them to colorectal cancer cells by coating them with antibodies against the receptors of epidermal growth factor EGFR (ErbB-1) and HER2 (ErbB-2). Nanocarriers were tested in vitro by flow cytometry for their interaction and internalization by the colorectal cancer cell line HCT-116 and Caco-2, their ability to induce apoptosis/necrosis and stop cell proliferation. Our results show that AuNP produced and functionalized with the molecules of interest have spherical structure, however, some formulations showed agglomeration due to the incorporation of organic molecules. Biological assays showed that AuNP 5FU EGFR had a significant effect on cytotoxic activity by the recent apoptotic pathway when cells were exposed to the highest concentration tested independently of the time of exposure. As a result, cell proliferation was stopped at this same treatment and both phenomena were observed most clearly in the Caco-2 cell line, including demonstrating superior effect to chemotherapy in free form. / FAPESP: 2015/26729-2.

Made available in DSpace on 2014-06-11T19:23:08Z (GMT). No. of bitstreams: 0 Previous issue date: 2012-04-26Bitstream added on 2014-06-13T19:29:07Z : No. of bitstreams: 1 castro_ra_me_botfm.pdf: 397298 bytes, checksum: bd41f7c70dc73b4d33ae31fb53337714 (MD5) / Universidade Estadual Paulista (UNESP) / O câncer colorretal é o segundo câncer mais comum com 2,4 milhões de pessoas diagnosticadas. Desses casos, 27% são neoplasias retais (NR). Quimiorradioterapia neoadjuvante (QRTN) tornou-se padrão nestes casos, mas trouxe controvérsia no tratamento adjuvante. O objetivo foi avaliar o impacto da resposta patológica completa (RPC). Além disso, investigamos a influência da quimioterapia adjuvante (QADJ) após QRTN, biópsia, tempo entre QRTN e cirurgia e ausência de cirurgia após QRTN. Métodos: Entre mar/96 e Out/2010, 84 pacientes receberam QRTN, 58 foram submetidos à ressecção retal (RR). A QRTN consistiu de 5-FU em bolus, na primeira e na quinta semana das 25 sessões de radioterapia (RT) no acelerador linear (total 45 - 50 Gy). A biópsia foi feita de acordo com a opção do cirurgião após a RT. A cirurgia (excisão mesorretal total - TME), foi realizada idealmente 8 semanas após a QRTN. Aqueles não submetidos à cirurgia, também foram seguidos. Quando realizada, a QADJ consistiu de 5-FU no D1-D5 por 4 ciclos. Avaliação da sobrevida global (SG) e sobrevida livre de doença (SLD) foi realizada com uso da curva de Kaplan-Meier. Resultados: Dos 58 pacientes submetidos à cirurgia, 90% eram estágio II, 51% ocorreram no reto inferior e 66% eram ECOG 1. RPC foi obtida em 25,8% (15) dos casos. Destes, 20% (3) receberam QADJ. Pacientes sem RPC receberam QADJ em 51% dos casos (22). O tempo médio de seguimento foi de 41 meses. Tanto o SLD (p = 0,024) e SG (p = 0,0488) foram maiores em pacientes com RPC independente do uso de QADJ. Por outro lado, o uso de QADJ vs sem QADJ, independente da presença de RPC, não alterou significativamente a SLD (p = 0,74) ou SG (p = 0,32). Em pacientes com RPC, QADJ não interferiu nos desfechos (SLD, p = 0,76; SG, p = 0,73). No grupo dos pacientes sem RPC, o subgrupo com QADJ... / Colorectal cancer is the second most common cancer with 2,4 million people diagnosed. The rectal cancer (RC) is 27% of these cases. Neoadjuvant chemoradiotherapy (NCRT) has become standard but brought controversy in the adjuvant treatment. The objective was to assess the impact of Pathologic Complete Response (pCR). Furthermore, we investigated the influence of adjuvant chemotherapy (ADJC) after NCRT, biopsy and time between NCRT and surgery, and the absence of surgery after NCRT. Methods: Between mar/96 and Oct/2010, 84 patients received NCRT, and 58 patients underwent resection of the rectum. The NCRT consisted of 5- Fluorouracil (5-FU) and Leucovorin (LV) bolus in the 1st and 5th week of the 25 sessions of radiotherapy (RT) in linear accelerator (total 45 - 50 Gy). Biopsy was made according to the surgeon option after RT. Ideally surgery (Total mesorretal excision - TME) was performed after 8 weeks NCRT ends. Those not undergoing surgery, were followed too. When performed, Adjuvant Chemotherapy (ADJC) consisted of 5-FU and LV bolus on D1-D5 for 4 cycles. Evaluation of Overall Survival (O.S) and Disease-Free Survival (DFS) performed using Kaplan-Meier curve. Results: Of the 58 patients who underwent surgery, 90% were stage II, 51% occurred in the lower rectum, 66% were ECOG 1 and pCR was obtained in 25.8% (15) of patients (group 1). Of these, 20% (3) received ADJC. Patients without PCR (group 2) received ADJC in 51% of the cases (22). The mean follow-up was 41 months. Both the DFS (p = 0.024) and OS (p = 0.0488) were higher in patients with pPCR independent of the use of ADJC. Patients treated with ADJC vs without ADJC, independent of presence of pCR, did not alter DFS (p = 0.74) or OS (p = 0.32). In pCR patients, ADJC do not interfere in the outcome... (Complete abstract click electronic access below)

Submitted by Élen Farinelli de Campos Silva (elenfarinelli@hotmail.com) on 2018-04-11T01:53:32Z No. of bitstreams: 1 Dissertacao.pdf: 1220781 bytes, checksum: 569fcdc5b7a92337431b3ae556c60152 (MD5) / Rejected by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br), reason: Solicitamos que realize uma nova submissão seguindo as orientações abaixo: problema 1: ficha catalográfica Falta ficha catalográfica. A ficha deve ser inserida no arquivo PDF logo após a folha de rosto do seu trabalho. Assim que tiver efetuado a correção ou correções submeta o arquivo em PDF novamente. 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Agradecemos a compreensão. on 2018-04-17T12:09:50Z (GMT) / Submitted by Élen Farinelli de Campos Silva (elenfarinelli@hotmail.com) on 2018-04-18T13:24:35Z No. of bitstreams: 1 Tese Defesa Elen 18 abril 2018 - Ellen.pdf: 1319266 bytes, checksum: 69a7a76892b1bad189a29b29c5bd54eb (MD5) / Approved for entry into archive by Luciana Pizzani null (luciana@btu.unesp.br) on 2018-04-19T12:52:32Z (GMT) No. of bitstreams: 1 silva_efc_me_bot.pdf: 1319266 bytes, checksum: 69a7a76892b1bad189a29b29c5bd54eb (MD5) / Made available in DSpace on 2018-04-19T12:52:32Z (GMT). No. of bitstreams: 1 silva_efc_me_bot.pdf: 1319266 bytes, checksum: 69a7a76892b1bad189a29b29c5bd54eb (MD5) Previous issue date: 2018-02-27 / Introdução: as Doenças Inflamatórias Intestinais (IBD), representadas pela Doença de Crohn e Retocolite Ulcerativa (RCU), podem evoluir com sintomas incapacitantes que comprometem a qualidade de vida de seus portadores. A identificação precoce de doença grave permite terapêutica inicial mais agressiva com menores taxas de complicações e hospitalizações, cirurgias e morte. O objetivo do presente estudo foi identificar as variáveis associadas à necessidade de hospitalização, cirurgia de colectomia, evolução para câncer colorretal e óbito em pacientes portadores de RCU. Metodologia: foi realizado estudo observacional e retrospectivo com coleta de dados de pacientes acompanhados no Ambulatório de DII da Faculdade de Medicina de Botucatu, totalizando 284 pacientes elegíveis. Excluímos 30 pacientes com dados faltantes, totalizando 254 pacientes analisados. As características demográficas, tabagismo, aspectos clínicos como extensão e atividade da doença, além da presença de manifestações extraintestinais (MEI), medicamentos em uso e comorbidades foram avaliados. Os defechos considerados foram necessidade de hospitalização por complicações da doença, necessidade de colectomia, evolução para câncer colorretal ou óbito. Análise estatística: análise descritiva e testes de associação. Foram realizadas análises de regressão logística univariada e multivariada para avaliar as variáveis associadas ao desfecho. As variáveis de desfecho foram necessidade de hospitalização, colectomia, câncer colorretal e óbito. A curva de sobrevida foi realizada utilizando o teste Log Rank, no qual o evento inicial foi a data do diagnóstico e o evento final foi a necessidade de hospitalização, colectomia, câncer colorretal ou óbito ou o último contato com o paciente. Nível de significância p <0,05. Resultados: a média de idade foi de 46,64 (± 16,88) anos, 62,99% eram mulheres, 49,61% apresentavam pancolite e 45,68% estavam em remissão clínica. Em relação ao tabagismo, 66,40% dos pacientes eram não-fumantes, 28,06% ex-fumantes e 5,53% fumantes. MEI foi observada em 52,36% dos pacientes e 10,63% dos pacientes estavam em uso de terapia biológica. Noventa e três pacientes (29,06%) necessitaram de hospitalização. As variáveis associadas com hospitalização foram extensão pancolite, presença de colangite esclerosante primária (OR: 4,884; IC95% 1,199-19,890; p=0,02) e presença de complicações (OR: 5,34; IC95% 2,445 -11,770; p<0,0001). Vinte e quatro pacientes (9,45%) foram submetidos à cirurgia de colectomia total. A necessidade de cirurgia foi associada ao tempo de seguimento (OR: 1,074; IC95% 1,074-1,13; p=0,01). Seis pacientes (2,36%) apresentaram câncer colorretal. A presença de câncer colorretal foi associada com a idade ao diagnóstico (OR: 1,060; IC95%: 1,003-1,119; p=0,04) e tabagismo ativo (OR: 6,999; IC95%: 1,017-48,161; p=0,02). Vinte e cinco pacientes (9,84%) morreram. As variáveis associadas ao óbito foram a pontuação total do escore de Mayo (OR: 1,338; IC95%: 1,011-1,770; p=0,04), uso de prednisona (OR: 5,218; IC95%; 2,053-13,261; p=0,0005), presença de desnutrição (OR: 3,307, IC95%: 1,300-8.408, p=0,01) e a necessidade de hospitalização (OR: 3,307; IC95%: 1,462-28,195; p=0,01). Conclusões: a presença de pancolite e a presença de colangite esclerosante primária foram associadas à necessidade de hospitalização. A presença de câncer colorretal foi associada ao tabagismo. As variáveis associadas ao óbito foram relacionadas com a atividade da doença, como a pontuação total do escore de Mayo, o uso de prednisona, a presença de desnutrição e a necessidade de hospitalização. / Introduction: Inflammatory bowel diseases (IBD), represented by Crohn's Disease (CD) and Ulcerative Colitis (UC), can evolve with disabling symptoms that compromise the patients quality of life. The early identification of severe disease allows a more aggressive therapeutic approach with a lower risk of complications and lower rates of hospitalizations, surgeries and death. The objective of the present study was to identify the variables associated with the need for hospitalization, need for colectomy, presence of colorectal cancer and death occurrence in UC patients. Methodology: An observational and retrospective study was carried out collecting data from patients from Botucatu Medical School, totalizing 284 eligible patients. We excluded 30 patients with insufficient data, totalizing 254 analyzed. Demographic characteristics, smoking status, clinical aspects of the disease as extension and disease activity, besides presence of extraintestinal manifestations (EIM), medications in use and comorbidities were evaluated. The severity criteria considered were hospitalization due to disease complication, need for colectomy, and evolution to colorectal cancer or death. Statistical analysis: descriptive analysis and association tests. Univariate and multivariate logistic regression analyzes were performed to study the variables associated with the outcome. The outcome variables were hospitalization, colectomy, colorectal cancer and death. Survival analysis was performed using the Log Rank test, in which the initial event was the date of diagnosis and the final events were the need for hospitalization, colectomy, colorectal cancer or death or the last contact with the patient. Significance level p <0.05. The local Ethic Committee approved the study. Results: Two hundred and fifty-four UC patients were evaluated. The mean age was 46.64 (±16.88)y, 62.99% were women, 49.61% presented pancolitis and 45.68% were in clinical remission. Regarding current smoking, 66.40% of the patients were non-smokers, 28.06% ex-smokers and 5.53% smokers. EIM was observed in 52.36% of the patients and 10.63% of them was receiving biological therapy. Ninety-three patients (29.06%) required hospitalization and it was associated with pancolitis extension, presence of primary sclerosing cholangitis (OR:4.884; IC95% 1.199- 19.890; p=0.02) and presence of complications (OR:5.364; IC95% 2.445-11.770; p<0.0001). Twenty-four patients (9.45%) underwent total colectomy. The need for surgery was associated with follow-up time (OR:1.074; IC95% 1.074-1.138; p=0.01). Six patients (2.36%) presented colorectal cancer. The presence of colorectal cancer was associated with age at diagnosis (OR:1.060; 95%CI 1.003- 1.119; p=0.04) and current smoking (OR:6,999; 95%CI 1.017-48.161; p=0.02). Twenty-five patients (9.84%) died. The variables associated with death were the total Mayo Score (OR:1.338; 95%CI 1.011-1.770; p=0.04), prednisone use (OR:5.218; 95%CI 2.053-13.261; p=0.0005), presence of malnutrition (OR:3.307, 95%CI:1.300-8.408, p=0.01), and the need for hospitalization (OR:3.307; 95%CI:1.462-28.195; p=0.01). Conclusions: The presence of pancolitis and the presence of primary sclerosing cholangitis were associated with the need for hospitalization. The presence of colorectal cancer was associated with current smoking. The variables associated with death were related with disease activity, such as the total Mayo Score, prednisone use, presence of malnutrition and the need for hospitalization.

Orientador: Ligia Yukie Sassaki / Resumo: Introdução: as Doenças Inflamatórias Intestinais (IBD), representadas pela Doença de Crohn e Retocolite Ulcerativa (RCU), podem evoluir com sintomas incapacitantes que comprometem a qualidade de vida de seus portadores. A identificação precoce de doença grave permite terapêutica inicial mais agressiva com menores taxas de complicações e hospitalizações, cirurgias e morte. O objetivo do presente estudo foi identificar as variáveis associadas à necessidade de hospitalização, cirurgia de colectomia, evolução para câncer colorretal e óbito em pacientes portadores de RCU. Metodologia: foi realizado estudo observacional e retrospectivo com coleta de dados de pacientes acompanhados no Ambulatório de DII da Faculdade de Medicina de Botucatu, totalizando 284 pacientes elegíveis. Excluímos 30 pacientes com dados faltantes, totalizando 254 pacientes analisados. As características demográficas, tabagismo, aspectos clínicos como extensão e atividade da doença, além da presença de manifestações extraintestinais (MEI), medicamentos em uso e comorbidades foram avaliados. Os defechos considerados foram necessidade de hospitalização por complicações da doença, necessidade de colectomia, evolução para câncer colorretal ou óbito. Análise estatística: análise descritiva e testes de associação. Foram realizadas análises de regressão logística univariada e multivariada para avaliar as variáveis associadas ao desfecho. As variáveis de desfecho foram necessidade de hospitalização, colectomia, câncer ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Inflammatory bowel diseases (IBD), represented by Crohn's Disease (CD) and Ulcerative Colitis (UC), can evolve with disabling symptoms that compromise the patients quality of life. The early identification of severe disease allows a more aggressive therapeutic approach with a lower risk of complications and lower rates of hospitalizations, surgeries and death. The objective of the present study was to identify the variables associated with the need for hospitalization, need for colectomy, presence of colorectal cancer and death occurrence in UC patients. Methodology: An observational and retrospective study was carried out collecting data from patients from Botucatu Medical School, totalizing 284 eligible patients. We excluded 30 patients with insufficient data, totalizing 254 analyzed. Demographic characteristics, smoking status, clinical aspects of the disease as extension and disease activity, besides presence of extraintestinal manifestations (EIM), medications in use and comorbidities were evaluated. The severity criteria considered were hospitalization due to disease complication, need for colectomy, and evolution to colorectal cancer or death. Statistical analysis: descriptive analysis and association tests. Univariate and multivariate logistic regression analyzes were performed to study the variables associated with the outcome. The outcome variables were hospitalization, colectomy, colorectal cancer and death. Survival analysis was performed using the L... (Complete abstract click electronic access below) / Mestre

Orientador: Rogério Saad-Hossne / Banca: Fábio Vieira Teixeira / Banca: Odair Carlito Michelin / Resumo: O câncer colorretal é o segundo câncer mais comum com 2,4 milhões de pessoas diagnosticadas. Desses casos, 27% são neoplasias retais (NR). Quimiorradioterapia neoadjuvante (QRTN) tornou-se padrão nestes casos, mas trouxe controvérsia no tratamento adjuvante. O objetivo foi avaliar o impacto da resposta patológica completa (RPC). Além disso, investigamos a influência da quimioterapia adjuvante (QADJ) após QRTN, biópsia, tempo entre QRTN e cirurgia e ausência de cirurgia após QRTN. Métodos: Entre mar/96 e Out/2010, 84 pacientes receberam QRTN, 58 foram submetidos à ressecção retal (RR). A QRTN consistiu de 5-FU em bolus, na primeira e na quinta semana das 25 sessões de radioterapia (RT) no acelerador linear (total 45 - 50 Gy). A biópsia foi feita de acordo com a opção do cirurgião após a RT. A cirurgia (excisão mesorretal total - TME), foi realizada idealmente 8 semanas após a QRTN. Aqueles não submetidos à cirurgia, também foram seguidos. Quando realizada, a QADJ consistiu de 5-FU no D1-D5 por 4 ciclos. Avaliação da sobrevida global (SG) e sobrevida livre de doença (SLD) foi realizada com uso da curva de Kaplan-Meier. Resultados: Dos 58 pacientes submetidos à cirurgia, 90% eram estágio II, 51% ocorreram no reto inferior e 66% eram ECOG 1. RPC foi obtida em 25,8% (15) dos casos. Destes, 20% (3) receberam QADJ. Pacientes sem RPC receberam QADJ em 51% dos casos (22). O tempo médio de seguimento foi de 41 meses. Tanto o SLD (p = 0,024) e SG (p = 0,0488) foram maiores em pacientes com RPC independente do uso de QADJ. Por outro lado, o uso de QADJ vs sem QADJ, independente da presença de RPC, não alterou significativamente a SLD (p = 0,74) ou SG (p = 0,32). Em pacientes com RPC, QADJ não interferiu nos desfechos (SLD, p = 0,76; SG, p = 0,73). No grupo dos pacientes sem RPC, o subgrupo com QADJ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Colorectal cancer is the second most common cancer with 2,4 million people diagnosed. The rectal cancer (RC) is 27% of these cases. Neoadjuvant chemoradiotherapy (NCRT) has become standard but brought controversy in the adjuvant treatment. The objective was to assess the impact of Pathologic Complete Response (pCR). Furthermore, we investigated the influence of adjuvant chemotherapy (ADJC) after NCRT, biopsy and time between NCRT and surgery, and the absence of surgery after NCRT. Methods: Between mar/96 and Oct/2010, 84 patients received NCRT, and 58 patients underwent resection of the rectum. The NCRT consisted of 5- Fluorouracil (5-FU) and Leucovorin (LV) bolus in the 1st and 5th week of the 25 sessions of radiotherapy (RT) in linear accelerator (total 45 - 50 Gy). Biopsy was made according to the surgeon option after RT. Ideally surgery (Total mesorretal excision - TME) was performed after 8 weeks NCRT ends. Those not undergoing surgery, were followed too. When performed, Adjuvant Chemotherapy (ADJC) consisted of 5-FU and LV bolus on D1-D5 for 4 cycles. Evaluation of Overall Survival (O.S) and Disease-Free Survival (DFS) performed using Kaplan-Meier curve. Results: Of the 58 patients who underwent surgery, 90% were stage II, 51% occurred in the lower rectum, 66% were ECOG 1 and pCR was obtained in 25.8% (15) of patients (group 1). Of these, 20% (3) received ADJC. Patients without PCR (group 2) received ADJC in 51% of the cases (22). The mean follow-up was 41 months. Both the DFS (p = 0.024) and OS (p = 0.0488) were higher in patients with pPCR independent of the use of ADJC. Patients treated with ADJC vs without ADJC, independent of presence of pCR, did not alter DFS (p = 0.74) or OS (p = 0.32). In pCR patients, ADJC do not interfere in the outcome... (Complete abstract click electronic access below) / Mestre