Introdução: a TC de tórax possui sensibilidade superior à do RX de tórax na detecção de metástases pulmonares do CCR. O uso rotineiro da TC de tórax préoperatória, no entanto, resulta na identificação de um alto número de lesões pulmonares indeterminadas (LPI), as quais raramente são malignas. Objetivo: nosso objetivo principal foi avaliar a eficácia da TC de tórax no estadiamento pré-operatório de pacientes com CCR. Investigamos, também, se os resultados da TC de tórax tiveram influência significativa no manejo oncológico e desfecho clínico dos pacientes. Métodos: realizamos uma revisão de todas as TCs e RXs de tórax realizados em pacientes operados eletivamente por CCR no período de 2005-2012 no serviço de coloproctologia do HCPA. Todos os exames de imagem foram analisados por um radiologista independente “cego”. Os achados dos exames foram classificados como benignos, malignos ou indeterminados. Os pacientes foram acompanhados por pelo menos 12 meses após a cirurgia para avaliar a evolução e real natureza das lesões indeterminadas. Resultados: duzentos e vinte e três pacientes foram incluídos. A TC de tórax demonstrou achados normais ou benignos em 157 (70,4%) pacientes, achados malignos em 17 (7,6%) e achados indeterminados (LPI) em 49 (22%). Dos 30 casos com metástases pulmonares comprovadas, o RX detectou as lesões em apenas 11 pacientes (36,7%). No seguimento pós-operatório (mediana de 27,5 meses), 14 pacientes (28,6%) com LPI tiveram progressão maligna das lesões. Dos 223 pacientes estudados, apenas 6 (2,7%) foram submetidos à ressecção pulmonar, 2 destes permanecendo em remissão até o fechamento do estudo. Conclusão: demonstramos que a TC é claramente superior ao RX na detecção de metástases pulmonares. Apesar das implicações médicas e financeiras do emprego da TC de tórax, apenas um número muito limitado de pacientes será eventualmente submetido à ressecção pulmonar. Nossos resultados contestam o uso da TC de tórax de rotina no estadiamento de pacientes com CCR. Sugerimos uma conduta mais seletiva, reservando a TC para aqueles pacientes com alto risco de metástases pulmonares. / Background: Chest computed tomography (CCT) has higher sensitivity than chest x-ray in detecting lung metastases from colorectal cancer (CRC). However, the routine use of pretreatment CCT results in a high number of indeterminate lung lesions (ILLs), which rarely prove to be malignant. Objective: our main goal was to evaluate the effectiveness of CCT in the preoperative staging of patients with CRC. We also tried to investigate whether the results of CCT have a significant influence on cancer management and clinical outcomes. Methods: we conducted a review of all preoperative CCTs and x-rays performed in patients submitted to an elective resection of CRC between 2005 and 2012 at our institution. All imaging tests were analyzed by a "blind" independent radiologist. Findings were classified as benign, malignant, or indeterminate. Patients were followed up for at least 12 months after surgery to assess clinical evolution of undetermined lesions and their oncological outcome. Results: Two hundred and twenty-three patients were included. CCTs showed normal or benign findings in 157 (70.4%) patients, malignant lesions in 17 (7.6%) patients, and indeterminate lung lesions (ILL) in 49 (22%) patients. Of the 30 cases with proven lung metastases, x-rays detected lesions in only 11 (36.7%) patients. During postoperative follow-up, 14 patients (28.6%) with the initial diagnosis ILL had malignant progression of their lung lesions. Of all 223 patients, only six (2.7%) underwent lung resection. Two of them remained in remission until the end of the study. Conclusion: We demonstrated that CCT is clearly superior to x-ray in the detection of lung metastases. Despite medical and financial implications of preoperative chest CT, only a very limited number of patients will eventually undergo lung resection. We call into question the role of routine chest CT in the staging of patients with CRC. A more selective approach, reserving CT for patients at high risk of lung metastases, is suggested.

<b>Background:</b> Systemic chemotherapy and radiotherapy play an important role in the treatment of colorectal cancer. Tumour perfusion and oxygenation is known to influence radiosensitivity and chemosensitivity. In this thesis, I propose that the evaluation of changes in tumour perfusion using perfusion CT (pCT) and dynamic contrast-enhanced (Dce) MRI can guide the rational sequencing of drugs and radiation. <b>Methods:</b> Dce-MRI and pCT scans were incorporated into a clinical trial of hypofractionated pelvic radiotherapy and nelfinavir in 10 patients with rectal cancer. Toxicity and tissue biomarkers (tumour cell density, microvessel density, CAIX, HIF1-alpha, phospho-Akt and phospho-PRAS40) were evaluated. pCT liver scans were incorporated into an imaging study in patients with colorectal liver metastases randomised to receive either oxaliplatin/ 5FU chemotherapy or oxaliplatin/ 5FU chemotherapy plus selective internal radiotherapy. <b>Results:</b> After 7 days of nelfinavir concurrent with hypo-fractionated pelvic radiotherapy, there was a mean 42&percnt; increase in median K^trans (P=0.03, paired t test) on Dce-MRI and a median 30&percnt; increase in mean blood flow on pCT (P=0.028, Wilcoxon Rank Sum), although no statistically significant changes in perfusion parameters were demonstrated after 7 days of nelfinavir prior to radiotherapy. The feasibility of evaluating tumour cell density in rectal biopsies before and after radiotherapy and a radiosensitising drug as an early endpoint of response was demonstrated. In patients with colorectal liver metastases who received oxaliplatin and modified de Gramont chemotherapy alone, after 4 cycles of chemotherapy, a 28&percnt; decrease in the mean hepatic arterial fraction was observed (P=0.018, paired t test). Between pCT scans 2 days before SIRT and 39-47 days following SIRT and continued 2-weekly chemotherapy, there was a mean 62&percnt; (P=0.009) reduction in Blood Flow and 61&percnt; (P=0.006) reduction in Blood Volume (paired t test). <b>Conclusions</b> This research does not support the hypothesis that nelfinavir before radiotherapy improves blood flow to human rectal cancer. Increases in rectal tumour perfusion during radiotherapy and concurrent nelfinavir are likely to be primarily explained by the acute biological effects of radiation. Four or more cycles of oxaliplatin and modified de Gramont chemotherapy may result in changes in tumour perfusion of colorectal liver metastases which would be detrimental to subsequent radiotherapy. Selective internal radiotherapy resulted in substantial reductions in tumour perfusion 39-47 days after the treatment. Perfusion imaging can be used to detect changes in tumour perfusion in response to radiotherapy and systemic therapy which have implications for the sequencing of therapies.

L’instabilité des séquences répétées microsatellites du génome (courtes répétitions en tandem d’un à cinq nucléotides) est une conséquence de l’inactivation du système MMR (MisMatch Repair), en charge de la réparation des erreurs produites au cours de la réplication de l’ADN. Cette instabilité est associée à un processus de transformation cellulaire original, observé chez l’homme dans des pathologies tumorales fréquentes, nommées MSI (pour Microsatellite Instability). Les localisations primaires les plus fréquentes de ces tumeurs sont le côlon, l’endomètre et l’estomac. Elles peuvent avoir une origine héréditaire (prédisposition familiale ; syndrome de Lynch et apparentés), mais sont dans la majorité des cas de survenue sporadique. La transformation des cellules MMR-déficientes s’observe dans le contexte de l’accumulation de nombreuses mutations somatiques dans l’ADN tumoral. Certaines ont un caractère oncogénique en favorisant la troncature et la perte de fonction de gènes suppresseurs de tumeur ou apparentés, impliqués dans des voies de signalisations diverses et qui contiennent des microsatellites codants (mutations indels d’une à deux paires de base, décalant le cadre de lecture, fréquemment rapportées dans ces tumeurs). Les travaux présentés dans le cadre de mon doctorat visent à mieux comprendre le rôle de l’instabilité microsatellitaire dans la tumorigenèse MSI. Ils s’inscrivent dans le contexte du décryptage et de l’analyse des données de séquençage d’exome de 47 cancers colorectaux primitifs MSI. Dans le contexte d’un niveau élevé d’instabilité génomique caractérisant ces tumeurs, la mise au point par mon laboratoire d’accueil de modèles probabilistes a permis de dresser une liste restreinte de gènes, remarquables par le fait qu’ils sont affectés par des mutations somatiques dont les fréquences sont exceptionnellement élevées ou basses dans l’ADN tumoral. Sous l’hypothèse que de tels évènements somatiques affectent des gènes clés de la tumorigenèse MSI colique, j’ai focalisé mes recherches sur les gènes dont les altérations sont peu fréquentes. Brièvement, j’ai pu démontrer le caractère délétère d’un petit nombre d’altérations microsatellitaires codantes dont la survenue semble soumise à une pression de sélection négative (N=13). Mes résultats indiquent que ces mutations semblent fragiliser le phénotype tumoral des cellules dans lesquelles elles surviennent, la perte de fonction des gènes qu’elles affectent conduisant à diverses conséquences délétères en fonction du gène candidat (e.g. sensibilisation à la mort cellulaire, perte des capacités proliférative et migratoire, ralentissement de la croissance tumorale). Ces résultats rapportent pour la première fois et à grande échelle, la sélection négative de mutations dans des tumeurs à forte instabilité génomique MSI. Ils ouvrent de nouvelles voies pour la compréhension de ce mode particulier de transformation cellulaire, et sont potentiellement d’intérêt pour la mise au point de thérapies personnalisées pour les patients. / Since the discovery of a link between mismatch repair (MMR) deficiency and cancer, microsatellite instability (MSI) is thought as a process underlying cell transformation and tumour progression and invasion. MSI tumours are a subset of frequent human neoplasms, both inherited and sporadic, associated with several primary locations (colon, stomach, endometrium…). In MMR-deficient cells, MSI generates hundreds of frameshift mutations in genes (MSI Target Genes, MSI-TGs) containing coding microsatellite sequences (e.g. -1/+1 bp, insertions/deletions, i.e. indels). Some of these mutations affect genes with a role in human carcinogenesis and are thus expected to promote the MSI-driven tumorigenic process. During my PhD, I aimed to decipher the role of MSI in colon tumorigenesis. I exploited exome-sequencing data available in my lab that were generated from the analysis of a series of 47 human MSI primary colorectal cancer (CRC). Through biostatistics analysis and mathematical models that we designed to interpret mutation rates in the context of the high background for instability characterizing MSI in CRC, we identified a few microsatellites containing genes coding mutations that were negatively selected in MSI colon tumours (N=13). Under the hypothesis that these events may have a negative impact in colon tumorigenesis, I demonstrated that the silencing of these MSI target genes (siRNA/shRNA) was deleterious for MSI cancer cells using in vitro and in vivo models (impairment of proliferation and/or migration and/or response to chemotherapy and/or tumour growth) (Jonchère*, Marisa*, Greene* et al., submitted).

La cycline A2 est un régulateur essentiel du cycle cellulaire qui, en association avec des kinases dépendantes des cyclines (CDK) régule la réplication de l'ADN et l’entré des cellules en mitose. Dans de nombreux types de cancers humains, la cycline A2 a été considérée comme un facteur de prolifération contribuant à la cancérogenèse de par ses fonctions dans la régulation du cycle cellulaire. Récemment, la complexité des fonctions de cycline A2 a été révélée. Certaines études in vitro ont démontré que l'inactivation de la cycline A2 induit une augmentation de la motilité cellulaire et de l'invasion dans les fibroblastes consécutive à une activation défective de RhoA. De plus, il a été montré que l'inactivation de la cycline A2 induit la EMT par l’intermédiaire d’une augmentation de l'activité transcriptionnelle de la β-caténine, mais aussi via la voie TGFβ/Prefoldin. Ces études suggèrent que des niveaux réduits de cycline A2 sont liés à une invasion accrue et à l’apparition de métastases dans certains types de cancer. A l’aide d’un modèle de souris mutante pour la cycline A2, une étude récente a établi une fonction de cette dernière, indépendante des CDK, dans la réparation des cassures double brin de l'ADN et a montré que la perte de la cycline A2 favorise l’apparition de cancers de la peau et du poumon. L’ensemble de ces études met en évidence l’existence de multiples fonctions pour la cycline A2. Mon travail de thèse a consisté à explorer le rôle de la cycline A2 dans l'homéostasie du colon et le développement du Le cancer colorectal.Pour évaluer la valeur pronostique de la cycline A2 dans le CCR, nous avons analysé l'expression de la cycline A2 par IHC sur un grand nombre d'échantillons tumoraux dérivés de patients atteints de CCR de différents stades. Nous avons trouvé que les niveaux élevés de la cycline A2 sont corrélés avec un mauvais pronostic et une survie plus faible chez les patients atteints de CCR de stade I et II. Cependant, une diminution de l'expression de la cycline A2 a été détectée aux stades III et IV par comparaison aux biopsies de CCR de stade I et II. Il est tentant de proposer que le profil d'expression de la cycline A2 reflète ses rôles distincts au cours de la cancérogenèse du côlon, comme la prolifération cellulaire au stade précoce, lorsqu'elle est fortement exprimée, mais favorise l'invasion et l'agressivité à des stades plus avancés, lorsque ses niveaux d’expression sont réduits.En complément de cette étude clinique, nous avons généré des modèles murins porteurs d’une mutation constitutive ou inductible de la cycline A2 dans l’épithélium intestinal. Nous avons montré que la déplétion de la cycline A2 dans l'épithélium intestinal de la souris provoque une rupture de la crypte colique, une inflammation, une augmentation de la prolifération des cellules épithéliales et l’apparition de dysplasies de bas et haut grade, reconnues comme lésions précancéreuses dans le CCR. Ces observations suggèrent un rôle majeur pour la cycline A2 dans la régulation de l'homéostasie du côlon et l'initiation de la tumorigénèse. Une analyse plus poussée a révélé une proportion accrue de lésions au niveau de l'ADN et une activation aberrante de la β-caténine, anomalies couramment détectées chez les patients humains atteints de CCR et considérées comme les premières altérations de cette pathologie. En outre, nous avons détecté une expression élevée de NFkB et YAP1 chez les souris mutantes pour la cycline A2, voies qui jouent un rôle critique dans la régénération tissulaire et peuvent conduire la dédifférenciation des cellules épithéliales du côlon contribuant ainsi à la tumorigenèse. Finalement, les souris mutantes cycline A2 ont été soumises à un protocole de colite associé au cancer et ont développé une proportion accrue d'inflammation, mais aussi de dysplasies et d'adénocarcinomes, en taille et en nombre, suggérant que la perte de la cycline A2 participe à la carcinogenèse colorectale chez la souris. / Cyclin A2 is an essential cell cycle regulator required for accurate DNA replication and mitotic entry in association with cyclin-dependent kinases (CDKs). In multiple types of human cancers, cyclin A2 was considered as a proliferation driver contributing to carcinogenesis based on its function to promote cell cycle.Recently, the complexity of cyclin A2 functions has been revealed. Some in vitro studies demonstrated that cyclin A2 inactivation induces increased cell motility and invasiveness of mouse fibroblasts due to defective RhoA activation. Moreover, cyclin A2 inactivation has been shown to induce EMT through the upregulation of β-catenin transcriptional activity, but also via the TGFβ/Prefoldin pathway. These studies suggest that reduced levels of cyclin A2 are linked to increased invasiveness and metastasis in some cancer types. Using a cyclin A2 mutant mouse model, a recent study established the CDK-independent function of cyclin A2 in the repair of double-stranded DNA breaks and showed that loss of cyclin A2 promotes tumorigenesis in skin and lung due to deficient DSBs repair.Altogether, these studies highlight the multiple functions cyclin A2 can execute. The aim of my thesis was to explore the role of cyclin A2 in colon homeostasis and colorectal cancer development.To evaluate the prognostic value of cyclin A2 in CRC, we analyzed cyclin A2 expression by IHC on tumor samples derived from CRC patients of different stages. We found that high levels of cyclin A2 correlate with bad prognosis and lower survival in patients with stage I and II CRC. However, decreased cyclin A2 expression was detected in stage III and IV by comparison to stage I and II CRC biopsies. Complementary to the clinical study, we generated tissue-specific mutant mouse models bearing either a constitutive or inducible cyclin A2 deletion in the intestinal epithelium. We showed that depletion of cyclin A2 in mouse intestinal epithelium causes colonic crypt disruption, inflammation, increased proliferation of epithelial cells and occurrence of low- and high-grade dysplasia, recognized as precancerous lesions of CRC. These observations suggest a major role for cyclin A2 in the regulation of normal colon homeostasis and tumor initiation. Further analysis revealed an increased proportion of DNA damage and aberrant activation of β-catenin, commonly detected in human patients with CRC and which are considered as the first occurring alterations in this pathology. Furthermore, we detected elevated expression of NFkB and YAP1 in the colons of cyclin A2 mutant mice, pathways that have been previously shown to play critical roles for tissue regeneration after tissue damage and to drive dedifferentiation of colonic epithelial cells thus contributing to tumorigenesis. Finally, cyclin A2 mutant mice were subjected to a modified colitis-associated CRC model and developed increased proportion of inflammation, but also dysplasia and adenocarcinomas, in size and numbers, suggesting that loss of cyclin A2 contributes to inflammation-associated colorectal carcinogenesis in mice.

O câncer de cólon e reto configura-se como a terceira causa mais comum de câncer no mundo, em ambos os sexos, e a segunda causa em países desenvolvidos. Estudar a qualidade de vida (QV) é fundamental para a presença de intervenções que promovam bem-estar e/ou o estar bem destes pacientes, cujo prognóstico nem sempre é o melhor. Esta dissertação tem como norte a seguinte questão: como é a qualidade de vida do paciente com câncer colorretal em quimioterapia ambulatorial? Trata-se de um estudo transversal com abordagem quantitativa descritiva, no qual buscou-se avaliar a qualidade de vida do paciente com câncer colorretal em quimioterapia ambulatorial. A pesquisa foi desenvolvida em uma Unidade de Quimioterapia Ambulatorial em um hospital do sul do Brasil, cujos pacientes eram portadores do diagnóstico de câncer colorretal e foram submetidos ao tratamento com o Protocolo 5FU. A amostra contou com 48 participantes que estavam em tratamento quimioterápico por um período de 6 meses. Utilizou-se como instrumento de levantamento de dados um questionário já validado e traduzido para o português, o WHOQOL-Bref. Nos resultados encontrados, prevaleceu a idade de 50 anos ou mais, todos os participantes estavam com estadiamento Dukes B e possuíam no mínimo um mês e no máximo 11 meses de tratamento. Os domínios do WHOQOL-Bref afetados mais significativamente foram os domínios II e III (psicológico e relações sociais), respectivamente, havendo diferença nas respostas quanto à QV geral naqueles que estavam no 1º ciclo de tratamento daqueles que já se encontravam no último ciclo (6º). A qualidade de vida é resultado da combinação de fatores subjetivos e de fatores objetivos, precisando suprir às necessidades humanas integrais, em seus aspectos físicos, psicológicos, sociais e espirituais. / Cancer of the colon and rectum appears as the third most common cancer worldwide in both sexes, and the second leading cause in developed countries. Studying the quality of life (QOL) is fundamental for the existence of interventions that promote wellness and/or well-being of these patients, whose prognosis is not always the best. This thesis is guided by the following question: how is the quality of life of patients with colorectal cancer in outpatient chemotherapy? It was a cross-sectional study with a descriptive quantitative approach, which aimed at assessing the quality of life of patients with colorectal cancer in outpatient chemotherapy. The research was conducted in an Outpatient Chemotherapy Unit at a hospital in Southern Brazil, whose patients were diagnosed with colorectal cancer and were treated with 5-FU protocol. The sample had 48 participants who were undergoing chemotherapy for a period of six months. It was used as an instrument of data collection a questionnaire, which has already been validated and translated into Portuguese, the WHOQOL-Bref. In the results found, prevailed the age of 50 years or more, all participants were in Dukes stage B, with at least a month and a maximum of 11 months of treatment. / El cáncer de colon y recto se configura como la tercera causa más frecuente de cáncer en el mundo, en ambos los sexos, y la segunda en los países desarrollados. Estudiar la calidad de vida (CV) es fundamental para la presencia de intervenciones que promueven bienestar y/o el estar bien de los pacientes cuyo pronóstico no siempre sea el mejor. Esta tesina se propone a la siguiente cuestión central: ¿cómo se presenta la calidad de vida de los pacientes con cáncer colorrectal sometidos a quimioterapia ambulatoria? Se trata de un estudio transversal con un abordaje cuantitativo descriptivo en el que se ha buscado evaluar la calidad de vida de pacientes con cáncer colorrectal sometidos a quimioterapia ambulatoria. Se ha desarrollado esta investigación en una Unidad de Quimioterapia Ambulatoria de un hospital ubicado al sur de Brasil, cuyos pacientes eran portadores de diagnóstico de cáncer colorrectal y fueran sometidos al tratamiento con el Protocolo 5-FU. La muestra dispuso de 48 pacientes en tratamiento quimioterápico por un periodo de 6 meses. Se ha utilizado como instrumento de recolección de datos un cuestionario validado y traducido al portugués, el WHOQOL-Bref. En los resultados obtenidos ha prevalecido la franja de edad de 50 años o más, todos los participantes se encontraban en el estadio Dukes B y poseían como mínimo un mes y como máximo 11 meses de tratamiento. The domains of the WHOQOLBref affected more significantly were the domains II and III (psychological and social relations), respectively, with significant differences in responses regarding overall QOL in those who were in the first cycle of treatment from those already in the last cycle (6th). Quality of life is the result of a combination of subjective and objective factors, needing help meeting human needs in full, in terms of physical, psychological, social and spiritual.

Introdução: a TC de tórax possui sensibilidade superior à do RX de tórax na detecção de metástases pulmonares do CCR. O uso rotineiro da TC de tórax préoperatória, no entanto, resulta na identificação de um alto número de lesões pulmonares indeterminadas (LPI), as quais raramente são malignas. Objetivo: nosso objetivo principal foi avaliar a eficácia da TC de tórax no estadiamento pré-operatório de pacientes com CCR. Investigamos, também, se os resultados da TC de tórax tiveram influência significativa no manejo oncológico e desfecho clínico dos pacientes. Métodos: realizamos uma revisão de todas as TCs e RXs de tórax realizados em pacientes operados eletivamente por CCR no período de 2005-2012 no serviço de coloproctologia do HCPA. Todos os exames de imagem foram analisados por um radiologista independente “cego”. Os achados dos exames foram classificados como benignos, malignos ou indeterminados. Os pacientes foram acompanhados por pelo menos 12 meses após a cirurgia para avaliar a evolução e real natureza das lesões indeterminadas. Resultados: duzentos e vinte e três pacientes foram incluídos. A TC de tórax demonstrou achados normais ou benignos em 157 (70,4%) pacientes, achados malignos em 17 (7,6%) e achados indeterminados (LPI) em 49 (22%). Dos 30 casos com metástases pulmonares comprovadas, o RX detectou as lesões em apenas 11 pacientes (36,7%). No seguimento pós-operatório (mediana de 27,5 meses), 14 pacientes (28,6%) com LPI tiveram progressão maligna das lesões. Dos 223 pacientes estudados, apenas 6 (2,7%) foram submetidos à ressecção pulmonar, 2 destes permanecendo em remissão até o fechamento do estudo. Conclusão: demonstramos que a TC é claramente superior ao RX na detecção de metástases pulmonares. Apesar das implicações médicas e financeiras do emprego da TC de tórax, apenas um número muito limitado de pacientes será eventualmente submetido à ressecção pulmonar. Nossos resultados contestam o uso da TC de tórax de rotina no estadiamento de pacientes com CCR. Sugerimos uma conduta mais seletiva, reservando a TC para aqueles pacientes com alto risco de metástases pulmonares. / Background: Chest computed tomography (CCT) has higher sensitivity than chest x-ray in detecting lung metastases from colorectal cancer (CRC). However, the routine use of pretreatment CCT results in a high number of indeterminate lung lesions (ILLs), which rarely prove to be malignant. Objective: our main goal was to evaluate the effectiveness of CCT in the preoperative staging of patients with CRC. We also tried to investigate whether the results of CCT have a significant influence on cancer management and clinical outcomes. Methods: we conducted a review of all preoperative CCTs and x-rays performed in patients submitted to an elective resection of CRC between 2005 and 2012 at our institution. All imaging tests were analyzed by a "blind" independent radiologist. Findings were classified as benign, malignant, or indeterminate. Patients were followed up for at least 12 months after surgery to assess clinical evolution of undetermined lesions and their oncological outcome. Results: Two hundred and twenty-three patients were included. CCTs showed normal or benign findings in 157 (70.4%) patients, malignant lesions in 17 (7.6%) patients, and indeterminate lung lesions (ILL) in 49 (22%) patients. Of the 30 cases with proven lung metastases, x-rays detected lesions in only 11 (36.7%) patients. During postoperative follow-up, 14 patients (28.6%) with the initial diagnosis ILL had malignant progression of their lung lesions. Of all 223 patients, only six (2.7%) underwent lung resection. Two of them remained in remission until the end of the study. Conclusion: We demonstrated that CCT is clearly superior to x-ray in the detection of lung metastases. Despite medical and financial implications of preoperative chest CT, only a very limited number of patients will eventually undergo lung resection. We call into question the role of routine chest CT in the staging of patients with CRC. A more selective approach, reserving CT for patients at high risk of lung metastases, is suggested.

L’évaluation de l’effet cytotoxique de différents jus de fruits naturellement riches en polyphénols vis-à-vis de quatre lignées de cancer colorectal a montré que le jus de la canneberge est particulièrement actif. En effet, les polyphénols de la canneberge induisent l’apoptose associée à une surexpression des deux facteurs de transcription pro-apoptotiques p73 et FOXO3a. Cette mort programmée est aussi associée à une diminution de l’expression de SIRT1 le déacétylateur de protéines non histone telles que p73, KU70, ou FOXO. D’autres événements précoces comme la production de ROS et les dommages à l’ADN connus pour réguler l’expression de SIRT1 ont été confirmés. Une deuxième étude avait pour objectif de valider le potentiel anticancéreux in vivo chez la souris Balb/C injectée de cellules d’adénocarcinome colique murin. Pour cela nous avons choisi le jus d’aronie noire qui a montré in vitro un profil de cytotoxicité intéressant. L’analyse des tumeurs a montré que l’administration de jus d’aronie entraine une réduction de la prolifération des cellules tumorales. Enfin, l’augmentation significative de la mobilité de LC3 suggère l’activation d’une mort cellulaire autophagique. Afin d’évaluer l’utilisation clinique des polyphénols, nous avons évalué les effets cytotoxiques des polyphénols de myrtille sur des lymphocytes, de patients atteints de LLC. Nos résultats montrent que l’extrait polyphénolique induit une apoptose dépendante du stress oxydant et impliquant aussi des protéines pro-apoptotiques dans des cellules de patients atteints de LLC mais pas dans les cellules de sujets sains. / The evaluation of the cytotoxic effect of different fruit juices, naturally rich in polyphenols, on four different colorectal cancer cell lines proved that cranberry juice was the most active. Indeed, cranberry polyphenols induce apoptosis associated with the overexpression of two important proapoptotic transcription factors, p73 and FOXO3a on one hand. Furthermore, it has been also correlated with a decrease in the expression of SIRT1, the deacetylase of several non-histone proteins such as p73, KU70 and FOXO. Other early events such as ROS production and DNA damage, which are known to regulate the expression of SIRT1 were confirmed. The second study aims at validating the potential anticancer effects in an in vivo model of colorectal cancer in BALB/c mice injected subcutaneously of murine colon adenocarcinoma cells. Accordingly, we chose the black chokeberry juice, which showed an interesting cytotoxic profile in vitro. The analysis of tumors demonstrated that the administration of chokeberry juice leads to a reduction in tumor cell proliferation. Finally, the significant increase in the mobility of LC3 suggests the activation of autophagic cell death. To validate the clinical use of polyphenols, we evaluated the cytotoxic effects of blueberry polyphenols on lymphocytes of CLL patients. Our results show that the polyphenolic extract induces an oxidative stress-dependent apoptosis that involve various pro-apoptotic proteins in cells of patients with CLL but not in healthy subjects.

Septinas constituem uma família de proteínas de ligação a GTP que foram inicialmente identificadas em levedura Saccharomyces cerevisiae, mas também estão presentes em outros eucariotos com exceção de plantas. Septinas são purificadas de leveduras, Drosophila e cérebros de mamíferos na forma de filamentos, porém o mecanismo através do qual acorre a formação destes filamentos ainda não é muito bem compreendido. Septinas são constituídas de três regiões principais: um N-terminal variável, um domínio central GTPase altamente conservado e um domínio coiled-coil C-terminal. O gene SEPT4 foi identificado por M. Tanaka e colaboradores a partir do cDNA de cérebro humano e apresentou duas distintas transcrições: Bradeiona ? e ?. Interessantemente, além de cérebro e coração, as proteínas Bradeiona &#913; e &#914;. são detectadas somente em câncer do cólon, reto, próstata e melanoma maligno. Neste trabalho, o gene da proteína Bradeiona &#914; foi subclonado em um vetor de expressão bacteriano, produzido em E. coli e purificado com sucesso. O espectro de dicroísmo circular (CD) mostrou o perfil característico de proteínas com hélices a na estrutura secundária. Resultados de cromatografia de exclusão molecular (SEC) e espalhamento dinâmico de luz (DLS) indicam que a septina Bradeina foi produzida na forma de um estável oligômero com características monodispersivas, que foi subseqüentemente cristalizado em PEG6000. A atividade GTPase da Bradeiona &#914; foi comprovada através da técnica de eletroforese capilar (CE), mostrando-se absolutamente dependente de íons Mg2+. Inibição da atividade GTPase foi verificada em altas concentrações de Mg2+ (maiores que 5 mM). Com a finalidade de caracterizar os domínios preditos da Bradeiona &#914; (Fragmento Conservado e domínio GTPase), essas regiões foram previamente definidas, expressas em E. cozi e purificadas com sucesso. Resultados de CD, SEC, espectroscopia de fluorescência e NMR-600MHz indicam que o FC foi produzido na forma de um estável monômero com pouca estrutura secundária regular. Resultados de DLS e CD indicam que a fusão 6xHis-DGTPase foi produzida na forma de um oligômero com a presença de hélices a na estrutura secundária. A fusão 6xHis-DGTPase mostrou-se instável a altas concentrações na ausência de imidazol. A atividade GTPase da fusão GST+DGTPase foi comprovada, similarmente a Bradeiona , através da técnica de CE. Novamente, verificou-se dependência de íons Mg2+ (para a atividade catalítica) e inibição em altas concentrações de Mg2+. A fusão GST+DGTPase também foi capaz de hidrolisar ATP. Espera-se que as informações relatadas neste estudo proporcionem um alicerce para estudos estruturais/funcionais futuros das proteínas Bradeiona &#913; e &#914;outras septinas. / Septins form a class of eukaryoyic guanine nucleotide-binding proteins that were first identified in budding yeast. Septins purified from yeast, Drosophila and mammalian brain form filaments, however the mechanism by which the filaments assemble is unclear. Septins have a highly conserved structure, which includes a central GTP-binding domain, a variable N-terminal region, and most septins also contain a coiled coil domain at the Cterminus. Bradeion p is one of the splice variants of the human septin gene, SEPT4, recently isolated by expression screening of an adult human brain cDNA library. The Bradeion gene resides at 17q23, and has been shown to present specific expression in both human colorectal cancer, urologic cancers and malignant melanoma. In order to characterize the GTPase activity of Bradeion &#914; , the protein was successfully expressed in E. coli and purified. The recombinant protein was characterized by circular dichroism (CD), dynamic light scattering (DLS) and a novel non-radioactive enzyme assay, which utilizes capillary electrophoresis (EC) to monitor GTP hydrolysis. The CD spectrum exhibited the typical shape characteristic of the presence of helical elements of secondary structure and the DLS pattern was indicative of a monodisperse solution, which was readily crystallized in the presence of PEG6000. GTP hydrolysis was shown to be Mg2+ dependent within the low millimolar range but at 5 mM was inhibitory. In order to characterize the predicted domains of Bradeion &#914;, these defined regions were successfully expressed in E. cozi and purified. The CD spectrum of CF exhibited the shape typically found for non-regular structure. The results of fluorescence spectroscopy, gel filtration (SEC) and NMR-600MHz also corroborate with the CD results indicating an irregular structure. The fusion protein 6xHis-DGTPase exhibited a CD spectrum with the typical shape characteristic of the presence of helical elements but was show to be instable at high concentrations in the absence of imidazole. To characterize the GTPase activity of the fusion protein GST+DGTPase, the CE technique was used to monitor GTP hydrolysis. Analysis by CE showed that GST+DGTPase was functional, since both GTP and ATP hydrolysis was observed in a Mg2+ dependent manner. This work provides novel approaches, which should aid in the fbture study of the structure and fùnction of Bradeion &#913; e &#914;, others septins and related GTPases.

O câncer de cólon e reto configura-se como a terceira causa mais comum de câncer no mundo, em ambos os sexos, e a segunda causa em países desenvolvidos. Estudar a qualidade de vida (QV) é fundamental para a presença de intervenções que promovam bem-estar e/ou o estar bem destes pacientes, cujo prognóstico nem sempre é o melhor. Esta dissertação tem como norte a seguinte questão: como é a qualidade de vida do paciente com câncer colorretal em quimioterapia ambulatorial? Trata-se de um estudo transversal com abordagem quantitativa descritiva, no qual buscou-se avaliar a qualidade de vida do paciente com câncer colorretal em quimioterapia ambulatorial. A pesquisa foi desenvolvida em uma Unidade de Quimioterapia Ambulatorial em um hospital do sul do Brasil, cujos pacientes eram portadores do diagnóstico de câncer colorretal e foram submetidos ao tratamento com o Protocolo 5FU. A amostra contou com 48 participantes que estavam em tratamento quimioterápico por um período de 6 meses. Utilizou-se como instrumento de levantamento de dados um questionário já validado e traduzido para o português, o WHOQOL-Bref. Nos resultados encontrados, prevaleceu a idade de 50 anos ou mais, todos os participantes estavam com estadiamento Dukes B e possuíam no mínimo um mês e no máximo 11 meses de tratamento. Os domínios do WHOQOL-Bref afetados mais significativamente foram os domínios II e III (psicológico e relações sociais), respectivamente, havendo diferença nas respostas quanto à QV geral naqueles que estavam no 1º ciclo de tratamento daqueles que já se encontravam no último ciclo (6º). A qualidade de vida é resultado da combinação de fatores subjetivos e de fatores objetivos, precisando suprir às necessidades humanas integrais, em seus aspectos físicos, psicológicos, sociais e espirituais. / Cancer of the colon and rectum appears as the third most common cancer worldwide in both sexes, and the second leading cause in developed countries. Studying the quality of life (QOL) is fundamental for the existence of interventions that promote wellness and/or well-being of these patients, whose prognosis is not always the best. This thesis is guided by the following question: how is the quality of life of patients with colorectal cancer in outpatient chemotherapy? It was a cross-sectional study with a descriptive quantitative approach, which aimed at assessing the quality of life of patients with colorectal cancer in outpatient chemotherapy. The research was conducted in an Outpatient Chemotherapy Unit at a hospital in Southern Brazil, whose patients were diagnosed with colorectal cancer and were treated with 5-FU protocol. The sample had 48 participants who were undergoing chemotherapy for a period of six months. It was used as an instrument of data collection a questionnaire, which has already been validated and translated into Portuguese, the WHOQOL-Bref. In the results found, prevailed the age of 50 years or more, all participants were in Dukes stage B, with at least a month and a maximum of 11 months of treatment. / El cáncer de colon y recto se configura como la tercera causa más frecuente de cáncer en el mundo, en ambos los sexos, y la segunda en los países desarrollados. Estudiar la calidad de vida (CV) es fundamental para la presencia de intervenciones que promueven bienestar y/o el estar bien de los pacientes cuyo pronóstico no siempre sea el mejor. Esta tesina se propone a la siguiente cuestión central: ¿cómo se presenta la calidad de vida de los pacientes con cáncer colorrectal sometidos a quimioterapia ambulatoria? Se trata de un estudio transversal con un abordaje cuantitativo descriptivo en el que se ha buscado evaluar la calidad de vida de pacientes con cáncer colorrectal sometidos a quimioterapia ambulatoria. Se ha desarrollado esta investigación en una Unidad de Quimioterapia Ambulatoria de un hospital ubicado al sur de Brasil, cuyos pacientes eran portadores de diagnóstico de cáncer colorrectal y fueran sometidos al tratamiento con el Protocolo 5-FU. La muestra dispuso de 48 pacientes en tratamiento quimioterápico por un periodo de 6 meses. Se ha utilizado como instrumento de recolección de datos un cuestionario validado y traducido al portugués, el WHOQOL-Bref. En los resultados obtenidos ha prevalecido la franja de edad de 50 años o más, todos los participantes se encontraban en el estadio Dukes B y poseían como mínimo un mes y como máximo 11 meses de tratamiento. The domains of the WHOQOLBref affected more significantly were the domains II and III (psychological and social relations), respectively, with significant differences in responses regarding overall QOL in those who were in the first cycle of treatment from those already in the last cycle (6th). Quality of life is the result of a combination of subjective and objective factors, needing help meeting human needs in full, in terms of physical, psychological, social and spiritual.

Introdução: a TC de tórax possui sensibilidade superior à do RX de tórax na detecção de metástases pulmonares do CCR. O uso rotineiro da TC de tórax préoperatória, no entanto, resulta na identificação de um alto número de lesões pulmonares indeterminadas (LPI), as quais raramente são malignas. Objetivo: nosso objetivo principal foi avaliar a eficácia da TC de tórax no estadiamento pré-operatório de pacientes com CCR. Investigamos, também, se os resultados da TC de tórax tiveram influência significativa no manejo oncológico e desfecho clínico dos pacientes. Métodos: realizamos uma revisão de todas as TCs e RXs de tórax realizados em pacientes operados eletivamente por CCR no período de 2005-2012 no serviço de coloproctologia do HCPA. Todos os exames de imagem foram analisados por um radiologista independente “cego”. Os achados dos exames foram classificados como benignos, malignos ou indeterminados. Os pacientes foram acompanhados por pelo menos 12 meses após a cirurgia para avaliar a evolução e real natureza das lesões indeterminadas. Resultados: duzentos e vinte e três pacientes foram incluídos. A TC de tórax demonstrou achados normais ou benignos em 157 (70,4%) pacientes, achados malignos em 17 (7,6%) e achados indeterminados (LPI) em 49 (22%). Dos 30 casos com metástases pulmonares comprovadas, o RX detectou as lesões em apenas 11 pacientes (36,7%). No seguimento pós-operatório (mediana de 27,5 meses), 14 pacientes (28,6%) com LPI tiveram progressão maligna das lesões. Dos 223 pacientes estudados, apenas 6 (2,7%) foram submetidos à ressecção pulmonar, 2 destes permanecendo em remissão até o fechamento do estudo. Conclusão: demonstramos que a TC é claramente superior ao RX na detecção de metástases pulmonares. Apesar das implicações médicas e financeiras do emprego da TC de tórax, apenas um número muito limitado de pacientes será eventualmente submetido à ressecção pulmonar. Nossos resultados contestam o uso da TC de tórax de rotina no estadiamento de pacientes com CCR. Sugerimos uma conduta mais seletiva, reservando a TC para aqueles pacientes com alto risco de metástases pulmonares. / Background: Chest computed tomography (CCT) has higher sensitivity than chest x-ray in detecting lung metastases from colorectal cancer (CRC). However, the routine use of pretreatment CCT results in a high number of indeterminate lung lesions (ILLs), which rarely prove to be malignant. Objective: our main goal was to evaluate the effectiveness of CCT in the preoperative staging of patients with CRC. We also tried to investigate whether the results of CCT have a significant influence on cancer management and clinical outcomes. Methods: we conducted a review of all preoperative CCTs and x-rays performed in patients submitted to an elective resection of CRC between 2005 and 2012 at our institution. All imaging tests were analyzed by a "blind" independent radiologist. Findings were classified as benign, malignant, or indeterminate. Patients were followed up for at least 12 months after surgery to assess clinical evolution of undetermined lesions and their oncological outcome. Results: Two hundred and twenty-three patients were included. CCTs showed normal or benign findings in 157 (70.4%) patients, malignant lesions in 17 (7.6%) patients, and indeterminate lung lesions (ILL) in 49 (22%) patients. Of the 30 cases with proven lung metastases, x-rays detected lesions in only 11 (36.7%) patients. During postoperative follow-up, 14 patients (28.6%) with the initial diagnosis ILL had malignant progression of their lung lesions. Of all 223 patients, only six (2.7%) underwent lung resection. Two of them remained in remission until the end of the study. Conclusion: We demonstrated that CCT is clearly superior to x-ray in the detection of lung metastases. Despite medical and financial implications of preoperative chest CT, only a very limited number of patients will eventually undergo lung resection. We call into question the role of routine chest CT in the staging of patients with CRC. A more selective approach, reserving CT for patients at high risk of lung metastases, is suggested.