Bakgrund: Aktuell forskning lyfter kostens betydelse för tillfrisknande vid kolorektal cancersjukdom och föreslår kostbehandling som ett kompletterande behandlingsalternativ. Trots detta finns osäkerhet hos både patienter och sjuksköterskor om egenvårdsråd gällande kost vid utskrivning från kirurgisk vårdavdelning. Syfte: Syftet var att, från ett sjuksköterskeperspektiv, beskriva vilka egenvårdsråd om kost patienter som behandlas för kolorektal cancersjukdom efterfrågar och får inför utskrivning från kirurgisk vårdavdelning. Ett annat syfte var att beskriva vilken kunskap sjuksköterskor har för att ge egenvårdsråd om kost. Metodbeskrivning: En deskriptiv kvalitativ intervjustudie med semistrukturerade intervjuer med sjuksköterskor (n=11) på kirurgisk vårdavdelning genomfördes. Konventionell innehållsanalys användes vid dataanalys. Huvudresultat: En vanligt förekommande fråga från patienter med kolorektal cancersjukdom var om något i kosten bör uteslutas relaterat till diagnos. Patienterna rekommenderades att återgå till normal kosthållning och uppmanades att anpassa intaget efter tarmfunktion. Sjuksköterskornas rekommendationer baserades ofta på vilka frågor patienterna själva ställde. Gällande sjuksköterskors kunskap om egenvårdsråd om kost beskriver sjuksköterskorna ett ökat kunskapsbehov. Sjuksköterskorna hänvisade till andra professioner vid kostrådgivning samt en avsaknad av rutin för kostrådgivning framkom. Slutsats: Vaga och generella egenvårdsråd om kost till patienter med kolorektal cancersjukdom har identifierats. Sjuksköterskor tenderar att lämna över ansvar om kostråd till andra professioner och rutinerna för hur egenvårdsråd om kost skall ges är oklara, vilket bidrar till att en evidensbaserad kirurgisk omvårdnad inte uppnås. Ett angeläget behov finns således för rutinutveckling och förbättrad kunskap i ämnet hos sjuksköterskor, för att säkerställa att patienter får ta del av viktig information för tillfrisknande och att förutsättningar för en god egenvård skapas. / Background: The importance of a nutritional diet in the recovery of patients with colorectal cancer disease is acknowledged in current research, with nutritional therapies recommended as a complementary treatment option. Despite this, it has been recognized that many nurses and patients experiencing uncertainty regarding evidence based dietary advice at the point of discharge from the surgical departments. Aim: Firstly, it sets out to describe, from a nurse perspective, what dietary advice patients with colorectal cancer asks for and receives at the point of discharge from the surgical care department. Secondly it aims to describe what knowledge nurses possess in providing dietary advice. Method: A descriptive qualitative interview study was conducted, involving semi-structured interviews with nurses within a surgical care department (n=11). Conventional content analysis was used in data analysis. Results: A common question from patients was if something should be excluded in their diet following their diagnosis. Patients were advised to return to their normal diets and were encouraged to adjust their food intake in accordance with their intestinal function. Recommendations given by nurses were often led by the questions asked by the patients themselves. The nurses described a need for increased knowledge and education to sufficiently advice patients in the effective dietary self-management following discharge. Nurses referred to other professions in dietary advice and a lack of routine for dietary advice emerged. Conclusion: Discharge dietary self-management advise for patients with colorectal cancer disease has been identified as vague and impersonal. It has been suggested that nurses are prone to delegate the responsibility for dietary advices to other professions. This is further complicated by no current clear guidance on what constitutes effective dietary self-management, thus hindering evidence-based practice. Subsequently, there is an urgent need for further developed protocols and improved knowledge among nurses to ensure optimal dietary self-management for patients with a view to increase effective recovery and general wellbeing.

LRP1 (low-density lipoprotein receptor–related protein 1), un récepteur endocytaire multifonctionnel, a récemment été identifié comme pivot d’un réseau de biomarqueurs pour la prédiction pronostique de plusieurs types de cancers. Son rôle dans le cancer du côlon n'a pas été caractérisé. Notre travail porte sur l’étude de la relation entre expression de LRP1 et cancer du côlon.L'expression de l'ARNm LRP1 a été déterminée dans des échantillons d'adénocarcinome et de muqueuses coliques appariées, ainsi que dans les cellules stromales et tumorales obtenues après microdissection laser. Les associations clinicopathologiques et moléculaires ont été étudiées par immunohistochimie dans une série de cancer colique (n = 307). La présence de méthylation ou mutation du gène LRP1 et l'expression de miR-205 ont été évaluées et comparées aux niveaux d'expression de LRP1.L’ARNm de LRP1 est sous exprimé dans les cellules d'adénocarcinome colique par rapport à la muqueuse colique par rapport aux cellules stromales. La faible expression immunohistochimique de LRP1 dans les adénocarcinomes était associée à un âge plus élevé, à localisation droite, une perte d'expression de CDX2, une expression d'Annexine A10, un statut CIMP-H, MSI-H et BRAFV600E muté. Cette faible expression était associée à un mauvais pronostic, en particulier chez les patients de stade IV. Les mutations du gène LRP1 entrainaient une sous-expression de LRP1. L’expression était peu modifiée par miR-205. Le promoteur de LRP1 n'était jamais méthylé.La perte d'expression de LRP1 est associée à un profil clinico-pathologique et moléculaire particulier et à un un mauvais pronostic dans les cancers du côlon. / LRP1 (low-density lipoprotein receptor–related protein 1), a multifunctional endocytic receptor, has recently been identified as a hub in a biomarker network for multi-cancer clinical outcome prediction. Its role in côlon cancer has not been characterized. Here, we investigate the relationship between LRP1 and colon cancer.LRP1 mRNA expression was determined in colon adenocarcinoma and paired colon mucosa samples, and in stromal and tumoral cells obtained after laser capture microdissection. The clinical potential was further investigated by immunohistochemistry in a population-based colon cancer series (n = 307). LRP1 methylation, mutation and miR-205 expression were evaluated and compared to LRP1 expression levels.LRP1 mRNA levels are significantly decreased in colon adenocarcinoma cells compared to colon mucosa and stromal cells. Low LRP1 immunohistochemical expression in adenocarcinomas was associated with higher age, right-sided tumor, loss of CDX2 expression, Annexin A10 expression, CIMP-H, MSI-H and BRAFV600E mutation. Low LRP1 expression correlates with poor clinical outcome, especially in stage IV patients. LRP1 expression was downregulated by LRP1 mutation. LRP1 expression was slightly modified by miR-205 expression. LRP1 promoter was never methylated.Loss of LRP1 expression is associated with peculiar clinocopathological and molecular characteristics and with worse colon cancer outcomes.

L'épithélium intestinal est caractérisé par un renouvellement et une différenciation continus dépendant des cellules souches somatiques situées au fond des cryptes. Le renouvellement rapide est assuré par plusieurs réseaux de voies signalisation dont la dérégulation peut être à l'origine de l'initiation et/ou de la progression tumorale. Mon laboratoire d'accueil a décrit l'implication des hormones thyroïdiennes et de leur récepteur nucléaire TRa1 dans le contrôle de l'homéostasie de l'épithélium intestinal via la régulation de la voie Wnt/b-caténine d'une part et l'implication de TRa1 dans l'induction de tumeurs intestinales grâce à des souris surexprimant TRa1 d'autre part. De plus, dans un contexte APC muté, l'expression transgénique de TRa1 accélère la progression tumorale et favorise la dissémination métastatique. Des analyses transcriptomiques mettent en évidence une forte activation de la voie Wnt par TRa1. Ces résultats ont été confirmés chez l'homme en étudiant la régulation de la voie Wnt par TRa1 dans des carcinomes colorectaux (CRC). Nous avons confirmé la surexpression de TRa1 dans les tumeurs humaines et validé son impact sur la voie Wnt tant dans les tumeurs humaines que dans des lignées cellulaires et sur leur agressivité. L'ensemble des données montre une forte implication de TRa1 dans la tumorigenèse chez la souris et chez l'homme et ouvrent des portes pour des recherches visant TRa1 comme cible de traitement thérapeutique contre le cancer / The intestinal epithelium is characterized by constant renewal and differentiation due to the presence of stem cells located at the bottom of the crypts. This permanent renewal depends on the crosstalk between several signaling pathways whose alteration can lead to tumor initiation and progression. Our team demonstrated the implication of the thyroid hormones and their nuclear receptor TRa1 in the control of the intestinal epithelium homeostasis through the regulation of the Wnt pathway. Moreover, the overexpression of TRa1 in the intestinal epithelium of mice is sufficient to promote tumor initiation, and in an APC loss of function context, it accelerates tumor progression highlighting its oncogenic potential. Through gene expression profiling, we highlighted an activation of the Wnt pathway activity by TRa1 during tumor progression. We next confirm these results in human patient samples by demonstrating that high TRa1 expression in tumors invariably is associated with an increased Wnt pathway activity. In addition, in CRC cell lines, TRa1-associated WNT pathway activation enhances their aggressiveness. Altogether these results showed the implication of TRa1 in intestinal carcinogenesis and open avenues for new therapeutic treatment against TRa1 targeting TRa1

Une analyse multiple des mutations, de l’expression des transcrits et de l’épissage alternatif a été réalisée dans des biopsies de lésions colorectales, correspondant à des stades variés de transformation, afin de rechercher des altérations qui caractériseraient la transformation de la muqueuse normale en adénome, puis en adénocarcinome. Cette analyse est basée sur l’utilisation de différentes technologies de puces à ADN. Des altérations spécifiques à chaque type de lésions colorectales ont été mises en évidence, démontrant que les adénomes et les adénocarcinomes sont des entités distinctes. Cependant, des altérations communes ont aussi été identifiées, confirmant que l’adénome est un état transitoire avant l’adénocarcinome. Une sélection clonale et des effets environnementaux sont sans doute à l’origine de la progression des adénomes en adénocarcinomes. Des voies de signalisation cellulaire caractéristiques de cette transformation ainsi qu’une classification des lésions colorectales ont été recherchées. Une signature de 40 transcrits a été identifiée, qui pourrait permettre de prédire la transformation des adénomes en adénocarcinomes. Des événements d’épissage alternatif ont aussi été détectés dans les adénomes, suggérant l’implication, à un stade précoce, de ces altérations dans le processus de cancérisation. Enfin, une puce à ADN « à façon » a été élaborée, qui s’inscrit dans une perspective d’appui à la mise en oeuvre de thérapeutiques anticancéreuses. Elle permet en effet d’analyser l’épissage alternatif des gènes codant les protéines cibles des nouvelles thérapies ciblées du cancer. / A genome-wide analysis of mutation, gene expression and alternative pre-mRNA splicing was performed in colorectal normal mucosa, adenoma and adenocarcinoma biopsy samples in order to look for some alterations that could characterize the stepwise “colorectal normal mucosa-adenoma-adenocarcinoma” transition. It was conducted through different microarray-based experiments. Alterations specific for either adenomas or adenocarcinomas were identified. Nevertheless, most deregulated genes in adenocarcinomas were shared between adenomas and adenocarcinomas, in agreement with the notion that adenomas are precursor lesions for adenocarcinomas. Adenomas may have different outcomes, depending on environment, some evolving towards cancer, while others could be prone to disappearance. Pathway enrichment in colorectal lesions and classification of colorectal lesions were investigated. A 40-gene set was identified as a gene expression signature that could help predicting patients, at time of adenoma ablation, with a risk for developing colorectal cancer. Splicing profiles were also identified in colorectal lesions, suggesting that alternative splicing may play a major role in cancer outcome. Finally, a custom microarray was designed with the aim to predict the response of patients before treatment. This custom microarray makes it possible to analyze transcript structure and levels for genes involved in the response to targeted anticancer therapies.

OBJETIVO: Determinar o impacto de fatores prognósticos na sobrevida de pacientes com metástases hepáticas ressecadas e originadas de câncer colorretal. CASUISTICA E MÉTODOS: Foram analisados os prontuários de 28 pacientes submetidos a ressecção hepática de metástases de câncer colorretal de Abril /1992 a Setembro /2001. Foram realizadas 38 ressecções (8 pacientes com mais de uma ressecção no mesmo tempo cirúrgico e 2 pacientes submetidos a re-ressecções). Todos haviam sido submetidos previamente à ressecção do tumor primário. Utilizou-se um protocolo de rastreamento de metástases hepáticas que incluiu revisões clinicas trimestrais, ecografia abdominal e dosagem de CEA até completarem-se 5 anos de seguimento e, após, semestralmente. Os fatores prognósticos estudados foram: estágio do tumor primário, tamanho das metástases > 5cm, intervalo entre ressecção do tumor primário e surgimento da metástase <1 ano, CEA>100ng/ml, margens cirúrgicas <1cm e doença metastática extra-hepática. O estudo foi retrospectivo e a análise estatística foi feita através da curva de Kaplan-Meier, do log rank e da regressão de Cox. RESULTADOS: A morbidade foi 39,3% e a mortalidade operatória foi 3,6%.A sobrevida em 5 anos foi de 35%. Os fatores prognósticos independentes adversos foram: intervalo <1 ano entre ressecção do tumor primário e surgimento da metástase (p=0,047 e RR 11,56) e doença metastática extra-hepática (p=0,004 e RR=57,28). CONCLUSÕES: A ressecção hepática de metástases de câncer colorretal é um procedimento seguro com sobrevida em 5 anos acima dos 30%. Foram fatores prognósticos independentes adversos: doença metastática extra-hepática e intervalo<1ano entre ressecção do tumor primário e surgimento da metástase. / Prognostic factors following liver resection for hepatic metastases from colorectal cancer. BACKGROUND: To determine the impact of prognostic factors on survival of patients with metastases from colorectal cancer that underwent liver resection. METHODS: The records of 28 patients that underwent liver resection for metastases from colorectal cancer between April /1992 and September/2001 were retrospectively analized. Thirty-eight resections were performed (more than one resection in eight patients and two patients underwent re-resections). The primary tumor was resected in all the patients. A screening protocol for liver metastases including clinical examinations every three months, abdominal ultrassonography and CEA level until five years of follow-up and after every six months, was applied. The prognostic factors analized regarding the impact on survival were: Dukes C stage of primary tumor, size of metastasis > 5cm, a disease-free interval from primary tumor to metastasis < 1 year, CEA level > 100ng/ml, resection margins < 1cm and extrahepatic disease. The Kaplan-Meier curves, log rank and Cox regression were used for the statistical analysis. RESULTS: Perioperative morbidity and mortality were 39,3% and 3,6% respectively. The 5-year survival rate was 35%. The independent prognostic factors were: disease-free interval from primary tumor to metastasis < 1year (p=0,047; RR=11,56) and extrahepatic metastatic disease (p=0,004; RR=57,28). CONCLUSIONS: The liver resection for metastases from colorectal cancer is a safe procedure with more than 30% 5-year survival .Disease- free interval from primary tumor to metastasis < 1year and extrahepatic disease were independent prognostic factors.

Abstract Colorectal cancer (CRC) is among the most common cancers in Finland. Prognostic factors are important for predicting disease outcome and adjusting optimal treatment. The currently used prognostic methods for CRC have their limitations and consequently several biomarkers have been studied to find potential prognostic markers, but none have been adapted for routine use so far. In the present study, the relationships between the components of the immune system and other factors modulating tumor growth were assessed and their suitability to be used for use as prognostic tools in CRC were studied. The study material consisted of blood samples and surgical specimens collected from 148 CRC patients operated on in Oulu University Hospital and blood samples of 86 healthy controls. Concentrations of endostatin and 27 cytokines were measured from preoperative serum samples and control samples. Immunohistochemical methods were used for collagen XVIII and inflammatory cell analyses. The levels of several cytokines were altered in CRC patients compared to the controls. The serum cytokine profile achieved an excellent accuracy in discriminating CRC patients from healthy controls. Advanced CRCs were associated with elevated cytokine levels and a metastasized disease was linked to an orientation towards Th2 cytokine milieu. The presence of systemic inflammation, depicted by a modified Glasgow Prognostic Score (mGPS), correlated to CRC progression. The serum endostatin levels were elevated in CRC and correlated with invasion through muscular layer and systemic inflammation, but not with densities of local inflammatory cells. Collagen XVIII was expressed in tumor stroma and in the muscle layer of bowel wall. The serum cytokines and tumor infiltrating immune cells showed relatively weak associations. In conclusion, CRC is associated with significant alterations in serum cytokine milieu, which underlines the relevance of studying several cytokines and their relative alterations. The serum cytokine profile is a promising tool for discriminating CRC patients from healthy controls, but its clinical value needs to be validated. The elevated endostatin levels may result from invasion-related cleavage of collagen XVIII in the bowel wall, but further studies are needed to determine the value of endostatin in CRC prognosis. / Tiivistelmä Paksu- ja peräsuolisyöpä (kolorektaalisyöpä) on yleisimpiä syöpämuotoja Suomessa. Sen ennustetta kuvaavat mittarit ovat tärkeitä taudin etenemisen ennustamisessa ja hoidon suunnittelussa. Käytössä olevat kolorektaalisyövän ennusteen arvioinnin menetelmät eivät ole riittäviä. Uusia merkkiaineita onkin kehitetty ja testattu, mutta rutiinikäyttöön soveltuvia menetelmiä ei ole vielä löydetty. Tässä tutkimuksessa selvitettiin immuunijärjestelmän ja muiden kasvaimen kasvua säätelevien tekijöiden keskinäisiä yhteyksiä ja niiden merkitystä kolorektaalisyövän ennusteen arvioinnissa. Tutkimusmateriaali koostui Oulun yliopistollisessa sairaalassa leikattujen kolorektaalisyöpäpotilaiden (n&#160;=&#160;148) leikkaus- ja verinäytteistä ja terveiden verrokkihenkilöiden (n&#160;=&#160;86) verinäytteistä. Endostatiinin ja 27 sytokiinin pitoisuudet mitattiin seeruminäytteistä. Kollageeni XVIII:n ja tulehdussolujen analysoimiseen käytettiin immunohistokemiallisia menetelmiä. Useiden sytokiinien pitoisuudet olivat korkeammat potilailla kuin verrokeilla, mutta osassa sytokiineista pitoisuudet olivat alentuneet. Seerumin sytokiiniprofiili erotteli luotettavasti potilaat verrokeista. Pidemmälle edenneeseen tautiin liittyi sytokiinien korkeampia pitoisuuksia ja etäpesäkkeitä muodostanut tauti oli yhteydessä Th1-tyypin sytokiinien esiintymiseen. Systeeminen tulehdusreaktio oli yhteydessä syövän etenemiseen. Endostatiinipitoisuudet olivat kohonneet potilailla ja olivat yhteydessä kasvaimen invaasioon suolen seinämän lihaskerroksen läpi. Endostatiinipitoisuudet korreloivat myös systeemisen tulehdusreaktion kanssa, mutta eivät liittyneet paikallisten tulehdussolujen määrään. Kollageeni XVIII ilmentyi kasvaimen stroomassa ja suolen seinämän lihaskerroksessa. Sytokiineilla ja kasvaimen paikallisilla tulehdussoluilla todettiin olevan vain vähän keskinäisiä yhteyksiä. Kolorektaalisyöpään liittyy useita erisuuntaisia muutoksia seerumin sytokiinipitoisuuksissa, joten on olennaista tutkia eri sytokiinien suhteellisia muutoksia. Seerumin sytokiiniprofiili on lupaava potilaita ja verrokeita erotteleva mittari, jolla voi olla diagnostista arvoa. Kohonneet endostatiinipitoisuudet potilailla voivat johtua kasvaimen invaasioon liittyvästä kollageeni XVIII:n hajoamisesta suolen seinämässä, mutta lisätutkimuksia tarvitaan endostatiinin ennustetta kuvaavan arvon määrittämiseksi.

Les tumeurs sont constituées de deux groupes cellulaires :les cellules tumorales et les cellules dites « hôtes ». Au sein de ce dernier groupe, on retrouve les cellules endothéliales, les cellules inflammatoires mais également les fibroblastes associés au cancer (FAC). De plus en plus de données dans la littérature suggèrent l’importance des FAC dans l’invasion tumorale et le développement métastatique. De nombreuses études immunohistochimiques ont démontré le rôle pronostique des FAC dans différents cancers. Les traitements néoadjuvants modifient l’environnement tumoral mais l’impact de ces traitements sur les FAC est assez méconnu.Notre travail porte, tout d’abord, sur une revue de littérature à propos de l’impact pronostique négatif des FAC dans différents cancers. Ensuite, nous avons étudié le ratio des FAC SMA+/surface épithéliale tumorale dans une cohorte de patients ayant été opérés d’un adénocarcinome rectal ayant bénéficié ou pas d’une thérapie néoadjuvante. La comparaison du ratio entre les groupes traités et non traités a montré un ratio plus élevé chez les patients ayant bénéficié d’une thérapie néoadjuvante. Par ailleurs, les tumeurs présentant un ratio élevé présentent également un indice de prolifération faible suggérant que la thérapie néoadjuvante modifie l’environnement tumoral par une majoration des FAC aux dépens des cellules tumorales et par l’acquisition d’un phénotype quiescent des cellules tumorales. Finalement, chez les patients traités par une thérapie néoadjuvante, un ratio supérieur à un est associé à une survie sans récidive mauvaise.Nous nous sommes ensuite intéressés à la protéine FHL2 qui est exprimée par les FAC mais également par les cellules tumorales. L’étude de l’expression immunohistochimique de la protéine FHL2 sur un tissue microarray de cancers coliques a démontré que celle-ci est exprimée fréquemment dans les FAC de cancers coliques alors que l’expression dans les cellules tumorales est plus variable. Nous avons démontré que les tumeurs coliques exprimant fortement FHL2 sont associées à un plus mauvais pronostic (survie et survie sans récidive). Ce résultat est probablement lié à l’implication de cette protéine dans la transition épithélio-mésenchymateuse.Finalement, nous avons étudié la possibilité d’une interaction entre FHL2 et ADAM-17. Nous avons démontré que cette interaction est plus fréquente dans le cancer colique comparé au tissu colique normal. Ce dernier résultat ouvre la voie vers un partenaire potentiel de FHL2 qui pourrait notamment interférer avec la voie de signalisation de l’EGF. / Tumours are composed of two cellular groups: the tumoural cells and the host cells. In this latter, we find endothelial cells, inflammatory cells but also the cancer-associated fibroblasts (CAFs). More and more litterature data suggest a key role of CAFs in the tumoural invasion and in the metastatic development. Several immunohistochemical studies have highlighted the prognostic role of CAFs in different cancers. Neoadjuvant treatments modulate the tumoural environment but the impact of such treatment on the CAFs is relatively unknown.In the first part of this thesis we revise the current knowledge on the adverse prognostic impact of CAFs in different cancers. We studied by immunohistochemistry the ratio CAFs SMA+/tumoural epithelial area within a patient cohort operated for rectal adenocarcinoma receiving or not a neoadjuvant treatment. The comparison of the ratio between the treated group and the non-treated group showed that this ratio is higher in patients treated with neoadjuvant therapy. Moreover, rectal cancer with a high ratio displayed a lower proliferation rate suggesting that the neoadjuvant treatment modifies the tumoural environment by an increase of CAFs and by acquisition of a quiescent phenotype of the tumoural cells. In the group of patients treated with neoadjuvant treatment, a ratio >1 was associated with an adverse impact on recurrence free survival.Secondly, we studied Four-and-a-half LIM Domain protein 2 (FHL2) which is a protein expressed by CAFs but also by the tumoural cells. Immunohistochemical study of FHL2 expression on a colon cancer tissue microarray demonstrated that FHL2 is frequently expressed in colon cancer CAFs while its expression is variable in the tumoural cells. We demonstrated that high FHL2 expression in colon cancer is related to poor prognosis (overall survival and metastasis free survival). Aggressive behaviour in such tumours might be related to the implication of FHL2 in epithelial-to-mesenchymal transition.Finally, we studied a possible interaction between FHL2 and ADAM-17. We demonstrated that this interaction is more frequent in colon cancer compared to normal colonic tissue, suggesting a role for it in colon cancer development. This interaction possibly interferes with the EGF pathway / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

Le but de ce travail est d'élaborer et d'évaluer une intervention de santé publique, visant à augmenter la participation au dépistage ciblé par coloscopie de la population à risque plus élevé de cancer colorectal (CCR) en raison d'antécédents familiaux en faisant appel à une méthodologie qui repose sur 3 étapes successives :1- une étude observationnelle : l'identification des déterminants associés à la réalisation de la coloscopie chez la fratrie d'un patient atteint de CCR avant 60 ans. (3 publications) 2- une expérimentation contrôlée, visant à tester l'efficacité d'une intervention personnalisée, par une infirmière de prévention, sur la participation au dépistage des fratries d'un patient atteint de CCR ou d'adénome avant 60 ans. L'intervention personnalisée qui a intégré non seulement les fratries mais également les cas index et les médecins a fait la preuve d'une efficacité jusque là jamais atteinte dans les études menées antérieurement aux USA, qui ciblaient uniquement les fratries. Cette analyse épidémiologique a été enrichie par des analyses linguistiques et sociologiques afin de mieux comprendre l'impact de cette intervention téléphonique. (1 publication)3- Cependant, les contraintes propres à la conduite d’un essai interventionnel randomisé, si elles garantissent un niveau de preuve élevé du bénéfice de l’intervention, ont aussi pour conséquence un caractère expérimental ; cet essai ne pourra être généralisé à l'identique. Une étude de recherche interventionnelle en santé des populations a été soumise à l'appel à projets 2016 de l'INCa. / The aim of this work was to develop and evaluate a public health intervention to increase participation in targeted screening colonoscopy for high-risk population of colorectal cancer (CRC) because of family history using a methodology based on three successive stages:1- an observational study to identify the determinants associated with the achievement of colonoscopy among siblings of a patient with CRC before age 60. (3 publications)2- a controlled experiment to test the effectiveness of a personalized intervention by a preventive nurse on the participation in screening of siblings of a patient with CRC or adenoma before age 60. The personalized intervention that included not only siblings but also the index case, specialists and general practitioners has demonstrated efficiency never achieved previously in earlier studies in the USA, which targeted only siblings. This epidemiological analysis was enriched by crossed linguistic and sociological analyses to better understand the impact of telephone interventions. (1 publication)3- However, the constraints on the conduct of a randomized interventional trial, if they guarantee a high level of evidence of the benefit of the intervention, also have the effect of an experimental nature that cannot be generalized. An original research study on population health intervention has been developed and submitted to the 2016 INCa call for projects.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: manganese dependent superoxide dismutase (SOD2), is an important antioxidant enzyme, superoxide dismutase to anion produced in mitochondria in hydrogen peroxide, which in turn is catalyzed by glutathione peroxidase (GPX) into water and oxygen. Although be crucial for healthy cell, the role of SOD2 in cancer is highly controversial because in some kinds of cancers this enzyme exhibits a marked antitumor activity, while in others have a pro-tumor role. Previous investigations involving a polymorphism in codon 16 of SOD2 gene in which there is an exchange of a valine with an alanine (Val16Ala-SOD2) have associated increased efficiency of enzyme SOD2 at high risk of some cancers. However, in certain types of tumors, such as colorectal cancer are conflicting results. Studies suggest that high levels in tumor cells SOD2 colorectal cancers are associated with tumor progression. Perhaps this difficulty in defining the role of SOD2 in colorectal cancer biology is linked to great influence of environmental factors on the gastrointestinal system, especially the diet. For this reason, the development of an unbalance pharmacological model to investigate the role of superoxide-anion imbalance hydrogen peroxide (Superoxide Anion Hydrogen Peroxide imbalance, AS-HP) in colorectal cancer may be relevant. Objective: This study investigated the in vitro effect of drug-AS-HP imbalance caused by exposure to paraquat and the porphyrin in the viability and proliferative rate of commercial line of colorectal cancer cells (HT-29) and the response of these cells to chemotherapy oxaliplatin. The study also assessed the effect of AS-HP unbalance in the modulation of the expression of apoptotic genes, cell cycle and oxidative in HT-29 cells. Methods. HT- 29 obtained from American Type Cell Culture Collection (ATCC) were grown in DMEM, 10% fetal bovine serum, 1% antibiotic and antifungal in an oven with 5% CO2 and 37 ° C temperature. After 24 h the transfer of cells to 96-well plates at a concentration of 10 5 cells per well were exposed to these concentrations of 0.1 uM paraquat which is a superoxide-generating molecule or porphyrin which is a molecule with a similar effect SOD2 enzyme. Part of the cells was treated with oxaliplatin at a concentration of 20um and the other not. The effect on the viability, cell proliferation, cell cycle, apoptosis and modulation of genes of the cell cycle, apoptosis and oxidative metabolism (SOD1, SOD2, CAT, GPX, Caspase 3, Caspase 8, BAX, BCL-2 and P53colocar the name gene) was also evaluated. Assays were done in triplicate and compared by analysis of variance followed via test post hoc Tukey. Results: pharmacological imbalance AS-HP obtained via exposure of colorectal cancer cells to paraquat and porphyrin changed the standard of viability, cell cycle and in the modulation of gene expression. Both paraquat as nna porphyrin concentration 0.1 uM reduced the viability and proliferation rate of HT-29 cells. However, this effect was more pronounced in cells exposed to paraquat. The action of oxaliplatin was enhanced by the presence of paraquat when analyzed, the mortality rate, apoptosis, cell proliferation rate. Paraquat tamém induced cell cycle interruption phases S and G2 / M Any paraquat as porphyrin were able to modulate differentially markers of oxidative metabolism and expression of genes investigated. However, the results were quite heterogeneous. This heterogeneity may be associated with chromosomal instability in cancer cells that have high levels, and varied mutational. Conclusion: The results confirm the hypothesis that the AS-HP unbalance acts on the biology of colorectal cancer, and in particular increased levels of superoxide, not only increase the mortality rate but also inhibit cell proliferation enhancing so antitumor action of oxaliplatin. These results may be clinically relevant in the construction of pharmaceutical and / or nutritional strategies as the use of vitamins and other dietary supplements which operate in AS-HP sheet and to assist in the successful chemotherapeutic treatment of disease. / Introdução: a superóxido dismutase dependente de manganês (SOD2), é uma importante enzima antioxidante, que dismuta o ânion superóxido produzido na mitocôndria em peróxido de hidrogênio, que por sua vez é catalisado pela glutationa peroxidase (GPX) em água e oxigênio. Apesar de ser crucial para a célula saudável, o papel da SOD2 no câncer é bastante controverso, pois em alguns tipos de neoplasias apresenta uma clara ação antitumoral, enquanto que em outras tem um papel pró tumoral. Investigações prévias envolvendo um polimorfismo no códon 16 do gene da SOD2 no qual ocorre uma troca de uma valina por uma alanina (Val16Ala-SOD2), têm associado maior eficiência da enzima SOD2 com risco elevado de alguns tipos de câncer. Entretanto, em certos tipos de tumores, como o câncer colorretal os resultados são conflitantes. Estudos sugerem que os níveis elevados de SOD2 em células de tumores colorretais estão associados com a progressão do tumor. Possivelmente esta dificuldade em definir o papel da SOD2 na biologia do câncer colorretal esteja vinculado a grande influência de fatores ambientais sobre o sistema gastrointestinal, com destaque a dieta. Por este motivo, o desenvolvimento de um modelo farmacológico de desbalanço para investigar o papel do desbalanço ânion superóxido-peroxido de hidrogênio (Superoxide Anion Hydrogen Peroxide imbalance, AS-HP) no câncer colorretal pode ser considerado relevante. Objetivo: investigar o efeito in vitro do desbalanço farmacológico do AS-HP causado pela exposição ao paraquat e a porfirina na viabilidade e taxa proliferativa da linhagem comercial de células de câncer colorretal (HT-29) e na resposta destas células ao quimioterápico oxaliplatina. O estudo também avaliou o efeito do desbalanço AS-HP na modulação da expressão de genes apoptóticos, do ciclo celular e oxidativos nas células HT-29. Métodos. Células HT-29 obtidas da American Type Culture Collection (ATCC) foram cultivadas em meio DMEM, 10% de soro bovino fetal, 1% de antibióticos e antifúngicos em estufa com CO2 a 5% e temperatura de 37oC. Após 24 h da transferência das células para placas de 96 poços na concentração de 10 5 células por poço, estas foram expostas a concentração de 0,1 uM de paraquat, que é uma molécula geradora de superóxido, ou de porfirina, que é uma molécula com efeito similar a enzima SOD2. Parte das células foi tratada com oxaliplatina na concentração de 20uM e outra não. O efeito na viabilidade, proliferação celular, ciclo celular, apoptose, e na modulação dos genes do ciclo celular, apoptose e metabolismo oxidativo (β-actina, SOD1, SOD2, CAT, GPX, Caspase 3, Caspase 8, BAX, BCL-2 e P53) também foram avaliados. Os ensaios foram realizados em triplicatas e comparados por análise de variância de uma via seguido de teste post hoc de Tukey. Resultados: o desbalanço farmacológico AS-HP obtido via exposição das células de câncer colorretal ao paraquat e porfirina alterou o padrão de viabilidade, ciclo celular e na modulação da expressão gênica. Tanto o paraquat quanto a porfirina na concentração 0,1 uM diminuíram a viabilidade e a taxa de proliferação das células HT-29. No entanto, este efeito foi mais pronunciado em células expostas ao paraquat. A ação da oxaliplatina foi potencializada pela presença do paraquat quando foram analisadas a taxa de mortalidade, apoptose, taxa de proliferação celular. O paraquat também induziu interrupção do ciclo celular nas fases S e G2 / M. Tanto o paraquat quanto a porfirina foram capazes de modular diferencialmente marcadores do metabolismo oxidativo e a expressão dos genes investigados. Entretanto, os resultados foram bastante heterogêneos. Esta heterogeneidade pode estar relacionada com a instabilidade cromossômica de células tumorais que apresentam níveis mutacionais altos e variados. Conclusão: os resultados obtidos corroboram a hipótese de que o desbalanço AS-HP age sobre a biologia do câncer colorretal, e que em especial o aumento nos níveis de superóxido, não só aumentam a taxa de mortalidade mas também inibem a proliferação celular, potencializando assim, a ação antitumoral da oxaliplatina. Estes resultados podem ser clinicamente relevantes na construção de estratégias farmacológicas e/ou nutricionais, como um adjuvante ao tratamento o uso de vitaminas ou outros suplementos dietéticos, que atuem no balanço AS-HP e que auxiliem no sucesso do tratamento quimioterápico da doença.

Les thérapies moléculaires ciblées ont changé la prise en charge des patients atteints de cancer, et en particulier dans le cancer colorectal (CCR). Il est important d’identifier des biomarqueurs de sensibilité ou de résistance à ces traitements. En premier, la signalisation en aval de l’EGFR au niveau tumoral pourrait conditionner la réponse au cétuximab dans les cancers colorectaux (CCR). Notre premier travail a évalué le niveau d’expression tumorale de phosphoprotéines de signalisation en aval de l’EGFR (p-MEK, p-ERK1/2, p-AKT, p-GSK3b, p-P70S6K) analysés par Bioplex phosphoprotein array chez 42 patients avec un CCR métastatique, traités par anti-EGFR. L’expression de p-P70S6K est plus faible chez les patients répondeurs (p=0,02). La survie sans progression (SSP) est supérieure en cas d’expression faible de p-P70S6K (p=0,0001) et p-MEK (p=0,0006). p-MEK et p-P70S6K ont une expression plus élevée chez les KRAS mutés et apparaissent comme deux marqueurs pronostiques indépendants de KRAS (HR 0,34, p=0,01 et HR 0,42, p=0,03). Ainsi, le niveau d’expression des phosphoprotéines en aval de l’EGFR pourrait prédire la réponse et la SSP dans les CCR traités par anti-EGFR, indépendamment du statut KRAS. Il est difficile dans certain cas d’avoir accès au tissu tumoral. L’ADN circulant (cADN) dans les stades avancés de cancer peut aider à la caractérisation moléculaire des tumeurs, en tant que biopsie. Notre deuxième travail a étudié la faisabilité, la sensibilité et la spécificité d’une technique de spectrométrie de masse (Sequenom) pour détecter des mutations (238 mutations parmi 19 oncogènes) à partir du tissu tumoral et du cADN de 105 patients ayant un cancer avancé. La concentration médiane de cADN était de 17ng/ml de plasma (0,5-1600), soit 3 fois le niveau chez les volontaires sains. En analyse multivariée, la concentration de cADN, l’albumine et l’état général étaient des facteurs prédictifs indépendants de la survie globale des patients. De plus, il existait une concordance élevée des statuts mutationnels (KRAS, BRAF et PIK3CA) entre le tissu tumoral et le cADN dans plusieurs types tumoraux (CCR, sein, mélanome): un taux de concordance de 70% pour le gène KRAS et de 100% pour le gène BRAF ont été retrouvés dans le CCR. Notre Étude suggère que l’analyse du cADN pourrait être un matériel utilisable pour la recherche de mutations, notamment dans le suivi des patients ayant un cancer du colon traités par thérapies ciblées. Notre travail a donc montré l’intérêt de poursuivre l’étude de facteurs moléculaires qui pourraient prédire la réponse ou la résistance à des thérapies ciblées utilisées dans les cancers du colon, au niveau du tissu tumoral (phosphoprotéines) ou au niveau du sang (cADN). / Especially in CRC, it is important to identify molecular targeted therapies biomarkers. First, additional markers of resistance to KRAS mutations could predict resistance to anti-epidermal growth factor receptor (EGFR) antibodies in advanced colorectal cancer (CRC). In our first study, in a series of 42 patients with advanced CRC treated with cetuximab/panitumumab, for whom KRAS status was previously determined, we retrospectively analyzed the intratumor expression of EGFR downstream signaling phosphoproteins of the RAS/MAPK and PI3K/AKT pathways (pERK1/2, pMEK1, pAKT, pP70S6K and pGSK3beta) using Bio-Plex phosphoprotein array. The expression of all the phosphoproteins was higher in KRAS mutated tumors than in WT tumors. The expression of pP70S6K was lower in responders than in nonresponder patients. In multivariate analysis, PFS was shorter for patients with high pMEK1 or pP70S6K expression, independently of KRAS status, as OS for patients with high pP70S6K expression. Our results suggest the importance of EGFR downstream signaling phosphoproteins expression in addition to KRAS status to define the subgroup of patients who will not benefit from anti-EGFR therapy. We hypothesized that circulating plasma DNA (cpDNA) in advanced cancer patients is largely derived from tumor, and can be utilized for tumor mutation sequencing when repeat biopsy is not feasible. In our second study, we utilized the Sequenom MassArray System and OncoCarta panel for somatic mutation profiling. Matched samples, acquired from the same patient but at different time points were evaluated; these comprised formalin-fixed paraffin-embedded (FFPE) archival tumor tissue (primary and/or metastatic) and cpDNA. The feasibility, sensitivity, and specificity of this high-throughput, multiplex mutation detection approach was tested utilizing specimens acquired from 105 patients with solid tumors referred for participation in Phase I trials of molecularly targeted drugs. The median cpDNA concentration was 17 ng/ml (range: 0.5-1600); this was 3-fold higher than in healthy volunteers. In multivariate analyses, cpDNA concentration, albumin, and performance status remained independent predictors of OS. We also observed high detection concordance for critical "hot-spot" mutations (70% for KRAS, 100% for BRAF) in matched cpDNA and archival tumor tissue. This multiplex sequencing assay can be utilized to detectsomatic mutations from plasma in advanced cancer patients, when safe repeat tumor biopsy is not feasible and genomic analysis of archival tumor is deemed insufficient. Our work did show the importance to search for molecular markers to predict response to targeted therapies, both in tumor tissu (phosphoproteins) and in blood (cpDNA).