CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / O linfoma difuso de grandes cÃlulas B (LDGCB) corresponde a 50 % dos casos de linfoma nÃo-Hodgkin (LNH). Seu tratamento de escolha à a quimioterapia de associaÃÃo, em especial o esquema CHOP (ciclofosfamida, doxorrubicina, vincristina e prednisona), considerado o tratamento inicial padrÃo dos LDGCB. VariaÃÃes deste esquema, como o protocolo CHOP-Bleo (ciclofosfamida, doxorrubicina, vincristina, prednisona e bleomicina) tem sido utilizadas com a intenÃÃo de se obter maiores taxas de remissÃo completa pelos pacientes. No Brasil, pouco se conhece a respeito da incidÃncia, do comportamento clÃnico, da resposta Ãs terapÃuticas utilizadas e da sobrevida de pacientes com LDGCB. Este estudo teve como objetivos traÃar o perfil epidemiolÃgico dos pacientes portadores de linfoma difuso de grandes cÃlulas B, atendidos no Hospital UniversitÃrio Walter CantÃdio (HUWC), com data de primeiro atendimento de janeiro de 1989 a dezembro de 2003, e que fizeram uso dos esquemas quimioterÃpicos CHOP e/ou CHOP-Bleo; avaliar a eficÃcia e seguranÃa terapÃutica dos esquemas propostos atravÃs da anÃlise do tipo de resposta terapÃutica, achados clÃnicos e laboratoriais destes pacientes. A coleta dos dados foi realizada a partir dos prontuÃrios mÃdicos dos 31 pacientes analisados. Destes, 21 (67,74%) eram do sexo masculino e 10 (32,26%) do feminino, com idade mÃdia de 45,81  16,3 anos. A ocupaÃÃo trabalhador agrÃcola representou 25,82% (8/31). O estÃdio III da classificaÃÃo de Ann Arbor foi o mais freqÃente (32,26%), mas apenas 45% dos pacientes apresentaram sintomas B. A lactato desidrogenase (LDH) sÃrica de 49% dos pacientes encontrava-se elevada à Ãpoca do diagnÃstico, sendo que outros 16% dos pacientes nÃo apresentavam resultado desta enzima em seus prontuÃrios. Quanto ao IPI, 71% foram classificados como de risco baixo e intermediÃrio, 13% de alto risco intermediÃrio, nenhum dos pacientes do estudo apresentou IPI compatÃvel com de alto risco e em 16% dos pacientes nÃo foi possÃvel estabelecer a classificaÃÃo devido à ausÃncia de dados nos prontuÃrios. Quanto à utilizaÃÃo dos protocolos quimioterÃpicos, 58% (18/31) dos pacientes fizeram uso do esquema CHOP, 36% (11/31) utilizaram CHOP-Bleo e 6% (2/31) utilizaram os dois esquemas quimioterÃpicos. Entre os pacientes que utilizaram o esquema CHOP, 78% atingiram a remissÃo completa (RC), 17% apresentaram recidiva da doenÃa e apenas 5 % foram a Ãbito. No grupo que utilizou o esquema CHOP-Bleo, 63% atingiram a RC, 18% apresentaram recidiva da doenÃa e 19% foram a Ãbito. Os 2 pacientes que utilizaram os dois esquemas como tratamento apresentaram recidiva da doenÃa. Os valores de LDH dos pacientes apÃs a quimioterapia apresentam-se reduzidos tanto em pacientes que atingiram a remissÃo completa como naqueles que tiveram recidiva. Verificamos que a sobrevida global (SG) e a sobrevida livre de doenÃa (SLD) nÃo foram influenciadas pelo estÃdio clÃnico e LDH inicial dos pacientes. A regressÃo logÃstica nÃo mostrou significÃncia estatÃstica quando analisou a remissÃo completa dos pacientes a partir dos resultados das variÃveis em estudo pÃs QT, com exceÃÃo da proporÃÃo de reduÃÃo da LDH e a resposta ao tratamento. Os resultados mostraram a eficÃcia e seguranÃa dos esquemas terapÃuticos CHOP e CHOP-Bleo em nossa populaÃÃo de estudo. Os resultados demonstram ainda que se faz necessÃrio o estudo epidemiolÃgico de diferentes populaÃÃes com LDGCB para que haja seguranÃa na escolha de esquemas quimioterÃpicos, bem como a uniformidade em descrever e classificar os linfomas e os seus fatores prognÃstico por parte dos patologistas e oncologistas. / Diffuse Large B-Cell Lymphomas (DLBCL) corresponds to 50% of non-Hodgkinâs lymphomas (LNH). Their treatment of choice is the association chemotherapy, in special the CHOP therapy (cyclophosphamide, doxorubicin, vincristine and prednisone) considered the standard treatment initial of the DLBCL. Variations of this therapy, with the CHOP-Bleo protocol (cyclophosphamide, doxorubicin, vincristine, prednisone and bleomycin) have been used with the intention of obtaining complete response rates for the patients. In Brazil, little is known about the incidence, clinical behavior, response to therapy and survival of the patients with DLBCL. This study aimed to set out the epidemiological profile of patients with diffuse large B-Cell lymphomas, who received medical care at Hospital UniversitÃrio Walter CantÃdio (HUWC), outline in Cearà state, with the first attendment from January 1989 to December 2003, who the used the CHOP and/or CHOP-Bleo therapy; Evaluating the security and efficiency of the protocols proposed by analysis of the kind of therapeutical response, clinical and laboratorial outcomes of these patients. The data collection was performed from medical recording of the 31 patients analyzed. These, 21 (67,74%) were the men and 10 (32,26%) women. The average age was 45,81  16,3 anos. Agriculturists represented 25,82% (8/31) of all patients. The stage III the Ann Arbor classification were the most frequent (32,26%), but only 45% of the patients had B symptoms. The values of lactate dehydrogenises (LDH) enzyme were elevated in 49% of the patients at diagnosis, but in 16% of the patients these values at diagnosis were unknown. As much as the IPI, 71% were classified as an IPI low and intermediate risk, 13% as an IPI intermediate-high risk, none of the study patients showed as an IPI high risk and 16% there is not possible the classification to establish due to the data is unknown. As much as the chemotherapy protocols used, 58% (18/31) of the patients was received CHOP chemotherapy, 36% (11/31) CHOP-Bleo chemotherapy and 6% (2/31) received CHOP associated with CHOP-Bleo chemotherapy. Among the patients who used CHOP chemotherapy, 78% was achieving complete response (CR), 17% was achieving relapse of the disease and only 5% were the death. In the group who used CHOP-Bleo chemotherapy, 63% was achieving RC, 18% was achieving relapse of the disease and 19% died. The 2 patients who used CHOP and CHOP-Bleo chemotherapy were achieving relapse of the disease. The values of the LDH after chemotherapy showed decreased in patients with RC as much as the relapsed patients. We verified that the overall survival (OS) and disease-free survival (DFS) were not influenced by the clinic stage and initial values of the LDH patients. The logistic regression did not show statistical differences when the complete response was analyzed comparing to outcomes the studied variables after QT, except for the proportion of reduction of LDH levels and response to the treatment. The results stress the security and efficiency of the protocols CHOP e CHOP-Bleo in our study population. The data obtained also the need epidemiological studies in different DLBCL populations for the security in the choice chemotherapy, well as standardized the classification and description of the DLBCL and prognoses factures by pathologists and oncologists.

Orientador: Oslei Paes de Almeida / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-23T09:15:14Z (GMT). No. of bitstreams: 1 ToralRizo_VictorHugo_D.pdf: 3216317 bytes, checksum: f10b9daa311d7ae2e304dc1ea8925abf (MD5) Previous issue date: 2013 / Resumo: O linfoma difuso de grandes células B (LDGCB) é o linfoma da cavidade bucal mais comum. Alguns dos LDGCB podem apresentar células grandes morfologicamente similares às células Hodgkin e Reed/Sternberg (HRS) dos linfomas de Hodgkin clássico (LHC). O objetivo deste estudo foi comparar os LDGCB bucal que apresentem células HRS-like (LDGCB-HRS) com o linfoma de Hodgkin primário nodal, considerando os aspectos histológicos e imunoistoquímicos (IQs), angiogênese, índice de mastócitos e células dendríticas (CD), por meio de um amplo painel IQ. Quize casos foram estudados, nos quais sete eram LDGCB-HRS like e oito eram LHC nodal. Para a análise dos aspectos histológicos e IQs foram utilizados os seguintes anticorpos: CD3, CD15, CD20, CD30, CD43, LCA, CD45RO, CD79a, CD83, EMA, MUM-1, PAX-5, perforina, granzyme B, FASN, Ki-67, LMP-1; e EBER1/2. Já para a análise da angiogênese foram utilizados os anticorpos CD34, CD31, D2-40, CD105, vWF e VEGF; e para o índice de mastócitos utilizou-se o mast cell triptase. Finalmente, para avaliar a expressão IQ das CD os anticorpos CD1a, CD83, CD123, CD207, S-100 e FXIIIa foram utilizados. Todas as lâminas foram escaneadas e as células HRS-like, mastócitos e CD imunopositivas foram analisados, assim como os parâmetros morfométricos da angiogênese. Os resultados mostraram que a imunoexpressão foi postiva em 100% de casos de LHC e em 57% dos casos de LDGCB de boca, enquanto que LCA, CD20 e CD79a foram exclusivos para todos os LDGCB, e apenas CD15 foi exclusivo para os LHC. Angiogênese e o índice de mastócitos estavam aumentados em ambas as lesões, e entre elas, o LHC obteve maiores valores que o LDGCB da cavidade bucal em todos os anticorpos analisados. Por fim, o índice de CDs foram estatisticamente significante entre os grupos, exceto para CD83, que não mostrou nenhuma diferença estatística. A distribuição de CD foi reconhecida principalmente na área tumoral e ao redor das células neoplásicas em ambas as entidades. Foi possível concluir que os LDGCB com células HRS-like da cavidade bucal devem ser incluídos no diagnóstico diferencial de LHC da cavidade bucal. Quando da avaliação destes casos, a analise morfológica detalhada assim como o uso de um amplo painel de IQ são recomendados para realizar o diagnóstico correto. A angiogênese é essencial para o desenvolvimento de LDGCB da cavidade bucal, e quaisquer dos anticorpos CD34, CD31 e vWF podem ser utilizados para avaliar os parâmetros morfométricos. A presença significativa de CD nestes linfomas provavelmente desempenha um papel patologicamente relevante nos linfomas. Nossos resultados sugerem que o aumento no número de CD parece ser um fator contribuinte para a resposta imune estimulada pelo crescimento tumoral / Abstract: Diffuse large B-cell lymphoma (DLBCL) is the most common oral lymphoma. Some DLBCLs can present large cells morphologically similar to Hodgkin and Reed-Sternberg (HRS) cells of classical Hodgkin lymphoma (cHL). The objective of this study was to compare oral DLBCL presenting HRS-like cells (DLBCL-HRS like) with primary nodal cHL, considering the following aspects: histological and immunohistochemical (IHC), angiogenesis, index of mast cells and dendritic cells (DCs); through a broad immunohistochemical panel. Fifteen cases were studied, of which, seven were DLBCL-HRS like and eight were nodal cHL. For histological and IHC aspects, immunoexpression of CD3, CD15, CD20, CD30, CD43, LCA, CD45RO, CD79a, CD83, EMA, MUM-1, PAX-5, perforin, granzyme B, FASN, Ki-67, LMP-1; and EBER1/2, were assessed. As for angiogenesis analysis, the antibodies used were CD34, CD31, D2-40, CD105, vWF and VEGF; and for the index of mast cell were used the mast cell tryptase. Finally, for IHC expression of DCs, the antibodies used were CD1a, CD83, CD123, CD207, S-100, and FXIIIa. All slides were scanned and positive immunoreactive cells HRS-like, mast cell and DCs were analyzed, as well as morphometric parameters of angiogenesis. The results showed that the immunoexpression of CD30 was 100% positive in cHL and 57% in oral DLBCL HRS-like, while LCA, CD20 and CD79a were exclusive for all oral DLBCL, and only CD15 was exclusive for cHL. Angiogenesis and mast cell index values were increased in both lesions and between them, cHL was greater than oral DLBCL with all antibodies studied. Finally, DC subsets were statistically significant between groups, except CD83, which did not show statistical significance. The distribution of DCs was mainly in the tumor area, around neoplastic cells in both entities. It was possible to conclude that DLBCL-HRS should be included in the differential diagnosis of oral cHL. When evaluating these cases, a detailed morphologic and a broad IHC analyses for the correct diagnosis are recommended. Angiogenesis is essential to the development of DLBCL of the oral cavity and any of the antibodies CD34, CD31 and vWF could be used to evaluate morphometric parameters. The presence of significantly higher numbers of DCs in these lymphomas could suggest that these cells are likely to play a pathological relevant role in lymphomas. Our findings suggest that increased number of DCs in lymphomas appears to be a factor contributing to the immune response against tumor growth / Doutorado / Patologia / Doutor em Estomatopatologia

Abstract In the present study, some of the difficulties in the treatment of the most common malignant lymphoma, diffuse large B-cell lymphoma (DLBCL), were evaluated. Some patients develop local or central nervous system (CNS) relapse after first-line treatment. The treatment of relapsed disease is challenging and despite all efforts, some patients die of the disease. Chemoresistant disease also remains challenging because some patients suffer from refractory disease of a progressive nature. The antioxidant enzymes peroxiredoxins (Prxs) and thioredoxin-1 (Trx) were evaluated as prognostic and predictive markers of DLBCL. High cytoplasmic expression of Prx VI was found to correlate with poor prognosis in patients with DLBCL. Trx knockdown in lymphoma cell culture revealed a possible predictive role of Trx. Trx knockdown sensitized cells to doxorubicin, a widely used chemotherapeutic agent in treatment schemas of DLBCL. Etoposide, another widely used chemotherapeutic agent, on the other hand, killed more native DLBCL cells than did doxorubicin. Patients with high Trx expression at the diagnostic stage of the disease benefitted from etoposide-containing high-dose chemotherapy and autologous stem cell transplantation and did not develop post-transplantation relapses which Trx-negative patients did. Antithrombin III (AT III) in cerebrospinal fluid has been suggested to be a biomarker in previous studies of CNS lymphoma. In the present study, AT III was evaluated in patients with CNS lymphoma and with neurological diseases. High concentrations of AT III in cerebrospinal fluid reflected the magnitude of blood-brain barrier leakage and because of this, AT III should not be used as a biomarker in clinical practice. / Tiivistelmä Tutkimuksessa arvioitiin osaa yleisimmän pahanlaatuisen imukudossyövän eli lymfooman, diffuusin suurisoluisen B-solulymfooman, hoidon haasteista. Osa potilaista saa ensilinjan hoidon jälkeen joko paikallisen tai aivoston alueen taudin uusiutuman. Uusiutuneen taudin hoito on haasteellista, ja hoitoyrityksistä huolimatta osa potilaista kuolee tautiinsa. Solunsalpaajille resistentti tauti on myös yksi haastavista hoitotilanteista, ja osa potilaista kärsiikin hoitojen läpi etenevästä taudista. Antioksidatiivisia entsyymejä, kuten peroksiredoksiineja ja tioredoksiinia, arvioitiin ennusteellisina ja ennakoivina merkkiaineina diffuusissa suurisoluisessa B-solulymfoomassa. Peroksiredoksiini VI:n korkea sytosolinen ilmaantuvuus korreloi tavallista huonompaan diffuusin suurisoluisen B-solulymfooman ennusteeseen. Tioredoksiinin hiljentäminen lymfoomasoluviljelyssä paljasti sen mahdollisen ennakoivan merkityksen hoitoon liittyvässä päätöksenteossa. Solut herkistyivät tiodredoksiinin hiljentämisen vuoksi doksorubisiinille, jota käytetään laajalti diffuusin suurisoluisen B-solulymfooman solunsalpaajahoidoissa. Etoposidi, joka on huomattavasti myrkyllisempi solunsalpaaja, päinvastoin tappoi enemmän tavallisia diffuusia suurisoluisia B-solulymfoomaa edustavia soluja kuin doksorubisiini. Potilaat, joilla oli korkea tioredoksiinin määrä taudin diagnostisessa vaiheessa, hyötyivät etoposidia sisältävästä korkea-annoshoidosta sekä autologisesta kantasolusiirrosta. Näille potilaille ei kehittynyt kantasolusiirron jälkeisiä taudin uusiutumia kuin taas niitä kehittyi potilaille, joilla oli tioredoksiini negatiivinen. Antitrombiini III:a on ehdotettu soveltuvaksi aikaisempien tutkimusten perusteella aivoston lymfooman merkkiaineeksi aivo-selkäydinnesteestä. Tässä tutkimuksessa antitrombiini III:n määrää mitattiin potilailta, joilla oli aivoston lymfooma tai neurologinen sairaus. Korkeat konsentraatiot antitrombiini III:a aivo-selkäydinnesteessä kuitenkin vain heijastivat veri-aivoesteen vuotamisen määrää, ja näin ollen antitrombiini III:a ei tulisi käyttää kliinisessä käytössä.

Introdução: O linfoma difuso de grandes células B é o mais freqüente grupo de linfoma não- Hodgkin, perfazendo quase 50% dos casos no serviço de hematologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e Instituto do Câncer do Estado de São Paulo. Possui heterogeneidade clínica e biológica traduzida em mais de vinte subtipos na Organização Mundial da Saúde. Sua terapêutica se baseia na associação do anticorpo monoclonal anti-CD20 e quimioterapia com antracíclico, esquema que resulta em 43,5% de sobrevida global em 10 anos. Determinantes de prognóstico clínico como o Índice Internacional de Prognóstico e o Índice Internacional de Prognóstico Revisado carecem de acurácia, pois até 20% dos pacientes de baixo risco falecerão da doença e 60% dos pacientes de alto risco estarão vivos em quatro anos. Essas discrepâncias podem, em parte, ser atribuídas a fatores genéticos. A assinatura gênica do linfoma difuso de grandes células B tipo centro germinativo apresenta sobrevida global superior ao tipo células B ativadas (76% versus 16%, p=0,01), contudo o perfil de expressão gênica por microarray ainda não está disponível na prática clínica. Entretanto, o escore preditivo de mortalidade para linfoma difuso de grandes células B baseado no valor prognóstico da expressão dos genes BCL2, BCL6, CCND2, FN1, LMO2 e SCYA3 por PCR em tempo real quantitativa mostrou-se independente do Índice Internacional de Prognóstico na era pré-rituximabe. Mas não foi significante em pacientes de alto risco clínico tratados com R-CHOP. Os genes BCL2, CCND2 e SCYA3 integram a assinatura de células B ativadas, BCL6 e LMO2 a do centro germinativo e FN1 a linfonodal. Objetivo: Avaliar o impacto da expressão absoluta dos genes BCL2, BCL6, CCND2, FN1, LMO2 e SCYA3 em população brasileira com linfoma difuso de grandes células B tratada com R-CHOP em relação à resposta global, sobrevida livre de doença, sobrevida livre de progressão e sobrevida global. Métodos: A expressão gênica foi analisada por PCR em tempo real quantitativa de RNA extraído de amostras parafinadas de 63 pacientes, porém foi avaliável em 42. Seus valores foram normatizados pelo gene endógeno ABL e transformados em escala logarítmica na base 2 para posterior correlação com variáveis clínicas e de desfecho. Resultados: Com mediana de seguimento de 29 meses, as sobrevidas global, livre de doença e livre de progressão foram, respectivamente, 82,8%, 97,14% e 87,53%, enquanto a resposta completa foi 82,5%. A expressão de LMO2>3logs e BCL6>3,5logs definiu um grupo de maior sobrevida global (91% versus 64,3%, p=0,040) e sobrevida livre de doença (95,5% versus 70,7%, p=0,03), independentemente do Índice Internacional de Prognóstico (p=0,010 e p=0,042) e com significativa hiperexpressão do SCYA3 (p=0,046). Não se observou associação entre escore preditivo de mortalidade baseado nos seis genes e prognóstico. Assim, foi criado novo escore genético prognóstico baseado no poder da expressão concomitante de LMO2 e CCND2, definindo-se grupos de baixo risco (<2,5) e alto risco (>=2,5) com distintas sobrevidas global (92,4% versus 57,1%, p=0,011) e livre de progressão (96,2% versus 66,7%, p=0,013), independentes do IPI. Conclusão: Em pacientes com linfoma difuso de grandes células B tratados com R-CHOP, a hiperexpressão de BCL6, LMO2 e SCYA3 correlacionou-se com melhor prognóstico. O novo escore genético prognóstico definido por LMO2 e CCND2 estratificou grupos de risco de prognósticos distintos independentes do Índice Internacional de Prognóstico / Introduction: Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma; which accounts for almost 50% of the cases at the Hematology Department of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and Instituto do Câncer do Estado de São Paulo. Its clinical and biological heterogeneity results in more than twenty subtypes according to the World Health Organization classification. Its treatment is based on a combination of anti-CD20 monoclonal antibody and antracycline-based chemotherapy, with a 10-year overall survival of 43.5%. Clinical prognostic determinants such as the International Prognostic Index and the Revised International Prognostic Index lack accuracy, since up to 20% of low-risk patients will die from the disease and up to 60% of high-risk patients will be alive within four years. Such discrepancies can partially be attributed to genetic factors. Diffuse large B-cell lymphoma germinal center gene signature shows superior overall survival compared to activated B-cell signature (76% versus 16%, p=0.01), however microarray gene expression profile is not yet available in clinical practice. Nonetheless, the Mortality Predictor Score for diffuse large B-cell lymphoma based on the prognostic value of BCL2, BCL6, CCND2, FN1, LMO2 and SCYA3 gene expression by quantitative real-time PCR has proved to be independent from the International Prognostic Index in the pre-rituximab era. But it was not significant in high clinical risk patients treated with R-CHOP. The genes BCL2, CCND2 and SCYA3 compose activated B-cell signature, whereas BCL6 and LMO2 compose the germinal center signature and FN1 the lymph-node signature. Objective: Evaluate the impact of BCL2, BCL6, CCND2, FN1, LMO2 and SCYA3 absolute gene expression in Brazilian population diagnosed with diffuse large B-cell lymphoma and treated with R-CHOP, with respect to overall response, disease free survival, progression free survival and overall survival. Methods: Gene expression was analyzed by quantitative real-time PCR of RNA extracted from paraffin-embedded samples of 63 patients, although evaluable in 42. Their values were normalized by endogenous gene ABL and log- transformed on a base 2 scale for subsequent correlation with clinical and outcome variables. Results: With a median follow-up of 29 months, overall survival, disease free survival and progression free survival accounted for 82.8%, 97.14% and 87.53% respectively, while complete response was 82.5%. The expression of LMO2>3logs and BCL6>3.5logs defined a group with higher overall survival (91% versus 64.3%, p=0.040) and progression free survival (95.5% versus 70.7%, p=0.03), independent of International Prognostic Index (p=0.010 and p=0.042) and with significant overexpression of SCYA3 (p=0.046). It was not identified any association between six gene Mortality Predictor Score and prognosis. As a result, we developed the New Genetic Prognostic Score based on the power of concomitant expression of LMO2 and CCND2, defining low-risk (<2.5) and high-risk (>=2.5) groups with distinct overall survival (92.4% versus 57.1%, p=0.011) and progression free survival (96.2% versus 66.7%, p=0.013), independent of International Prognostic Index. Conclusion: In patients with diffuse large B-cell lymphoma treated with R-CHOP, hyperexpression of BCL6, LMO2 and SCYA3 was correlated with a better prognosis. The New Genetic Prognostic Score, defined by LMO2 and CCND2, stratified risk groups with different prognosis, independent of International Prognostic Index

Introdução: O linfoma difuso de grandes células B é o mais freqüente grupo de linfoma não- Hodgkin, perfazendo quase 50% dos casos no serviço de hematologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e Instituto do Câncer do Estado de São Paulo. Possui heterogeneidade clínica e biológica traduzida em mais de vinte subtipos na Organização Mundial da Saúde. Sua terapêutica se baseia na associação do anticorpo monoclonal anti-CD20 e quimioterapia com antracíclico, esquema que resulta em 43,5% de sobrevida global em 10 anos. Determinantes de prognóstico clínico como o Índice Internacional de Prognóstico e o Índice Internacional de Prognóstico Revisado carecem de acurácia, pois até 20% dos pacientes de baixo risco falecerão da doença e 60% dos pacientes de alto risco estarão vivos em quatro anos. Essas discrepâncias podem, em parte, ser atribuídas a fatores genéticos. A assinatura gênica do linfoma difuso de grandes células B tipo centro germinativo apresenta sobrevida global superior ao tipo células B ativadas (76% versus 16%, p=0,01), contudo o perfil de expressão gênica por microarray ainda não está disponível na prática clínica. Entretanto, o escore preditivo de mortalidade para linfoma difuso de grandes células B baseado no valor prognóstico da expressão dos genes BCL2, BCL6, CCND2, FN1, LMO2 e SCYA3 por PCR em tempo real quantitativa mostrou-se independente do Índice Internacional de Prognóstico na era pré-rituximabe. Mas não foi significante em pacientes de alto risco clínico tratados com R-CHOP. Os genes BCL2, CCND2 e SCYA3 integram a assinatura de células B ativadas, BCL6 e LMO2 a do centro germinativo e FN1 a linfonodal. Objetivo: Avaliar o impacto da expressão absoluta dos genes BCL2, BCL6, CCND2, FN1, LMO2 e SCYA3 em população brasileira com linfoma difuso de grandes células B tratada com R-CHOP em relação à resposta global, sobrevida livre de doença, sobrevida livre de progressão e sobrevida global. Métodos: A expressão gênica foi analisada por PCR em tempo real quantitativa de RNA extraído de amostras parafinadas de 63 pacientes, porém foi avaliável em 42. Seus valores foram normatizados pelo gene endógeno ABL e transformados em escala logarítmica na base 2 para posterior correlação com variáveis clínicas e de desfecho. Resultados: Com mediana de seguimento de 29 meses, as sobrevidas global, livre de doença e livre de progressão foram, respectivamente, 82,8%, 97,14% e 87,53%, enquanto a resposta completa foi 82,5%. A expressão de LMO2>3logs e BCL6>3,5logs definiu um grupo de maior sobrevida global (91% versus 64,3%, p=0,040) e sobrevida livre de doença (95,5% versus 70,7%, p=0,03), independentemente do Índice Internacional de Prognóstico (p=0,010 e p=0,042) e com significativa hiperexpressão do SCYA3 (p=0,046). Não se observou associação entre escore preditivo de mortalidade baseado nos seis genes e prognóstico. Assim, foi criado novo escore genético prognóstico baseado no poder da expressão concomitante de LMO2 e CCND2, definindo-se grupos de baixo risco (<2,5) e alto risco (>=2,5) com distintas sobrevidas global (92,4% versus 57,1%, p=0,011) e livre de progressão (96,2% versus 66,7%, p=0,013), independentes do IPI. Conclusão: Em pacientes com linfoma difuso de grandes células B tratados com R-CHOP, a hiperexpressão de BCL6, LMO2 e SCYA3 correlacionou-se com melhor prognóstico. O novo escore genético prognóstico definido por LMO2 e CCND2 estratificou grupos de risco de prognósticos distintos independentes do Índice Internacional de Prognóstico / Introduction: Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma; which accounts for almost 50% of the cases at the Hematology Department of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and Instituto do Câncer do Estado de São Paulo. Its clinical and biological heterogeneity results in more than twenty subtypes according to the World Health Organization classification. Its treatment is based on a combination of anti-CD20 monoclonal antibody and antracycline-based chemotherapy, with a 10-year overall survival of 43.5%. Clinical prognostic determinants such as the International Prognostic Index and the Revised International Prognostic Index lack accuracy, since up to 20% of low-risk patients will die from the disease and up to 60% of high-risk patients will be alive within four years. Such discrepancies can partially be attributed to genetic factors. Diffuse large B-cell lymphoma germinal center gene signature shows superior overall survival compared to activated B-cell signature (76% versus 16%, p=0.01), however microarray gene expression profile is not yet available in clinical practice. Nonetheless, the Mortality Predictor Score for diffuse large B-cell lymphoma based on the prognostic value of BCL2, BCL6, CCND2, FN1, LMO2 and SCYA3 gene expression by quantitative real-time PCR has proved to be independent from the International Prognostic Index in the pre-rituximab era. But it was not significant in high clinical risk patients treated with R-CHOP. The genes BCL2, CCND2 and SCYA3 compose activated B-cell signature, whereas BCL6 and LMO2 compose the germinal center signature and FN1 the lymph-node signature. Objective: Evaluate the impact of BCL2, BCL6, CCND2, FN1, LMO2 and SCYA3 absolute gene expression in Brazilian population diagnosed with diffuse large B-cell lymphoma and treated with R-CHOP, with respect to overall response, disease free survival, progression free survival and overall survival. Methods: Gene expression was analyzed by quantitative real-time PCR of RNA extracted from paraffin-embedded samples of 63 patients, although evaluable in 42. Their values were normalized by endogenous gene ABL and log- transformed on a base 2 scale for subsequent correlation with clinical and outcome variables. Results: With a median follow-up of 29 months, overall survival, disease free survival and progression free survival accounted for 82.8%, 97.14% and 87.53% respectively, while complete response was 82.5%. The expression of LMO2>3logs and BCL6>3.5logs defined a group with higher overall survival (91% versus 64.3%, p=0.040) and progression free survival (95.5% versus 70.7%, p=0.03), independent of International Prognostic Index (p=0.010 and p=0.042) and with significant overexpression of SCYA3 (p=0.046). It was not identified any association between six gene Mortality Predictor Score and prognosis. As a result, we developed the New Genetic Prognostic Score based on the power of concomitant expression of LMO2 and CCND2, defining low-risk (<2.5) and high-risk (>=2.5) groups with distinct overall survival (92.4% versus 57.1%, p=0.011) and progression free survival (96.2% versus 66.7%, p=0.013), independent of International Prognostic Index. Conclusion: In patients with diffuse large B-cell lymphoma treated with R-CHOP, hyperexpression of BCL6, LMO2 and SCYA3 was correlated with a better prognosis. The New Genetic Prognostic Score, defined by LMO2 and CCND2, stratified risk groups with different prognosis, independent of International Prognostic Index

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L’outil génomique a considérablement modifié notre connaissance des hémopathies malignes, que ce soit sur le plan physiopathologique, diagnostique, pronostique ou thérapeutique. Dans la première partie de ce travail, nous avons travaillé sur une grande cohorte d’anémies réfractaires sidéroblastiques avec thrombocytose (ARS-T). Nous avons démontré qu’il s’agissait d’une entité indépendante, avec une présentation moléculaire particulière associant (i) des mutations de SF3B1 dans plus de 85% des cas, expliquant son versant myélodysplasique et (ii) des anomalies de JAK2 dans plus de 50% des cas, expliquant son versant prolifératif. La perspective de cette première partie est d’identifier la ou les mutation(s) responsables du caractère myéloprolifératif dans les ARS-T JAK2WT. Les lymphomes B-diffus à grandes cellules (LBDGC) représentent les lymphomes malins non-Hodgkiniens les plus fréquents chez l’adulte. Dans la deuxième partie de ce travail, nous avons réalisé l’analyse par SNP-array d’une série homogène d’échantillons issus de la cohorte CORAL, une étude prospective internationale portant sur les LBDGC en rechute. Notre objectif était d’identifier les anomalies de nombre de copies (ANC) associées à chacun des deux types de rechutes, précoces ou tardives. Les rechutes précoces sont associées à une forte proportion d’anomalies affectant les régulateurs du cycle cellulaire, de l’apoptose et de la transcription. Les rechutes tardives sont associées à des anomalies affectant les régulateurs de l’immunité et de la prolifération cellulaire. Cette étude permet de mieux comprendre les déterminants de la rechute dans les LBDGC et ouvre de nouvelles perspectives thérapeutiques / Genomics provided new insights in our knowledge of pathophysiology, diagnostic approach, prognosis and therapeutic perspectives in hematological malignancies. In the first part of this work, we studied a large cohort of Refractory Anemia with Ring sideroblasts and marked Thrombocytosis (RARS-T). We demonstrated that RARS-T can be considered as an independent entity, with a specific molecular pattern, associating : (i) SF3B1 mutations in more than 85% of cases, accounting for its myelodysplastic aspect and (ii) JAK2 mutations, accounting for its myeloproliferative aspect in more than 50% of cases. Future prospects of the first part of this work is to identify (the) mutation(s) responsible for the myeloproliferative part of JAK2WT RARS-T. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma in adults. In the second part of this work, we performed SNP-array analysis of a homogeneous series of samples from the CORAL cohort, an international prognostic study on relapsed DLBCLs. Our purpose was to identify Copy Number Variations (CNV) associated ER or LR. ER DLBCLs are associated with high rates of CNVs affecting regulators of cell cycle, apoptosis and transcription. In LR DLBCLs, CNVs are related to immune response and cell proliferation. This study provides new insights into the genetic aberrations in relapsed DLBCLs and open up new therapeutic perspectives

L'étude de la survie nette des patients atteints de cancer en population générale permet d'apprécier l'efficience globale du système de soin d'un pays. La survie nette se définit comme la survie qui serait observée si la seule cause de décès possible était le cancer. Ce concept est fondamental dans les comparaisons entre zones géographiques et/ou périodes de diagnostic dont l'intérêt est d'estimer les variations spécifiques de la mortalité due au cancer. Le concept de survie nette permet de prendre en compte les éventuelles différences de mortalité naturelle entre les groupes comparés. Actuellement, seuls deux outils estiment la survie nette sans biais : l'estimateur non paramétrique de Pohar-Perme et la modélisation paramétrique ajustée sur certaines covariables (essentiellement l'âge). Par ailleurs, les outils paramétriques s'étant perfectionnés, de nouveaux modèles flexibles permettent de modéliser les effets complexes des variables sur la mortalité. Ce travail repose sur la modélisation du taux de mortalité en excès à la suite d'un lymphome malin non hodgkinien, en se basant sur le modèle proposé par Remontet et al. et sur la nécessité de modéliser conjointement les effets complexes des covariables (telles que le temps de suivi, l'année de diagnostic et l'âge) sur la mortalité à l'aide d'une stratégie de modélisation adaptée. L'effet des variables est restitué sur la survie nette mais aussi sur le taux de mortalité en excès ce qui représente un élément nouveau dans les études de survie. Deux applications ont été menées sur des bases de données collaboratives de population : d'une part sur les données françaises du réseau FRANCIM à la suite d'un diagnostic de lymphome folliculaire entre 1995 et 2010 et, d'autre part, sur les données européennes d'EUROCARE-5 après un lymphome folliculaire ou un lymphome B diffus à grandes cellules diagnostiqué entre 1996 et 2004. Les résultats montrent que la dynamique du taux de mortalité en excès au cours du temps de suivi varie en fonction du sous-type de lymphome, de l'âge et de la zone géographique. Les tendances de cette dynamique en fonction de l'année de diagnostic sont également différentes / The net survival of cancer patients in population studies is the most relevant indicator to assess the overall efficiency of the healthcare system of a country. Net survival is defined as the survival that would be observed if the sole cause of death were cancer. This concept is crucial in comparative studies (between geographical areas and/or periods of diagnosis) that estimate specific variations of cancer-related deaths. Net survival takes into account potential differences in mortality patterns between groups. Currently, two methods provide unbiased estimations of net survival: the non-parametric estimator of Pohar-Perme and the parametric model adjusted on specific covariates (mainly, the age at diagnosis). Moreover, new improved parametric tools, such as flexible models, can model the complex covariate effects on mortality. In this work, we modeled the excess mortality rate after a non Hodgkin lymphoma diagnosis, with a model developed by Remontet et al. In addition, we used an appropriate model-building-strategy to model jointly the complex effects of some covariates (such as the time elapsed since diagnosis, the year of diagnosis, and age) on the excess mortality. Finally, this approach allowed for the covariate effects on the net survival and on the excess mortality rate. We applied this method to two different collaborative databases: first on the French database FRANCIM (1995 to 2010) to study the excess mortality after diagnosis of follicular lymphoma, then on the European data of EUROCARE-5 (1996 to 2004) to study the excess mortality after diagnosis of follicular lymphoma and diffuse large B-cell lymphoma. According to the results, the dynamics of the excess mortality rate varies over the time elapsed since diagnosis according to the lymphoma subtype, the age, and the geographical area. The trends of these dynamics over the years of diagnosis are different too

Para avaliar a influência dos polimorfismos de nucleotídeo único (SNPs) do CYP2B6, CYP3A5, GSTM1, GSTP1, GSTT1, PON1, NQO1 e MDR1 na resposta ao tratamento com R-CHOP e CHOP, 82 pacientes com Linfoma Difuso de Grandes Células B, sem evidências de infecção por HIV, foram selecionados nesse estudo. Amostras de sangue periférico foram coletadas para extração de DNA. Os SNPs foram analisados por PCR-RFLP. Em relação aos pacientes que apresentaram resposta completa (RC) ao tratamento (70%), 51% foram tratados com R-CHOP. Sobre o tratamento, 50% dos pacientes com RC apresentaram classificação de ECOG 0-1 (p=0,0193) e a maioria desses pacientes (41%) não apresentaram envolvimento extranodal (p=0,0377). Não houve associação entre os SNPs do CYP2B6, CYP3A5, GSTT1, NQO1 e MDR1 (C3435T) e as variáveis estudadas. Apenas CYP3A5 (sexo p=0,0519), GSTM1 (idade p=0,016; tratamento p=0,0372), GSTP1 (envolvimento extranodal p=0,0307), PON1 (sintomas B p=0,0201; Bulky p=0,0148) e MDR1 C1236T (sexo p=0,0316) mostraram associação. Em relação à sobrevida global, apenas tratamento (p=0,0129), IPI (p=0,000342), idade (p=0,0155), estadiamento (p=0,00281) e ECOG (p=0,00869) apresentaram resultados significantes. Quanto à sobrevida livre de doença (SLD), apenas idade (p=0,0292), estadiamento (p=0,0402) e ECOG (p=0,0142) apresentaram resultados significantes / To evaluated the influence of single nucleotide polymorphisms (SNPs) of CYP2B6, CYP3A5, GSTM1, GSTP1, GSTT1, PON1, NQO1 and MDR1 in the treatment response with R-CHOP and CHOP, 82 patients with Diffuse Large B-cell Lymphoma, without evidence of HIV infection, were enrolled in this study. Peripheral blood samples were collected for DNA extraction. The SNPs were analyzed by PCR-RFLP. In relation the patients that showed complete response (CR) to the treatment (70%), 51% were treated with R-CHOP. About the treatment, 50% of the patients with CR showed ECOG classification of 0-1 and the most of these patients (41%) did not showed extranodal involvement (p=0,0377). There was no association between CYP2B6, CYP3A5, GSTT1, NQO1 and MDR1 (C3435T) SNPs and the variables studied. Only CYP3A5 (gender p=0,0519), GSTM1 (age p=0,016; treatment p=0,0372), GSTP1 (extranodal involvement p=0,0307), PON1 (B symptoms p=0,0201; Bulky p=0,0148) e MDR1 C1236T (gender p=0,0316) showed association. In relation to overall survival, only treatment (p=0,0129), IPI (p=0,000342), age (p=0,0155), stadiament (p=0,00281) and ECOG (p=0,00869) showed significant results. To disease-free survival, only age (p=0,0292), stadiament (p=0,0402) e ECOG (p=0,0142) showed significant results

<p>Patients with rheumatoid arthritis (RA) are at increased risk of developing malignant lymphoma, although details about this association remain unclear. The aims of this thesis were to investigate risk factors for lymphoma in patients with RA and to characterize these lymphomas regarding subtype, presence of Epstein-Barr virus (EBV), clinical manifestations and prognosis. </p><p>The Swedish hospital discharge register and the cancer register were used to identify RA patients with lymphoma. Two case-control studies were performed, one smaller including RA patients with lymphoma hospitalised in Uppsala health care region 1964-1983 (n=41) and one larger study of hospitalised RA patients with lymphoma in Sweden 1964-1995 (n=378). RA patients from the same cohorts, but without lymphoma, were matched as controls. Medical records for cases and controls were scrutinized for exposure information. The lymphoma tissues were reclassified according to the WHO classification, and presence of EBV was analysed by EBER in situ hybridisation.</p><p>The most important risk factor for lymphoma development was high RA disease activity. No association was determined between treatment with traditional disease modifying drugs, non-steroidal anti-inflammatory drugs, aspirin, peroral and intra-articular corticosteroids and lymphoma risk. Diffuse large B-cell lymphoma (DLBCL) was more frequent in RA patients than in lymphoma patients in the general population and displayed stronger association with RA disease activity than other lymphoma subtypes. RA patients with DLBCL had increased extranodal involvement and more advanced lymphoma stage at presentation than DLBCL patients in general, and the prognosis was poor. </p><p>A further subdivision of DLBCL into germinal centre (GC) and non-GC subtypes by the expression patterns of CD10, bcl-6 and IRF-4 showed a predominance of the non-GC subtype. This suggested peripheral activated B-cells as the cells of origin in these lymphomas. </p><p>The presence of EBV was low in lymphomas in RA patients (12%). </p>