L'insuline, hormone clé du contrôle de l'homéostasie métabolique, exerce également des effets trophiques sur la croissance et la prolifération cellulaire. Des études épidémiologiques ont récemment montré que les individus obèses ou diabétiques de type 2 ont un risque plus élevé de développer des cancers et elles ont également suggéré que l’insuline jouerait un rôle dans ce développement tumoral. Ainsi, une signalisation adéquate en aval du récepteur de l’insuline est indispensable pour éviter des processus physiopathologiques. La signalisation de l’insuline est contrôlée par des mécanismes de rétrocontrôle, dont l’adaptateur moléculaire Grb14 qui agit comme un inhibiteur endogène de l’activité catalytique du RI. L’objectif de ma thèse a été d’étudier les conséquences métaboliques et mitogéniques de l’inhibition de Grb14 in#vivo spécifiquement dans le foie de souris. Dans une première étude, nous montrons que sept jours après l’invalidation de Grb14, les souris présentent une activation des voies de signalisation de l’insuline, qui s’accompagne d’une amélioration de la tolérance au glucose et de la production hépatique de glucose. Cependant, de façon paradoxale, la voie de la lipogenèse est très fortement diminuée. En décryptant le mécanisme moléculaire impliqué, nous montrons que l’inhibition de Grb14 permet la libération de la protéine p62/sqstm1 qui active le facteur de transcription Nrf2, ce qui entraine une inhibition du récepteur nucléaire pro-lipogénique LXR. De façon intéressante, l’invalidation de Grb14 chez des souris ob/ob permet de restaurer la glycémie et la stéatose hépatiques à des valeurs comparables aux témoins. Cette étude a ainsi permis de mettre en évidence une nouvelle voie de régulation de la lipogenèse hépatique. Dans une deuxième étude, nous nous sommes intéressés à l'action mitogénique de l'insuline. Nous montrons que 48 heures après l'inhibition de Grb14, les hépatocytes, qui sont des cellules quiescentes, entrent massivement dans le cycle cellulaire. Ce processus est dépendant de l’expression du RI et est médié par la signalisation PI3K/Akt/mTORC1 et la voie Rb/E2F1. Ces données révèlent ainsi que l'insuline est un puissant facteur mitogène dans le foie et que son action est étroitement contrôlée par l’adaptateur Grb14. D’un point de vue physiopathologique, nous avons pu mettre en évidence une diminution de significative de 58% de l’expression de Grb14 dans une collection de 70 CHC humains, apportant ainsi une explication moléculaire à une action pro-tumorigène de l’insuline dans le foie. L’ensemble de ces deux études permet de placer Grb14 au centre de la régulation des actions métaboliques et mitogéniques de l’insuline dans le foie. / Insulin is a key hormone controling metabolic homeostasis which also exerts having trophic effects on cell growth and proliferation. Epidemiological studies have recently shown that obese and type 2 diabetes patients are at higher risk of developing cancers, suggesting that insulin could be involved in tumor development. Proper signaling downstream the insulin receptor is thus essential to prevent pathophysiological processes. Insulin signaling is controlled by feedback mechanisms including the molecular adapter Grb14 which acts as an endogenous inhibitor of the IR catalytic activity. The aim of my PhD was to investigate the metabolic and mitogenic consequences of liver specific Grb14 inhibition in mouse. In the first study, we showed that after seven days of Grb14 invalidation, liver insulin signaling is enhanced, resulting in improved glucose tolerance and diminished hepatic glucose production. However, paradoxically, lipogenesis was greatly decreased. Deciphering the molecular mechanism, we show that Grb14 inhibition leads to the release of its partner p62/SQSTM1, inducing the activation of the Nrf2 transcription factor, which ultimatly inhibited the pro-lipogenic LXR nuclear receptor. Interestingly, Grb14 invalidation in ob/ob mice can restore blood glucose and hepatic steatosis comparable to control values. The study thus highlighted a new pathway controlling lipogenesis that could be targetted to improve metabolic diseases. In the second study, we were interested in insulin mitogenic action. We showed that 48 hours after Grb14 inhibition, hepatocytes that are quiescent cells, massively go through one cell cycle. This process depend on IR expression and is mediated by the PI3K/Akt/mTORC1 pathway and the Rb/E2F1 complex. Our data thus suggest that insulin is a potent mitogenic factor in the liver whose action is closely controlled by the Grb14 adapter in physiological conditions. Importantly, Grb14 expression is significantly decreased in a collection of human HCC, hence bringing out a molecular basis for a pro-tumorigenic action of hyperinsulinemia. Together these two studies reveal that Grb14 is a crucial gatekeeper of insulin metabolic and mitogenic actions in the liver.

Hepatocellular carcinoma (HCC) is a devastating form of liver cancer that accounts for 80% of liver cancers. HCC has a poor prognosis with five-year survival of less than 12% in the United States. We in previous studies have identified Astrocyte Elevated Gene-1 (AEG-1) as an aberrantly overexpressed gene in many cancers including HCC, regulating tumor progression. Microarray studies identified the small transmembrane protein, tetraspanin8 (TSPAN8) as a downstream of AEG-1. TSPAN8 belongs to the family of TETRASPANINS with the characteristic of crossing the membrane four times, and regulating a wide range of cellular phenomena. TSPAN8 is implicated in metastasis and is classified as a metastasis promoting tetraspanin. To understand the role of TSPAN8 in the context of AEG-1 regulated tumor progression of HCC, we generated knockdown clones of TSPAN8 in AEG-1-8 cell lines (HepG3 cell lines with stable overexpression of AEG-1), and analyzed cellular events that mediate metastasis such as migration, invasion and in-vivo tumorogenesis. Our in-vitro studies show that knockdown of TSPAN8 in AEG-1 overexpressing cells significantly abrogated migration, matrigel invasion, proliferation and endothelial cell activation. Moreover, we show that knockdown of TSPAN8 significantly inhibited intrahepatic metastasis of orthotopic xenografts in the livers of athymic nude mice. TSPAN8 might be a useful diagnostic marker and potential therapeutic target for HCC. These findings indicate that upregulation of TSPAN8 might be an important event in mediating the oncogenic function of AEG-1.

The described experimental model of clonal tumors induced through the insertional mutagenesis with MAV-2 proved to be a valid and rich source of information describing the process of transformation of normal into tumor cell. We have mapped more than 2000 individual clonal VISs from several hundreds of tumor tissue samples. We have analyzed five tumor types of different histology and tissue of origin along with their derivative tissue cultures. Furthermore, we have discovered the industasis phenomenon and described it during the course of the study. The goal of my study was to uncover common reasons for neoplastic transformation of the cell. The results of my study led me to the paradoxical conclusion that the significance of genetic changes as the primary cause of induction of neoplastic transformation is being overestimated. Although studying the functions of individual genes and search for new tumor markers and therapeutical targets are still beneficial, I believe that the traditional perception of tumor formation as a function/result of mutation accumulation and selection is becoming a serious drawback in further investigations. These conclusions are further discussed in the last section of the presented Ph.D. thesis.

Au sein des tumeurs, y compris pour le carcinome hépatocellulaire (CHC), des sous-populations de cellules néoplasiques ont révélé une grande capacité à initier de nouvelles tumeurs et à induire des métastases. Les premières études sur ces cellules ont rapidement montré que la présence de ces cellules était déterminante dans le développement tumoral et elles ont donc été renommées « cellules souches cancéreuses » (CSCs). Malheureusement les mécanismes impliqués dans la maintenance de ces CSCs ne sont que partiellement compris. Par ailleurs dans le CHC un lien a été établi entre les signaux du facteur de croissance de transformation (Transforming Growth Factor, TGF-ß) provenant du microenvironnement tumoral et certaines populations de cellules cancéreuses dont la présence est corrélée à un faible pronostic. La façon dont TGF-ß peut ainsi établir et modifier un phénotype cellulaire dans le CHC reste néanmoins obscure. La méthylation de l’ADN étant un acteur majeur dans la mise en place des programmes cellulaires, notre but a été de caractériser le méthylome de CSCs hépatiques et son lien avec la capacité de TGF-ß à induire des CSCs. Nous nous sommes appuyés sur l’expression du marqueur CD133 pour définir la population de CSCs hépatiques. Afin comprendre l’importance des marques de méthylation de l’ADN dans les CSCs hépatiques, nous avons dans un premier temps déterminé quelle était la signature des cellules CD133+ au niveau de la méthylation de l’ADN en utilisant des puces de méthylation à grande échelle. Les sites CpG différentiellement méthylés ont montré un enrichissement pour d’une part des voies de signalisation déjà identifiées dans les CSCs et, d’autre part, pour des voies de signalisation associées au processus inflammatoire dont la voie TGF-ß/SMAD. Par la suite, nous avons montré que TGF-ß pouvait induire de façon permanente les cellules CD133+ contrairement à une autre cytokine influente dans le cancer du foie, l’interleukine 6. Cette augmentation de cellules CD133+ induite par TGF-ß est associée à des changements de méthylation de l’ADN sur l’ensemble du génome et qui sont, de plus, maintenus au cours des divisions cellulaires. La comparaison entre les deux méthylomes (liés aux cellules CD133+ et à l’action de TGF-ß) a exposé une signature commune significative indiquant que TGF-ß pourrait promouvoir le phénotype de CSC via le processus de méthylation de l’ADN. Mais nous avons également déterminé qu’une grande partie des effets sur la méthylation induits par TGF-ß était totalement indépendante de l’induction de cellules CD133+. Enfin, nous avons observé que les sites de méthylation sensibles au signal de TGF-ß étaient regroupés de façon significative au niveau de régions « enhancer » qui régulent la transcription des gènes. Par ailleurs, ces sites incluaient également des gènes précédemment identifiés comme cibles de TGF-ß mais aussi des gènes codant pour des acteurs épigénétiques de premier ordre comme les méthyltransférases de l’ADN. Ces résultats constituent la première description d’une signature de méthylation de l’ADN induite par TGF-ß permettant une reprogrammation stable vers un profil épigénétique de CSC hépatiques. / Distinct subpopulations of neoplastic cells within tumors, including hepatocellular carcinoma (HCC), display a pronounced ability to initiate new tumors and induce metastasis. Investigations on theses cells rapidly described them as essential for tumor growth and based on theses observations they have been named “cancer stem cells” (CSCs). Unfortunately, the mechanisms involved in sustaining their programs are only partially known. In HCC, there is an established link between microenvironmental signals from Transforming Growth Factor beta (TGF-ß) and survival of certain cell subpopulations which is results in a bad prognosis. However, how TGF-ß establishes and modifies cell behavior in HCC is not fully understood. As DNA methylation is involved in establishing cellular programs, our aim was to characterize the methylome of putative liver CSCs, and its link to the ability of TGF-ß to induce liver CSCs. We used CD133 expression as a positive marker for liver CSC. To understand the relevance of DNA methylation programs in liver CSCs, we first defined the methylome signature of CD133+ cells in liver cancer cells using methylation bead arrays. Differentially methylated CpG sites were enriched in known pathways related to CSC survival and to inflammation, including the TGF-ß/SMAD pathway. Next, we showed that TGF-ß persistently induces CD133+ cells in opposition to another cytokine related to HCC, interleukin 6. We observed that this increase is associated with genome-wide changes in the methylome induced by TGF-ß and that are perpetuated through cell division. We observed a significant overlap between the CD133+ methylome and the methylome induced by TGF-β, indicating that TGF-ß may induce CSC phenotype through DNA methylation reprogramming. Additionally, we observed genome-wide effects of TGF-ß that are independent of the induction of CD133. Finally, TGF-ß methyl-sensitive sites were significantly concentrated in enhancer regions of the genome, and include well-known targets of TGF-ß, and epigenetic players, such as de novo DNA methyl-transferases. In conclusion our results are the first indication of the ability of TGF-ß to induce genome-wide changes of DNA methylation, leading to a stable switch to a liver cancer stem cell epigenetic program.

Le carcinome hépatocellulaire (CHC) est la 3ème cause de mortalité par cancer dans le monde. L'identification de nouveaux marqueurs sériques est cruciale pour améliorer le pronostic. Dans ce travail, nous avons évalué l'intérêt de la spectroscopie vibrationnelle, infrarouge et Raman, appliquée au sérum pour le diagnostic du CHC. Dans un premier temps, nous avons réalisé 2 études pilotes pour évaluer le potentiel de ces deux approches. L'intérêt de la spectroscopie Raman appliquée au sérum a été évalué chez 37 patients cirrhotiques avec CHC et 34 patients cirrhotiques sans CHC. L'analyse des données spectrales a permis de classer les patients avec un taux d'exactitude diagnostique de 85 à 91%. Nous avons également démontré l'intérêt diagnostique de la spectroscopie IRTF dans une population de 40 patients avec CHC et 39 patients sans CHC. Dans cette étude, le taux d'exactitude diagnostique était de 82 à 86%. Dans un deuxième temps, nous avons mené une étude sur un plus grand nombre de patients afin de valider les résultats obtenus dans l'étude pilote IRTF. Les caractéristiques spectrales IRTF du sérum de 308 patients cirrhotiques avec CHC ont été comparées à celles du serum de 509 patients cirrhotiques sans CHC. L'analyse des données spectrales par deux méthodes de classification supervisée, SVM et PLS-DA, n'a pas permis de confirmer les résultats obtenus dans cette étude pilote. Avec un taux d'exactitude diagnostique entre 50 et 60 %, l'analyse spectrale IRTF du sérum entier n'apparait pas discriminante pour distinguer les patients cirrhotiques avec et sans CHC. Ce résultat souligne la nécessité de confirmer sur un grand nombre de patients les résultats obtenus dans des études pilotes. L'analyse spectrale ciblée sur des fractions du sérum pourrait permettre d'identifier plus efficacement des marqueurs diagnostiques en évitant la superposition des informations spectrales liées aux multiples molécules présentes dans le sérum entier. / Hepatocellular carcinoma (HCC) is the third cause of cancer death in the world. The identification of novel serum markers is crucial to improve the prognosis. In this work, we evaluated the potentiels of vibrational spectroscopy, infrared and Raman spectroscopy, applied to serum to diagnose HCC. On a first step, two pilot studies were conducted to evaluate these two approaches. Raman spectroscopy applied to the serum was tested in 37 cirrhotic patients with HCC and 34 cirrhotic patients without HCC. Analysis of spectral data showed that it was possible to classify patients with a diagnostic accuracy rate of 85 to 91%. We also demonstrated the diagnostic performance of FTIR spectroscopy in a population of 40 patients with HCC and 39 patients without HCC. In this study, the diagnostic accuracy rate was 82 to 86%. In a second step, an FTIR study on a larger number of patients was performed to validate the results obtained in the pilot studiey. FTIR spectral characteristics of 308 serum from cirrhotic patients with HCC were compared with those of 509 cirrhotic patients without HCC. The supervised classification methods, SVM and PLS -DA were applied but did not confirm the results obtained in the pilot study. The diagnostic accuracy was between 50 and 60%, FTIR spectral analysis of whole serum does not appear discriminant enough to differentiate cirrhotic patients with and without HCC. This result highlights the need to confirm on a large number of patients results in pilot studies. Spectral analysis of serum fractions could be an alternative to more effectively identify diagnostic markers avoiding overlapping spectral information related to the complex composition of whole serum.

Dans les pays d’Afrique Sub-Saharienne et d’Asie du Sud-Est, l’infection chronique par le virus de l’hépatite B (VHB) et l’exposition à l’aflatoxine B1 (AFB1) ont un rôle synergique dans le développement du carcinome hépatocellulaire (CHC). Cependant les mécanismes impliqués ne sont pas élucidés à ce jour. Le VHB est un petit virus à ADN qui induit différentes maladies du foie allant du portage asymptomatique au CHC. L’AFB1 est une mycotoxine qui contamine la nourriture. Après activation en époxyde, elle forme des adduits à l’ADN puis des mutations, dont la mutation au codon 249 du gène suppresseur de tumeur TP53 (AGG → AGT, mutation R249S). Nous avons utilisé les caractéristiques uniques de la lignée cellulaire HepaRG pour étudier les interactions entre le VHB et l’AFB1 : ces cellules se différencient in vitro en hépatocytes qui métabolisent l’AFB1 et peuvent être infectés par le VHB. Nous avons montré que l’AFB1 induit une réponse de p53 dose-dépendante et agit comme un agent antiviral en réprimant la production de particules virales après 48h d’exposition. D’autre part, l’infection par le VHB n’a montré aucun effet sur la formation ou la réparation des adduits. De la réparation et de la prolifération cellulaire ont été observées suite au traitement à l’AFB1, suggérant la faisabilité de l’étude de mutations dans ce système, dont R249S. Ces résultats suggèrent que l’AFB1 atténue l’hépatite chronique tout en maintenant les hépatocytes sous intense pression mutagène, ce qui favoriserait la progression vers le CHC / In sub-Saharan Africa and South-East Asia, chronic infection by hepatitis B virus (HBV) and exposure to aflatoxin B1 (AFB1) play a synergic role in the development of hepatocellular carcinoma (HCC). However mechanisms are still largely unknown. HBV is a small DNA virus which induces different liver diseases from asymptomatic carriage to HCC. AFB1 is a mycotoxin which contaminates food. After activation into an epoxide, it forms DNA adducts and mutations, such as R249S mutation at codon 249 in tumor suppressor TP53 gene (AGG → AGT). We have taken advantage of the unique features of the cell line HepaRG to investigate interactions between both risk factors: cells differentiate in vitro into hepatocytes which metabolize AFB1 and can be infected by HBV. We have shown that AFB1 induces a dose-dependent p53 response and act as an antiviral agent by repressing production of HBV particles after 48 hours of exposure. Nevertheless HBV infection had no effect on adduct formation or repair. Moreover DNA synthesis activity associated to DNA repair and cell proliferation were observed following AFB1 treatment, suggesting the feasibility of mutation research in this model, especially R249S. Overall these results suggest that AFB1 may attenuate HBV chronic hepatitis while maintaining hepatocytes under intense mutagenic pressure, thus enhancing the progression towards HCC

Le carcinome hépatocellulaire est l'un des cancers les plus fréquents et des plus sévères à travers le monde. Le diagnostic est souvent tardif et les traitements curatifs ne peuvent être proposés qu'à un nombre limité de patients. Les technologies modernes ont permis le développement de nouvelles méthodes de radiothérapie qui montrent aujourd'hui de bons résultats. Par ailleurs, bien que des déficiences dans les voies de réparation de l'ADN soient associées à une instabilité génomique et une susceptibilité au cancer, une inhibition de ces voies sensibilise les cellules cancéreuses à la chimiothérapie et à la radiothérapie. Dans ce contexte, les inhibiteurs de poly(ADP-ribose) polymérases (PARP) ont déjà montré des résultats prometteurs dans des études pré-cliniques et sont en cours d'évaluation clinique pour de nombreux cancers. Ce travail de thèse a consisté en l'évaluation du potentiel des inhibiteurs de PARP en combinaison avec la radiothérapie comme nouvelle option thérapeutique pour le carcinome hépatocellulaire. La première étape de ce travail a été de caractériser les profils d'expression et d'activité de plusieurs membres de la famille PARP dans des cellules cancéreuses du foie et des hépatocytes primaires humains ainsi que dans des tissus hépatiques. En second lieu, nous avons étudié le potentiel de l'inhibiteur de PARP ABT-888 seul et en combinaison à des radiations ionisantes in vitro. Le traitement par l'inhibiteur de PARP ABT-888 en agent seul a montré une sensibilité variable des différentes lignées cellulaires étudiées à cette drogue. Afin de comprendre la sensibilité variable des cellules cancéreuses hépatiques à l'ABT-888, nous avons analysé leur capacité de réparation des dommages à l'ADN et avons observé des capacités différentes entre les lignées cellulaires. Finalement, nous avons pu montrer que l'ABT-888 sensibilise les cellules cancéreuses hépatiques aux radiations ionisantes. Ce travail de recherche a permis de montrer que les inhibiteurs de PARP ont un fort potentiel pour améliorer les méthodes de radiothérapie utilisées dans la prise en charge du carcinome hépatocellulaire / Hepatocellular carcinoma is the third cause of cancer related death. Due its often late diagnosis and advanced stage, a limited number of patients can benefit from curative treatments. There is thus a constant need for new treatment strategies for patients with hepatocellular carcinoma. Targeting DNA repair pathways to sensitize tumor cells to chemoor radiotherapeutic treatments is now a common strategy under investigation for cancer treatment with inhibitors of poly(ADP-ribose) polymerases (PARP) showing great potential. The aim of this work was to evaluate the potential of PARP inhibitors alone and in combination with radiation therapy as a new strategy for the treatment of hepatocellular carcinoma. We first analyzed the expression and activity of different PARP genes in a panel of liver cancer cell lines and primary human hepatocytes as well as their DNA repair capacity and assess the impact of PARP inhibitors alone and in combination with ionizing radiation in these models on cell survival. A large range in expression of PARP family members, PARP activity and sensitivity to ABT-888 in the panel of liver cells was observed as well as differential excision/synthesis repair capacity. Finally, we showed that ABT-888 sensitizes liver cancer cells to the cell killing effects of ionizing radiation. PARP inhibitors show great potential for improving radiation therapy strategies used in the management of hepatocellular carcinoma

Student Number : 9902006N - MSc(Med) Dissertation - School of Medicine - Faculty of Health Sciences / Hepatocellular carcinoma (HCC) is the most common primary malignant tumour of the liver. Aflatoxin B1 (AFB1) is a potent hepatocarcinogen, and dietary iron overload has been shown to contribute to HCC development in black africans. Both are well studied hepatotoxins. The aim of this study was to use a Wistar rat model over a 12 month period to investigate synergy and the extent thereof between AFB1 ingestion and dietary iron overload. 25ug/day of AFB1, reconstituted in DMSO, was administered by gavaging the animals, over a period of 10 days with a 2 day interval in between. The chow diet was supplemented with 0.75% (w/w) ferrocene iron. Experimental subjects were divided into 4 groups. Group 1 was fed the normal chow diet. Group 2 was fed 0.75% (w/w) ferrocene iron alone. Group 3 was gavaged 250μg AFB1 alone. Group 4 was fed the 0.75% (w/w) ferrocene iron and gavaged 250μg AFB1. A number of assays were conducted to investigate synergy. Colorimetric assays were used to measure serum iron, total-iron binding capacity, ALT, AST, GGT, nitrite production, lipid peroxidation and hydroxyproline concentrations. ELISA’s were used to determine ferritin, 8-isoprostane and 8-hydroxyguanosine concentrations. Nontransferrin bound iron was measured using an HPLC method. A chemiluminescent assay was used to measure superoxide anion production. Cytokines were measured using a suspension array system. Mutagenicity was assessed using the Ames mutagenicity assay using salmonella typhimirium strains TA97, TA98, TA100 and TA102. Iron profiling indicated that iron overloading occurred with the ingestion of the ferrocene diet. Biomarkers of oxidative stress, as illustrated by the measurement of 8-hydroxyguanosine and lipid peroxidation, showed additive synergistic effects between the two carcinogens. The anti-inflammatory interleukin-10 was shown to be markedly elevated with the co-administration of the two carcinogens, indicating the elevated inflammatory processes. Additive synergistic effects were noted in terms of the liver disease marker ALT. The salmonella typhimirium strain TA102 used in the Ames mutagenicity test showed increased colony counts with respect to the coadministration of carcinogens (P<0.05), although no synergistic effect was noted. In a few of the presented parameters, the AFB1 group was not significantly different to the control group, although significant differences between the Fe group and the Fe + AFB1 groups were noted. The implication of which is that the presence of AFB1 is increasing the activity of Fe as a carcinogen, thereby acting as a co-carcinogen. Examples of such parameters illustrating this are presented in the results section including serum ALT, serum nitrite, liver and serum lipid peroxidation, liver and serum 8-hydroxyguanosine, some of the mutagenicity assays, and interleukin-10. The conclusion of this study suggests that AFB1 acts as a co-carcinogen in the presence of iron overloading, implying that a synergistic relationship between these two toxins exists.

No description available.

INTRODUÇÃO: O transplante (TX) de fígado corresponde ao tratamento de escolha em pacientes com cirrose e carcinoma hepatocelular (CHC) precoce irressecável. A recidiva do CHC pós-transplante, entretanto, ainda apresenta impacto na sobrevida dos pacientes transplantados com este tumor. As taxas de recidiva, nos estudos mais recentes, variam de 8 a 20%. O tamanho e número de nódulos, a presença de invasão vascular e de nódulos satélites no explante, são fatores de risco relacionados à recidiva tumoral pós-transplante. No Brasil, observamos um crescimento importante do número de transplantes de fígado, inclusive por CHC. Entretanto, existem poucos estudos nacionais analisando os resultados do transplante hepático por CHC. Os objetivos do nosso estudo foram analisar as características demográficas, clínicas e a evolução dos pacientes submetidos a transplante hepático com CHC no Brasil, avaliando os fatores prognósticos relacionados com a recidiva do CHC pós-transplante e sobrevida e estudar o desempenho dos critérios de seleção para transplante utilizados no nosso país, os \"Critérios de Milão Brasil\" (CMB). MÉTODOS: Estudo de coorte retrospectivo, multicêntrico, para analisar os resultados do transplante de fígado em pacientes com CHC, após a implantação do sistema MELD. Foram incluídos 1.119 pacientes transplantados com CHC, de 07/2006 até 07/2015, em 13 centros de transplante, no Brasil. Características clínicas, demográficas, exames laboratoriais e de imagem e dados anatomopatológicos, foram retrospectivamente analisados e correlacionados com a sobrevida e recidiva do CHC pós-transplante. RESULTADOS: A maioria dos pacientes era do sexo masculino (81%), com uma idade média no TX de 58 anos. A etiologia mais associada ao tumor foi a Hepatite C (VHC), presente em 60% dos casos. O tempo médio de espera em lista foi de 9,8 meses. Setenta e oito pacientes (8%) foram incluídos por \"Down-staging\". Nos exames de imagem do diagnóstico, a maioria dos casos (67%) apresentava um nódulo, com tamanho médio de 30 mm; 85% estavam dentro dos Critérios de Milão (CM), 8% fora dos CM, mas dentro dos \"Critérios de Milão Brasil\" (CMB) e 7% fora de ambos os critérios. O tratamento do CHC em lista foi realizado em 67% dos pacientes. Na análise do explante, 44% apresentavam tumor uninodular, com tamanho médio de 26 mm e a maioria (71%) tinha CHC moderadamente diferenciado. A invasão vascular foi observada em 26% dos casos e nódulos satélites em 22%. No explante, 70% dos pacientes estavam dentro dos CM, 20,5% fora dos CM, mas dentro dos CMB e 9,5%fora de ambos os critérios. A sobrevida global foi de 79% em 1 ano, 72,5% em 3 anos e 63%, em 5 anos, com um tempo médio de seguimento de 28 meses. Excluindo os pacientes que foram a óbito no pós-operatório ( < 30 dias pós-transplante), a sobrevida global foi de 89% em 1 ano e 75%, em 5 anos. A recidiva do CHC pós-TX ocorreu em 8% (86/1.119) dos casos, em um tempo médio de 12 meses. A sobrevida livre de recidiva (SLR) foi de 94,4% em 1 ano e 88,3%, em 5 anos. A recidiva do CHC foi extra-hepática em 55% dos casos, hepática em 27% e hepática e extra-hepática em 18%. Os pacientes transplantados que evoluíram com recidiva tumoral apresentaram alta mortalidade, com uma sobrevida em 1 ano de 34% e em 5 anos de 13%. Em relação aos fatores prognósticos, os pacientes transplantados dentro dos Critérios de Milão apresentaram melhor sobrevida e SLR quando comparados aos pacientes transplantados fora dos CM, mas dentro dos CMB, tanto quando analisamos os dados do diagnóstico, quanto através da análise do explante. Os pacientes transplantados após realização de \"Down-staging\" apresentaram taxas de recidiva e sobrevida semelhantes aos pacientes transplantados sem \"Down-staging\". Os níveis séricos elevados de alfa-fetoproteína (AFP) foram um fator prognóstico importante de sobrevida e recidiva tumoral. Os melhores pontos de corte de AFP encontrados para avaliação do risco de recidiva e sobrevida foram: AFP > 400 ng/ml, no momento do diagnóstico e AFP > 200 ng/ml pré-transplante. Realizamos, também, uma comparação dos \"Critérios de Milão Brasil\" com os Critérios de Milão, através do índice IDI (Integrated Discrimination Index) e os CMB apresentaram performance inferior aos CM, na capacidade de classificar corretamente os pacientes em relação ao risco de recidiva tumoral. Os níveis séricos elevados de AFP, o estádio fora dos Critérios de Milão no momento do diagnóstico e no explante e a presença e invasão vascular no explante, foram fatores de risco independentes de recidiva do CHC pós-transplante e pior sobrevida. A idade > 60 anos e a etiologia da hepatopatia (VHC), também foram fatores prognósticos negativos de sobrevida. CONCLUSÕES: A presença de recidiva tumoral teve grande impacto na sobrevida do paciente transplantado com CHC. O estadiamento tumoral no diagnóstico e no explante, avaliado através dos Critérios de Milão, os níveis séricos elevados de AFP e a presença de invasão vascular no explante foram fatores prognósticos importantes de recidiva do CHC pós-transplante e sobrevida. Os pacientes transplantados após \"Down-staging\" apresentaram evolução pós-transplante semelhante a dos pacientes transplantados sem \"Down-staging\". Os pacientes transplantados fora dos CM, mas dentro dos CMB, apresentaram pior sobrevida, quando comparados aos pacientes dentro dos CM. Os CMB apresentaram desempenho inferior aos CM na capacidade de classificar corretamente os pacientes em relação ao risco de recidiva tumoral / INTRODUCTION: Liver transplantation (LT) is the treatment of choice for patients with cirrhosis and unresectable early hepatocellular carcinoma (HCC). HCC post-transplant recurrence, however, still has an impact on survival. In recent studies, the incidence of HCC recurrence after transplantation ranged from 8% to 20%. Tumor number, size, vascular invasion and satellite nodules have emerged as risk factors for HCC recurrence. In Brazil, in the last decade, we observed a significant increase in the number of liver transplants performed, including in patients with HCC. However, there are few national studies analyzing the results of liver transplantation for HCC. The aim of this multicentric study was to analyze the demographic characteristics, clinical features and outcomes of patients submitted to liver transplantation with HCC in Brazil, evaluate prognostic factors related to HCC post-transplant recurrence and survival, and study the performance of the national selection criteria for liver transplantation, the \"Brazilian Milan Criteria\" (BMC). METHODS: We conducted a national, multicentric, retrospective study to analyze the results of liver transplantation in patients with HCC, in \"MELD era\". Medical records of 1,119 transplanted patients with HCC between 07/2006 and 07/2015, from 13 transplant centers in Brazil, were collected. Patient and tumor characteristics, radiologic and pathologic data were retrospectively analyzed and correlated with post-transplant HCC recurrence and survival. RESULTS: Of the 1,119 HCC transplanted patients, median age was 57 years and 81% were male. Etiology of liver disease was HCV in 60%. Median time on transplant list was 9.8 months. Seventy-eight patients (8%) were included after \"Down-staging\". At diagnosis, most patients had uninodular HCC (67%) and median tumor burden was 30 mm. At diagnosis, in imaging studies, 85% of patients were within the Milan criteria (MC), 8% out of the MC but within the \"Brazilian Milan Criteria\" (BMC) and 6% out of both criteria. During the waiting list period, HCC treatment was performed in 67%. In explant analysis, tumor was uninodular in 46% and moderately differentiated in the majority of cases (71%). Median HCC size was 26 mm. Vascular invasion and satellite nodules were observed in 26% and 22% of patients, respectively. In explant, 70% of patients were within Milan Criteria, 20.5% outside MC but within BMC and 9.5% out of both criteria. Mean follow-up was 28 months, an overall survival was 79% in 1 year, 72.5% in 3 years and 63% in 5 years. Excluding patients who died within 30 days after surgery, overall survival was 89% in 1 year and 75% in 5 years. HCC post-transplant recurrence occurred in 86/1,119 (8%) cases, at a mean time of 12 months. Recurrence-free survival (RFS) was 94.4% in 1 year and 88.3% in 5 years. Sites of recurrence were extrahepatic in 55%, hepatic in 27% and both hepatic and extrahepatic in 18%. Transplanted patients with tumor recurrence presented high mortality, with 1-year survival rate of 34% and 5-year survival rate of 13%. Analyzing the prognostic factors, patients transplanted under Milan Criteria, in radiologic or explant analysis, presented better survival and RFS when compared to patients transplanted outside MC, but within BMC. Patients submitted to liver transplantation after \"Down-staging\" present long-term survival and RFS similar to patients transplanted without \"Down-staging\". Alpha-fetoprotein (AFP) levels were an important pre-transplant prognostic factor for tumor survival and recurrence. The best AFP cut off points found for relapse risk and survival assessment were: AFP at diagnosis > 400 ng / ml and AFP pre-transplant > 200 ng / ml. We also performed a comparison of the \"Brazilian Milan Criteria\" with the Milan Criteria through the Integrated Discrimination Index (IDI). The BMC presented a lower performance than the MC, in the ability to correctly classify patients in relation to the risk of relapse. Elevated AFP levels before liver transplantation, tumor outside Milan Criteria at diagnosis and in explant, and vascular invasion, were independent risk factors for post-transplant HCC recurrence and worse survival. Age > 60 years and etiology of liver disease (HCV), were also negative prognostic factors for survival. CONCLUSIONS: The presence of tumor recurrence had a major impact on survival of transplanted patients with HCC. Tumor staging, evaluated by Milan Criteria on imaging studies or explant analysis, high serum AFP levels and presence of vascular invasion in explant were important prognostic factors for post-transplant HCC recurrence and survival. Patients transplanted after Down-staging presented long-term outcomes similar to patients transplanted under conventional criteria. Patients transplanted outside Milan Criteria, but within \"Brazilian Milan Criteria\" presented worse survival, when compared to patients within MC. The BMC showed lower performance than MC in the ability to correctly classify patients in relation to the risk of tumor recurrence