Le cancer pulmonaire non à petites cellules (CNPC) est la première cause de décès par cancer dans le monde. Ce cancer est souvent découvert tardivement, il est agressif, et il est chimio-résistant. La découverte de biomarqueurs pourraient représenter une percée majeure pour la prise en charge de ces patients, en facilitant le diagnostic, le pronostic et orienter vers le choix du traitement le plus approprié. Nous avons exploré plusieurs aspects liés à la progression tumorale dans le but d’identifier de nouveaux biomarqueurs dans les CNPC. Nous avons démontré un impact antagoniste sur l’évolution des CNPC des anhydrases carboniques IX et XII, induites par l’hypoxie tumorale. Une forte expression tissulaire et plasmatique de CAIX est un biomarqueur de mauvais pronostic chez les patients présentant un CNPC, tandis que l’expression tissulaire de CAXII serait prédictive d’une évolution favorable. De plus, nous avons montré que la réoxygénation dynamique des tumeurs serait à l’origine de cet antagonisme. Deuxièmement, la composante cellulaire du microenvironnement tumoral a été étudiée et plus particulièrement nous avons démontré qu’un recrutement par les cellules tumorales des neutrophiles exprimant un marqueur spécifique CD66b pourrait avoir un signal positif au cours de la progression tumorale des CNPC. Troisièmement, le compartiment sanguin a été évalué en relation avec l’évolution des tumeurs et plus particulièrement nous avons démontré la valeur majeure diagnostique et pronostique des cellules tumorales circulantes (CTC) chez les patients atteints d’un CNPC. Enfin, les CTC semblent représenter également le support idéal pour la mise en évidence de biomarqueurs théranostiques dans les CNPC. En conclusion, ces travaux explorent les possibilités et les limites de l’identification de biomarqueurs, en soulignant l'importance de la qualité des échantillons et de l'exactitude et l'exhaustivité des données cliniques afin d'obtenir des résultats reproductibles. / The non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths in the world. Reliable and validated biomarkers could represent a possible breakthrough in the management of this tumour type, by facilitating diagnosis, refining prognosis and providing guidance towards the choice of the most appropriate therapy. In this thesis we approach the field of NSCLC biomarkers by exploring several aspects related to carcinogenesis and tumour progression. First, we have demonstrated a dual impact of two proteins activated by hypoxia, carbonic anhydrases IX and XII, on the outcome of NSCLC patients. We have demonstrated that high tissue and plasma CAIX expression may be a biomarker of poor prognosis and early relapse in NSCLC patients, whereas the CAXII tissue expression would be predictive of a favourable evolution. In addition, we have shown that dynamic reoxygenation of tumours would be at the origin of this antagonism. Furthermore, the cellular component of the tumour microenvironment has been studied and more particularly we have demonstrated that recruitment by the tumour cells of a subpopulation of neutrophils expressing a specific marker CD66b could have a positive signal during tumour progression of NSCLC. Thirdly, the blood compartment has been evaluated in relationship with the evolution of tumours and in particular we have demonstrated the major diagnostic and prognostic value of circulating tumour cells (CTCs) in patients with NSCLC. Finally, the CTC seem to represent the ideal tool for the detection of biomarkers theranostic in the NCPC. In conclusions, the works presented in this thesis explore possibilities and limitations of biomarker research in NSCLC, highlighting the importance of the quality of the samples and of the accuracy and completeness of clinical data in order to obtain reproducible results.

Le cancer du poumon est la première cause de mortalité par cancer en France et dans le monde. Aujourd'hui, en France, la survie cinq ans après un diagnostic de cancer du poumon est de seulement 14%, ce qui en fait l'un des cancers les plus difficiles à soigner. La médecine personnalisée, notamment l’immunothérapie, est désormais l’approche privilégiée pour les cancers du poumon aux stades métastatiques. Au sein d’une tumeur, les cellules cancéreuses sont entourées par un microenvironnement inflammatoire riche en polymorphonucléaires neutrophiles (PMN). Alors qu’il est établi que la présence répétée de PMN est associée au développement des carcinomes, la contribution de l'interaction intratumorale des PMN avec les cellules cancéreuses dans la progression tumorale n’est pas claire. Pour cela nos objectifs ont été de : 1) décrypter les moyens de communication engagés entre les neutrophiles et les cellules tumorales (miARNs et microvésicules) et 2) la régulation de ces acteurs dans les cellules réceptrices, 3) démontrer leur rôle dans la progression et la dissémination tumorale. La plasticité tumorale et l’invasion font parties des caractéristiques les plus importantes de la progression du cancer. Ces travaux nous ont permis d’identifier un nouveau mécanisme d'acquisition transitoire du phénotype invasif via le transfert de miARNs extracellulaires dans les cellules tumorales. Nous avons pu observer que le miR-223-3p extracellulaire est transféré des PMN aux cellules tumorales pulmonaires via des exosomes. / Lung cancer is the leading cause of cancer mortality in France and worldwide. Today in France, the overall five-year survival rate after diagnosis is only 14%, making it one of the most challenging cancers to treat. Personalized medicine is now the preferred approach for lung cancer for metastatic stage, including so-called immunotherapy. Within a tumor, cancer cells are surrounded by an inflammatory microenvironment rich in polymorphonuclear neutrophils (PMN). While it is established that the presence of PMN is associated with the development of carcinomas, the contribution of intratumoral PMN and their interaction with cancer cells in tumor progression is unclear. To explore these hypotheses, objectives of our study were: 1) to decrypt the communication between neutrophils and tumor cells (miRNAs and microvesicles) and 2) the regulation of these actors in the recipient cells, 3) to demonstrate their role in tumor progression and dissemination. Tumor plasticity and invasion are part of the most important features of cancer progression. This work has allowed us to identify a new mechanism of transient acquisition of phenotype by transfer of extracellular miRNA (ex-miRNA) into cancer cells with and, importantly, by letting the ex-miRNA decay. We observed that the ex-miR-223-3p is transferred from PMN to lung tumor cells via exosomes. This transfer is functional, as demonstrated by the occurrence of epithelial to mesenchymal transition (EMT) associated with an invasive phenotype and inhibition of one of its targets, FOXO1 transcription factor.

Responsable d'environ 30000 décès/an en France, le cancer du poumon est un problème de santé publique majeur. Un des enjeux actuels est d'adapter le traitement du cancer du poumon pour proposer des thérapeutiques ciblées plus efficaces et moins agressives. Les inhibiteurs de l'activité tyrosine kinase du récepteur de l'EGF (EGFR-TKI, gefitinib et erlotinib) constituent un réel progrès pour le traitement des cancers du poumon. Cependant, des mécanismes de résistance ont été décrits et des traitements combinés de thérapies ciblées avec des EGFR-TKI pourraient permettre de surmonter les résistances dans les cancers du poumon.Dans ce contexte, nous avons étudié les mécanismes impliqués dans la résistance à ces traitements. Nous montrons que l'activation de la voie de signalisation PI3K/AKT joue un rôle majeur dans la résistance aux EGFR-TKI, en inhibant l'apoptose par des mécanismes dépendant de l'acétylation. Les histones déacétylases (HDACs) et les sirtuines interviennent dans ces mécanismes de résistance, en modulant l'activation de la voie PI3K/AKT et l'apoptose. Ainsi l'utilisation d'inhibiteurs des HDACs (HDACi) et des sirtuines permettent de restaurer la sensibilité aux EGFR-TKI. Ces résultats confirment l'intérêt thérapeutique de l'association EGFR-TKI/HDACi et montrent le potentiel thérapeutique d'associer des inhibiteurs de l'EGFR et de la voie PI3K/AKT pour contourner la résistance aux EGFR-TKI.Les molécules thérapeutiques doivent atteindre spécifiquement le site tumoral, nécessitant parfois de les protéger contre leur dégradation, de réduire leurs effets indésirables, et de contrôler leur libération dans le temps et l'espace, à l'aide de transporteurs. Ainsi dans la deuxième partie de cette thèse, nous avons évalué les capacités de ciblage des tumeurs pulmonaires de nanoparticules à base de copolymère amphiphile, contenant une partie polysaccharidique hydrophile (le hyaluronane) et une partie polypeptidique hydrophobe (le poly(γ‐benzyl L‐glutamate, PBLG). Nos travaux mettent en évidence la capacité de ciblage tumoral de ces nanoparticules injectées par voie intraveineuse, ouvrant ainsi de nouvelles perspectives thérapeutiques. Notre objectif est de charger les combinaisons de traitements EGFR-TKI/HDACi que nous avons identifiées dans ces vecteurs, afin de traiter les tumeurs pulmonaires résistantes aux EGFR-TKI. / Responsible of 30000 deaths each year in France, lung cancer is a major public health problem. One of the current challenges is to adapt the treatment of lung cancer to offer more effective and less aggressive targeted therapies. EGFR tyrosine kinase inhibitors (EGFR-TKI, gefitinib and erlotinib) represent a real progress in lung cancer therapy. However resistance mechanisms have been described and combination of targeted therapy with EGFR-TKI could overcome resistance in lung cancer.In this context, we studied mechanisms involved in resistance to EGFR-TKI. We show that PI3K/AKT activation is a major pathway leading to EGFR-TKI resistance leading to apoptosis inhibition through acetylation-dependent mechanisms. Histone deacetylase (HADCs) and sirtuin are involved in these mechanisms and modulate PI3K/AKT activation and apoptosis. The use of HDACs inhibitors (HDACi) and sirtuins inhibitors thus restores the sensitivity to EGFR-TKI. Altogether these results confirm the therapeutic effect of the EGFR-TKI/HDACi combination and show the therapeutic potential of the association of EGFR and PI3K/AKT inhibitors to overcome EGFR-TKI resistance.Therapeutic molecules must specifically reach the tumor site, sometimes requiring to protect them against degradation, to reduce their side effects, and to control their release in time and space, using transporters. In the second part of this thesis, we have thus evaluated the lung tumors targeting capabilities of amphiphilic copolymer-based nanoparticles, containing an hydrophilic polysaccharidic block (hyaluronan) and an hydrophobic polypeptidic block (the poly(γ‐benzyl L‐glutamate PBLG). Our work highlights the tumor targeting capability of these nanoparticles injected intravenously, offering new lung cancer therapy perspectives. Our aim is to load the drugs combination (EGFR-TKI/HDACi) in these vectors, to treat the lung tumors resistant to EGFR-TKI.

Lung cancer is the leading cause of cancer mortality worldwide. Understanding biological processes of specific antitumor immune response remains of an eminent interest and represents necessity for designing successful antitumor immunotherapeutic strategies. The theoretical part of the thesis describes components of the immune system that are involved in antitumor response and discusses their role in the hitherto known and used lung cancer immunotherapy. In the practical part of the thesis, two studies studying different aspects of anticancer immune response are described. Both studies were conducted in cooperation with 3rd Surgical Department 1st Faculty of Medicine, Charles University and University Hospital Motol and with the biotechnology company Sotio a.s. The first study is focused on the humoral component of the specific antitumor response and prospectively analyses serum frequency of antitumor antibodies against NY-ESO-1, Her2/neu and MAGE-A4 antigens in 121 patients with NSCLC. Here it was shown for the first time that tobacco smoking significantly increases the frequency of NY- ESO-1 antibodies in sera of smokers in comparison to ex-smokers and non-smokers. The second study is focused on the cellular component of the specific antitumor response investigating the activity of the dendritic...

La sénescence cellulaire est un mécanisme de suppression cellulaire caractérisé par un arrêt irréversible du cycle cellulaire. Les cellules sénescentes ont également un secrétome spécifique qui influe sur les cellules voisines, pouvant induire leur entrée prématurée en sénescence, l'apoptose, la prolifération cellulaire et le développement tumoral. Dans ce contexte, l'objectif de ma thèse était d'identifier une nouvelle protéine sécrétée par les fibroblastes sénescents et de caractériser ses fonctions dans les cellules sénescentes et dans les cellules tumorales. Nous avons mis en évidence la protéine WNT16B. Elle est surexprimée dans plusieurs modèles de sénescence cellulaire obtenus à partir de fibroblastes pulmonaires. Dans un modèle de souris transgénique, WNT16B est également associée avec l'accumulation de cellules sénescentes dans les lésions précancéreuses pulmonaires. WNT16B est impliqué dans le mécanisme de sénescence cellulaire. En effet, l'inhibition de WNT16B prévient l'entrée en sénescence, en empêchant l'activation de p53 et l'expression de p21/WAF1, et donc l'arrêt du cycle cellulaire.Nous avons finalement associé l'expression de WNT16B avec la présence de cellules sénescentes dans des tumeurs prélevées chez des patients atteints de carcinomes pulmonaires non à petites cellules. Cette expression est corrélée avec une meilleure survie pour les patients ayant reçu un traitement chimiothérapeutique. Ce dernier résultat fait donc le lien entre traitement, sénescence cellulaire et survie, et illustre le rôle potentiel des marqueurs des cellules sénescentes pour le suivi des patients. Globalement, ces travaux ont donc non seulement permis d'identifier WNT16B comme nouveau marqueur des cellules sénescentes, mais ils ont également ouvert des perspectives d'utilisation de ce marqueur pour l'identification, le traitement et le suivi des patients atteints d'un cancer. / Cellular senescence is a tumor suppression mechanism consisting of an irreversible cell cycle arrest. Senescent cells also express a specific secretome that plays a role in the microenvironment. It may induce premature senescence, apoptosis, cellular proliferation or tumor development in the neighboring cells. In this context, my thesis aimed to identify and characterize a new senescence-associated secreted protein, before highlighting its role in tumorigenesis. We identified the WNT16B protein. It was overexpressed in various cellular senescence models obtained from lung fetal fibroblasts. Moreover, WNT16B expression was associated with the accumulation of senescent cells in precancerous lesions in a transgenic mice model. WNT16B is also involved in the senescence machinery. Indeed, WNT16B inhibition prevented the senescence onset through inactivation of the p53/p21 pathway, thus stopping the cell cycle progression. Finally, we observed a correlation between the WNT16B expression and the occurrence of senescent tumoral cells in NSCLC samples. This expression was also correlated with a better patient outcome after chemotherapeutical treatment. Thus, this last result linked the treatment efficiency, the occurrence of senescence and the patient survival. Overall, my thesis established elevated WNT16B levels as a novel biomarker for senescence that might be useful for the identification, the treatment follow-up and the prognosis of patient outcome.

Objetivo: Analisar o impacto das co-morbidades no desempenho pós-operatório de lobectomia por carcinoma brônquico. Pacientes e Métodos: Entre Janeiro de 1998 e Dezembro de 2004, foram estudados retrospectivamente 493 pacientes submetidos à lobectomia por carcinoma brônquico, dentre os quais 305 preencheram os critérios de inclusão. Todos os pacientes foram submetidos à lobectomias com técnica cirúrgica semelhante. Foi realizada análise das co-morbidades de forma a categorizar os pacientes nas escalas de Torrington-Henderson (PORT) e de Charlson, estabelecendo-se assim grupos de risco para complicações e óbito. Resultados: a mortalidade operatória foi 2,9% e o índice de complicações de 44%. O escape aéreo prolongado foi a complicação mais freqüente (20.6%). A análise univariada mostrou que sexo, idade, tabagismo, terapia neoadjuvante e diabetes apresentaram impacto significativo na incidência de complicações. O índice de massa corporal (23,8 ± 4,4), o VEF1 (74,1±24%), bem como a relação VEF1/CVF (0,65 ± 0,1) foram fatores preditivos da ocorrência de complicações. Ambas as escalas de Charlson e PORT foram eficazes na identificação de grupos de risco e na relação com a morbi-mortalidade (p=0,001 e p<0,001). A análise multivariada identificou que o IMC e o índice de Charlson foram os principais determinantes de complicações, enquanto que o escape aéreo prolongado foi o principal fator envolvido na mortalidade (p=0,01). Conclusão: Valores reduzidos de VEF1, VEF1/CVF e IMC baixo, assim como graus 3-4 de Charlson, e 3 de PORT estão associados a maior número de complicações após lobectomias por carcinoma brônquico. Nesta amostra, o escape aéreo persistente esteve fortemente associado à mortalidade. / Objetive: To analyze the impact of comorbidities on the postoperative outcome of patients who underwent lobectomy for lung cancer. Patients and Methods: From January 1998 to December 2004, records of 493 lobectomies for lung cancer were reviewed and 305 met the inclusion criteria. All resections were carried out by the same team using the same surgical technique. The co-morbidity analysis was done in a way that all the patients could be categorized both on the Torrington-Henderson scale (PORT) and the Charlson comorbidity index to identify the highest risk patients as well as the factors involved in morbidity and mortality. Univariate and multivariate analyses were performed to define the impact of comorbidities on the postoperative outcome. Results: the operative mortality was 2.9% and complication rate was 44 %. The univariate analysis showed that gender, age, diabetes, smoking and neoadjuvant chemotherapy had no impact on morbidity. Conversely, BMI (23.8 ± 4), FEV1 (74.1±24%) and FEV1/CVF (0.65 ± 0,1) were predictors of complications (p<0.05). The PORT scale and the Charlson index were both useful to identify the patients at risk and their relationship with morbidity and mortality. The logistic regression showed that BMI (p=0.03) and the Charlson index (p=0.01) were the only significant variables involved in postoperative complications. In this study, prolonged air leak was a factor associated in mortality (p=0.01). Conclusions: low preoperative FEV1, FEV1/FVC, BMI and grades 3-4 on the Charlson and grade 3 on PORT scale were associated to higher postoperative complications. Persistent air leak was a strong predictor of postoperative mortality.

Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2013-10-15T18:53:45Z No. of bitstreams: 1 Ana Maria_da_Silva Carvalho. A utilização...2009.pdf: 4646765 bytes, checksum: 5565a182ac26f49c19a96b8c347526f5 (MD5) / Made available in DSpace on 2013-10-15T18:53:45Z (GMT). No. of bitstreams: 1 Ana Maria_da_Silva Carvalho. A utilização...2009.pdf: 4646765 bytes, checksum: 5565a182ac26f49c19a96b8c347526f5 (MD5) Previous issue date: 2009 / Universidade Federal da Bahia. Salvador, BA, Brasil / Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, BA, Brasil / O Câncer de Pulmão (CP) é uma neoplasia de grande prevalência no mundo e apresenta taxas crescentes de incidência. Acomete principalmente homens entre 40 a 70 anos, sendo responsável por 1/3 dos óbitos por câncer. Os fatores etiológicos frequentemente associados a esta patologia são o tabagismo, as exposições industriais ao asbesto, urânio, níquel, arsênico, assim como poluentes atmosféricos como o gás radônio. Representa um grande desafio para os oncologistas, especialmente pela pequena taxa de sobrevida dos pacientes, em torno de 5 a 10% após 5 anos do diagnóstico. A complexidade de padrões morfológicos e pouca diferenciação representam desafios para o diagnóstico do CP. Dentre as estratégias introduzidas para auxiliar no reconhecimento dos tipos histológicos do CP, a imuno-histoquimica (IHQ) vem se destacando no estudo histogenético destes tumores. O objetivo dessa pesquisa foi o estudo retrospectivo de 244 casos de CP, procedentes do Hospital Especializado Otávio Mangabeira, diagnosticados em biópsias brônquica transbrônquica no Serviço de Histopatologia do Centro de Pesquisas Gonçalo Moniz, no período compreendido entre 1986 e 2004. Todos os casos foram visados de acordo com a classificação de câncer de pulmão da OMS (2004), sendo os diagnósticos da presente investigação confrontados com os diagnósticos iniciais. Os tumores definidos como carcinomas pouco diferenciados ou indiferenciados (n=67) e as neoplasias definidas como casos difíceis para a avaliação diagnóstica pelo HE (n=34) (divergência diagnóstica), foram submetidos a IHQ. Esta foi realizada através do sistema Envision TM e utilizando o seguinte painel minimo de marcadores antigênicos: CKAE1/AE3, CK8, CK34BE12, CK7, CK20, PA, CROMOGRANINA A e TTF-1. A freqüência dos diferentes tipos neoplásicos nos 244 casos analisados foi: carcinoma escamocelular, 36,9% (n=90); adenocarcinoma, 27,0% (n=66); carcinoma neuroendócrino de pequenas células, 11,9% (n=29); tumor carcinóide, 8,6% (n=21); linfoma/sarcoma, 2,4% (n=6); carcinoma neuroendócrino de grandes células, 0,4% (n=1); carcinoma adenoescamoso, 0,4% (n=1), permaneceram com o diagnóstico de carcinoma não pequenas células pouco diferenciado, 5,7% (n=14) dos casos e 2,4% (n=6) continuaram como neoplasia maligna indiferenciada. A IHQ definiu histogeneticamente 93,1 % (n=94) dos casos examinados e 6,9% (n=7) deixaram de ser avaliados por ausência de tecido tumoral nas secções (exigüidade de material). A modificação do diagnóstico entre a análise histológica e análise dos 101 casos através da IHQ, apresentou uma concordância negativa de 71,3% e concordância positiva de 28,7%. A avaliação geral de todos os tumores (244 casos) na 18 análise (HE) e as neoplasias classificadas na 28 análise em HE+IHa resultaram em uma concordância negativa de 27,5% e concordância positiva de 72,5%. Concluímos que a IHQ é um bom método complementar para o diagnóstico de câncer de pulmão; o painel mínimo de marcadores antigênicos utilizados foi capaz de definir histogeneticamente 93,1 % dos casos submetidos à IHQ; o diagnóstico preciso e rigoroso do câncer de pulmão não prescinde do exame convencional em HE para a escolha dos marcadores antigênicos a serem utilizados na interpretação diagnóstica final. / Lung cancer (LC) is one of the neoplasias mostly prevalent worldwide and it shows increasing rates of incidence. It attacks mainly men between the ages of 40 and 70, and It has being responsible for 1/3 of all deaths caused by cancer. The most important etiological factors associated with this kind of pathology are cigarrete smocking and industrial expositions to asbestos, uranium, nickel, arsenic and atmospheric pollutants as radon gas. It presents a great challenge for oncologists, especially due to the low five years survival rate after diagnosis. Complex morphological patterns and also lack of differentiation in many cases poses as difficulties for the diagnosis of LC. Among the strategies introduced to help the recognition of different histological types of LC, the immunohlstochemistry (IHC) appears as one of the most important methods in the histological diagnosis of these tumors. The main objective of this research was to perform a retrospective study of 244 cases of LC, coming from the Otavio Mangabeira Thoracic Hospital through the analysis of bronchial and transbronquial biopsies during the period of 1986-2004, at the Histopathological Service, Gonçalo Moniz Research Center. All of the cases were revised according to the LC classification of WHO (2004) and the diagnosis of this investigation were confronted with the first ones that are present in our files. The criteria for sending the cases for IHC were tumors defined as indifferentiated/poorly differentiated cases (n=67) and the ones considered as difficult cases for evaluation on HE stain only (divergent diagnosis, n=34). The immunohistochemical study was done using the Envision system™ and making use of the followings antigenic markers; CKAE1/AE3, CK8, CK34BE12, CK7, CK20, SPA CHROMOGRANIN A and TTF-1. The frequency of the different neoplasic types in the 244 analysed cases were: squamous cell carcinoma, 36,9% (n=90); adenocarcinoma, 27% (n=66); small cells neuroendocrine carcinoma, 11,9% (n=29) carcinoid tumor, 8,6% (n=21); linfomas/sarcomas, 2,4% (n=6); large cell neuroendocrine carcinoma, 0,4% (n=1); adenosquamous carcinoma, 0,4% (n=1). 5,7% of the tumors (n=14) remained as non-small poorly differentiated cell carcinoma and 0,8% of cases (n=2) remained as indifferentiated malignant tumor. The IHC was able to histogenetically define 93,1% (n=94) of the cases analysed by this technique and 6,9% (n=7) could not be evaluated due the lack of tumoral material on the slides. The diagnosis change between the HE stain and the IHC analysis of the 101 cases showed a negative concordance of 71,3% and a positive concordance of 28,7%. The evaluation of all 244 cases comparing the first analysis in HE stain and the second one including HE + IHC disclosed a positive concordance of 72,5% and a negative one of 27,5%. We concluded that the IHC is a good auxiliary method for the LC diagnosis; the minimum set of antigenic markers used in this study was to precisely define the histogenesis of 93,1% of the cases evaluated by IHC; the precise e rigorous diagnosis of LC can not rule out the conventional HE satain exam in order to select the main diagnosis possibilities and than choose the antigenic markers to be used in the final diagnostic conclusion.

Nowadays, to diagnose a lung cancer, a bronchoscopy is performed and a biological sample is extracted and analyzed by the anatomical pathology department of the hospital. Currently, there are no commercially available techniques allowing a real-time, in vivo, label-free diagnosis of lung cancer. The PREDICTION project aims to develop a biosensing tool gathering all the attributes mentioned above by combining optics, biochemistry and mechanics. The role of my research is to focus on the mechanics and to develop an instrumented catheter, acting as a shield of the biosensor. The choice of the material and the design were made based on the optical properties (visible under fluoroscopy) and the mechanical characteristics (trade-off between rigidity and compliance). In order to provide a stable measurement, the distal extremity of the instrumented catheter was shaped in the form of a conical needle. A window was patterned on the side of the instrumented catheter to expose the biosensor to the targeted tissue. The instrumented catheter was designed to be able to embed one biosensor and one control fibre. Its measurement integrity has been validated through in vitro and ex vivo experiments. In order to improve navigation outside the scope of the working channel of the bronchoscope, i.e. add one degree of freedom to the catheter, Shape Memory Polymers were investigated. Two prototypes were designed. The first prototype combines a soft pneumatic actuator with a shape memory polymer strip acting as a stiffness tuner. The Shape Memory Polymer structure proved to be efficient to fix the shape of the soft pneumatic actuator and also to increase the force it can provide. The second prototype combines a catheter with a Shape Memory Polymer strip. The experimental results proved the ability of the Shape Memory Polymer strip to develop a force high enough to bend a catheter with an adequate bending angle for in vivo lung navigation. To conclude, the work produced during this PhD resulted in the development of an instrumented catheter allowing real time, ex vivo, label-free diagnosis of lung cancer. Further work should be done on the instrumented catheter dimensions and sterilization to apply these results to in vivo diagnosis. / Doctorat en Sciences de l'ingénieur et technologie / info:eu-repo/semantics/nonPublished

Introdução: O reconhecimento de problemas relacionados ao estado nutricional de pacientes com câncer de pulmão é escasso; estima-se, todavia, que em torno de 46,0% desses pacientes encontram-se desnutridos. Nos que são candidatos à cirurgia, é importante de se ter uma avaliação nutricional, pois além de definir o grau do problema, identifica potenciais riscos de complicações, possibilitando mais precocemente a instituição da terapia especializada. Objetivo: Avaliar o estado nutricional de pacientes submetidos à ressecção pulmonar por carcinoma não de pequenas células, relacionando-o com a ocorrência de complicações e/ou mortalidade pós-operatória, e verificar a concordância entre os métodos de avaliação utilizados. Métodos: Estudo retrospectivo de 180 pacientes adultos (27-87 anos), de ambos os sexos, que foram submetidos à ressecção pulmonar por carcinoma não de pequenas células no período de 2006 a 2014. Resultados: Havia 122 casos (67,8%) de adenocarcinomas, 38 (21,1%) de carcinomas escamosos, e 20 (11,1%) de formas indiferenciadas ou outras – 85,5% em estádios IA-IIB, e IIIA nos restantes 14,5%. DPOC foi à comorbidade mais vezes associada (em 26,1% dos casos). Os pacientes apresentaram-se com peso de 71,0±13,9 Kg, peso habitual de 71,3±13,9 Kg e altura de 1,64±0,08 m. Em 166 pacientes, o Índice de Massa Corporal (IMC) encontrado foi de 26,3 ± 4,4 Kg/m2 – 79 (47,6%) deles classificados como eutróficos, 74 (44,6%) com excesso de peso, pré-obesidade ou obesidade, e13 (7,8%) com magreza. Em 157 pacientes, a Avaliação Subjetiva Global (ASG) classificou 153 (97,5%) como bem nutridos (ASG: A), 4 (2,5%) como moderadamente desnutridos ou com suspeita de serem desnutridos (ASG: B), e nenhum deles como gravemente desnutrido (ASG: C). Mostrou-se baixa a concordância entre os métodos de avaliação IMC e ASG. Ocorreram 64 casos (35,5%) de complicações no pós-operatório de 30 dias, especialmente infecção respiratória, pneumotórax e fibrilação atrial, e 4 pacientes (2,2%) foram ao óbito, 2 com obesidade. O tempo de internação foi de 7 (5,5-12,5) dias, e foi significativamente maior nos pacientes com história de perda de peso (p=0,042). O índice de Charlson foi de 5,0 ±1,5%, com a estimativa de óbito em 10 anos de 27,6% (1,2-56,4), maior para os obesos. Conclusões: Os pacientes apresentaram-se em adequado estado nutricional, tanto pelo IMC quanto pela ASG, mas a concordância entre os métodos IMC e ASG foi baixa. Não houve significância entre a associação do estado nutricional pelo IMC e ASG com complicações ou óbito após cirurgia. Os pacientes com história de perda de peso tiveram tempo de internação significativamente mais elevado, e os obesos uma maior estimativa de óbito em 10 anos. / Introduction: Recognition of problems related to nutritional status of patients with lung cancer is scarce, and it is estimated that 46.0% of these patients are malnourished. In the preoperative period, the nutritional assessment is important, as it defines the degree of malnutrition, may identify individuals able to develop risk of complications, and provides early the specialized nutritional therapy. Objective: To relate the nutritional status of patients undergoing pulmonary resection for non-small cell carcinoma with occurrence of complications and/or postoperative mortality, assess the nutritional status of patients undergoing pulmonary resection for non-small cell carcinoma and evaluate the concordance between nutritional assessment methods BMI and SGA. Methods: Retrospective study, by reviewing medical records of 180 adult patients of both sexes who underwent pulmonary resection for non-small cell lung carcinoma from 2006 to 2014. Results: 122 (67.8%) were cases of adenocarcinoma, 38 (21.1%) of squamous cell carcinoma, 20 (11.1%) of undifferentiated or other – 85.5% in IA-IIB staging, and 14.5% another. COPD was the morbidity more times registered (26.1%). The patients had weight 71.0±13.9 Kg, usual weight 71.3±13.9 Kg, and height 1.64±0.08 m. The BMI value of 166 patients was 26.3±4.4 Kg/m2, with a predominance of eutrophic individuals (79 – 47.6%), followed by either, preobesity, overweight or obesity (74 – 44.6%), and thinness (13 – 7.8%). By SGA of 157 patients, (97.5%) were classified as well-nourished (SGA: A), 4 (2.5%) moderately or suspected of being malnourished (SGA: B), and no patient was classified as severely malnourished (SGA: C). No significant association was observed between nutritional status evaluated by Mass Index (BMI) and Subjective Global Assessment (SGA) with clinical outcomes. Immediate postoperative complications occurred in 64 cases (35,5%), mainly respiratory infection, pneumothorax and atrial fibrillation, and 4 patients (2.2%) dead, two with obesity. The hospitalization time was 7 (5.5-12.5) days, longer for those with weight loss history (p=0.042). The Charlson Index was 5.0 ± 1.5%, with the estimation of death in 10 years of 27.6% (12-56.4), largest for obese ones. Conclusions: Patients undergoing pulmonary resection had adequate nutritional status, verified either by BMI or SGA. There was a poor correlation between anthropometric methods of evaluation, BMI and SGA. Patients with weight loss history had significantly higher hospitalization time, and the obese a greater estimate of death in 10 years.

Introdução: O câncer é considerado, atualmente, um problema de saúde pública mundial. Estudos epidemiológicos fornecem inúmeras evidências que a prática de diferentes tipos de exercício físico promove reduções consideráveis nas taxas de mortalidade dos indivíduos com câncer. Entretanto, no câncer de pulmão as evidências são inconclusivas sobre os efeitos do treinamento no tratamento e na reabilitação. Objetivo: analisar, através de uma revisão sistemática, os efeitos de um programa de treinamento físico em pacientes com câncer de pulmão. Métodos: foram incluídos apenas ensaios clínicos randomizados que avaliaram os efeitos de um programa de treinamento físico em pacientes com câncer de pulmão. Critérios de inclusão: indivíduos com câncer de pulmão, protocolos de treinamento físico (aeróbio e anaeróbio), parâmetros pulmonares (capacidade vital, pressão inspiratória e expiratória máximas), parâmetros de capacidade física (consumo máximo de oxigênio e teste de caminha de 6 minutos), questionário de avaliação de qualidade de vida e de sensação subjetiva de fadiga. Para a busca, utilizou-se os bancos de dados eletrônicos: PubMed, Embase, Lilacs e Cochrane Central, e as palavraschave “lung neoplasm” e “exercise” e seus correspondentes. Foram designados dois avaliadores independentes para análise dos artigos. A qualidade metodológica dos estudos foi avaliada pela Escala PEDro. Resultados e Discussão: a busca identificou 316 artigos e após exclusão automática dos artigos em duplicata, restaram 40 estudos para primeira análise. Foram excluídos mais 22 artigos, por não se enquadraram nos critérios de seleção. Restaram, portanto, 18 artigos elegíveis para leitura na íntegra. Ao final, foram incluídos nesse trabalho 8 artigos que preenchiam totalmente os critérios avaliados. Reunindo os resultados encontrados nesse trabalho, não podemos concluir o melhor protocolo de treinamento para a prevenção e tratamento de pacientes portadores de câncer de pulmão, pois os estudos são escassos, de baixa qualidade, as metodologias e os desfechos analisados são muito diferentes e os resultados são contraditórios. / Introduction: Cancer is currently considered a global health matter. Numerous epidemiological studies provide evidence that different types of exercise promotes significant reductions in mortality rates of individuals with cancer. However, in lung cancer the evidence about the effects of training in treatment and rehabilitation of cancer is inconclusive. Objective: To analyze, through a systematic review, the effects of a physical training program in patients with lung cancer. Methods: Only randomized clinical trials that assessed the effects of a physical training program in patients with lung cancer were included. Inclusion criteria: patients with lung cancer, physical training (aerobic and anaerobic) protocols, pulmonary parameters (maximum vital capacity, inspiratory and expiratory pressures), parameters of physical capacity (maximal oxygen uptake and 6-minute walk test) questionnaire for assessing quality of life and subjective feeling of fatigue. For the search, we used the electronic databases: PubMed, Embase, Lilacs and Cochrane Central, and the keywords "lung neoplasm" and "exercise" and their corresponding terms. Two independent evaluators were assigned to analysis of articles. The methodological quality of studies was assessed by the PEDro scale. Results and Discussion: The search identified 316 articles and after automatic exclusion of duplicate articles, 40 studies remained for initial examination. 22 more articles were excluded because they did not fit the selection criteria. Therefore remaining 18 eligible articles to a full read. At the end, were included in this study eight articles that fully met the all the criteria. Bringing together the results found in this work, we can not conclude what was the best training protocol for the prevention and treatment of patients with lung cancer, as studies are scarce, low quality, methodologies and outcome measures are very different and the results are contradictory.