A Leucemia Linfóide Aguda (LLA) é uma doença heterogênea em relação à biologia e ao prognóstico. Além de alterações genéticas, anormalidades epigenéticas, estão estreitamente relacionadas ao processo de carcinogênese e entre os mecanismos epigenéticos, a acetilação das histonas é um componente essencial para a regulação da estrutura da cromatina e atividade transcricional. Esse processo é mediado pelas histonas acetiltransferases (HATs). Por outro lado, a desacetilação, por meio das histonas desacetilases (HDACs), está relacionada à condensação da cromatina e repressão transcricional. A expressão anormal das HDACs tem sido associada ao processo de leucemogênese, revelando ser uma área promissora na caracterização de grupos de risco e tratamento do câncer. Os objetivos deste trabalho foram avaliar a expressão dos genes da classe I de HDACs (HDAC 1, 2, 3 e 8), correlacionar os resultados com as características clínicas e de prognóstico (idade, gênero, grupo de risco, contagem inicial de blastos, imunofenótipo, resposta ao tratamento, doença residual mínima nos dias 14 e 18 e a sobrevida livre de eventos) em 46 amostras consecutivas de medula óssea de crianças e adolescentes portadores de LLA; comparar e correlacionar a expressão dos genes estudados entre as amostras de pacientes portadores LLA e 10 amostras de medula óssea sem doença hematológica. A análise da expressão gênica foi realizada através da técnica de PCR em Tempo Real pelo método TaqMan®. Foi observado um aumento da expressão do gene HDAC1 nas amostras dos pacientes bons respondedores ao ix tratamento. O gene HDAC2 foi mais expresso no grupo de pacientes do gênero masculino (p=0,038). Esse gene também mostrou uma expressão aumentada nos pacientes de alto risco (p=0,060) e com sobrevida menor (p=0,065), entretanto os valores encontrados não foram estatisticamente significativos. Além disso, foi observada uma expressão aumentada dos genes HDAC2 (p=0,007), HDAC3 (p=0,014) e HDAC8 (p=0,002) em amostras de pacientes com LLA quando comparadas às amostras de medula óssea sem doença hematológica. Houve correlação entre a expressão de todos os genes de classe I das HDACs, exceto entre HDAC1 e HDAC8. Os resultados obtidos nesse trabalho sugerem que as HDACs de classe I, podem representar importantes alvos para futuros estudos em LLA, no entanto são necessários de testes funcionais para confirmar estes resultados. / Acute Lymphoblastic Leukemia (ALL) is a heterogeneous disease with distinct biologic and prognostic groups. In addition to genetic alterations, epigenetic processes play an important role in carcinogenesis, among which histone acetylation/deacetylation is crucial for chromatin modulation structure and transcriptional activity. Histone acetylation is regulated by the enzyme histone acetyl transferases (HATs). On the other hand, the deacetylation process is regulated by histone deacetylases (HDACs) enzymes, which is associated with the chromatin condensation and transcriptional repression. Abnormal expression of HDACs is a common feature of cancer and has revealed a promising field to stratify cancer treatment and risk classification. The investigation of these expression profiles may represent an important clinical factor for diagnosis and management of hematological malignances. The objectives of the present study were to analyze the expression profile of the class 1 HDACs (HDAC1, 2, 3 and 8) genes in bone marrow samples obtained from 46 childhood ALL samples, to correlate the results with prognostic and clinical features (age, gender, risk group, immunophenotype, treatment response, minimal residual disease and event free survival) of the patients; to evaluated differences in gene expression between ALL samples and 10 bone marrow samples without hematological disease and to verify the correlation of these genes. The gene expression analysis were made using xi TaqMan real-time polymerase chain reaction. A higher expression of HDAC1 in patients with better treatment response was observed. The HDAC2 showed a higher expression in male gender (p=0,038). HDAC2 also showed a higher expression for higher risk (p=0,060) and lower survival patients (p=0,065), however the statistical analysis did not show significant results. Furthermore, there was a higher expression of HDAC2 (p=0,007), HDAC3 (p=0,014) and HDAC8 (p=0,002) in ALL samples when compared to healthy donors. Class I HDACs showed correlation in gene expression, except for HDAC1 and HDAC8. These results suggest that class I HDACs can represent important targets for ALL research; however, it is necessary to perform functional investigation to confirm these results.

A leucemia linfóide aguda (LLA) é a neoplasia hematológica mais comum na infância e representa uma doença heterogênea em relação à biologia e ao prognóstico e seu tratamento consiste principalmente em quimioterapia. Apesar dos avanços no tratamento, cerca de 20% dos pacientes apresentam recaída da doença e/ou óbito indicando a necessidade de terapias diferenciadas para esse grupo. Recentemente, drogas epigenéticas como inibidores de DNA metiltransferases (iDNMTs) tem mostrado efeitos anti-neoplásicos promissores para o tratamento de diversos tipos de neoplasias incluindo a LLA. Nos tumores, a hipermetilação gênica é encontrada em vários genes, incluindo genes de reparo do DNA, reguladores do ciclo celular e apoptose. Sendo assim, drogas desmetilantes estão sendo apontadas como promissores agentes para o tratamento do câncer. A Zebularina (ZB) é um iDNMT análogo de citidina que inibe a metilação do DNA. Esta droga tem mostrado resultados animadores para o tratamento de diversas neoplasias, incluindo glioblastoma, leucemia mielóide aguda, câncer de mama, próstata e outros. O objetivo deste trabalho foi avaliar os efeitos do tratamento com a ZB, associada ou não à quimioterápicos, em linhagens celulares pediátricas de LLA, por meio de ensaios funcionais como proliferação celular, capacidade clonogênica, apoptose e ciclo celular. Além disso, foi analisada a capacidade desmetilante da droga e a expressão dos genes DNMT1, DNMT3a e DNMT3b após o tratamento com a ZB. A ZB inibiu a proliferação celular de maneira dose e tempo-dependente e agiu sinergicamente quando combinada com o MTX em ambas as linhagens. Ela também diminuiu a capacidade clonogênica e aumentou a taxa de apoptose nas duas linhagens estudadas. Além disso, o tratamento com ZB causou uma parada na fase S do ciclo celular na linhagem ReH. A ZB foi capaz de desmetilar parcialmente o gene AhR e reduzir a expressão dos genes DNMT1, DNMT3a e DNMT3b. Todos os dados encontrados no presente trabalho sugerem que as drogas desmetilantes podem ser interessantes agentes para o tratamento da LLA pediátrica. / Acute lymphoblastic leukemia (ALL) is the most common hematologic malignancy in childhood and represents a heterogeneous disease regarding its biology and prognosis. Its treatment consists mainly of chemotherapy. Despite advances in treatment, about 20% of patients experience disease recurrence and/or death indicating the need for differentiated therapies for this group. Recently, epigenetic drugs such as DNA methyltransferases inhibitors (iDNMTs) has shown antineoplastic and promising results for several types of tumors including ALL. Gene hypermethylation is found in several genes in tumors cells, including genes responsible for DNA repair, cell cycle and apoptosis regulators. Therefore, demethylating agents may be promising agents for cancer treatment. Zebularine (ZB) an iDNMT is a cytidine analogue that inhibits DNA methylation. This drug has shown promising results for the treatment of many cancers, including glioblastoma, acute myeloid leukemia, breast and prostate cancer and others. The aim of this study was to evaluate the effects of ZB treatment, associated or not with chemotherapeutic agents, in childhood ALL cell lines through functional tests such as cell proliferation, clonogenic capacity, apoptosis and cell cycle. In addition, we examined the demethylating ability of ZB and the expression of DNMT1, DNMT3a and DNMT3b genes after treatment with this agent. ZB inhibited cell proliferation in a dose- and time-dependent manner and showed synergistic effects when combined with MTX in both cell lines. ZB treatment also reduced clonogenic capacity and increased the number of apoptotic cells in both cell lines studied. Furthermore, treatment with ZB caused an S phase cell cycle arrest in ReH cell line. ZB was able to partially demethylate AhR gene and reduce the expression of genes DNMT1, DNMT3a and DNMT3b. These results suggest that demethylating drugs may be interesting agents for the treatment of childhood ALL.

Orientadores: José Andrés Yunes, Ana Carolina de Mattos Zeri / Tese (doutorado) - Universidade Estadual de Campinas, Instituo de Biologis / Made available in DSpace on 2018-08-19T21:00:30Z (GMT). No. of bitstreams: 1 Melo_CarolinaPereiradeSouza_D.pdf: 3404055 bytes, checksum: 57f3eb2b6199d017aab0f03512317367 (MD5) Previous issue date: 2012 / Resumo: O uso intensivo e combinado de diferentes quimioterápicos tem permitido a cura de 70-80% das leucemias linfóides agudas (LLA) da infância. A intensidade e o uso das drogas são adaptados ao risco de recaída dos pacientes, aferido ao diagnóstico e nas primeiras semanas do tratamento. Embora existam diferenças, os principais critérios utilizados na estratificação dos pacientes nos grupos de risco são idade, contagem leucocitária, imunofenotipagem e a resposta inicial ao tratamento, mensurada pela citoredução na medula óssea e/ou sangue periférico. Este último, tem se mostrado um fator prognóstico poderoso, independente, que permite identificar pacientes com maior ou menor risco de recaída. Ao mensurar a citoredução, faz-se, indiretamente, uma avaliação in loco, da sensibilidade intrínseca da leucemia à quimioterapia. A proposta deste trabalho foi a implementação do uso da metodologia de Ressonância Magnética Nuclear (RMN) para futura identificação de pacientes de LLA com resistência aos quimioterápicos usados na fase de indução. A implementação do método de RMN foi feito com células (linhagens celulares e células primárias de LLA) em cultura com doses de dois quimioterápicos: Prednisolona (PRED) e L-asparaginase (ASNase). O perfil dos metabólitos presentes no meio de cultura das células tratadas com as drogas foi obtido por meio da análise de espectros de RMN, e buscou-se associá-lo à resistência das células aos quimioterápicos. Os biomarcadores identificados neste trabalho permitiram distinguir tanto as linhagens sensíveis das resistentes quanto pacientes que recaíram dos que entraram em remissão, utilizando a técnica da metabolômica. Além disso, a análise do perfil metabólico permitiu formular algumas hipóteses sobre as vias metabólicas implicadas na resistência às drogas. Experimentos complementares com um maior número de pacientes se fazem necessários. Porém, nossos resultados indicam que este método poderá ser futuramente usado para análise de células de pacientes em tratamento, subsidiando, com maior precisão do que os métodos atuais, a alocação dos pacientes nos grupos de risco / Abstract: Intensive and combined use of different chemotherapic drugs has improved the cure rate of childhood Acute Lymphoblastic Leukemia (ALL) to 70-80%. Drugs use and intensity are determined based on patient relapse risk, which is measured at diagnosis and during the first weeks of treatment. Although differences may exist, the main criteria used to stratify patients in risk groups are age, leukocyte count, immunophenotyping and initial response to treatment, measured by cytoreduction in bone marrow and / or peripheral blood. The latter has proved to be a powerful independent prognostic factor, which allows identification of patients at higher or lower risk of relapse. By measuring cytoreduction, an in situ evaluation of the leukemia intrinsic sensitivity to chemotherapy is done indirectly. The aim of this study was to implement the use of Nuclear Magnetic Resonance (NMR) methodology for future identification of ALL patients resistance to chemotherapeutic agents used in the induction phase. NMR method implementation was done with cells (cell lines and primary ALL cells) kept in culture with two chemotherapic drugs: prednisolone (PRED) and L-asparaginase (ASNase). NMR spectra analysis provided information about the metabolic profile of drug treated cells culture medium, which was associated with the cells resistance to chemotherapic drugs. The biomarkers identified in this study allowed distinguishing, not only between the resistant and sensitive strains, but also between relapsed patients and those ones who remained in remission, using the metabolomics technique. Furthermore, analysis of the metabolic profile allowed the formulation of some hypotheses about the metabolic pathways involved in drug resistance. Further experiments with larger numbers of patients are needed. However, our results indicate that this method can be used for future analysis of patients treated cells, supporting, with greater precision than current methods, the allocation of patients into risk groups / Doutorado / Genetica Animal e Evolução / Doutor em Genetica e Biologia Molecular

THE INFLUENCE OF MOTIVATIONAL ELEMENTS IN PAEDIATRIC PHYSIOTHERAPY FOCUSED ON THE PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA - PILOT STUDY Abstract The efficacy of acute lymphoblastic leukemia (ALL) treatment in childhood is still increasing and the quality of life of these children is starting to be the focus of interest. The physiotherapy affects in preventive and reactive way the late effects of treatment which may reduce the quality of life. An insufficient motivation of children can be a reason of a reduced adherence to a physiotherapeutic intervention. The goal of this study was to ascertain the influence of the motivational elements in the paediatric physiotherapy in the improvement of motor functions, the quality of life, the motivation to the exercise and the frequency of exercise. There were 9 patients diagnosed with ALL in the maintenance phase of treatment (average age 7,3 years, age range 5,2 - 10,1, 5 girls and 4 boys). All probands underwent a 6- weeks-excercise programme that contains the exercise from the DNS method, yoga for children and stretching. The assessment was performed by Bruninks-Oseretsky Test (BOT2), 6 minute walking test (6MWT), goniometric measurement of ankle joint dorsiflexion, Pediatric Quality of Life Inventory (PedsQL), Intrinsic Motivation Inventory (IMI) and the...

Glucocorticoids have long been used in the treatment of acute lymphoblastic leukaemia due to their ability to cause cell cycle arrest and apoptosis of lymphoid cells. However, some patients do not respond to glucocorticoid treatment and the majority, who initially respond, may relapse upon prolonged hormone treatment. The inefficiency of the treatment is mainly attributed to the gradual loss of the cellular sensitivity to glucocorticoid-induced apoptosis. Therefore, the need to understand the molecular mechanisms of resistance/ sensitivity of acute lymphoblastic leukaemia cells to glucocorticoid-induced apoptosis is of vital importance, as this will help to develop better prognostic outcomes and improve glucocorticoids therapy. Several mechanisms have been proposed to explain the evasion of glucocorticoid mediated apoptosis in resistant cells. These include post-translational modifications of GR especially phosphorylation which modulates the GR transcriptional activity, and GR mediated signalling thereby affecting gene expression and hence the balance between pro- and anti-apoptotic Bcl-2 family members. In addition the concentration of components of the energy metabolism pathways (i.e. oxidative phosphorylation and glycolysis) and ROS generation are altered in the acute lymphoblastic leukaemia cells. The hypothesis that differentially phosphorylated GR in the resistant versus sensitive ALL cells modulate GR transcriptional activity and target selectively resulting in diverse pro- or anti-apoptotic Bcl-2 family members' gene expression in the two cell lines was tested. Furthermore, in a similar manner, the possibility that differential GR phosphorylation diversely affected gene expression of GR transcriptional target genes that are components of cellular energy production pathways in resistant versus sensitive cells, altering energy and ROS production levels in distinct ways in the two cell lines was explored. GR was found to be predominantly phosphorylated at S211 in the glucocorticoid-sensitive CEM C7-14, and at S226 in the glucocorticoid-resistant CEM C1-15 cells. Differential GR phosphorylation is presumably an indication of dominant p38 MAPK activity in CEM C7-14 and JNK kinase activity in CEM C1-15, which could lead to adverse gene expression of some pro- and anti-apoptotic Bcl-2 family members and particularly Mcl-1, in the two cell lines. Furthermore, differential GR phosphorylation at S211 and S226 in CEM C7-14 and CEM C1-15 affected the gene expression of the Cytochrome C Oxidase assembly factors Surf-1 and SCO2 as well as the nuclear encoded Cytochrome C Oxidase subunit COX-Va and the mitochondrial encoded COX-I, COX-II and COX-III. This effect was more pronounced in the glucocorticoid-sensitive CEM C7-14 cells, probably due to the fact that GR was predominantly phosphorylated at S211 and hence transcriptionally active in these cells. Moreover, in comparison to the resistant CEM C1-15 cells, the CEM C7-14 cells exhibited higher levels of ROS, increased number of active mitochondria and up-regulated glycolysis upon inhibition of oxidative phosphorylation. Glucocorticoids further reduced ROS levels in the CEM C1-15 cells, and increased the NADH/ NAD+ ratio. In conclusion results presented in this thesis provide evidence that differential GR phosphorylation in resistant versus sensitive to glucocorticoid induced apoptosis cells plays essential role in the regulation of programmed cell death and energy metabolism pathways, offering a potential explanation for the molecular events that determine resistance/sensitivity to glucocorticoid-induced apoptosis in ALL cells.

Oncolytic viruses (OVs) are novel biological agents that selectively infect and kill malignant cells. OVs can also generate anti-cancer immunity. Our lab exploited this phenomenon and developed an in vitro vaccine with infected leukemia cells with oncolytic virus vaccine – and named immunotherapy by leukemia-oncolytic virus (iLOV) – that provided in vivo protection in a murine model for acute lymphoblastic leukemia. This work further characterizes iLOV biology and the interaction of its immune responses. An in vitro immune response assay was optimized to detect and quantify the in vivo anti-leukemia immunity generated by iLOV. Anti-viral immunity is an obstacle for OV therapy. Although iLOV created anti-viral antibodies towards itself, these neutralizing antibodies did not hinder the vaccine’s ability to initiate complement or dendritic cell activation. We envision personalized versions of iLOV for leukemia patients in remission to prevent the possibility of relapse. This work highlights new advantages for infected cell vaccines and supports the progress of iLOV toward clinical testing.

<p>It has been long known that many types of cancers have high metabolic requirements and use reprogrammed metabolism to support cellular activities. The first identified metabolic alteration in cancer cells was elevated glucose uptake, glycolysis activity and lactate production even in the presence of oxygen. This metabolic program, termed aerobic glycolysis or the Warburg effect, provides cells with energy as well as biosynthetic substrates to sustain cell survival and rapid cell proliferation. Cancer metabolism is closely linked to genetic mutations and oncogenic signaling pathways, such as PI3K/Akt, cMyc and HIF pathways. These oncogenic signals can direct metabolic reprogramming while changes in metabolic status can regulate activities of these signaling pathways in turn. In addition to glucose, later studies also found utilization of alternate nutrients in cancer cells, including glutamine and lipids. Glutamine is the second major metabolic fuel and can be converted to various substrates to support cell bioenergetics needs and biosynthetic reactions. Usage of metabolic fuels in cancer cells, however, is variable. While certain cancers display addiction to one type of nutrient, others are capable of using multiple nutrients. </p><p>The unique metabolic features of cancer cells raise the possibility of targeting metabolism as a novel therapeutic approach for cancer treatment. Using pharmacological inhibitors, previous research has provided corroborating evidence that metabolic stress can impact survival and growth of proliferative cancer cells by regulating cell apoptotic machinery and cell cycle checkpoints. Due to lack of genetic tools and side effects from these inhibitors, however, mechanistic understanding of cell response to metabolic inhibition was limited in these studies. More importantly, how metabolic stress affects cancer progression in a physiological condition has not yet been well investigated. Lastly, current research has not examined metabolic program in indolent cancers and the metabolic requirements and activities in less proliferative cells also remain to be understood.</p><p>This work examines nutrients utilization in B cell derived acute and chronic leukemia (B-ALL and B-CLL). B-ALL is an aggressive form of leukemia. Using cell lines and primary patient samples, we found B-ALL cells primarily used glucose through aerobic glycolysis, similar to other proliferative cancer cells. B-ALL cells were also more sensitive to inhibition of glycolysis than normal B cells. Employing an untargeted metabolomics profiling in combination with isotope labeled glucose tracing approach, we show in a B-ALL model that genetic ablation of glucose transporter Glut1 partially reduced glucose uptake, sufficiently hindered anabolic pathways and promoted catabolic metabolism. This metabolic shift led to sharply curtailed B-ALL proliferation in vitro and reduced leukemic burden in vivo. Furthermore, this partial inhibition of glucose metabolism sensitized B-ALL cells to apoptotic stimuli and non-cytotoxic metabolic inhibition significantly enhanced efficacy of a tyrosine kinase inhibitor to eliminate B-ALL cells in vitro and in vivo. Thus, partial inhibition of glucose metabolism can provide a plausible adjuvant therapy to treat cancers that depend on glycolysis for survival and proliferation. </p><p>In contrast to B-ALL, B-CLL is an indolent form of cancer. Most B-CLL cells exhibited low glucose metabolic activities that were comparable with normal B cells at resting stage. Similar to chronically stimulated and anergic B cells, these B-CLL cells also failed to upregulate glucose metabolism in response to IgM stimulation. We also observed an altered amino acid and acyl-carnitine profile and increased glutaminase mRNA in B-CLL relative to normal B cells, suggesting the capability of using alternate nutrients such as glutamine in these cells. Finally, we explored the possibility of suppressing mitochondria metabolism to induce B-CLL cell death through inhibition of the nuclear hormone receptor and metabolic regulator ERRalpha. ERRalpha is known to regulate mitochondrial metabolism and was expressed higher in B-CLL than normal B cells. ERRalpha inhibition decreased viability of oncogene transformed pro-B cells, suggesting ERRalpha as a potential target for B-CLL treatment.</p><p> Collectively, this work investigates metabolic phenotype in two forms of leukemia derived from B cells. It reveals different metabolic requirements and activities in aggressive and indolent leukemia and explores different approaches to suppress metabolism in these cancers. Findings of this work shed light on how to potentially design metabolic approach to improve cancer treatment.</p> / Dissertation

RUNX1, a transcription factor required for hematopoiesis and lymphocyte differentiation, is one of the most commonly targeted genes in hematopoietic malignancies. Mutations in the RUNX1 gene are associated with a poor prognosis in a subset of T cell acute lymphoblastic leukemia (T-ALL) and RUNX1 has been proposed as a tumor suppressor in TLX1/3-transformed human T-ALL. Recent ChIP-seq studies in human T-ALL cell lines demonstrated that a large portion of TAL1- and NOTCH1- bound regions contain RUNX binding sites in promoter or enhancer regions, suggesting oncogenic roles for RUNX1 in T-ALL. To interrogate RUNX1 functions in leukemogenesis, we depleted RUNX1 in a T-ALL mouse model and in human T-ALL cell lines. We found that RUNX1 is required for the maintenance of mouse T-ALL growth in vivo and the survival of human T-ALL cell lines in vitro. In addition, inhibition of the RUNX1 activity with a small molecule inhibitor impairs the growth of human T-ALL cell lines and primary patient samples. RUNX1 depletion reduces the expression of a subset of TAL1- and NOTCH1- regulated genes including the MYB and MYC oncogenes, respectively. We demonstrate that RUNX1 regulates transcription factor binding and acetylation of H3K27 at the Myb and Myc enhancer loci. These studies provide genetic and pharmacological evidences that RUNX1 supports T-ALL cell survival and suggest RUNX1 inhibitor as a therapeutic strategy in T-ALL treatment.

Bakgrund: Varje år insjuknar 300 000 barn i cancer och akut lymfatisk leukemi (ALL) är den vanligaste cancersjukdomen hos barn. Sjukdomen innebär intensiva behandlingar som kommer påverka barnet men även barnets föräldrar. Kvalitén på vårdandet påverkar föräldrarnas upplevelse av vården och detta innebär att sjuksköterskor har ett stort ansvar att vårda utifrån ett livsvärldsperspektiv. Syfte: Syftet med denna studie var att belysa föräldrars upplevelser när deras barn insjuknat i akut lymfatisk leukemi. Metod: Metoden som används var en litteraturöversikt, nio kvalitativa artiklar och en kvantitativ artikel analyserades för att bidra till evidensbaserad kunskap. Resultat: Utifrån analysen framkom fyra kategorier; När sjukdomen blir ett faktum, Tillvägagångssätt för att hjälpa sitt barn, Faktorer som påverkar hanteringen av behandling samt Relationer och kommunikationens betydelse med tillhörande underkategorier. Konklusion: Föräldrar upplever starka känslor i samband med att barnet får diagnosen. Sjukdomen medför förändringar i det som tidigare ansågs som en normal vardag. Information och kunskap från vårdpersonal är betydelsefullt för föräldrarna då det kan underlätta föräldrars förståelse för sjukdomen. Genom att belysa föräldrarnas upplevelse när deras barn drabbats av ALL kan bredare förståelse för hur grundutbildade sjuksköterskor kan bemöta dessa föräldrar. / Background: Every year, 300 000 children develop cancer where Acute Lymphoblastic Leukemia (ALL) is the most common form of childhood cancer. The disease involves intensive treatment which will not only affect the child but also the parents. The quality of care affects parents’ experience of Health Care, this means that nurses have responsibility to care from a life-world-perspective. By paying attention to how illness, suffering and health are experienced and affect parents, the quality of care can be ensured. Aim: The aim of this study is to highlight parents’ experiences when their child has developed ALL. Method: The method is a literature review, ten scientific articles were selected and formed the basis of the study. Results: Based on the analysis, four categories emerged; When the disease becomes reality, Approaches to help their child, Factors affecting the management of treatment and The importance of relationships and communication with associated subcategories. Conclusion: Parents experience strong emotions related to their child’s diagnosis. The disease will lead to changes in what was previously considered a normal everyday life. Information and knowledge from healthcare providers is important as it can strengthen parents’ management of the disease. By highlighting the parents’ experience when their child has developed ALL, a broader understanding of how registered nurses encounter these meetings.

Acute lymphoblastic leukaemia (ALL) is the most frequent childhood malignancy. One of the recent improvements in ALL treatment was the introduction of minimal residual disease (MRD) monitoring that enables risk stratification based treatment adaptation. The same MRD monitoring helps to choose relapse treatment, to guide indication for stem cell transplantation (SCT) and allows for a more personalized management of patients undergoing SCT. One of the main routes of MRD levels detection is characterisation of leukemic blasts using flow cytometry. However, flow cytometry is limited by its mainly manual expertise-based analysis. Such analysis is subjective and clearly insufficient for current complex data. While new computational tools are available for multidimensional flow cytometry data, there is an urgent need to test and adapt them for the use in clinical environment. The goal of this thesis is to detect immunophenotypes associated with leukaemia and their development by leveraging machine-assisted analysis of a set of diagnostic files selected based on information about more than three hundred thousand of multiparameter flow cytometry datasets. Advanced bioinformatic tools will help to detect blast and healthy haematopoietic populations, to derive their immunophenotypes and to identify individual...