A grande aplicação dos radiofármacos está em medicina nuclear diagnóstica representando 95% dos procedimentos realizados, porém, nos últimos anos, tem crescido consideravelmente a sua aplicação em procedimentos terapêuticos. Os radionuclídeos que emitem particulas ionizantes (α, β e elétrons Auger) são indicados para tratamento de tumores. Tumores malignos são responsáveis por aproximadamente 12% dos óbitos e representam a terceira causa de mortalidade no Brasil. O 188Re é um dos mais atrativos radioisótopos para uma variedade de aplicações terapêuticas em medicina nuclear, oncologia e intervenções cardiológicas, é totalmente favorável e conveniente pelo fato de que ele é livre de carregador e pode ser obtido de forma econômica na forma de um gerador de 188W/188Re, além de possuir uma meia-vida fisica de 16,9 horas e 100% de emissão de radiação β-. A partir da década de 2000 vêm sendo realizadas diversas investigações envolvendo marcações de moléculas com 188Re. Os tumores metastáticos são a forma mais comum de malignidade esquelética. Em casos metastáticos os principais objetivos do tratamento são a prevenção de fraturas patológicas e promover a sobrevida com o máximo de preservação de função permitindo que o paciente mantenha o máximo possível de mobilidade e controle da dor. O objetivo deste trabalho foi realizar a comparação das marcações de diversos fosfonatos (Metileno disfofonato de Sódio MDP, Ácido Etilenodiaminotetrametilenofosfônico EDTMP, e do diclorometilenobifosfonato de sódio - Clodronato) com 188Re para terapia de metastáses ósseas. Fosfonatos são inibidores da reabsorção óssea osteoclástica e são efetivos neste tratamento. As marcações do MDP, EDTMP e Clodronato com 188Re foram otimizadas utilizando como agente redutor o cloreto estanoso (SnCl2 2H2O) e como agente estabilizante o ácido ascórbico. As variáveis estudadas foram massa do ligante, massa do SnCl2.2H2O, massa do ácido ascórbico, tempo, pH e temperatura da reação. Os resultados mostraram que se obteve um excelente rendimento de marcação de 98% para o 188Re-MDP, de 83% para o 188Re-EDTMP e 85% para o 188Re-Clodronato. / The wide application of radiopharmaceuticals in nuclear medicine, representing 95% of procedures performed is in diagnosis, but in recent years, its application in therapeutic procedures has grown considerably. The radionuclides that emit ionizing particles (α, β, and Auger electrons) are indicated for the treatment of tumors. Malignant tumors account for approximately 12% of deaths and represent the third cause of mortality in Brazil. 188Re is one of the most attractive radioisotopes for a variety of therapeutic applications in nuclear medicine, oncology and cardiology interventions, is fully favorable and convenient because it is carrier free and can be obtained inexpensively in the form of a generator of 188W/188Re, and has a physical half-life of 16.9 hours and 100% of β-radiation emission. From the 2000s several investigations have been conducted involving molecules labeled with 188Re. Metastatic tumors are the most common form of malignancy in the skeleton. In metastatic cases the main goals of treatment are the prevention of pathological fractures and the promotion of survival with maximum preservation of function allowing the patient to maintain the greatest possible mobility and pain control. The objective of this study was to compare the labeling of various phosphonates (Sodium methylene diphosphonate - MDP, Ethylenediaminetetramethylene phosphonic acid - EDTMP, and sodium dichloromethylenediphosphonate - clodronate) with 188Re for bone metastases therapy. Phosphonates are inhibitors of osteoclastic bone resorption and are effective in treatment. The labeling of MDP, EDTMP and Clodronate with 188Re was optimized using stannous chloride (SnCl2·2H2O) as reducing agent, and ascorbic acid as stabilizing agent. The variables studied were the ligand mass, SnCl2.2H2O mass, mass of ascorbic acid, time, pH and temperature of the reaction. The results showed an excellent labeling yield of 98% for 188Re-MDP, 83% for 188Re-EDTMP and 85% for 188Re-Clodronate.

Proposta: O objetivo do presente estudo foi a análise da associação entre a vascularização das metástases hepáticas, detectadas através de exames de ressonância magnética, e a progressão da doença em pacientes com câncer de mama. Casuística e Métodos: Partiu-se do rastreamento de pacientes com câncer de mama dentre todos os pacientes atendidos para exames de ressonância magnética, entre 1995 e 2002, no Hospital da Universidade da Carolina do Norte em Chapel Hill, USA. Foram identificadas 16 pacientes com câncer primário de mama e com metástases hepáticas, com 99 exames de ressonância magnética antes e após a terapia sistêmica. Comparando-se cada exame de ressonância magnética com o seu anterior, a doença das pacientes foi classificada em quatro diferentes status: Resposta Completa, Resposta Parcial, Doença Estável e Doença em Progressão. As metástases hepáticas foram caracterizadas como hipervasculares ou hipovasculares, de acordo com a intensidade do realce durante a fase arterial do exame de ressonância magnética. Estatisticamente, o teste exato de Fisher e o modelo de regressão logística ordinal foram usados para estimar o não ajustamento e o risco de ajustamento entre a presença de metástases hepáticas hipervasculares e a progressão da doença. Resultados: Todas as pacientes eram do sexo feminino, com uma média de idade de 51.5 anos. Na análise não ajustada, a associação entre a presença de hipervascularização nas metástases hepáticas e a progressão da doença foi, de um ponto de vista estatístico, altamente significativa (p< 0,0001). Na análise de regressão logística múltipla, a hipervascularidade de metástases hepáticas foi caracterizada como um fator preditivo independente de progressão da doença. Pacientes com lesões hepáticas hipervasculares apresentaram uma incidência 20,5 vezes maior de progressão da doença, comparadas com pacientes sem hipervascularidade (relação das probabilidades= 20,5; 95% de intervalo de confiança [5,1; 83,5], p < 0,0001). Conclusão: Os resultados de nossa análise mostram evidências de que a progressão da doença pode ser predita através da avaliação da vascularidade das metástases hepáticas pelo exame de ressonância magnética, em pacientes com metástases hepáticas de câncer de mama / Purpose: The aim of the present investigation was to evaluate the association of liver metastases vascularity, as characterized by MR imaging, and disease progression in breast cancer patients. Materials and Methods: Breast cancer patients undergoing liver MR from 1995 through 2002 were extracted from University of North Carolina at Chapel Hill\'s database. Sixteen patients with liver metastases were identified who had 99 MR imaging studies prior and after receiving systemic therapy. Based on comparison of MR imaging with the previous MR examination, disease status of patients were classified as Complete Response, Partial Response, Stable Disease, and Progressive Disease. Liver metastases were characterized as hypervascular or hypovascular based on the degree of enhancement in arterial, portal and interstitial phase after administration of contrast agent. Fisher\'s exact test and ordinal logistic regression models were used to estimate the unadjusted and risk adjusted association between the presence of hypervascular liver metastases and disease progression. Results: All patients were female, and had a median age of 51.5 years old. In unadjusted analyses the association between the presence of hypervascularity of liver metastases and disease progression was highly statistically significant (p < 0.0001). In multiple logistic regression analyses, hypervascularity of liver metastases was found to be an independent predictor of disease progression. Patients with hypervascular liver lesions were 20.5 times more likely to experience disease progression compared with patients without hypervascularity (odds ratio: 20.5; 95% confidence interval [5.1, 83.5], p<0.0001). Conclusion: Our analysis provides suggestive evidence that disease progression can be predicted through MR imaging assessment of the vascularity of liver metastases in breast cancer patients

The aim of this thesis is to investigate the role of inflammatory infiltrates and chemokines in metastasis of high-grade serous ovarian cancer, HGSC, to the omentum using human tissue biopsies and a 3- dimensional (3D) cell culture model. In ten patients with metastatic HGSC, omental tumour deposits contained a prominent leukocyte infiltrate of CD3+ T cells (9% of total cells) and CD68+ macrophages (11% of total cells). The presence of CD68+ macrophages showed a significant positive correlation with tumour cell proliferation analysed by Ki67 expression. Four ovarian cancer cell lines were co-cultured on a 3D model mimicking the microenvironment of the omentum for two weeks. The model was composed of collagen embedded human fibroblasts covered in a confluent layer of human primary mesothelial cells. The mesothelial cells in the 3D model significantly increased the growth (p = 0.002) and invasion (p = 0.0004) of the ovarian cancer cells. CXCL12 is the macrophage chemoattractant and ligand for the major chemokine receptor expressed on ovarian cancer cells. An association between CXCL12 and extracellular matrix remodelling was identified in two independent gene expression microarrays of ovarian cancer biopsies. The expression of CXCL12 in the HGSC omental metastases measured by quantitative Real Time-PCR positively correlated with decorin expression. Antibody mediated neutralisation of CXCL12 reduced growth (p = 0.012) and invasion (p = 0.029) in the 3D model. Mimicking an infiltrate of CD68+ macrophages in this multicellular 3D in vitro system also produced measurable changes in inflammatory cytokine and chemokine expression. There is currently a demand for more accurate models of HGSC and a necessity to study its metastasis that presents itself as the major clinical problem in patients. Therefore the development of this 3D model to mimic tumour-promoting inflammation in HGSC metastasis will provide researchers with an essential tool for testing novel therapeutic strategies.

Metástases para a região oral podem ocorrer nos tecidos moles ou nos ossos maxilares. Tumores metastáticos para a cavidade oral são raros, compreendendo aproximadamente 1% das neoplasias encontradas na região oral. Devido à sua raridade, o diagnóstico de uma lesão metastática na região oral é difícil; tanto para o clínico como para o patologista, ao reconhecer que uma lesão é metastática e na determinação do local de origem. Foram revisados 9 casos sendo 5 mulheres e 4 homens com idades entre 57 e 80 anos e realizada uma crítica revisão da literatura. No presente estudo não foi possível determinar a prevalência das metástases para os ossos maxilares ou para os tecidos moles da cavidade oral; Entretanto, nosso estudo mostra que o exame das estruturas orais é absolutamente fundamental no acompanhamento desses pacientes, pois a presença de possíveis massas metastáticas pode indicar uma neoplasia oculta ou mesmo a falha terapêutica. / Metastasis to the oral region may occur in the soft tissue or jaw bone. Metastatic tumors to the oral cavity are rare, comprising about 1% of neoplasms found in the oral region. Because of its rarity, the diagnosis of a metastatic lesion in the oral region is difficult; both for the clinician and for the pathologist to recognize that an injury is metastatic and determination of the place of origin. 9 cases with 5 women and 4 men aged between 57 and 80 years and performed a critical review of the literature were reviewed. In the present study could not determine the prevalence of metastasis to the jaw bones or the soft tissues of the oral cavity; However, our study shows that the examination of oral structures is absolutely essential to monitor these patients, because the presence of possible metastatic masses may indicate a hidden cancer or treatment failure.

Radiological imaging already has a key role in the detection and management of patients with metastatic colorectal cancer (mCRC). With the evolution of personalised medicine there is a need for non-invasive imaging biomarkers that can detect early tumour response to targeted therapies. Translation from bench to bedside requires a multicentre approach that follows an agreed development roadmap to ensure that the proposed biomarker is precise (reproducible/ repeatable) and accurate in its characterisation of a meaningful physiological, pathological or post treatment response. The following thesis (organized in the alternative format with experimental studies written as individual complete manuscripts) investigates methods to improve precision and accuracy of the Apparent Diffusion Coefficient (ADC), a proposed quantitative imaging biomarker with a potential role in characterisation of post treatment responses in mCRC. The first objective was to establish baseline multicentre reproducibility (n=20) for ADC. A change in ADC greater than 21.1% was required to determine a post treatment response. Using a statistical error model, the dominating factors that influenced reproducibility were motion artefact and tumour volume. In the second study these factors were addressed using a single centre cohort with pre and post treatment data. Correcting for errors due to motion and tumour volume improved sensitivity from 30.3% to 1.7%, so a post treatment response was detected in 6/12 tumours compared to 0/12 using the baseline approach. In the third study, motion correction was implemented and the statistical error model was applied successfully to a multicentre cohort of 15 patients (1.9% sensitivity). The results of this thesis highlights that with careful consideration and correction of factors that negatively influence sensitivity, ADC is a potential imaging biomarker for use in post treatment response for patients with mCRC.

Introdução: Atualmente a ressecção hepática é o melhor tratamento para metástases de câncer colorretal. Diversos fatores prognósticos foram estudados e muitos estudos têm demonstrado que metástases nos linfonodos hilares constituem um fator prognóstico adverso. Este estudo avaliou a frequência e as características do envolvimento linfonodal hilar microscópico, através de linfadenectomia sistemática, com pesquisa de micrometástases em pacientes submetidos à hepatectomia por metástases colorretais. Métodos: Os critérios de exclusão foram: irressecabilidade detectada no pré e intraoperatório, condições clínicas e fatores intraoperatórios que exigiam menor tempo cirúrgico, metástases linfonodais macroscópicas confirmadas por exame de congelação e menos de três linfonodos no produto da linfadenectomia. De 38 pacientes iniciais, 28 foram submetidos ressecção hepática em associação com linfadenectomia sistemática do hilo, apresentando três ou mais linfonodos dissecados. Os linfonodos negativos ao método convencional de hematoxilina e eosina foram avaliados através de cortes seriados com intervalos de 100 m associada à imunoistoquímica com anticorpos contra pancitoqueratinas humanas AE1/AE3. Resultados: Em média, 6,18 linfonodos foram dissecados por paciente. A linfadenectomia aumentou o tempo operatório em 48 minutos, no entanto, não houve morbimortalidade associada a este procedimento. Dois pacientes (7,2%) apresentaram metástase linfonodal microscópica ao exame convencional com hematoxilina e eosina. Quando aplicado os cortes seriados associados à imunoistoquímica, três pacientes adicionais (10,8%) foram identificados como portadores de micrometástases linfonodais. Conclusão: A frequência global de metástases microscópicas, incluindo micrometástases foi de 18%. Não houve correlação estatística entre outros fatores prognósticos e a presença de metástases microscópicas. A linfadenectomia sistemática associada à pesquisa de micrometástases ampliou a detecção de envolvimento linfonodal microscópico, contribuindo assim, com o estadiamento de doença extra-hepática / Introduction: Currently, hepatectomy is considered the best treatment of metastatic colorectal cancer. Several prognostic factors have been investigated, and many studies have shown that the involvement of regional lymph nodes at the hepatic hilum represents a negative prognostic factor. The present study investigated the frequency and characteristics of microscopic involvement of hilar lymph nodes, through systematic lymphadenectomy and analysis of micrometastases in patients undergoing hepatectomy due to colorectal metastases. Methods: Exclusion criteria were: no resectable disease detect in the pre or intra-operative; clinics conditions and intraoperative factors what required minor surgical time; macroscopic hepatic lymph node metastases, confirmed by frozen section and less of three lymph nodes resected for patient. Of the 38 patients, 28 underwent hepatic resection in association with systematic lymphadenectomy of the hepatic hilum, with three or more lymph nodes resected for patient. Lymph nodes considered negative by conventional hematoxylin and eosin staining were analyzed by serial sectioning with 100 m intervals and immunohistochemistry with antibodies to cytokeratins AE1/AE3. Results: In average, 6.18 lymph nodes were dissected per patient. Lymphadenectomy increased surgical time by 48 minutes in average, but no morbi-mortality was associated to the procedure. In two of the patients (7,2%), conventional hematoxylin and eosin analysis showed the presence of microscopic lymph node metastases. Immunohistochemistry analysis of serial sections allowed the identification of three other patients with lymph node micrometastases (10,8%). Conclusion: The overall frequency of microscopic metastases, including micrometastases, was 18%. No statistically significant relationships were observed between other prognostic factors and the presence of microscopic metastases. Systematic lymphadenectomy with inclusion of micrometastases protocols improved the detection of microscopic lymph node involvement, resulting in more accurate staging of extrahepatic disease

Laser thermal ablation (LTA) is an in situ ablative technique that induces heat destruction of liver tumours. Despite increasing clinical use of LTA, reports of long-term outcomes and limitation of treatment in specific cohorts of patients with liver tumours are lacking. In addition, the mechanisms of action of therapy have not been fully elucidated. This study highlights the long-term clinical results and limitations of LTA in the treatment of a cohort of patients with unresectable colorectal liver metastases and examines the mechanisms of action of thermal ablative injury in a murine model.

Background and aims: Laparoscopic technique was quickly adopted in general surgery because of less pain, quicker recovery and shorter hospital stay. In the 1990´s several reports on port site metastases restrained the enthusiasm to use laparoscopic surgery in malignant diseases. The numerous reports on port site metastases initiated a debate whether laparoscopic surgery would increase the risk of tumour spread and growth. Personal experience of two patients who devloped port site metastases from an incidental gall bladder cancer (GBC) after laparoscopic cholecystectomy (LC), encouraged us to study the incidence of wound metastases from GBC after laparoscopic and open cholecystectomy (OC). Experimentally we examined whether pneumoperitoneum would increase the risk of tumour development. Several studies had demonstrated that minimally invasive procedures exert a less negative influence on the immune system and may have beneficial effects for cancer patients. We wanted to compare the long term survival after OC and LC and if the occurence of port site metastases had any impact on survival. Material and methods: A questionnaire was sent out to all major hospitals in Sweden requesting information obout the number of port site metastases encountered 1991-94. Data on all pateints with verfied GBC were obtained from the Swedish Oncological Centres. Data on all patients with GBC registered with surgical codes for cholecystectomy were collected from the National Board of Health and Welfare (EpC). The patient files were scrutinized and long term survival data was achieved (EpC). In the first experiment on Wistar Fu rats, adenocarcinoma cells were injected intraperitoneally in animals insufflated with air, CO2 and not insufflated controls. In the following studies, rats were similarly insufflated with air,CO2 and compared to not insufflated controls. Laser Doppler blood flow in the abdominal wall was concomitantly measured. To study the effect of reduced blood flow, one rectus muscle was clamped and the other not and laser Doppler Blood flow was measured in both rectus muscles. Adenocarcinoma cells were injected into the rectus muscles in all animals at the induction of pneumoperitoneum/clamping. Results: 14 of 55 patients developed wound metastases from GBC after LC and 12 of 187 after OC. Gallbladder perforation was overrepresented in patients with wound metastases. Improved survival was noted after LC in patients with T3 tumours. Experimentally, air and CO2 equally increased intraperitoneal tumour development, Insufflation with air,CO2 and clamping decreased blood flow in the abdominal wall and increased tumour growth at the same site. Conclusion: Despite a high rate of wound metastases, LC does not seem to worsen the prognosis of GBC and may even have a positive effect on survival. Perforation of the malignant gallbladder seems to be associated with an increased risk of metastatic formation. In the experimental setting, pneumoperitoneum seems to increase tumour development. Other features of laparoscopic surgery such as decreased blood flow in the abdominal wall may contribute to increased risk of tumour progress.

Background: Colorectal cancer (CRC) remains one of the leading causes of cancer-related mortality. About 50 % of patients with CRC will develop subsequent liver metastases (CLM). The survival for untreated CLM is only a few months and liver resection provides the only chance for a lasting cure. It is therefore essential to detect CLM early, enabling successful surgical resection and achieving a long-term cure. There are no optimal tumour markers for CRC or CLM. The best marker available is Carcinoembryonic Antigen (CEA), a marker found elevated in about 50-60% of patients with CLM, but also in many other conditions. The main focus of cancer research has been on the malignant cancer cell. However, a tumour consists of more than cancer cells. A major part of all solid tumours is made up by the stroma. The tumour stroma is defined as the non-malignant cells of a tumour such as fibroblasts, the cells of the vascular and immune systems as well as the extracellular matrix (ECM). The basement membrane (BM) is a specialized form of the ECM in which type IV collagen is the major protein component. All epithelial cells need a contact to the BM and the definition of an invasive cancer is the degradation of the BM and the spread of cancer cells beyond this structure. Different metastatic growth patterns of CLM have previously been described, namely the desmoplastic, pushing and replacement type of CLM. These differ in their stromal reaction in the border, which separates the tumour from the normal liver. In this thesis the tumour stroma of CRC and CLM is studied with a special emphasis on stromal collagens. The aim is to investigate whether stromal collagens/ circulating type IV collagen can be used as tumour markers for CRC and CLM, and to compare this to the conventional marker CEA. The circulating type IV collagen level is also measured in liver metastases from other primary tumours than CRC. Furthermore, the differences between the stroma of a primary CRC that metastasizes to the liver when compared to a CRC that never spreads are analysed. Additionally, the metastatic growth pattern of CLM is studied in relation to the primary tumour, stromal components and survival. We also sought out to find whether CRC cell lines possess the trait to produce ECM proteins endogenously, and in response to a normal liver stroma in a novel organotypic model for CLM. Methods: Expression patterns of type I, III and IV collagen were studied by immunofluorescence (IF), chemical staining and immunohistochemistry (IHC) in normal colorectal tissue, normal liver, CRC, CLM, benign liver lesions and in liver metastases of other origin than CRC. Circulating plasma levels of type IV collagen were analysed in healthy controls, patients with CRC (T stage I-III) and in patients with CLM. Samples were analysed at the time of diagnosis, during and after oncological and surgical treatment and at the time of relapsing or progressive disease. Additionally, circulating levels were analysed in patients with benign liver lesions and in liver metastases of other origin than CRC. The metastatic growth pattern of CLM was classified according to earlier descriptions. CRC cell lines were studied regarding their production of type IV collagen. The growth, invasiveness and stromal production in CRC cell lines were also investigated in a new organotypic model for CLM using human liver specimens. Results: Circulating type IV collagen levels are increased in patients with CLM and other epithelial-derived liver metastases, and is found normal in patients with primary CRC (stage I-III), with liver metastases from tumours of non-epithelial origin, benign liver lesions and in healthy controls. The type IV collagen levels in patients with CLM reflect the tumour burden in the liver, decreases in response to therapy and is found increased in progressive or relapsing disease. The combination of circulating type IV collagen and CEA increased the sensitivity and specificity for detecting CLM. Livermetastatic CRC displayed an increased stromal production when compared to non-metastatic CRC, with an increased type IV collagen expression in the direct vicinity of the CRC cells. The earlier described growth patterns of CLM were verified, with the pushing type of CLM associated with a short survival and poor outcome. Furthermore, CRC cell lines possess the trait of endogenously producing type IV collagen. The novel organotypic liver model revealed that CRC cell lines grown in the context of normal liver stroma, devoid of other cells, does not elicit a desmoplastic reaction. Conclusion: Circulating type IV collagen is a promising tumour marker for CLM, where the levels reflect the hepatic tumour burden and can detect disease relapse after liver surgery. The combination of the tumour markers CEA and type IV collagen is superior to CEA alone. The stromal composition of primary CRC predicts the risk of subsequent CLM and the metastatic growth pattern of CLM is related to survival.

Background : Many cancer patients who get bone metastases live longer thanks to the successful research and development of medicines during recent years. Many studies show general health benefits from physical activity. For patients with bone metastases the possibility of physical activity perhaps should limit? Nurses at oncological units are often in lifelong contact with this group of patients. It´s therefore important to have knowledge about the bone metastases and how it influence the patient´s possibility of performing physical activity in order to support and encourage the patient to safely physical activity. Aim : To describe the patient´s possibility of physical activity with metastases to the bone. Method : A literature study. Results : The extension of the bone metastases shall be verified through X-ray. Based on the result estimation should be done regarding the risks for fractures. Few metastases allow the patient to perform more physical activity. No study showed that physical activity according to carefully elaborated exercise programmes will be of any risk for patients with bone metastases. Conclusions : The conclusion of this study was that research within nursing of the chosen problem is limited. The nurse is the one who often meets this group of patients in treatment and it is important that he/she has adequate knowledge about the individual patients’ possibilities to perform physical activity. Even if the result was not that big there is still a consensus among the articles included. Nevertheless this area seems to be fairly unexplored and more studies are needed to strengthen the evidence.