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Zytogenetische und molekularbiologische Untersuchungen an intrakraniellen Meningeomen unter Anwendung der GTG-Bänderung, SKY-Technik, FISH-Analyse und genomweiter SNP-A KaryotypisierungMocker, Kristin 22 July 2013 (has links) (PDF)
Meningeome sind Tumore der Hirnhäute und stellen zirka 24-30% aller intrakraniellen Tumore dar. Obwohl sie in den meisten Fällen als solitär, langsam wachsend und benigne (WHO Grad 1) beschrieben werden, ist ihr ausgeprägtes Rezidivverhalten die größte Herausforderung in der Therapie. Bisherige Arbeiten verwendeten zur genetischen Analyse von Meningeomen meist Untersuchungstechniken mit eingeschränkter (molekular-)zytogenetischer Aussagekraft. Mit der Kombination der Methoden Giemsa-Bandendarstellung (GTG-Bänderung), Spektrale Karyotypisierung (SKY-Technik), Fluoreszenz in situ Hybridisierungstechniken (FISH-Analyse) und molekulare Karyotypisierung unter Verwendung von 100K beziehungsweise 6.0 SNP-Arrays (SNP-A Karyotypisierung) sollte es möglich sein, in effizienterer Form bislang unentdeckte chromosomale Aberrationen zu identifizieren und weiterführende tumormechanistische Hinweise zu erhalten. In der vorliegenden Arbeit wurde zunächst ein multipel aufgetretenes Meningeom mit zwei Tumoren unterschiedlicher Malignität (1 WHO Grad 1; 1 WHO Grad 2) analysiert, anschließend erfolgte die Untersuchung einer Gruppe von 10 Meningeomen (5 WHO Grad 1; 5 WHO Grad 2). Bisher nicht beschriebene Aberrationen wie ein dizentrisches Chromosomen 4, die parazentrische Inversion im chromosomalen Bereich 1p36 und die balancierte reziproke Translokation t(4;10)(q12;q26) wurden detektiert. Die genomweite SNP-A Karyotypisierung ermöglichte neben der genaueren Betrachtung der zytogenetischen Ergebnisse die simultane Analyse von Blut und Tumor-DNA der Patienten und lieferte Hinweise auf konstitutionelle Aberrationen. Es zeigte sich eine signifikante Anreicherung von rekurrenten Regionen kopienneutraler Verluste der Heterozygotie als Hinweis auf das Vorliegen potenzieller segmentaler Uniparentaler Disomie (UPD) jeweils in Blut und Tumor der Patienten. Außerdem wurden nur im Tumor befindliche potentielle rekurrente segmentale UPD Regionen detektiert. Die weitere Analyse der konstitutionellen sowie somatischen segmentalen UPD hinsichtlich ihrer Rolle im Rahmen der Tumorgenese ist eine wichtige Aufgabe für die Zukunft.
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Lifestyle Risk Factors Associated with Adult Primary Brain Tumours: Quality Assessment of Existing Systematic Reviews, Followed by Updated Analyses and De-Novo SynthesesQuach, Pauline 16 October 2013 (has links)
Background: A compilation of high quality systematic reviews (SRs) on lifestyle factors associated with adult glioma and meningioma was developed.
Methods and Materials: Phase 1 consisted of a systematic overview of existing SRs. For Phase 2, high quality SRs were incorporated in an update. Moderate or low quality SRs which had not been considered in a high quality review were eligible for a de-novo synthesis.
Results: Phase 1 resulted in seven moderate to low quality reviews. From this, in Phase 2, smoking, mobile phone and hair dye use were subjected to de-novo reviews. For smoking, it was suggestive that past smokers had an increased risk. For mobile phone use, there was no overall association, however it was suggestive that ipsilateral and high cumulative call time were associated with slight increased risk. No association was observed for personal hair dye use.
Conclusions: Despite these null associations, rigorous SR methods were used providing confidence in conveying these results.
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Genotype-phenotype studies in brain tumorsGhasimi, Soma January 2013 (has links)
Meningioma and glioma are the most common primary brain tumors, but their etiologies are largely unknown. Although meningioma is usually benign, their intracranial location can lead to lethal consequences, and despite progress in surgery, radiotherapy, and chemotherapy the prognosis for patients with glioma remains poor. The only well-established environmental risk factor for meningioma and glioma is ionizing radiation. Evidence for inherited predisposition to meningioma and glioma is provided by a number of rare inherited syndromes where collectively these diseases account for only a small proportion of the twofold increased risk of brain tumors seen in first-degree relatives for meningioma and glioma patients. It is very possible that much of the excess familial risk is a consequence of co-inheritance of multiple low-risk genetic variations. With this in mind, the aims of the studies in this thesis were to discover genetic risk variants influencing the probability of acquiring the disease and to identify the association between risk variants on the tumor phenotype. To identify genetic variants influencing meningioma risk, a comprehensive tagging of the selected genes in a case-control study was performed. We identified nine risk variants in EGF, ERBB2, and LRIG2 genes. However, these findings could not be confirmed in another larger independent dataset. In addition, the study identified a correlation between LRIG2 protein expression and ER status when analyzed with different parameters. In a separate study with a larger sample of meningioma patients, the same correlation between LRIG2 and ER status was observed. To explore the potential association between reported germline risk variants and somatic genetic events, matched tumor and blood samples from glioma patients were analyzed by SNP array. The results identified correlations between EGFR gene variants and somatic aberrations within the EGFR locus and CDKN2A/B locus. To further study the relationship between germline risk variants and tumor phenotype, the same patient material was used and analyzed by three different techniques: SNP array, IHC, and FISH. The results revealed EGFR risk variants effecting copy number variation of the EGFR gene and the expression of the IDH1 and p53. Further comparison between different techniques such as SNP array and FISH analysis revealed the difficulty in achieving consistent results with different techniques. To summarize, the glioma studies show a link between genotype and phenotype where genetic risk variants in the EGFR gene were found to be associated with specific somatic aberrations. These associations are biologically interesting because EGFR is involved in multiple cellular processes. Additional studies of the direct functional role of these observations need to be conducted to elucidate the molecular mechanisms underlying the identified association between germline gene variants and somatic aberrations. For the meningioma studies, no significant risk variants influencing the disease were found but a correlation between LRIG2 and ER status was observed. This result suggests a potential role for the LRIG protein in the pathogenesis of meningioma, but more studies are needed to confirm this hypothesizes. / <p>Cancer research foundation in northern Sweden and Lions cancer research foundation at Umeå university</p>
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Meningiomas: caracterização da indução da via de sinalização de Notch e desenvolvimento de modelo ortotópico animal / Meningiomas: characterization of the induction of notch signaling pathway and development of orthotopic animal modelBaia, Gilson Soares [UNIFESP] 30 July 2008 (has links) (PDF)
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Publico-10890d.pdf: 1518283 bytes, checksum: 5bd6b7757a463a7b6c64cd275e3e0014 (MD5) / É observado que a cascata de sinalização de Notch tem ativação desregulada em diversos tipos de cânceres. Em câncer, é descrito que a função específica da via de sinalização de Notch e dependente do contexto celular, dos tipos específicos expressos de receptores homólogos e do cruzamento de informação (crosstalk) entre as diferentes vias de sinalização. Nosso laboratório descreveu previamente, que a via de sinalização de Notch apresenta-se desregulada em meningiomas de todos os graus. Entretanto, a conseqüência funcional desta sinalização anormal de Notch e desconhecida. Neste trabalho, descrevemos que, em linhagens celulares de meningiomas, a expressão exógena do gene Hes-1, o componente efetor da via de Notch, esta associada à formação de células tetraplóides. De forma similar, a expressão exógena das formas ativas dos receptores Notch 1 e Notch2, induz ao aumento da expressão de Hes-l, que contribui para a formação de células tetraplóides. Células tetraplóides de meningioma exibem indícios de instabilidade genética, caracterizados pelo aumento da freqüência de figuras atípicas nucleares, como a presença de mitoses com fusos multipolares e de células com núcleos de tamanho aumentado. As células tetraplóides isoladas por citometria de fluxo demonstram ser viáveis em cultura, embora apresentem uma maior taxa de apoptose espontânea, quando comparadas as células diplóides. A técnica de cariotipagem espectral foi usada para demonstrar que, em comparação as células diplóides, as células tetraplóides desenvolvem uma taxa mais elevada de aberrações cromossômicas estruturais e numéricas. Nossos resultados identificam uma nova função para a via de sinalização de Notch na geração tetraplóidia e conseqüentemente de instabilidade cromossômica. Portanto, a via desregulada da sinalização de Notch pode ser um mecanismo genético inicial em meningiomas, contribuindo potencialmente para a tumorigênese.. / TEDE / BV UNIFESP: Teses e dissertações
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Évaluation de la qualité de vie en relation avec la santé des patients atteints de méningiome / Assessment of quality of life in relation with miningiomas patient's healthDa Silva, Manuel 18 November 2016 (has links)
L’évaluation de la qualité de vie des patients avec méningiome revêt un intérêt clinique important pour les futures modalités de prise en charge. Néanmoins les outils les plus spécifiques à disposition des praticiens et chercheurs aujourd’hui ont été élaborés à destination de patients avec des pathologies cancéreuses. Le caractère bénin des méningiomes (95% des cas) tend à influencer différemment la qualité de vie de ces patients. Afin d’évaluer la qualité de vie des patients avec méningiome, nous avons élaboré et validé un questionnaire spécifique : le M-QoL. Un groupe composé de 25 spécialistes d’horizons différents ont participé à l’élaboration du questionnaire. Ce dernier a été administré à 128 participants, dont 85 ont également rempli le questionnaire une seconde fois dans les semaines suivantes. Les résultats des M-QoL ont été comparés aux questionnaires WHOQOL-Bref de l’OMS pour 122 participants. 70 participants ont également bénéficié d’une évaluation neuropsychologique. Les analyses démontrent les qualités psychométriques du questionnaire (validité, fidélité, sensibilité) et des corrélations ont été retrouvées avec les évaluations cognitives. L’évaluation de la qualité de vie avec le M-QoL permet de mieux appréhender les difficultés rencontrées par les patients dans leur vie quotidienne. En conséquence, il est possible d’améliorer l’orientation de ces patients pour une meilleure prise en charge de leurs difficultés. / Evaluation of quality of life of patients with meningioma is particularly important as a clinical aspect for medical and psychological cares. Nevertheless, the most specific tools available for practitioners and researchers nowadays were implemented for cancer patients. The benign nature of meningiomas (in 95% of cases) tends to influence differently the quality of life of those patients.In order to evaluate the quality of life of meningioma patient, we’ve made and validated a specific questionnaire: the M-QoL.A group of 25 experts with different specialities participated to the development of this questionnaire. It was administrated to 128 participants, 85 of them whom completed it a second time in the following weeks. M-QoL results were compared to WHOQOL-Bref questionnaire from the WHO for 122 participants. 70 participants had benefited of a neuropsychological assessment.Analyses demonstrated psychometric qualities of the questionnaire (validity, reliability, sensitivity) and correlations were found with cognitive evaluations. Evaluation of quality of life through the M-QoL allows a better perception of the difficulties which impair the patients in everyday life.In consequences, it is possible to improve orientation of those patients for a better care of their difficulties.
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Análise da Frequência de Polimorfismos nos genes IL28B e IL28R1 em pacientes acometidos por Meningioma / Analysis of the frequency of the polimorphisms in IL28B and IL28R1 genes in patients affected by meningiomasGalvani, Aline Faria [UNESP] 20 August 2015 (has links) (PDF)
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000855110.pdf: 1362897 bytes, checksum: 814c66d0d4dd13dba974090ba33240c7 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Os meningiomas são os tumores mais frequentes do Sistema Nervoso Central e sua classificação é dada quanto ao tipo celular envolvido e grau de malignidade. Os intérferons (IFNs) foram inicialmente associados à resposta antiviral, contudo, estudos posteriores evidenciaram o envolvimento dessas citocinas na regulação do crescimento celular e no efeito imunomodulatório. A Interleucina 28B (IL28B), membro da família dos IFNs do tipo III, parece estar envolvida na resposta imune antiviral e antitumoral. Sendo assim, o objetivo do presente estudo foi avaliar a frequência de variações genéticas em IL28B e IL28R1 em pacientes acometidos por Meningiomas. Sessenta paciente tratados pelo serviço de Neurocirurgia da UNESP de Botucatu/SP foram incluídos neste estudo. A análise do polimorfismo rs12979860 C/T teve significância estatística quando comparou-se a frequência genotípica da população brasileira em relação a presente casuística. Foi descrito a detecção de novas variações genéticas (missense e silent) nos genes IL28B e IL28R1 ao comparar com as respectivas sequencias referencias disponíveis em banco de dados (NCBI). Estes dados sugerem uma importante relação destas variações genéticas em relação a estrutura e função das proteínas envolvidas, entretanto um estudo mais aprofundado das consequências dessas alterações na gênese e/ou progressão dos meningiomas devem ser considerado / Meningiomas are the most common tumors of the central nervous system, despite being benign and grow slowly, can recur in case of incomplete surgical resection. They are classified according to the cells involved and their rate of malignancy. The role of the immune system in preventing the emergence and progression of tumors has been the subject of many studies in the field of tumor immunology. Interferon (IFNs) were originally associated with antiviral response, however, subsequent studies revealed the involvement of these cytokines in the regulation of cell growth and their immunomodulatory effect.Thus, the aim of this study was to analyze the genetic variation frequency of IL28B and IL28R1 in patients with meningioma. Sixty patients treated by UNESP Neurosurgery service of Botucatu/SP were included in this study. Polymorphism rs12979860 C/T analysis showed statistical significance when compared with healthy Brazilian's genotypic frequency. New genetic variation (missense and silent) were detected in IL28B and IL28R1 through reference sequences analysis (NCBI). These data support an important relation of these genetic variations related to protein functions, however other studies of the consequences of these changes in the development and progression of meningiomas should be considered
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Metilação e expressão do gene BRCA1 em meningiomasLombardi, Ismael Augusto Silva [UNESP] 29 January 2013 (has links) (PDF)
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lombardi_ias_me_botfm.pdf: 529927 bytes, checksum: 6cb4e1254a86d1683806ac3cb6ca21b7 (MD5) / Meningiomas são os tumores intracranianos primários mais comuns e correlacionam-‐se com câncer de mama, compatilhando características como incidência maior no sexo feminino, receptores para hormônios sexuais e crescimento a exposição a hormônios sexuais. O gene BRCA1 é amplamente estudado no câncer de mama hereditário e esporádico, entretanto, são poucos os trabalhos que correlacionam BRCA1 e meningiomas. O BRCA1 é gene de supressão tumoral, interagindo com outros oncogenes, atuando no reparo do DNA durante a divisão celular e modulando negativamente receptores de estrógeno e progesterona. Avaliar o padrão de metilação de e expressão de BRCA1 em meningiomas e tecidos controles, e a expressão de receptores de estrógeno e progesterona em meningiomas e controles, correlacionando estes dados com dados epidemiológicos da casuística. Casuística e métodos: pacientes com diagnóstico de meningiomas tiveram amostras tumorais colhidas durante cirurgias de rotina pela disciplina de Neurocirurgia da Faculdade de Medicina de Botucatu (FMB) e do Hospital Mário Gatti, em Campinas. Previamente, o projeto foi aprovado pelo Comitê de Ética em Pesquisa e cada paciente concordou em participar ao assinar o Termo de Consentimento Livre e Esclarecido. Amostras controle de aracnóide foram colhidas de cadáveres no serviço de necropsia da disciplina de Patologia da FMB. As amostras tumorais foram avaliadas para metilação de BRCA1 por PCR específica para metilação e os resultados avaliados por eletroforese. A expressão foi avaliada por PCR em tempo real os resultados dados em relação a amostras comtroles. A expressão de receptores de estrógeno (RE) e progesterona (RP) foram analisadas por imuno-histoquímica, conforme rotina da disciplina de Patologia da FMB. Foram avaliados 50 meningiomas entre... / Meningiomas are the most common primary intracranial tumors and correlate with breast cancer, shearing features like higher incidence in female, sexual hormone receptors and growth to exposure to sexual hormones. The gene is widely studied in hereditary and sporadic breast cancer, however, there are few studies that correlate BRCA1 and meningiomas. The BRCA1 is a tumor suppressor gene and interacts with other oncogenes by DNA repairing during cell division and also negative modulating estrogen and progesterone receptors. To assess the pattern of methylation and expression of BRCA1 in meningiomas and control tissues, and the expression of estrogen and progesterone receptors in meningiomas and control tissues, and to correlate these data with patients epidemiological data. Patients diagnosed with meningioma had collected tumors samples during routine surgeries by the discipline of Neurosurgery in Faculty of Medicine of Botucatu (FMB) and Mario Gatti Hospital in Campinas. Previously, the project was approved by the Research Ethics Committee and each patient agreed to participate by signing the Instrument of Consent. Control arachnoid samples were collected from cadavers during routine of necropsy of Pathology departament in FMB. The tumor samples were analyzed for methylation of BRCA1 by methylation specific PCR and the results were evaluated by electrophoresis. The expression was assessed by real-‐time PCR results given in relation to samples comtroles. The expression of estrogen receptors (ER) and progesterone (PR) were analyzed by immunohistochemistry, as routine in Pathology departament. There were 50 meningiomas between January 2009 to September 2012, 22 male and 28 female. The methylation of BRCA1 in meningiomas was statistically significant compared to control tissues... (Complete abstract click electronic access below)
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Análise da Frequência de Polimorfismos nos genes IL28B e IL28R1 em pacientes acometidos por Meningioma /Galvani, Aline Faria. January 2015 (has links)
Orientador: Maria Inês de Moura Campos Pardini / Coorientador: Adriana Camargo Ferrasi / Banca: Sílvia Helena Barem Rabenhorst / Banca: Marcelo Lima Ribeiro / Resumo: Os meningiomas são os tumores mais frequentes do Sistema Nervoso Central e sua classificação é dada quanto ao tipo celular envolvido e grau de malignidade. Os intérferons (IFNs) foram inicialmente associados à resposta antiviral, contudo, estudos posteriores evidenciaram o envolvimento dessas citocinas na regulação do crescimento celular e no efeito imunomodulatório. A Interleucina 28B (IL28B), membro da família dos IFNs do tipo III, parece estar envolvida na resposta imune antiviral e antitumoral. Sendo assim, o objetivo do presente estudo foi avaliar a frequência de variações genéticas em IL28B e IL28R1 em pacientes acometidos por Meningiomas. Sessenta paciente tratados pelo serviço de Neurocirurgia da UNESP de Botucatu/SP foram incluídos neste estudo. A análise do polimorfismo rs12979860 C/T teve significância estatística quando comparou-se a frequência genotípica da população brasileira em relação a presente casuística. Foi descrito a detecção de novas variações genéticas (missense e silent) nos genes IL28B e IL28R1 ao comparar com as respectivas sequencias referencias disponíveis em banco de dados (NCBI). Estes dados sugerem uma importante relação destas variações genéticas em relação a estrutura e função das proteínas envolvidas, entretanto um estudo mais aprofundado das consequências dessas alterações na gênese e/ou progressão dos meningiomas devem ser considerado / Abstract: Meningiomas are the most common tumors of the central nervous system, despite being benign and grow slowly, can recur in case of incomplete surgical resection. They are classified according to the cells involved and their rate of malignancy. The role of the immune system in preventing the emergence and progression of tumors has been the subject of many studies in the field of tumor immunology. Interferon (IFNs) were originally associated with antiviral response, however, subsequent studies revealed the involvement of these cytokines in the regulation of cell growth and their immunomodulatory effect.Thus, the aim of this study was to analyze the genetic variation frequency of IL28B and IL28R1 in patients with meningioma. Sixty patients treated by UNESP Neurosurgery service of Botucatu/SP were included in this study. Polymorphism rs12979860 C/T analysis showed statistical significance when compared with healthy Brazilian's genotypic frequency. New genetic variation (missense and silent) were detected in IL28B and IL28R1 through reference sequences analysis (NCBI). These data support an important relation of these genetic variations related to protein functions, however other studies of the consequences of these changes in the development and progression of meningiomas should be considered / Mestre
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Metilação e expressão do gene BRCA1 em meningiomas /Lombardi, Ismael Augusto Silva. January 2013 (has links)
Orientador: Adriana Camargo Ferrasi / Coorientador: Maria Inês de Moura Campos Pardini / Coorientador: Marco Antonio Zanini / Banca: Carlos Gilberto Carlotti Junior / Banca: Eny Maria Goloni-Bertollo / Resumo: Meningiomas são os tumores intracranianos primários mais comuns e correlacionam-‐se com câncer de mama, compatilhando características como incidência maior no sexo feminino, receptores para hormônios sexuais e crescimento a exposição a hormônios sexuais. O gene BRCA1 é amplamente estudado no câncer de mama hereditário e esporádico, entretanto, são poucos os trabalhos que correlacionam BRCA1 e meningiomas. O BRCA1 é gene de supressão tumoral, interagindo com outros oncogenes, atuando no reparo do DNA durante a divisão celular e modulando negativamente receptores de estrógeno e progesterona. Avaliar o padrão de metilação de e expressão de BRCA1 em meningiomas e tecidos controles, e a expressão de receptores de estrógeno e progesterona em meningiomas e controles, correlacionando estes dados com dados epidemiológicos da casuística. Casuística e métodos: pacientes com diagnóstico de meningiomas tiveram amostras tumorais colhidas durante cirurgias de rotina pela disciplina de Neurocirurgia da Faculdade de Medicina de Botucatu (FMB) e do Hospital Mário Gatti, em Campinas. Previamente, o projeto foi aprovado pelo Comitê de Ética em Pesquisa e cada paciente concordou em participar ao assinar o Termo de Consentimento Livre e Esclarecido. Amostras controle de aracnóide foram colhidas de cadáveres no serviço de necropsia da disciplina de Patologia da FMB. As amostras tumorais foram avaliadas para metilação de BRCA1 por PCR específica para metilação e os resultados avaliados por eletroforese. A expressão foi avaliada por PCR em tempo real os resultados dados em relação a amostras comtroles. A expressão de receptores de estrógeno (RE) e progesterona (RP) foram analisadas por imuno-histoquímica, conforme rotina da disciplina de Patologia da FMB. Foram avaliados 50 meningiomas entre... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Meningiomas are the most common primary intracranial tumors and correlate with breast cancer, shearing features like higher incidence in female, sexual hormone receptors and growth to exposure to sexual hormones. The gene is widely studied in hereditary and sporadic breast cancer, however, there are few studies that correlate BRCA1 and meningiomas. The BRCA1 is a tumor suppressor gene and interacts with other oncogenes by DNA repairing during cell division and also negative modulating estrogen and progesterone receptors. To assess the pattern of methylation and expression of BRCA1 in meningiomas and control tissues, and the expression of estrogen and progesterone receptors in meningiomas and control tissues, and to correlate these data with patients epidemiological data. Patients diagnosed with meningioma had collected tumors samples during routine surgeries by the discipline of Neurosurgery in Faculty of Medicine of Botucatu (FMB) and Mario Gatti Hospital in Campinas. Previously, the project was approved by the Research Ethics Committee and each patient agreed to participate by signing the Instrument of Consent. Control arachnoid samples were collected from cadavers during routine of necropsy of Pathology departament in FMB. The tumor samples were analyzed for methylation of BRCA1 by methylation specific PCR and the results were evaluated by electrophoresis. The expression was assessed by real-‐time PCR results given in relation to samples comtroles. The expression of estrogen receptors (ER) and progesterone (PR) were analyzed by immunohistochemistry, as routine in Pathology departament. There were 50 meningiomas between January 2009 to September 2012, 22 male and 28 female. The methylation of BRCA1 in meningiomas was statistically significant compared to control tissues... (Complete abstract click electronic access below) / Mestre
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Lifestyle Risk Factors Associated with Adult Primary Brain Tumours: Quality Assessment of Existing Systematic Reviews, Followed by Updated Analyses and De-Novo SynthesesQuach, Pauline January 2013 (has links)
Background: A compilation of high quality systematic reviews (SRs) on lifestyle factors associated with adult glioma and meningioma was developed.
Methods and Materials: Phase 1 consisted of a systematic overview of existing SRs. For Phase 2, high quality SRs were incorporated in an update. Moderate or low quality SRs which had not been considered in a high quality review were eligible for a de-novo synthesis.
Results: Phase 1 resulted in seven moderate to low quality reviews. From this, in Phase 2, smoking, mobile phone and hair dye use were subjected to de-novo reviews. For smoking, it was suggestive that past smokers had an increased risk. For mobile phone use, there was no overall association, however it was suggestive that ipsilateral and high cumulative call time were associated with slight increased risk. No association was observed for personal hair dye use.
Conclusions: Despite these null associations, rigorous SR methods were used providing confidence in conveying these results.
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