Multiple myeloma is a malignant bone marrow plasma cell tumor which is responsible for approximately 12,000 deaths per year in the United States and two percent of all cancer deaths. It is recognized clinically by the presence of more than ten percent bone marrow plasma cells, the detection of a monoclonal protein (M-protein), anemia, hypercalcemia, renal insufficiency, and lytic bone lesions. The disease is usually preceded by a premalignant tumor called monoclonal gammopathy of undetermined significance (MGUS), which is present in one percent of adults over the age of fifty, three percent over the age of seventy and ten percent of those in the tenth decade. MGUS is also recognized by the detection of M-protein, but with less than ten percent bone marrow plasma cells and without the other features exhibited by myeloma. The majority of MGUS patients remain stable for long periods without ever developing myeloma. Only a small percentage of patients with MGUS eventually develop multiple myeloma. However, the reason for this is not yet known. Once the myeloma stage is reached, a sequence of well-understood mutational evets eventually lead to the escape of the tumor from the control of the immune system. We propose a mathematical model of tumor-immune system interactions at the onset of the disease in an effort to better understand the early events that take place and their influence on the outcome of the disease. The model is calibrated with parameter values obtained from available data and we study the resulting dynamics. Next, we study how the behavior of the system is affected as parameters are varied. Finally, we interpret the results and draw some conclusions.

Orientador: Maria Aparecida Custodio Domingues / Resumo: Mieloma Múltiplo é uma neoplasia maligna de células plasmocitárias, cujas repercussões clínicas de interação da célula tumoral com seu microambiente e com o hospedeiro podem causar danos irreversíveis e progressivos ao doente. Estratégias terapeuticas têm tentado reunir antídotos às várias linhas de atuação da célula tumoral. Objetivou-se avaliar características clíncas e possíveis interações com o microambiente da medula óssea. Foram colhidos dados clínicos, reavaliado material histológico e confeccionado bloco de TMA com grupos de pacientes ao diagnóstico, na primeira recaída e após transplante autólogo de medula óssea. A análise estatística compreendeu descrição dos dados de distribuições de frequência para as variáveis qualitativas e calculadas as médias, desvios padrão, valores mínimo e máximo e mediana para as variáveis quantitativas. O teste de Qui-quadrado de Pearson foi empregado para variáveis qualitativas. Gráficos do tipo mosaico apresentaram os cruzamentos das variáveis discretas e técnica FAMD para verificação da contribuição das variáveis qualitativas e quantitativas simultaneamente. As curvas de sobrevida foram obtidas usando a metodologia de Kaplan & Meier e a estatística de Breslow foi empregada para testar a diferença entre as curvas observadas. Os intervalos de confiança para as curvas e testes foram feitos com nível de significância de 5%. As análises e figuras foram elaboradas com o software R (R Core Team, 2017). Concluímos que pacientes com condições c... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Multiple Myeloma is a malignant neoplasm of plasma cells whose clinical repercussions of tumor cell interaction with its microenvironment and host may cause irreversible and progressive damage to the patient. Therapeutic strategies have attempted to gather antidotes to the various lines of action of the tumor cell. This study aimed to evaluate clinical characteristics and possible interactions with the bone marrow microenvironment. Clinical data were collected, histological material was reevaluated and an AMT block was made with patient groups at diagnosis, in the first relapse and after autologous bone marrow transplantation. Statistical analysis included description of frequency distribution data for qualitative variables and calculated means, standard deviations, minimum and maximum values and median for quantitative variables. Pearson's chi-square test was used for qualitative variables. Mosaic graphs showed the intersections of discrete variables and FAMD technique to verify the contribution of qualitative and quantitative variables simultaneously. Survival curves were obtained using the Kaplan & Meier methodology and the Breslow statistic was employed to test the difference between the observed curves. Confidence intervals for curves and tests were made at a significance level of 5%. The analyzes and figures were elaborated with the R software (R Core Team, 2017).We conclude that patients with clinical conditions for more aggressive initial therapies may impact their su... (Complete abstract click electronic access below) / Doutor

Granulocyte colony-stimulating factor (GCSF) is currently the most widely used cytokine for stem cell mobilization. There are few studies suggesting GCSF administration may induce activation of both coagulation and endothelial cells that could favor the developing of thrombotic events. We report a 58-year-old female with vasculitis and renal impairment. She was found to have an underlying monoclonal gammopathy of unknown significance (MGUS). The monoclonal protein was felt to play a role in her underlying renal disease and peripheral neuropathy. She was considered a candidate for peripheral blood stem cell transplantation to manage the monoclonal protein. During stem cell mobilization with GCSF, she developed worsening of anemia; thrombocytopenia and worsening of renal function. She was diagnosed with thrombotic microangiopathy (TMA) which was successfully treated with therapeutic plasma exchange and rituximab. It is possible that GCSF may have directly (activating endothelial cells) or indirectly (activation of underlying autoimmune disorder) contributed to TMA in this patient.

IgM monoclonal gammopathy is a common age-related demyelinating sensory and motor polyneuropathy. It has been shown to be associated with antibodies against myelin-associated glycoproteins (MAG/SGPG). The HNK-1 carbohydrate epitope is a terminal 3-sulfo-glucuronyl residue attached to lactosamine structures and it is shared both in MAG and SGPG (SO4-3-GlcA(β1-3)Gal-(β1-4)GlcNAc(β1-3)Gal-(β1-4)Glcβ(1-1′)Cer). It is mostly expressed in the nervous system and plays an important role in preferential motor reinnervation. Nevertheless, the HNK-1 epitope is difficult to be isolated and synthesized and diagnostic assays used in the clinics are not always reproducible and reliable. Therefore in our study, our goal is to identify a simple synthetic diagnostic tool (peptide or monosaccharide), mimetic of the HNK-1 epitope, able to recognize antibodies in neurogammopathies sera by Surface Plasmon Resonance to be used in earlier stage patients and possibly to monitor disease activity. For this reason, we firstly tried to synthesize this trisaccharide and then we achieved the synthesis of its terminal monosaccharides with different function groups (octyl glucopyranoside, octyl glucuronic acid, octyl 3-O-sulfo-glucuronic acid and 8-amino octyl 3-O-sulfo-glucuronic acid). Then 10 linear and cyclic peptides conformationally and/or structurally mimicking HNK-1 were also synthesized (LSETTI, LSETTl, cyclo(-TTILSE-), cyclo(-TTlLSE-), cyclo(-TKTlLSE-), cyclo(-TETKlLSE-), TYTKlLSE, TY(SO3)TKlLSE, cyclo(-TYTKlLSE-) and cyclo(-TY(SO3)TKlLSE-)). The SPR kinetic binding affinities of all these sugar and peptide mimics were studied with commercial anti HNK-1 antibody using Biacore. Moreover, mimics with highest binding affinities were chosen for antigen-antibody interaction study in IgM gammopathy patients' serum.

We hypothesized that the presence of monoclonal free light chains (FLC) in the serum of patients with monoclonal gammopathy of undetermined significance (MGUS) is a marker of clonal evolution and a risk factor for progression. Forty-seven patients with MGUS and documented progression to myeloma or related malignancy were compared with 50 age- and gender-matched patients with MGUS and no evidence of progression after 5 or more years of follow-up. The presence of an abnormal kappa/lambda FLC ratio in the serum was associated with a higher risk of MGUS progression (relative risk 2.5; 95% confidence interval: 1.6-4.0; P < 0.001).

De façon physiologique, la voie alterne (VA) du complément est activée en permanence. Elle doit donc être finement régulée à tous les niveaux de la cascade afin de ne pas être délétère pour l'hôte. Chez l'homme, deux pathologies rénales sont associées à une activation non contrôlée de la VA du complément: le syndrome hémolytique et urémique atypique et la glomérulopathie à dépôts de C3 (GP-C3). Pathologie du sujet jeune essentiellement, la GP-C3 regroupe deux entités, la maladie des dépôts denses (GN-DD) et la glomérulonéphrite à dépôts de C3 (GN-C3), d'expressions clinique et histologique hétérogènes et toutes les deux de pronostic rénal réservé en l’absence de traitement efficace disponible (médiane de survie rénale de l’ordre de 8 à 10 ans). Les anomalies de la VA du complément mises en évidence dans la GP-C3 sont essentiellement acquises en rapport avec la présence d'auto anticorps (Ac) dirigés contre la C3 convertase alterne, le C3NeF, ou contre le FH, une protéine régulatrice essentielle de la VA. Dans 15 à 20% des cas seulement, les anomalies sont génétiques en rapport avec des mutations du FH, du FI. Les approches in silico de modélisation moléculaire des protéines mutées apportent des éléments de réponse quant à la responsabilité potentielle d'une mutation dans l’activation non contrôlée de la VA, néanmoins, l'étude des conséquences fonctionnelles est indispensable pour relier l'anomalie à la survenue de la pathologie rénale mais aussi pour comprendre les mécanismes précis impliqués dans le déterminisme des lésions rénales, de GN-DD ou de GN-C3. J'ai dans un premier temps étudié les conséquences fonctionnelles de la première mutation de C3 identifiée dans une forme familiale de GN-C3. In silico, cette mutation I734T est située au niveau d'un site impliqué dans la liaison de C3 avec deux protéines régulatrices, le FH et CR1 et à proximité du site d’interaction avec le FB. In vitro, j'ai pu confirmer que la mutation était responsable d'une activation de la VA au niveau tissulaire en rapport avec un défaut induit de régulation par le FH mais surtout CR1, une protéine régulatrice membranaire, identifié pour la première fois comme acteur dans la physiopathologie de la GP-C3. Par ailleurs, en raison de l'expression exclusivement podocytaire de CR1 au niveau glomérulaire, nous avons émis l'hypothèse que les régulateurs pouvaient jouer un rôle déterminant dans la localisation préférentielle des dépôts de C3 au niveau glomérulaire dans cette pathologie. Dans une deuxième partie, à la fois clinique et expérimentale, j'ai travaillé sur les formes acquises de GP-C3 en étudiant un sous-groupe particulier de patients de la cohorte française de GP-C3, âgés de plus de 50 ans et présentant une gammapathie monoclonale. La partie clinique de ce travail a permis de démontrer que la fréquence des gammapathies monoclonales est très nettement augmentée dans la GP-C3 chez les patients âgés de plus de 50 ans comparée à la population générale, que le pronostic rénal est particulièrement sombre avec une médiane de survie rénale de l’ordre de 2 ans et demi mais que le traitement efficace du clone B sous-jacent permet d'améliorer significativement la survie rénale. Les données de l’étude clinique suggèrent indirectement qu’il existe un lien entre l'immunoglobuline (Ig) monoclonale et l'activation de la VA responsable de l'apparition des lésions rénales. Dans la partie expérimentale, j'ai étudié les mécanismes d'activation de la VA dans ce contexte de gammapathie afin de confronter les données de l’étude clinique. L'étude des biomarqueurs d'activation de la C3/C5 convertase et le démembrement des mécanismes d'activation ont permis de conclure que la GP-C3 associée aux gammapathies monoclonales est caractérisée par une activation tissulaire de la VA impliquant la C3 convertase mais aussi et surtout la C5 convertase. (...) / Complement alternative pathway is physiologically activated. It need to be tightly regulated to avaoid uncontrolled deleterious overactivation on host cell surface. In human, two renal diseaes are associated with uncontrolled AP activation, hemolytic uremic syndrom atypical (aHUS) and C3 glomerulopathy (C3G). C3G occures mainly in children and young adults and regoups two distinct histopathological entities, dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). Renal outcomes in C3G is poor since up to 50% of patients reach end stage renal disease 8 to 10 years after diagnosis. Complement abnormalities in C3G are mainly acquired induced by the presence of C3 Nephritic Factor (C3NeF): an autoantibdy targeting the AP C3 convertase. Less frequently C3G patients have anti-FH autoantibodies (Ref) or genetic abnormalities (variants in the FH, FI or CFHR5 genes. In silico analysis of mutated proteins give information about the role of mutation on AP overactivation. However, characterization of functional consequences of these mutations is required to proved the direct link between the abnormality and the occurrence of C3G. I first studied the functional consequences of the first C3 mutation, C3I734T, identified in a familial C3GN. In silico analysis revealed that the mutated residue, T734, is located on the C3 and C3b protein surface and that the substitution I734T may not be associated with major structural changes. The mutated amino acid is located on interaction site between C3b and complement regulatory proteins, FH and CR1. In vitro, the major defect of C3I734T was a decrease in binding to CR1, resulting in lower CR1 dependent cleavage of C3b by FI. These results provide evidence for a CR1 functional deficiency being responsible for deficient complement regulation. Binding of C3I734T to Factor H (FH) was normal, but C3I734T was less efficiently cleaved by Factor I, leading to enhanced C3 fragments binding on glomerular cells. In the second part of my work, I studied acquired C3G in patients with concomitant monoclonal gammopathy. In the clinical part of this study, we demonstrated The high prevalence of monoclonal gammopathy in C3G patients aged over 50, reaching 65% in the French C3G national cohort, strongly suggests a pathogenic link between the two conditions. Next, we demonstrated that renal outcomes is significantly worser in patients with monoclonal gammopathy compared to patients without monoclonal gammopathy but that efficient chemotherapy resulted in higher renal response rate and longer renal survival than conservative or immunosuppressive therapy. Results of the clinical part of the study strongly suggest a link betwwen the monoclonal gammopathy and the occurrence of C3G. In the experimental part of this work, I studied the mechanisms of complement AP activation in these population. Biomarkers of C3 and C5 convertase activation were present 40% and 81% of patients respectively. Anti-complement protein antibodies were found in 23/41 (56%) patients, including in most of patients, anti-FH and anti-CR1 antibodies. I found new antigenic target, C5 and properdin in few cases. The anti-FH and anti-CR1 antibodies were associated with clear functional consequences. Nevertheless, the anti-complement proteins reactivity was not carried out by the MIg in 75% of the cases. I discovered that the MIg induced a direct AP C3 convertase overactivation in 23/34 (67%) patients responsaible for a C5 convertase overactivation in presence of patients’ Ig, in a properdin dependant manner. Our results suggest that MIg and polyclonal autoantibodies could act in synergy: AP overactivation induced by the MIg could be amplified by the inefficient complement regulation, caused by the polyclonal anti-complement autoantibodies. All my results allow to better understand the pathophysiological mechanisms involved in C3G and open up reflection on therapeutic approaches for C3G associated with monoclonal gammopathy.

La gammopathie monoclonale IgM est une polyneuropathie démyélinisante sensorielle et motrice. Il a été montré qu'elle est associée à des anticorps contre des glycoprotéines associées à la myéline (MAG/SGPG). L'épitope HNK-1 est un résidu 3-sulfo-glucuronyle lié à des structures lactosamine et il est présent aussi bien dans MAG que dans SGPG (SO4-3-GlcA(β1-3)Gal-(β1-4)GlcNAc(β1-3)Gal-(β1-4)Glcβ(1-1′)Cer). Il est exprimé principalement dans le système nerveux et joue un rôle important dans la réinnervation motrice préférentielle. Toutefois, l'épitope HNK-1 est difficile à isoler et à synthétiser et les essais diagnostiques cliniques ne sont pas toujours reproductibles et fiables.Le but de notre étude est d'identifier un outil synthétique simple de diagnostic (peptide ou monosaccharide), mimétique de l'épitope HNK-1, capable de reconnaître les anticorps dans les sera des neurogammapathies par Surface Plasmon Resonance (SPR) afin qu'il soit utilisé chez des patients à l'état précoce et qu'il puisse éventuellement permettre le suivi de l'évolution de la maladie. Pour cela, nous avons essayé de synthétiser ce trisaccharide, puis nous avons réalisé la synthèse de ses monosaccharides terminaux avec différents groupements fonctionnels (glucopyranoside d'octyle, acide 1-O-octylglucuronique, acide 1-O-octyl-3-O-sulfoglucuronique et acide 8-aminooctyl-3-O-sulfo-glucuronique).Puis 10 peptides linéaires et cycliques mimant conformationellement et/ou structuralement le HNK-1 ont également été synthétisés (LSETTI, LSETTl, cyclo(-TTILSE-), cyclo(-TTlLSE-), cyclo(-TKTlLSE-), cyclo(-TETKlLSE-), TYTKlLSE, TY(SO3)TKlLSE, cyclo(-TYTKlLSE-) et cyclo(-TY(SO3)TKlLSE-)). Les cinétiques d'affinité de ces mimes sucres et peptides ont été étudiées avec un anticorps anti HNK-1 commercial en utilisant le Biacore. De plus, les mimes avec les plus fortes affinités ont été choisis pour des études d'interaction antigène-anticorps dans des sera de patients atteints de gammapathie IgM. / IgM monoclonal gammopathy is a common age-related demyelinating sensory and motor polyneuropathy. It has been shown to be associated with antibodies against myelin-associated glycoproteins (MAG/SGPG). The HNK-1 carbohydrate epitope is a terminal 3-sulfo-glucuronyl residue attached to lactosamine structures and it is shared both in MAG and SGPG (SO4-3-GlcA(β1-3)Gal-(β1-4)GlcNAc(β1-3)Gal-(β1-4)Glcβ(1-1′)Cer). It is mostly expressed in the nervous system and plays an important role in preferential motor reinnervation. Nevertheless, the HNK-1 epitope is difficult to be isolated and synthesized and diagnostic assays used in the clinics are not always reproducible and reliable. Therefore in our study, our goal is to identify a simple synthetic diagnostic tool (peptide or monosaccharide), mimetic of the HNK-1 epitope, able to recognize antibodies in neurogammopathies sera by Surface Plasmon Resonance to be used in earlier stage patients and possibly to monitor disease activity. For this reason, we firstly tried to synthesize this trisaccharide and then we achieved the synthesis of its terminal monosaccharides with different function groups (octyl glucopyranoside, octyl glucuronic acid, octyl 3-O-sulfo-glucuronic acid and 8-amino octyl 3-O-sulfo-glucuronic acid). Then 10 linear and cyclic peptides conformationally and/or structurally mimicking HNK-1 were also synthesized (LSETTI, LSETTl, cyclo(-TTILSE-), cyclo(-TTlLSE-), cyclo(-TKTlLSE-), cyclo(-TETKlLSE-), TYTKlLSE, TY(SO3)TKlLSE, cyclo(-TYTKlLSE-) and cyclo(-TY(SO3)TKlLSE-)). The SPR kinetic binding affinities of all these sugar and peptide mimics were studied with commercial anti HNK-1 antibody using Biacore. Moreover, mimics with highest binding affinities were chosen for antigen-antibody interaction study in IgM gammopathy patients' serum.