The two purposes of this thesis were to evaluate new diagnostic techniques of lymphnode staging in invasive bladder cancer and to evaluate the results of neoadjuvant chemotherapy in invasive bladder cancer. Sentinel node detection was performed in 13 patients in preparation for radical cystectomy. The method showed to be feasible, and the results displayed the occurrence of metastatic nodes outside the traditional area of diagnostic dissection in a majority of patients. Four patients were metastasized, each one with one metastatic node detected with the help of the sentinel node procedure. Four randomly selected sentinel nodes from four different unmetastasized patients were compared to the four metastatic sentinel nodes from the first series. After microdissection, p53 genomic structure, immunohistochemical expression and MVD (microvessel density) were assessed in the primary tumors and corresponding sentinel nodes. The results suggested that invasive bladder cancer mainly involved monoclonal proliferation with predominantly homogenous biomarker profile, but there were also signs of clonal evolution. The Nordic Cystectomy Trial 2 (NCT2), is a randomized prospective trial investigating the possible benefit of neoadjuvant chemotherapy versus cystectomy only, in 311 eligible patients with urinary bladder cancer T2-T4aNXM0.Evaluation of overall survival did not show any statistically significant benefit in the experimental arm. This probably due to lack of statistical power. To increase the statistical power we performed a combined analysis of randomized patients from both the Nordic Cystectomy Trial 1 (NCT1) and NCT2, n = 620. Eligible patients from NCT1 had T1G3, T2-T4a NXM0 urinary bladder cancer. Standard meta-analysis methods were used. The only end-point analysed was overall survival. Neoadjuvant platinum based combination therapy was associated with a 20 % reduction in the relative hazard in probability of death.

Background: GISTs are gastrointestinal mesenchymal tumours that express the type III receptor tyrosine kinase KIT. The KIT proto-oncogene encodes the receptor KIT. Most GISTs have gain-of-function mutations in the KIT or PDGFRA gene. The tyrosine kinase is therefore continuously activated leading to ligand-independent dimerization. Imatinib mesylate (Glivec®) is considered to be the first-line palliative treatment. The activated form of the KIT receptor tyrosine kinase is inhibited by imatinib. The aim of the study was to compare the survival of patients treated with either adjuvant or down-staging imatinib with historic controls treated with radical surgery (R0) only. Methods: A historic control group was chosen from a population-based series from western Sweden (population 1.6 million) that matched the adjuvant (n=23) and down-staging (n=7) groups respectively. Mutation analysis was performed in all cases with bidirectional direct sequencing. The recurrence-free survival was calculated. Results: There was only one recurrence (4 %) in the adjuvant group, and no recurrences in the down-staging study group, compared to 32/48 patients (67 %) in the control group. Tumour size decreased in diameter from 20 cm to 11 cm with down-staging treatment. Conclusion: Adjuvant imatinib improves recurrence-free survival in R0 resected patients. Down-staging treatment with imatinib is recommended for patients with large tumours or metastases. The importance of mutation analysis was established.

<p>Background: GISTs are gastrointestinal mesenchymal tumours that express the type III receptor tyrosine kinase KIT. The KIT proto-oncogene encodes the receptor KIT. Most GISTs have gain-of-function mutations in the KIT or PDGFRA gene. The tyrosine kinase is therefore continuously activated leading to ligand-independent dimerization. Imatinib mesylate (Glivec®) is considered to be the first-line palliative treatment. The activated form of the KIT receptor tyrosine kinase is inhibited by imatinib. The aim of the study was to compare the survival of patients treated with either adjuvant or down-staging imatinib with historic controls treated with radical surgery (R0) only.</p><p>Methods: A historic control group was chosen from a population-based series from western Sweden (population 1.6 million) that matched the adjuvant (n=23) and down-staging (n=7) groups respectively. Mutation analysis was performed in all cases with bidirectional direct sequencing. The recurrence-free survival was calculated.</p><p>Results: There was only one recurrence (4 %) in the adjuvant group, and no recurrences in the down-staging study group, compared to 32/48 patients (67 %) in the control group. Tumour size decreased in diameter from 20 cm to 11 cm with down-staging treatment.</p><p>Conclusion: Adjuvant imatinib improves recurrence-free survival in R0 resected patients. Down-staging treatment with imatinib is recommended for patients with large tumours or metastases. The importance of mutation analysis was established.</p>

EGFR TKIs are standard therapy for advanced NSCLC. In order to define their role in early disease, we implemented a phase II trial of neoadjuvant gefitinib in clinical stage I NSCLC. Tumour shrinkage was seen in 43% of patients, with 11% achieving RECIST partial response (PR). Analysis of molecular markers showed EGFR TKD mutations in 17% of cases, being the only associated with PR. For the first time we defined the histopathological response of NSCLC to these agents, characterized by reduction in tumour cellularity and proliferative index as well as presence of non-mucinous BAC histology. Clinical PR tumours also presented large areas of stromal fibrosis with presence of focal residual tumour. In a characterization of intracellular signalling response, EGFR dephosphorylation in the residues Y1068 and Y1173 was not concordant and only the former was significantly reduced. pAkt Ser473/Akt and Thr308/Akt ratios were significantly reduced but observed among both, clinical responders and resistant patients. Interestingly, reduction in pEGFR Y1068 was significantly associated with increase in tumour cellularity (p=0.047), Ki-67 index (p=0.018) and tumour growth (p=0.019) with a residual perinuclear localization been detected, suggesting a novel mechanism of resistance involving receptor internalization. Finally, we determined that the EGFR protein remains stable up to one hour of post resection ischemia but two to three tumour samples are necessary for an adequate tumour representation. Furthermore, EGFR cytoplasmic compartment presented the best association with clinical response in our cohort. Taking all together, we were able to generate the first clinical trial exploring the use of an EGFR TKI in early NSCLC, characterizing for the first time the histopathological and signalling responses to these agents with an evidence of a potential novel mechanism of resistance. Finally, we observed that multiple samples collection for an adequate tumour representation, and assessment of the cytoplasmic compartment, are warrant.

EGFR TKIs are standard therapy for advanced NSCLC. In order to define their role in early disease, we implemented a phase II trial of neoadjuvant gefitinib in clinical stage I NSCLC. Tumour shrinkage was seen in 43% of patients, with 11% achieving RECIST partial response (PR). Analysis of molecular markers showed EGFR TKD mutations in 17% of cases, being the only associated with PR. For the first time we defined the histopathological response of NSCLC to these agents, characterized by reduction in tumour cellularity and proliferative index as well as presence of non-mucinous BAC histology. Clinical PR tumours also presented large areas of stromal fibrosis with presence of focal residual tumour. In a characterization of intracellular signalling response, EGFR dephosphorylation in the residues Y1068 and Y1173 was not concordant and only the former was significantly reduced. pAkt Ser473/Akt and Thr308/Akt ratios were significantly reduced but observed among both, clinical responders and resistant patients. Interestingly, reduction in pEGFR Y1068 was significantly associated with increase in tumour cellularity (p=0.047), Ki-67 index (p=0.018) and tumour growth (p=0.019) with a residual perinuclear localization been detected, suggesting a novel mechanism of resistance involving receptor internalization. Finally, we determined that the EGFR protein remains stable up to one hour of post resection ischemia but two to three tumour samples are necessary for an adequate tumour representation. Furthermore, EGFR cytoplasmic compartment presented the best association with clinical response in our cohort. Taking all together, we were able to generate the first clinical trial exploring the use of an EGFR TKI in early NSCLC, characterizing for the first time the histopathological and signalling responses to these agents with an evidence of a potential novel mechanism of resistance. Finally, we observed that multiple samples collection for an adequate tumour representation, and assessment of the cytoplasmic compartment, are warrant.

Introduction Recent advances in microarray technology have allowed more understanding of the complex molecular biology of breast cancer. The traditional prognostic information afforded by hormone receptor status and pathology variables is being supplemented and superseded by gene signatures predictive of risk of recurrence and response to treatments. Approximately 75% of breast cancers are oestrogen receptor positive (ER+) and can be treated by drugs that block oestrogen production such as letrozole. However not all ER+ tumours respond and even those that initially respond can develop resistance. Treating patients with neoadjuvant letrozole affords a unique opportunity to sample the same tumour in vivo at different time points reducing any potential inter-patient and inter-tumour variability. The molecular effects of drugs can be assessed long before clinical outcome is apparent. Underlying genetic differences or characteristics of the patient, tumour or sample may affect the molecular response to treatment. This project set out to use sequential patient-matched samples to evaluate molecular changes in breast tumours in the presence or absence of endocrine treatment in different subtypes, defined by histology or mutation status and to assess molecular variation between primary tumour and nodal metastasis. Methods RNA was extracted and processed to generate whole transcriptome Illumina Beadarray gene expression data from four unique cohorts of patients. Clinical data on treatments, recurrence and survival was collected from medical records. The first cohort compared 25 breast cancer patients with matched samples at diagnosis and at surgery, 14-35 (median 23) days later, with no intervening treatment; with 36 patients treated with neoadjuvant letrozole. A PCR assay to detect 8 known PIK3CA mutations and assessment of PTEN status was performed at both the primary and secondary event in a second cohort of 120 patients with endocrine treated disease who relapsed with either recurrence, lymph node metastases, a new second primary or progression of disease on primary endocrine therapy. The third cohort compared the molecular response to neoadjuvant letrozole in 14 patients with invasive lobular cancer (ILC) and 14 patients with invasive ductal cancer (IDC). A fourth cohort of women with node positive disease at diagnosis were assessed for variations in gene expression profiles between primary tumour and synchronous metastatic axillary lymph nodes (68 samples from 31 patients). Results The genomic profile of the no intervening treatment cohort did not differ significantly. Some changes in inflammatory genes were evident. This reassures us that changes seen during treatment are truly due to drug effect. This validates the use of a second biopsy to explore prediction of response. PIK3CA mutation status is maintained in the majority of patients with endocrine resistant disease and changed in only 15.7%. Where there was a change in PIK3CA this was significantly more likely to be a second primary breast cancer rather than a recurrence or progression of the primary cancer. PTEN status was also maintained in most patients. This does not support the theory that acquisition of a PIK3CA mutation is responsible for developing endocrine resistance. Novel PI3K inhibitor drugs may still be suitable in endocrine-resistant disease if activation of the pathway develops by other mechanisms. Consistent with previous studies, significant molecular differences were observed between ILC and IDC pre-treatment. Over half of these molecular differences were maintained after 3 months of letrozole. However, changes over time in individual tumours in response to letrozole were highly consistent in both ILC and IDC. When comparing primary with synchronous metastatic nodes only 39% of tumours clustered together with their matched primary or node. The molecular subtype of the node was often a poorer prognosis than the primary. There were also differences in subtype between nodes in a small cohort of patients with 2 involved nodes. Conclusions We have demonstrated that neoadjuvant window studies are a valid model for assessment of drug effects and evaluated differences in histology and mutation status. Endocrine resistance in breast cancer is rarely related to acquisition of PIK3CA mutations. Synchronous lymph node metastases can differ greatly from their matched primary. These findings are highly relevant when considering prescribing (neo)/adjuvant therapy and have significantly improved our understanding of breast cancer as we strive towards personalised medicine.

Introdução: O carcinoma de mama é uma doença altamente prevalente e incidente. Em nosso meio, ainda cerca de metade dos casos são diagnosticados em estadios localmente avançados e/ou disseminados. Nesta situação, a quimioterapia neoadjuvante é o tratamento padrão.. Infelizmente, o padrão de resposta ao tratamento sistêmico é variável e existe um parcela de pacientes que não apresentam redução tumoral significativa e outros que apresentam progressão da doença. A identificação prévia do grupo de pacientes que mais se beneficiariam da quimioterapia neoadjuvante poderia evitar os efeitos adversos dos quimioterápicos no grupo de pacientes com baixa probabilidade de resposta bem como otimizar custos de tratamento. A ressonância magnética (RM) devido a sua análise tridimensional das imagens, alta sensibilidade e resolução espacial vem sendo empregada na monitorização do tratamento do câncer de mama, utilizando-se, principalmente, técnicas funcionais, como a avaliação farmacocinética após injeção do meio contraste paramagnético e as imagens ponderadas em difusão (DWI). A difusão pode ser utilizada para calcular o valor do coeficiente aparente de difusão (ADC). Recentemente, o ADC vem sendo utilizado como ferramenta diagnóstica e prognóstica no câncer de mama.. Alguns estudos mostraram que pacientes respondedoras à quimioterapia neoadjuvante apresentaram um aumento dos valores médios do ADC tumoral logo após o segundo ciclo do tratamento. Porém, poucos estudos, e com alguns resultados discordantes, avaliaram a capacidade do ADC em discriminar, previamente ao tratamento quimioterápico, aqueles tumores que terão melhor resposta patológica. Objetivos: comparar os diversos parâmetros derivados do ADC de neoplasias mamárias para avaliar possíveis preditores de resposta patológia à quimioterapia neoadjuvante. Materiais e métodos: Estudo retrospectivo envolvendo 57 pacientes com carcinoma de mama localmente avançado que realizaram RM previamente à quimioterapia neoadjuvante. Múltiplos métodos de medida do ADC foram realizados, sendo estudadas as validades das medidas calculando-se a área sobre a curva ROC e estabelecendo-se os valores de sensibilidade e especificidade. Os dados das diferentes mensurações foram analisados através do teste ANOVA. Para avaliação da variabilidade inter-observador foi utilizado o teste de Kappa. Resultados: As diferentes mensurações dos valores de ADC dos tumores não evidenciou diferença estatística significativa entre o grupo respondedor e não respondedor. Nenhum dos parâmetros analisados pode ser considerado como preditor de resposta. Não houve diferença significativa na obtenção dos diferentes parâmetros derivados do ADC entre a medida de um único corte na região central da lesão, quando comparada com a medida de toda a lesão (volumetria). Conclusão: Os diferentes parâmetros derivados da medida do ADC, pré-quimioterapia neoadjuvante não predizem resposta ao tratamento em pacientes com tumores de mama localmente avançados / Introduction : Breast cancer is a highly prevalent and incident disease. In Brazil , although about half of cases are diagnosed in locally advanced or disseminated stages . In this situation, the neoadjuvant chemotherapy is a standard treatment. Unfortunately, the pattern of response to systemic treatment is variable and there is a proportion of patients with no significant tumor reduction and others that have disease progression. Prior identification of the group of patients who would most benefit of neoadjuvant chemotherapy could avoid the adverse effects of chemotherapy in patients with low probability of response and optimize treatment costs. Magnetic resonance imaging ( MRI) due to its three-dimensional image analysis, high sensitivity and spatial resolution has been used for monitoring the treatment of breast cancer, using mainly functional techniques such as pharmacokinetic evaluation after injection of paramagnetic contrast medium and diffusion weighted imaging (DWI) . It can be used to calculate the apparent diffusion coefficient (ADC). Recently, the ADC has been used as a diagnostic and prognostic tool in breast cancer. Some studies have shown that patients who respond to neoadjuvant chemotherapy showed an increase of the mean ADC tumor values after the second cycle of treatment. However, few studies and with some discordant results, reviewed the ADC \'s ability to discriminate, prior to chemotherapy, those tumors that have better pathological response. Objectives: To compare the various parameters derived ADC of breast tumors to evaluate possible predictors of response to neoadjuvant chemotherapy pathology. Methods : a retrospective study of 56 patients with locally advanced breast carcinoma who underwent MRI prior to neoadjuvant chemotherapy. Multiple ADC measurement methods were performed and the validity of the measures was studied by calculating the area under the ROC curve and setting up the sensitivity and specificity values. The data of different measurements were analyzed using ANOVA test. To evaluate the interobserver variability was used Kappa test. Results: The different measurements of ADC values of tumors showed no statistically significant difference between the responder group and the group with no response. None of the analyzed parameters can be suggested as predictor of response. There was no significant difference in obtaining the various parameters derived from the ADC either measuring a single slice, at the central region of the lesion or measuring the whole lesion (volumetry). Conclusion: The different parameters derived from the measurement of the ADC prior to neoadjuvant chemotherapy do not predict response to therapy in patients with locally advanced breast cancers..

Orientadores: Nelson Adami Andreollo, Luiz Roberto Lopes / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-16T06:07:19Z (GMT). No. of bitstreams: 1 TerciotiJunior_Valdir_M.pdf: 3600998 bytes, checksum: 6867e524b51d1a71d777c2132d9f2244 (MD5) Previous issue date: 2010 / Resumo: A neoplasia de esôfago é a oitava neoplasia mais incidente no Brasil, mantendo alta letalidade a despeito da melhora do tratamento cirúrgico nas últimas décadas. Os tratamentos utilizados dividem-se em: I) paliativos (sondas para nutrição enteral, próteses endoscópicas, gastrostomia, jejunostomia, derivação esôfago-gástrica, quimioterapia, radioterapia) e; II) curativos (esofagectomias isoladas, terapias neo-adjuvantes e terapias adjuvantes). Sendo assim, estratégias de tratamento neo-adjuvante tornam-se objeto de estudo. O objetivo do trabalho é avaliar em estudo retrospectivo não-randomizado a morbidade, a mortalidade e a sobrevida dos pacientes operados na Faculdade de Ciências Médicas da UNICAMP no período de 1979 a 2006, divididos em três grupos: I) esofagectomia; II) radioterapia neo-adjuvante seguido de esofagectomia; e III) radioterapia-quimioterapia neo-adjuvante seguido de esofagectomia. Na análise dos resultados, os grupos não diferem significativamente quanto ao sexo, cor, idade, alguns sintomas pré-operatórios (pirose, tabagismo), complicações pós-operatórias, mortalidade, N patológico, grau de diferenciação histológica e estadiamento; os grupos diferem significativamente em relação a outros sintomas (disfagia, dor retroesternal, etilismo), localização tumoral, T patológico e resposta tumoral. As conclusões mostram diferenças de sobrevida entre os grupos após a exclusão dos óbitos peri-operatórios, com benefício estatisticamente significativo para a terapêutica neo-adjuvante / Abstract: Neoplasm of esophagus cancer is the eighth highest incidence in Brazil, maintaining a high mortality rate despite the improvement of surgical treatment in recent decades. Treatments are divided into: I) palliative (nasogastric tube for enteral nutrition, prosthetics, endoscopic gastrostomy, jejunostomy, esophageal-gastric bypass, chemotherapy, radiotherapy) and; II) radical (esophagectomy isolated, neo-adjuvant therapy and adjuvant therapy) . Thus, neoadjuvant treatment strategies become the object of study. The objective is to evaluate with a non-randomized retrospective study morbidity, mortality and survival of patients operated in the Faculty of Medical Sciences of Campinas in the period 1979-2006, divided into three groups: I) esophagectomy; II) neoadjuvant radiotherapy followed by esophagectomy, and III) neoadjuvant radiotherapy and chemotherapy followed by esophagectomy. Results show that groups did not differ significantly regarding gender, race, age, some preoperative symptoms (heartburn, smoking), postoperative complications, mortality, N pathological, histological grade and stage; groups differ significantly for other symptoms (dysphagia, retrosternal pain, alcoholism), tumor location, T and pathological tumor response. Findings show differences in survival between groups after the exclusion of perioperative deaths, with statistically significant benefit for neoadjuvant therapy / Mestrado / Cirurgia / Mestre em Cirurgia

Orientadores: Luiz Carlos Teixeira, Marcelo Alvarenga / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-06T06:39:22Z (GMT). No. of bitstreams: 1 Campos_GraceImaculadaPereira_M.pdf: 240494 bytes, checksum: cd5e0f3dc3493ba406e12d65609a451f (MD5) Previous issue date: 2006 / Resumo: Objetivo: Avaliar a expressão imunoistoquímica da P-glicoproteína e sua correlação com a resposta à quimioterapia com esquemas contendo antraciclina em mulheres portadoras de carcinoma de mama estádio III. Sujeitos e Métodos: Estudo de coorte retrospectivo, em que foram analisados 88 prontuários de pacientes matriculadas no período de Junho de 1996 a novembro de 2003 no Ambulatório de Oncologia Clinica do CAISM-Unicamp, e portadoras de carcinoma ductal infiltrativo localmente avançado, que receberam quimioterapia neo-adjuvante com esquemas contendo antraciclina, excluindo as portadoras de carcinoma inflamatório. O tumor foi biopsiado antes do tratamento (core biopsy ou incisional) e submetido a exame imunoistoquímico pelo sistema envision peroxidase, utilizando-se anticorpos monoclonais anti-P-glicoproteína (P-gp), C494 (Signet) trans-menbrana e C219 (Signet) intra-citoplásmatico. Considerou-se positivo coloração citoplasmática ou trans-membrana em 10% ou mais das células. O controle externo positivo usado foi tecido normal de rim humano. A resposta clínica foi avaliada antes da cirurgia, após no mínimo dois ciclos de quimioterapia e os dados correlacionados com a expressão da p-glicoproteína. Empregou-se o teste exato de Fisher ou qui-quadrado para avaliar as possíveis associações. Resultados: A freqüência da positividade da P-glicoproteína na amostra foi de 23,86%. A resposta clínica objetiva à quimioterapia foi semelhante nos casos com e sem expressão da p-glicoproteína, considerando o tumor primário (57,1% vs 58,2%), axila (67,8% vs 78,8%) e resposta total (57,2% vs 65,7 %, p = 0,851). Conclusão: Não encontramos relação entre a expressão da P-glicoproteína e a resposta clínica à quimioterapia neo-adjuvante, sugerindo que este marcador não deve ser considerado como fator preditivo de resposta à quimioterapia com antraciclina / Abstract: Objective: Evaluate the immunohistochemical expression of P-glycoprotein and its correlation to the response to chemotherapy with schemes containing antraciclin in women who are carriers of stage III breast carcinoma. Subjects and Methods: In the study of retrospective cohort, 88 files of patients who are carriers of locally advanced infiltrative ductal carcinoma were analyzed, and received neoadjuvant chemotherapy containing antraciclin, excluding the inflammatory cases, from June 1996 to November 2003, in the Oncology Clinic of CAISM-Unicamp. The tumor was biopsized before treatment (core biopsy or incisional biopsy) and subjected to the immunohistochemical exam by using the envision peroxidase system and utilizing anti-P-glycoprotein monoclonal antibodies (P-gp), C494 (Signet) trans-menbrane and C219 (Signet) intra-cytoplasmatic. The cytoplasmatic coloring or trans-membrane was considered positive in a rate of 10% or more of the cells. The external positive control which was used was human kidney normal tissue. Clinical response was evaluated before surgery, after a minimum of two cycles of chemotherapy and the data was correlated to the expression of P-glycoprotein. The exact Fisher test or Qui-square test was used to evaluate any possible associations. Results: The frequency of the positivity of P-glycoprotein in the samples was 23.86%. The objective clinical response to chemotherapy was similar in the cases with and without the expression of P-glycoprotein, considering the primary tumor (57.1% vs 58.2%), arm pit (67.8% vs 78.8%) and total response (57.2% vs 65.7%, p = 0.851). Conclusion: The relation between the expression of P-glycoprotein and the clinical response to to neoadjuvant chemotherapy was not found, what suggests that this marker should not be considered as a response predictive factor to chemotherapy with anthracyclin / Mestrado / Ciencias Biomedicas / Mestre em Tocoginecologia

Background: Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of US cancer related deaths. This study assessed the oncologic benefit of a neoadjuvant chemotherapy (NAC) treatment strategy for patients with clinical Stage I/II PDAC. Methods: Patients with biopsy confirmed PDAC and clinical Stage I/II disease were treated with a protocol of NAC. The primary study endpoint was median overall survival (OS). Kaplan-Meier survival curves were compared using the log-rank test. Results: 56 patients met inclusion criteria. Of these, 21 patients (38%) had Stage I disease and 35 (62%) had Stage II disease. The median OS for the entire study population was 18.7 months. A total of 22 (39%) patients were managed with NAC+S; 34 (61%) received NAC alone. Median OS and 2-year survival rates were greater in those completing NAC+S compared to NAC alone (median OS 28.8 months vs. 17.3 months: p=0.05; 2-year OS: 55% vs 21%: p=0.01) . Interestingly, patients managed with NAC who were not candidates for surgical resection after restaging demonstrated a survival advantage (17.3 months) compared to what was previously reported in historical controls. Conclusion: NAC+S provided a significant 11.5 month improvement in median OS compared to treatment with NAC alone. Modern NAC may contribute a significant oncologic benefit in the overall treatment strategy for patients with Stage I/II PDAC, even if surgery is not ultimately pursued.