O objetivo do estudo foi avaliar a importância da expressão das proteínas topoisomerase II alfa (topo II) e HER-2 como fatores preditvos da resposta à quimioterapia neoadjuvante e prognóstico em pacientes com câncer de mama nos estádio clínico II e III. Pacientes e métodos: 99 pacientes receberam quimioterapia neoadjuvante com docetaxel (75mg /m²) e epirrubicina (50 mg/m²) em infusão endovenosa no dia 1 a cada 3 semanas após terem sido submetidas a biópsia incisional. Foi complementado tratamento sistêmico com quimioterapia adjuvante com CMF ou FEC de acordo com o estado axilar avaliada após a cirurgia definitiva e/ou hormonioterapia de acordo com a avaliacãodos receptores hormonais. Avaliamos a taxa de resposta ao tratamento neoadjuvante e a influência da topo II alfa e do HER-2 na taxa de resposta à quimioterapia neoadjuvante bem comona sobrevida livre de doença e sobrevida global. Também foram avaliadas a expressão dos receptores hormonais. Resultados: a taxa de resposta clínica objetiva foi de 80,8 % com 9,1 % de resposta patológica completa. A expressão da topo II alfa nao apresentou significância nas taxas de resposta ou na sobrevida das pacietnes e nao houve correlação entre a expressão desta proteína e de HER-2. A superexpressão da proteína HER-2 foi associada com uma redução significante nas taxas de sobrevida livre de doença e sobrevida global (p= 0,04 e p= 0,004, respectivamente). Conclusão: a expressão da topo II alfa não demonstrou, em nosso estudo, ser fator preditivo ou prognóstico nas pácientes submetidas a quimioterapia neoadjuvante com docetaxel e epirrubicina. / The objective of this study is to evaluate the importance of the expression of the proteins topoisomerase II alpha (topo II) and HER-2 as predictive factors to response to neoadjuvant chemotherapy and the prognosis of patients diagnosed with clinical stage II and stage III breast cancer. Patients and methods: 99 patients have received neoadjuvant chemotherapy with docetaxel (75mg /m²) and epirrubicine (50 mg/m²) through intravenous infusion on D1 q3 weeks, after submitted to pathologic specimen harvest. Systemic treatment was then complemented with CMF or FEC according to the status of axilla involvement after surgical staging and/or hormone therapy according tohormone receptor status. We evaluated the response rate to neoadjuvant treatment and the influence of topo II alpha and HER-2 expression on the response rate and disease free survival and overall survival. The expression of hormone receptors was also evaluated. Results: Objective clinical response was 78,8%, with 8,2% of complete pathological response.Topo II alpha expression did not correlate to response to chemotherapy or survival and there was no correlation between topo II alpha expression and HER-2 expression. Superexpression of HER-2 protein was associated to a significant reduction in disease free survival and overall survival (p=0,04 and p=0,004, respectively). Conclusion: topo II alpha expression did not demonstrate, in our study, to be a predictive nor prognostic factor to the patientssubmitted to neoadjuvant with docetaxel and epirrubicin.

Determinar o valor prognóstico e preditivo do VEGF (vascular endothelial growth factor) e do HIF-1? (Hypoxia-inducible factor-1) em relação à sobrevida livre de doença (SLD) e sobrevida global (SG) em pacientes com carcinoma de mama localmente avançado (CMLA) tratadas primariamente pela quimioterapia neoadjuvante. MATERIAIS E METODOS: VEGF e HIF foram quantificados consecutivamente em plasma de 36 pacientes com CMLA pelo método de ELISA (enzyme labeling immunoassay absorbant) para o VEGF165 e o HIF-1?. O tratamento neoadjuvante foi realizado em todas as pacientes com docetaxel e epirrubicina. O tempo médio de seguimento foi de 56 meses. RESULTADOS: Uma análise univariada demonstrou que o HIF-1? está significantemente relacionado à SLD (P =.0238) e à SG (P = .0121) com as pacientes HER-2 positivas. Não houve diferença significante para a SLD ou SG no que diz respeito aos receptores de hormônio, comprometimento axilar ou grau tumoral. Os valores de VEGF foram maiores no grupo de pacientes RE+ do que no grupo RE negativo (P =.01). Inversamente os valores de HIF-1? foram menores no grupo RE+ comparados ao grupo RE - (P =.02). Pacientes com recorrência óssea apresentaram uma tendência a apresentarem valores de VEGF menores (media, 175.7 pg/ml) do que aquelas com recorrência visceral (441 pg/ml). Uma análise multivariada demonstrou o comprometimento axilar (P =.0004), receptores de estrógeno (ER) (P < .0001), e tamanho do tumor (P = .0085) como fatores independentes de SLD. O HIF-1? foi tido como um fator independente preditivo de SG (P =.0180). Não houve diferença estatisticamente significante entre os valores plasmáticos de HIF-1? ou VEGF nos períodos pré e pós quimioterapia. CONCLUSÕES: Os resultados sugerem que o nível plasmático do HIF-1? é preditivo de SLD e SG nas pacientes com CMLA apresentando uma sobreposição as pacientes HER-2 positivas. As dosagens de VEGF podem ser preditivas de resposta e prognóstico no tratamento neoadjuvante, mas são necessários novos estudos prospectivos comparados ao HIF-1? para conclusões mais consistentes. / To determine the predictive and prognostic value of vascular endothelial growth factor (VEGF) and Hypoxia-inducible factor-1 (HIF-1?) for relapse-free survival (RFS) and overall survival (OS) in locally advanced breast cancer (LABC) primarily submitted to neoadjuvant chemotherapy. MATERIALS AND METHODS: VEGF and HIF were quantitatively measured in plasma sample from 36 consecutive patients with LABC using an enzyme immunoassay for human VEGF165 and HIF-1?. Neoadjuvant treatment was given to all patients as docetaxel and epirrubicin. The follow-up median time was 56 months. RESULTS: Univariate analysis showed that HIF-1? is a significant predictor of RFS ( P = .0238) and OS (P = 0121) in HER-2 positive patients. No significant difference was seen in RFS or OS related to hormonal receptor, axillary status or tumoral grade. The VEGF level was higher in the group of patients who ER was positive than ER negative (P = .01). On the other hand, the HIF-1? level is higher in ER negative patients than ER positive ( P=.02). Patients with bone recurrences tended to have lower VEGF plasma level (median, 175.7 pg/ml) than patients with visceral metastasis (441 pg/ml). Multivariate analysis showed nodal status (P = .0004), estrogen receptor (ER) status (P < .0001), and tumor size (P = .0085) to be independent predictors of RFS. HIF-1? was found to be an independent predictor of OS (P = .0180). No statistically differences were observed related to pre and post chemotherapy period in HIF-1? or VEGF measurements. CONCLUSION: The results suggest that high level of plasma HIF-1? is associated to HER-2 over expression and they are major predictive factors of RFS and OS in LABC. VEGF content might also predict outcome after neoadjuvant treatment, however further studies in a prospective setting with HIF-1? homologous treatments are required.

Dans le cancer du sein, la recherche de nouveaux biomarqueurs, permettant de prédire la réponse thérapeutique et de déterminer le pronostic d’une patiente, est importante pour adapter au mieux les traitements mais aussi pour améliorer la compréhension des phénomènes physiopathologiques. Nous nous sommes particulièrement intéressés aux cancers du sein traités par chimiothérapie néoadjuvante. Nous avons étudié, dans des biopsies tumorales réalisées avant traitement et dans des résidus tumoraux, à la fois les paramètres télomériques et la réparation des lésions d’ADN puisque ces 2 mécanismes, lorsqu’ils sont dysfonctionnels, sont à l’origine d’une forte instabilité génomique. Nous avons corrélés ces paramètres à la réponse à la chimiothérapie néoadjuvante et à la survie des patientes. Dans un 1er temps, nous avons montré que des télomères courts, une surexpression de la télomérase (TERT) et une sous-expression d’une protéine impliquée dans différents mécanismes de réparation de l’ADN, ERCC1, sont des marqueurs de mauvais pronostic. La dysfonction simultanée des télomères et des mécanismes de réparation de l’ADN peut contribuer de façon synergique à la progression tumorale et à la résistance thérapeutique. Nous avons ensuite étudié une population de tumeurs du sein triple négatives. Nous avons montré que des télomères courts sont associés aux tumeurs les plus agressives et les plus résistantes. De plus, une résistance thérapeutique est retrouvée associée à une instabilité génomique plus importante. Nous avons enfin analysé les altérations génomiques caractéristiques permettant d’identifier le statut BRCA1-like. Le profil BRCA1-like est corrélé à une résistance thérapeutique et à une forte instabilité génomique.Enfin, nous avons réalisé une étude plus fondamentale visant à identifier les mécanismes à l’origine de la réactivation de la télomérase dans le cancer du sein. Nous avons démontré que la surexpression de TERT, dans le cancer du sein, n’est pas liée à la présence de mutations somatiques activatrices mais plutôt à celle de gain du locus TERT. Ces gains sont associés à une résistance thérapeutique et un risque de rechute plus important. Enfin, la présence de gain de TERT combinée à la surexpression de MYC, permet de définir un sous groupe de très mauvais pronostique et pourrait être utilisé pour évaluer le risque de récidives. Les paramètres télomériques et l’instabilité génomique semblent donc être des biomarqueurs prédictifs de la réponse à la chimiothérapie néoadjuvante dans le cancer du sein triple négatif. Ces paramètres ont également une forte valeur pronostique dans le cancer du sein en général et pourraient être utilisés cliniquement comme biomarqueurs utiles au choix des traitements. / In breast cancer, discovering new biomarkers, that can predict therapeutic response and prognosis, is important to find the best therapeutic options and improve our understanding of physiopathology. Our particular interest is in breast cancer treated by neoadjuvant chemotherapy (NCT). In pre-NCT biopsies and post-NCT tumors, we studied both telomeric parameters and DNA damage repair (DDR), because when these are dysfunctional, both result in high genomic instability. We correlated these parameters to neoadjuvant chemotherapy response and patient outcomes. First, we demonstrated that short telomeres, high telomerase (TERT) expression and low expression of ERCC1 (a protein involved in a number of DNA repair mechanisms) are markers of poor prognosis. Telomere and DDR dysfunction can contribute synergistically to tumor progression and chemoresistance. We then studied a triple negative breast cancer population. We demonstrated that short telomeres were associated with tumor aggressiveness and chemoresistance. Chemoresistance was also associated with high genomic instability. We analyzed genomic alterations specific to BRCA1-like status and demonstrated that BRCA1-like profile correlated with chemoresistance and high genomic instability. Finally, we performed a comprehensive study of telomerase reactivation in breast cancer. We demonstrated that high TERT expression in breast cancer is not associated with somatic enhancer mutations but more probably to TERT locus gains. These gains were correlated to chemoresistance and increased risk of relapse. TERT gain, combined with high MYC expression, was able to isolate a subgroup with a very poor prognosis, and this could be used to evaluate risk of relapse. Telomeric parameters and genomic instability seem to be predictive biomarkers for neoadjuvant chemotherapy response in triple negative breast cancer. These parameters also have strong prognostic value in breast cancer and could be used clinically as biomarkers for tailoring treatment.

O carcinoma de mama é uma doença altamente prevalente e incidente. Em nosso meio, cerca de metade dos casos são diagnosticados em estádios localmente avançados e/ou disseminados. Nesta situação o índice de sucessos terapêuticos é pequeno. Recentemente vem sendo citado na literatura as células tronco tumorais (CTT) como aquelas responsáveis pelas recorrências tumorais, pois este tipo de células seria capaz de repovoar o hospedeiro com células tumorais de mesma origem. Postula-se também que este tipo de células é resistente ao tratamento quimioterápico. Assim, o prognóstico de uma paciente dependeria diretamente da quantidade de CTT presentes em seu tumor na época do tratamento. As expressões de CD44/CD24, CXCR4 e ABCG2 têm sido relatadas como potenciais marcadores de células tronco no câncer de mama (CTCM). A associação entre a quantidade de CTCMs e a resposta à quimioterapia neoadjuvante (QNA) permanece obscura. Métodos: Foram analisadas prospectivamente a expressão de CD44/CD24, CXCR4 e ABCG2 em 41 pacientes com câncer de mama localmente avançado ou metastático (CMLA) submetidas à QNA. O ensaio de mamosferas (Mammocult ®) foi estudado em 25 amostras. Idade média dos pacientes foi de 52,9 ± 10,3 anos. De acordo com o estádio clínico (EC), uma paciente foi classificada como IIa, 5 pacientes foram IIb, 10 foram IIIa, 16 foram IIIb, uma foi IIIc e 8 foram IV. O diâmetro médio do tumor clínico foi de 5,6 ± 3 centímetros. Os receptores de estrógeno (RE), receptores de progesterona (PgR) e HER2 positivos apresentaram as taxas de expressão de 65%, 58% e 46%, respectivamente. A porcentagem mediana de células ESA+/CD44+/CD24-, ESA+/CXCR4 + e ESA+/ABCG2 + foram determinados por citometria de fluxo em tumores frescos amostrados após a digestão do tecido. A relação entre as análises de citometria de fluxo e resposta clínica e patológica à terapia foi analisada. Resultados: A resposta clínica completa (RCC) e resposta patológica completa (PCR) foram observadas em 15 (36%) e 10 (24%) pacientes respectivamente. Não observamos uma associação significativa entre PCR, ER, PgR ou expressão HER2. Observamos uma associação entre o tamanho clínico com percentual de células ESA+/ABCG2+ dentro do tumor (p = 0,0481) e do grau tumoral com a capacidade de formação de esferas (p = 0,0392). Nenhuma correlação entre PCR e a população de células CD44+/CD24- dentro do tumor foi observada. Houve uma correlação positiva entre a expressão de ESA+/ABCG2+ e ESA+/CXCR4+ com o número de formação de mamosferas (p = 0,0007 e p = 0,0497, respectivamente). Esta correlação não foi significativa em comparação com células ESA+/CD44+/CD24-. Conclusões: O percentual de células cancerosas ABCG2+ dentro do tumor e do número de formação mamosferas são fatores preditivos de PCR em pacientes submetidos à QNA para CMLA. ABCG2 é um marcador potencial para CTCMs. Palavras chave: Câncer de mama, Célula tronco tumoral, Quimioterapia neoadjuvante, Taxanos, Fatores prognósticos. / Breast cancer is a disease highly prevalent and incident. In our country, about half of cases are diagnosed in advanced stages locally and / or disseminated. In this situation the therapeutic success rate is small. Recently been reported in the literature cancer stem cells (CSC) as those responsible for tumor recurrence, as this type of cells could repopulate the host cell tumor of the same origin. It is also postulated that this type of cells are resistant to chemotherapy. Thus the prognosis of a patient depend directly on the amount of CSC present in their tumor at the time of treatment. The expressions of CD44/CD24, CXCR4 and ABCG2 have been reported as potential breast cancer stem-like cell (CSLC) markers. The association between the quantity of CSLCs and the response to neoadjuvant chemotherapy (NACT) remains unclear. Methods: We prospectively analyzed the expression of CD44/CD24, CXCR4 and ABCG2 in 41 breast cancer patients with locally advanced or metastatic (CMLA) submitted to NAC. The assay mamosferas (Mammocult ®) was studied in 25 samples. Mean age of patients was 52.9 ± 10.3 years. According to the clinical stage (CS), one patient was classified as IIa, IIb 5 patients, 10 were IIIa, IIIb were 16, 1 and 8 have been IIIc IV. The mean diameter of tumor therapy was 5.6 ± 3 cm. The estrogen receptor (ER), progesterone receptor (PgR) and HER2 showed positive expression rates of 65%, 58% and 46%, respectively. The median percentage of cells ESA+/CD44+/CD24-, ESA+/CXCR4+ and ESA+/ABCG2+ were determined by flow cytometry in tumors sampled after digestion fresh tissue. The relationship between flow cytometric analysis and clinical and pathological response to therapy was assessed. Results: The complete clinical response (CCR) and pathologic complete response (PCR) was seen in 15 (36%) and 10 (24%) patients, respectively. We did not observe a significant association between CRP, ER, PgR and HER2 expression. An association was observed between the size clinical percentage of cells ESA+/ABCG2+ within the tumor (p = 0.0481) and tumor grade with the ability to form spheres (p = 0.0392). No correlation between PCR and cell population CD44+/CD24-within the tumor was observed. There was a positive correlation between the expression of ESA+/ABCG2+ and ESA+/CXCR4+ with the number of training mamosferas (p = 0.0007 and p = 0.0497, respectivamenete). This correlation was not significant compared with cells ESA+/CD44+/CD24-. Conclusions: The percentage of ABCG2 + cancer cells within the tumor and the number of training mamosferas are predictors of CRP in patients undergoing NAC for CMLA. ABCG2 is a potential marker for CTCMs. Keywords: Breast cancer, stem cell tumor, neoadjuvant chemotherapy, taxanes, Prognostic factors.

Determinar o valor prognóstico e preditivo do VEGF (vascular endothelial growth factor) e do HIF-1? (Hypoxia-inducible factor-1) em relação à sobrevida livre de doença (SLD) e sobrevida global (SG) em pacientes com carcinoma de mama localmente avançado (CMLA) tratadas primariamente pela quimioterapia neoadjuvante. MATERIAIS E METODOS: VEGF e HIF foram quantificados consecutivamente em plasma de 36 pacientes com CMLA pelo método de ELISA (enzyme labeling immunoassay absorbant) para o VEGF165 e o HIF-1?. O tratamento neoadjuvante foi realizado em todas as pacientes com docetaxel e epirrubicina. O tempo médio de seguimento foi de 56 meses. RESULTADOS: Uma análise univariada demonstrou que o HIF-1? está significantemente relacionado à SLD (P =.0238) e à SG (P = .0121) com as pacientes HER-2 positivas. Não houve diferença significante para a SLD ou SG no que diz respeito aos receptores de hormônio, comprometimento axilar ou grau tumoral. Os valores de VEGF foram maiores no grupo de pacientes RE+ do que no grupo RE negativo (P =.01). Inversamente os valores de HIF-1? foram menores no grupo RE+ comparados ao grupo RE - (P =.02). Pacientes com recorrência óssea apresentaram uma tendência a apresentarem valores de VEGF menores (media, 175.7 pg/ml) do que aquelas com recorrência visceral (441 pg/ml). Uma análise multivariada demonstrou o comprometimento axilar (P =.0004), receptores de estrógeno (ER) (P < .0001), e tamanho do tumor (P = .0085) como fatores independentes de SLD. O HIF-1? foi tido como um fator independente preditivo de SG (P =.0180). Não houve diferença estatisticamente significante entre os valores plasmáticos de HIF-1? ou VEGF nos períodos pré e pós quimioterapia. CONCLUSÕES: Os resultados sugerem que o nível plasmático do HIF-1? é preditivo de SLD e SG nas pacientes com CMLA apresentando uma sobreposição as pacientes HER-2 positivas. As dosagens de VEGF podem ser preditivas de resposta e prognóstico no tratamento neoadjuvante, mas são necessários novos estudos prospectivos comparados ao HIF-1? para conclusões mais consistentes. / To determine the predictive and prognostic value of vascular endothelial growth factor (VEGF) and Hypoxia-inducible factor-1 (HIF-1?) for relapse-free survival (RFS) and overall survival (OS) in locally advanced breast cancer (LABC) primarily submitted to neoadjuvant chemotherapy. MATERIALS AND METHODS: VEGF and HIF were quantitatively measured in plasma sample from 36 consecutive patients with LABC using an enzyme immunoassay for human VEGF165 and HIF-1?. Neoadjuvant treatment was given to all patients as docetaxel and epirrubicin. The follow-up median time was 56 months. RESULTS: Univariate analysis showed that HIF-1? is a significant predictor of RFS ( P = .0238) and OS (P = 0121) in HER-2 positive patients. No significant difference was seen in RFS or OS related to hormonal receptor, axillary status or tumoral grade. The VEGF level was higher in the group of patients who ER was positive than ER negative (P = .01). On the other hand, the HIF-1? level is higher in ER negative patients than ER positive ( P=.02). Patients with bone recurrences tended to have lower VEGF plasma level (median, 175.7 pg/ml) than patients with visceral metastasis (441 pg/ml). Multivariate analysis showed nodal status (P = .0004), estrogen receptor (ER) status (P < .0001), and tumor size (P = .0085) to be independent predictors of RFS. HIF-1? was found to be an independent predictor of OS (P = .0180). No statistically differences were observed related to pre and post chemotherapy period in HIF-1? or VEGF measurements. CONCLUSION: The results suggest that high level of plasma HIF-1? is associated to HER-2 over expression and they are major predictive factors of RFS and OS in LABC. VEGF content might also predict outcome after neoadjuvant treatment, however further studies in a prospective setting with HIF-1? homologous treatments are required.

Introdução: A neoplasia de mama é o tipo mais comum de câncer entre as mulheres. A despeito dos programas de rastreamento, que marcadamente reduziram a mortalidade, devido, principalmente ao diagnóstico precoce, uma significativa parcela de mulheres, apresenta-se com tumores localmente avançados na ocasião do diagnóstico. Nestas situações o tratamento neoadjuvante (TNA) está indicado. Com o advento de novos esquemas medicamentosos e crescentes indicações de TNA, busca-se fatores preditores da resposta tumoral, que a determinem de maneira precoce, precisa, objetiva e reprodutível. Até o momento, não há consenso em como determinar, clinicamente, a resposta da neoplasia ao TNA. Objetivo: O presente estudo investigou a associação entre o realce de fundo do tecido fibroglandular (BPE) em exames de RM da mama contralateral a neoplasia e a resposta patológica ao tratamento quimioterápico neoadjuvante (TNA), em pacientes portadoras de câncer de mama localmente avançado. Materiais e Métodos: Um total de 55 pacientes apresentando carcinoma ductal invasivo de mamas foram avaliadas, consecutivamente, entre setembro de 2010 e novembro de 2013. As pacientes selecionadas realizaram RM previamente ao início do tratamento quimioterápico e foram submetidas a tratamento cirúrgico após término do TNA. O BPE foi aferido através da avaliação qualitativa, de acordo com as categorias preconizadas pela 5° edição do BI-RADS e por método quantitativo, por segmentação automática do tecido fibroglandular da mama contralateral a neoplasia e cálculo do coeficiente de realce do parênquima. As pacientes foram divididas em dois grupos, de acordo com os achados anatomopatológicos encontrados na peça cirúrgica obtida ao término do TNA: Grupo Resposta Completa: ausência de neoplasia na peça cirúrgica e Grupo Resposta Ausente: presença de neoplasia residual na peça cirúrgica. O BPE destes dois grupos foi então comparado. Resultados: Encontramos diferença significativa (p<0,001) entre os grupos para a variável BPE, quando aferida de maneira qualitativa, sendo que o grupo que obteve resposta patológica completa apresentou maior BPE. A análise do coeficiente do BPE não demonstrou diferença significativa entre os grupos (p=0,075), porém uma tendência a diferença significativa, com o grupo resposta patológica completa apresentando valores superiores de coeficiente de realce, em concordância com a avaliação qualitativa. Conclusões: Os resultados sugerem que o BPE da mama contralateral à neoplasia pode estar relacionado à resposta patológica após TNA, quando aferido de maneira qualitativa. Maiores valores de coeficiente de BPE também parecem estar associados a maior chance de obter resposta patológica completa. / Introduction: Breast cancer is the most common type of cancer among women. Despite screening programs, which markedly reduced mortality mainly due to early diagnosis, a significant number of women present with locally advanced tumors at diagnosis. The neoadjuvant chemotherapy treatment (NAT) is indicated in these situations. The advent of new drug regimens and growing indications of NAT requires biomarkers for assessing and predicting the response of breast cancer to neoadjuvant therapy. At presente, there is no consensus to the early assessment of breast cancer response to NAT. Objective: This study investigated the association between Backgroud Parenchymal Enhancement (BPE) of contralateral breast cancer and the pathologic response to neoadjuvant chemotherapy treatment in patients with locally advanced breast cancer. Materials and Methods: A retrospective study of 55 patients with locally advanced breast cancer. The selected patients underwent MRI before the start of chemotherapy and underwent surgery after TNA completion. The BPE was determined by qualitative assessment, according to the categories recommended by the 5th edition of BI- RADS, and quantitative method by automatic segmentation of fibroglandular tissue of contralateral breast and calculation of BPE coefficient. The patients were divided into two groups according to pathological findings in surgical specimens obtained at the end of TNA, Group Complete Response: no tumor in the surgical specimen and Group Response Absent: presence of residual tumor in the surgical specimen .The BPE of these two groups were compared. Results: We found a significant difference (p <0.001) between the groups for the BPE variable when measured in a qualitative manner. The complete pathological response group got highest category of BPE. The analysis of the BPE coefficient showed no significant difference between groups (p=0.075), but a tendency to significant differences, with complete pathological response group presenting higher values of BPE coefficient. Conclusions: The results suggest that the BPE of contralateral breast is correlated to the pathological response after neoadjuvant chemotherapy treatment, when measured in a qualitative manner. Higher values of BPE coefficient appear to be associated with a higher chance of getting complete pathological response to neoadjuvant chemotherapy treatment.

Introduction Axillary dissection has little diagnostic and therapeutic benefit in the node-positive breast cancer patients in whom axillary disease has been completely eradicated after neoadjuvant chemotherapy (ypN0). We sought to assess the efficacy of an algorithm used for the identification of the ypN0 patients consisting of intraoperative evaluation of sentinel and tattooed (initially positive) lymph nodes. Methods Included were T1 and T2 breast cancer patients with one to three positive axillary lymph nodes marked with carbon who were referred for neoadjuvant chemotherapy followed by a surgery. Axillary dissection was performed only in the patients with residual axillary disease after neoadjuvant chemotherapy on ultrasound or with metastases described in the sentinel or tattooed lymph nodes either intraoperatively or in the final histology. Results Out of 62 included initially node-positive patients, 15 (24%) were spared axillary dissection. The detection rate of tattooed lymph node after neoadjuvant chemotherapy was 81%. The ypN0 patients were identified with 91% sensitivity and 38% specificity using ultrasound and intraoperative assessment of both sentinel and tattooed lymph node according to the final histology. Discussion/Conclusion Lymph node marking with carbon dye is a useful and...

Le cancer du sein triple négatif (CSTN) est le sous-type de cancer du sein le plus hétérogène et le plus défavorable. La pierre angulaire du traitement de ces tumeurs repose sur la chimiothérapie systémique, de plus en plus fréquemment administrée en néoadjuvant, puisqu’aucune thérapie ciblée n’est à ce jour validée. L'obtention d'une réponse complète histologique (RCH) constitue un marqueur pronostique favorable majeur ainsi qu'un test in vivo de la sensibilité aux médicaments anti-tumoraux. L’objectif de notre travail de thèse a donc été d’apporter des éléments de compréhension de cette hétérogénéité grâce à la dissection clinique, biologique et moléculaire de ces tumeurs. Nous avons analysé les profils d'expression géniques de ces CSTN et ainsi identifié 6 sous-types moléculaires distincts avec des biologies et des pronostics différents. Cette classification s’appuie sur une méthodologie originale basée à la fois sur des outils bioinformatiques classiques associée à l’utilisation de réseaux biologiques. L’enrichissement en gènes de l'immunité issus du compartiment stromal de la tumeur représente un déterminant majeur du pronostic de ces tumeurs : une forte expression des gènes de l'immunité est associée un pronostic significativement plus favorable. Notre principale contribution repose sur une meilleure compréhension de l’immunité et de l’infiltrat lymphocytaire (TILS) de ces CSTN. Il s’agit probablement du sous-groupe de cancers du sein le plus immunogène avec des taux de TILS pré-CNA parmi les plus élevés avec les tumeurs HER2-positives. Cet infiltrat lymphocytaire est d'ailleurs très corrélé aux gènes de notre module immunitaire pronostique dans les CSTN. La valeur prédictive et pronostique des TILS du stroma tumoral est différente selon le sous-type moléculaire de cancer du sein, suggérant une immunité complètement différente de ces tumeurs. Le taux de TILS varie également différentiellement au sein de chaque sous-groupe sous l'influence de la CNA, témoignant d'une interaction complexe entre les TILS et les traitements. Nous montrons que la cinétique des TILS sous l'effet de la CNA est un indicateur pertinent de réponse à la CNA avec une réponse d'autant plus importante qu'une décroissance du taux de TILS sera importante. Les tumeurs les plus immunogènes avec une activité immunitaire importante sont donc les tumeurs triple-négatives les plus favorables. L'un des challenge des années à venir sera donc d'identifier le plus tôt possible les CSTN les moins immunogènes susceptibles de bénéficier au mieux des immunothérapies seules ou combinées au traitement chimiothérapique afin d'activer ou de rétablir précocement une immunité déficiente. Sous une même dénomination de TILS se trouve très certainement des populations phénotypiques de lymphocytes différentes. En effet, après CNA, leur valeur pronostique est opposée entre les CSTN et les tumeurs HER2-positives: des taux élevés de TILS sont associés à un pronostic défavorable dans les tumeurs HER2-positives alors qu’ils ont une tendance à être associés à des CSTN de meilleur pronostic. Les interactions sont complexes entre les agents cytotoxiques et la tumeur et/ou son microenvironnement. L'analyse du résidu tumoral mammaire ou ganglionnaire représente un matériel sous-exploité qui pourrait permettre de mieux comprendre les mécanismes de sensibilité ou de résistance aux traitements. Au delà de la pierre angulaire que constitue l'immunité pour ces tumeurs, nos travaux identifient certains CSTN pour lesquels l'environnement hormonal, au travers de l'indice de masse corporel ou du statut ménopausique, pourrait jouer un rôle. Ainsi l'exploration du métabolome, des particularités immunitaires chez les patientes en surpoids/obèses ou l'analyse de la voie androgène-récepteur (et ses connexions avec les voies oestrogène et progestérone-récepteur) des CSTN doit aussi être explorée de manière détaillée. Ceci ouvre des perspectives de traitement possibles pour certaines patientes. / Triple negative breast cancer (TNBC) is the most heterogeneous and pejorative subtype of breast cancer. The cornerstone of the treatment of such tumors is based on systemic chemotherapy, more and more frequently administered before surgery, since no targeted therapy has been validated to date. Obtaining a pathological complete response (PCR) is a major favorable prognostic marker as well as an in vivo test of anti-tumor drug susceptibility. The objective of our thesis work was therefore to provide elements of understanding of this heterogeneity through the clinical, biological and molecular dissection of these tumors.We analyzed gene expression profiles of TNBCs and identified 6 distinct molecular subtypes with different biologies and prognoses. This classification used an original methodology based on both classical bioinformatic tools and biological networks. The enrichment of immunity genes from the stromal compartment of the tumor represents a major determinant of the prognosis of these tumors: a strong expression of the immunity genes is associated with a significantly more favorable prognosis.Our main contribution is based on a better understanding of immunity and tumor infiltrated lymphocytes (TILS) of these TNBCs. It is probably the most immunogenic subgroup of breast cancers with the highest TILs levels pre-NAC with HER2-positive tumors. TILS levels are also highly correlated with genes of our immune prognosis module. The predictive and prognostic value of stromal TILS is different according to the molecular subtype of breast cancer, suggesting a completely different immunity of these tumors. The rate of TILS also varies differentially within each subgroup under the influence of the NAC, indicating a complex interaction between TILS and treatments. We show that the kinetics of TILS levels with NAC is a relevant indicator of response to NAC with a response that is all the more important that a decrease in the TILS rate will be important. The most immunogenic tumors with an important immune activity are therefore the most favorable triple-negative tumors. One of the challenges of the coming years will therefore be to identify, as soon as possible, the least immunogenic TNBC that can best benefit from immunotherapies alone or in combination with chemotherapeutic treatment in order to activate or restore early a deficient immunity.Under the same denomination of TILS there are probably different phenotypic populations of lymphocytes. Indeed, after CNA, their prognostic value is opposite between the TNBC and the HER2-positive tumors: high levels of TILS are associated with an unfavorable prognosis in HER2-positive tumors whereas they have a tendency to be associated with a better prognosis for TNBC tumors. The interactions are complex between cytotoxic agents and the tumor and / or its microenvironment. The analysis of the breast or axillary lymph node residual disease represents an underutilized material that could lead to a better understanding of the mechanisms of sensitivity or resistance to treatment.Beyond the key role immunity for these tumors, our work identifies some TNBCs for which the hormonal environment, through the body mass index or the menopausal status, could play a role. Thus, the exploration of the metabolome, immune features in overweight / obese patients or the analysis of the androgen-receptor pathway (and its connections with the estrogen and progesterone-receptor pathways) of the TNBC must also be explored. This opens up possible treatment perspectives for some patients.

Objetivos: Determinar a expressão imunohistoquímica do fator indutor de hipóxia 1-alfa (HIF-1-alfa) e suas variáveis associadas em pacientes com câncer de mama localmente avançado. Pacientes e método: Vinte e sete mulheres foram biopsiadas para diagnóstico histopatológico do carcinoma mamário e submetidas a tratamento quimioterápico pré-cirúrgico. Analisou-se a associação do HIF-1-alfa com idade, tamanho tumoral, grau histológico, estadio clínico, status hormonal e axilar, resposta clínica e patológica após tratamento quimioterápico, expressão do receptor de estrogênio, progesterona e cerbB2. Resultados: A expressão de HIF-1-alfa foi presente em 66,7% das pacientes. O único fator associado à sua presença foi o status axilar positivo (p=0,02), tendo permanecido durante a análise univariada. As demais variáveis não apresentaram associação estatisticamente significante. Conclusão: Existe uma associação estatisticamente significante entre o acometimento linfonodal e a presença de HIF-1-alfa em pacientes com câncer de mama localmente avançado. / Objectives: To assess the expression of HIF-1 and its associated variables with locally advanced breast cancer (LABC) patients. Methods: Twenty-seven women were submitted to incisional biopsy for histopathological diagnosis of breast carcinoma and undertaken to neoadjuvant chemotherapy (NACT). It was studied the association of HIF-1 with age, tumoral size, histological grade, clinical stage, hormonal and axillary status, clinical and pathological response after NACT, expression of estrogen and progesterone receptors, as well as the presence of cerbB2 antigen. Results: HIF-1-alpha expression was found in 66.7% of patients. Only axillary status was the associated factor with its presence (p=0.02), and remained after univariate analysis. The others did not present any significant statistically difference. Conclusion: There is a significant statistically association between axillary status and HIF-1-alpha expression in LABC patients.

Objetivos: Determinar a expressão imunohistoquímica do fator indutor de hipóxia 1-alfa (HIF-1-alfa) e suas variáveis associadas em pacientes com câncer de mama localmente avançado. Pacientes e método: Vinte e sete mulheres foram biopsiadas para diagnóstico histopatológico do carcinoma mamário e submetidas a tratamento quimioterápico pré-cirúrgico. Analisou-se a associação do HIF-1-alfa com idade, tamanho tumoral, grau histológico, estadio clínico, status hormonal e axilar, resposta clínica e patológica após tratamento quimioterápico, expressão do receptor de estrogênio, progesterona e cerbB2. Resultados: A expressão de HIF-1-alfa foi presente em 66,7% das pacientes. O único fator associado à sua presença foi o status axilar positivo (p=0,02), tendo permanecido durante a análise univariada. As demais variáveis não apresentaram associação estatisticamente significante. Conclusão: Existe uma associação estatisticamente significante entre o acometimento linfonodal e a presença de HIF-1-alfa em pacientes com câncer de mama localmente avançado. / Objectives: To assess the expression of HIF-1 and its associated variables with locally advanced breast cancer (LABC) patients. Methods: Twenty-seven women were submitted to incisional biopsy for histopathological diagnosis of breast carcinoma and undertaken to neoadjuvant chemotherapy (NACT). It was studied the association of HIF-1 with age, tumoral size, histological grade, clinical stage, hormonal and axillary status, clinical and pathological response after NACT, expression of estrogen and progesterone receptors, as well as the presence of cerbB2 antigen. Results: HIF-1-alpha expression was found in 66.7% of patients. Only axillary status was the associated factor with its presence (p=0.02), and remained after univariate analysis. The others did not present any significant statistically difference. Conclusion: There is a significant statistically association between axillary status and HIF-1-alpha expression in LABC patients.