京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22316号 / 医博第4557号 / 新制||医||1040(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 溝脇 尚志, 教授 松田 秀一, 教授 安達 泰治 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Made available in DSpace on 2015-07-22T20:50:28Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-11-25 / O melanoma é a forma mais agressiva de câncer de pele em virtude do elevado grau de proliferação, invasão e metástase das células tumorais. Menos de 10% dos pacientes com melanoma metastático sobrevivem por 5 anos. Quimioterapias com um único composto são bem toleradas, mas associadas a baixas taxas de resposta terapêutica. Associações de quimioterápicos já aprovados para uso humano também foram relacionadas a baixas taxas de resposta, sem redução da toxicidade. Logo, a identificação de novos agentes antitumorais é crítica para o tratamento do melanoma, e este trabalho buscou avaliar a atividade antitumoral de novos quimioterápicos derivados de paládio e rutênio no modelo pré-clínico de melanoma murino B16F10-Nex2. Um composto ciclopaladado, [Pd2(S(-)C2, N-dmpa)2 (μ-dppe)Cl2], denominado C7A, avaliado anteriormente pelo nosso grupo, demonstrou elevada atividade antitumoral e baixa toxicidade in vivo, porém, seu mecanismo de ação ainda não estava determinado. Neste trabalho demonstramos que este composto interage com grupos tiol presentes em proteínas da membrana mitocondrial, induzindo uma abrupta redução na acidificação extracelular, colapso do potencial de membrana mitocondrial e translocação da proteína Bax para o interior dessa organela. Evidenciamos também um aumento nas concentrações intracelulares de cálcio, proveniente de organelas celulares e do meio extracelular. Estes efeitos iniciais causaram ativação de caspases efetoras, condensação nuclear, degradação do DNA e dramáticas alterações morfológicas nessas células. Esses dados sugerem que C7A provoca uma morte celular por apoptose induzindo a via intrínseca em células de melanoma murino B16F10-Nex2. Observou-se que células tumorais humanas são sensíveis ao C7A, e o mecanismo de ação do composto nessas células parece ser idêntico ao observado em células murinas. O ciclopaladado 7A reduziu significativamente o número de nódulos pulmonares sem toxicidade aparente, indicando sua eficiência também contra tumores metastáticos. A atividade antitumoral de diversos compostos nitrosil-tetraamina-rutênio (trans-[RuII(NH3)4(L)NO+], onde L corresponde a diferentes ligantes de estabilização, e que são doadores de óxido nítrico (NO) em meios biológicos foi avaliada. Todos os compostos testados foram citotóxicos in vitro para células tumorais murinas e humanas. Alguns compostos foram selecionados e avaliados in vivo, mostrando uma elevada toxicidade em paralelo a uma atividade antitumoral. No entanto, observou-se que os compostos onde o NO havia sido substituído por um radical sulfato, utilizados como controles dos compostos doadores de NO, apresentaram elevada atividade antitumoral e baixa toxicidade in vivo, retardando o desenvolvimento do tumor subcutâneo e prolongando a sobrevida dos animais tratados. Os compostos sulfatados também apresentaram baixa toxicidade ao reduzir o número de nódulos metastáticos dos animais tratados. Esses compostos também foram citotóxicos in vitro para células tumorais humanas, e as alterações morfológicas, externalização de fosfatidilserina, condensação nuclear e degradação de DNA observados sugerem que os compostos tetraamina rutênio sulfatados levam a célula tumoral à morte por apoptose. Ambos os quimioterápicos testados abrem novas possibilidades para o tratamento do melanoma maligno. / Melanoma is the most aggressive form of skin cancer mainly because of the high degree of tumor cell proliferation, invasion and metastasis. Less than 10% of metastatic melanoma patients show 5 years survival. Single drug chemotherapy is well tolerated but associated with low response rates. Associations of chemotherapeutic agents approved for human use are related to low response rates, without improvement on side effects. Therefore, the identification of new antitumor agents is critical to melanoma treatment, and this study aimed to evaluate the antitumor effect of novel palladium and rutheniun derived chemotherapeutic drugs in the preclinical model of murine melanoma B16F10-Nex2. A cyclopalladated compound, [Pd2(S(-)C2, N-dmpa)2 (μ-dppe)Cl2], named C7A was previously evaluated by our group. The complex showed high antitumor and low toxicity in vivo, however, the targets for this compound in tumor cells were not determined yet. In this work we demonstrated that C7A interacts with thiol proteins present in the mitochondrial membrane, leading to an abrupt reduction of extracellular acidification, collapse of mitochondrial membrane potential and Bax translocation to the interior of this organelle. It was also observed an increase in intracellular calcium concentrations, originated from cellular organelles as well as from extracellular medium. These initial effects caused activation of effector caspases, nuclear condensation, DNA degradation and dramatic morphological changes in these cells. All these data suggests that the cyclopalladated 7A induces the intrinsic pathway apoptotic cell death on B16F10-Nex2 murine melanoma cells. Human tumor cells are sensitive to this compound and mitochondria also seem to be the target for C7A on these cells. Cyclopalladated 7A significantly reduced the number of pulmonary nodules with no apparent toxicity, indicating that this compound is also active against metastatic melanoma lesions. Antitumor activity of several nitrosyl tetraammine ruthenium compounds with general formula (trans-[RuII(NH3)4(L)NO+], where L corresponds to different stabilization ligands, were evaluated. These compounds are nitric oxide (NO) donors in biological media. All tested compounds were cytotoxic in vitro to human and murine tumor cells. Some compounds were selected and evaluated in vivo, showing numerous side effects in association with the antitumor effect. However, it was found that the compounds where the NO was replaced by a sulfate group, used regularly as a negative control for NO-donor ruthenium complexes, showed a pronounced antitumor activity and low toxicity in vivo, delaying subcutaneous tumor development and extending survival of treated animals. Sulfate compounds also reduced the number of metastatic lung nodules with no apparent toxicity. These compounds were also cytotoxic for human tumor cells in vitro, and the morphological alterations, phosphatidylserine externalization, nuclear condensation and DNA degradation observed after cell treatment suggested that sulfate tetraamine compounds induced an apoptotic cell death. Both evaluated chemotherapeutic drugs open new possibilities for malignant melanoma treatment. / TEDE / BV UNIFESP: Teses e dissertações

Metastases pulmonares isoladas de sarcomas de partes moles ocorrem em 20%-50% dos pacientes, e 70% destes pacientes apresentarão doença limitada aos pulmões. A ressecção cirúrgica é bem aceita como tratamento padrão nas metastases de sarcomas de partes moles confinadas aos pulmões, com muitos estudos relatando sobrevida em cinco anos de 305-40%, ssndo que o fator preditor de sobrevida é a ressecção completa. O objetivo deste estudo é determinar as variáveis clínicas e demográficas relacionadas ao tratamento e associadas com a sobrevida global a longo prazo (90 meses) nos pacientes submetidos a metastasectomia pulmonar de sarcomas de partes moles. Uma revisão retrospectiva foi realizada nos pacientes com metastases pulmonares que foram submetidos à toracotomia para ressecção das metástases, após o tratamento do tumor primário. Os dados foram coletados de acordo com as características do tumor primário, dados demográficos, tipo de tratamento e evolução. Pacientes (n=77) com sarcomas de partes moles previamente tratados foram submetidos a um total of 122 toracotomias e 273 nódulos ressecados. O seguimento mediando de todos os pacientes foi de 36.7 meses (variação: 10-138 meses). O índice de complicações pós-peratórias foi 9.1%, e a mortalidade em 30 dias de 0%. A sobrevida global em 90 meses para todos os pacientes foi de 34.7%. A análise multivariada identificou o número de metástases, o intervalo livre de doença, e ressecção completa, como fatores prognósticos independentes para a sobrevida global. Estes resultados confirmam que a metastasectomia pulmonar é um procedimento seguro e com potencial curativo para pacientes com tumors primários tratados. Um grupo seleto de pacientes pode apresentar uma sobrevida a longo prazo interessante após a ressecção pulmonar / Isolated pulmonary metastases from soft tissue sarcomas occur in 20%-50% of these patients, and 70% of these patients will have disease limited only to the lungs. Surgical resection is well accepted as a standard approach to treat metastases from soft tissue sarcomas isolated to the lungs, with many studies reporting overall 5-year survival ranging from 30% to 40%, and the most consistent predictor of survival in these patients is complete resection. The aim of this study is to determine demographics and clinical treatment-related variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy from soft tissue sarcomas. A retrospective review was performed of patients who were admitted with lung metastases and underwent thoracotomy for resection, after treatment of the primary tumor. Data were collected regarding primary tumor features, demographics, treatment, and outcome. Patients (n=77) with preview soft tissue sarcomas treated, were submitted to a total of 122 thoracotomies and 273 nodules resected. Median follow-up time of all patients was 36.7 months (range: 10-138 months). The postoperative complication rate was 9.1%, and the 30-day mortality rate was 0%. The 90-month overall survival rate for all patients was 34.7%. Multivariate analysis identified the number of metastases resected, disease-free interval, and complete resection as the independent prognostic factors for overall survival. These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after lung resection

INTRODUÇÃO: O mixofibrossarcoma (MFS) é um dos mais frequentes sarcomas de partes moles (SPM) em idosos que afeta principalmente as extremidades. Historicamente, é um grupo de tumores heterogêneos. Clinicamente está caracterizado por apresentar uma alta incidência de recorrência local (RL) e um conhecimento limitado sobre a sua capacidade de metástase. O índice de RL após a ressecção cirúrgica é relativamente maior quando comparado com outros SPM. Não existe um consenso em como identificar os pacientes com maior risco. O objetivo deste estudo foi analisar os fatores de prognóstico dos pacientes diagnosticados com MFS em uma instituição única. MÉTODOS: Foram analisados retrospectivamente os prontuários de 75 pacientes com diagnóstico confirmado de MFS nas extremidades, que foram submetidos a tratamento cirúrgico, nos últimos 25 anos. Comparamos idade, sexo, tamanho e localização do tumor, grau histológico segundo a Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) e o estádio segundo a American Joint Committee on Cancer (AJCC). A média de idade foi 49,7 anos. A localização foi: membro superior (25,4%), membro inferior (66,6%) e pelve (8%). Os pacientes apresentaram baixo, intermediário e alto grau, em: 29,3%, 24% e 46,7% dos tumores, respectivamente. Pelo tamanho foram categorizados em: =/< 5 cm (13,3%), > 5 e <10 cm (42,7%), > 10 e <15 cm (9%) e =/> 15 cm (18,7%). Em total, 26,7% receberam radioterapia pós-operatória. As margens foram livres em 76% e comprometidas em 24%. A análise da regressão de Cox bivariada foi utilizada para determinar as associações entre os fatores clínicos e de tratamento com a RL. RESULTADOS: O tempo médio de seguimento foi 30.7 meses. O 26,7% dos pacientes apresentaram RL. Metástase foi reportada em 27 (36%) pacientes. O local mais comum de metástase foi: pulmão (92,6%) e gânglios linfáticos (18,5%). O tempo médio de sobrevida dos pacientes com metástase foi 21,2 meses. Os fatores preditivos para RL foram: margens comprometidas (hazard ratio 5.47, 95% intervalo de confiança, 2.23-13.40, P < 0.001) e metástase (hazard ratio 10.24, 95% intervalo de confiança, 3.53-26.68, P < 0.001). Os fatores preditivos da sobrevida livre de RL foram: grau histológico, margens comprometidas (hazard ratio 3.18, 95% intervalo de confiança, 1.51-6.70, P =0.001), e metástase (hazard ratio 15.23, 95% intervalo de confiança, 5.57-41.61, P= 0.001). Os fatores preditivos de sobrevida em geral foram: RL (hazard ratio 5.13, 95% intervalo de confiança, 2.15-12.24, P < 0.001), e metástase (hazard ratio 540.97, 95% intervalo de confiança, 5.04-58112.03, P < 0.001). CONCLUSÃO: As margens cirúrgicas comprometidas e a metástase estão diretamente associadas com a RL. O grau histológico do tumor, as margens comprometidas, a RL e a metástase, são fatores de pior prognóstico no MFS / BACKGROUND AND AIMS: Myxofibrosarcoma (MFS) is one of the most common soft tissue sarcomas (STS) in elderly patients and it primarily affects the extremities. They are a historically heterogeneous group of tumors. The clinical course of MFS is characterized by a high incidence of local recurrences (LR), but knowledge about distant metastasis is sparse. MFS is reported to have a higher risk of LR following definitive surgical excision relative to other STS. There is no agreement on how to identify patients at major risk. The objectives of this study were to analyze the prognostic factors and outcomes of patients with MFS treated at a single institution. METHODS: We retrospectively reviewed the records of 75 patients with pathologically confirmed MFS of the extremities who underwent surgery in the last 25 years. We compared the age, sex, tumor size and location, Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grade and the American Joint Committee on Cancer (AJCC) stage. Median age was 49.7 years (range, 1 to 88 y). Site of disease was: upper extremity (25.4%), lower extremity (66.6%) and pelvic (8%). Patients had low, intermediate and high-grade, in: 29.3%, 24% and 46.7% of tumors, respectively. Tumors were categorized as =/< 5 cm (13.3%), > 5 and < 10 cm (42.7%), > 10 and < 15 cm (9%) and =/> 15 cm (18.7%). In total, 26.7% received postoperative radiotherapy. All patients underwent surgery. Margins were negative in 76% and positive in 24%. Bivariate Cox regression analysis was utilized to determine associations between clinical and treatment factors with LR. RESULTS: Median follow-up time was 30.7 months (range, 1.8 to 383.8 m). We found a 26.7% of LR. Distant metastasis was reported in 27 (36%) patients. The most common sites of metastasis were: lung (92.6%) and lymph nodes (18.5%). The overall survival rate in patients with metastasis was 21.2 months (range, 4.8 to 114.8 m). Predictors of LR were: positive margins (hazard ratio 5.47, 95% confidence interval, 2.23-13.40, P < 0.001) and distant metastasis (hazard ratio 10.24, 95% confidence interval, 3.53-26.68, P < 0.001). Predictors of overall survival free of LR were: grade, positive margins (hazard ratio 3.18, 95% confidence interval, 1.51-6.70, P =0.001), and distant metastasis (hazard ratio 15.23, 95% confidence interval, 5.57-41.61, P= 0.001). Predictors of overall survival were grade, LR (hazard ratio 5.13, 95% confidence interval, 2.15-12.24, P < 0.001), and distant metastasis (hazard ratio 540.97, 95% confidence interval, 5.04-58112.03, P < 0.001). CONCLUSION: In this institutional series of MFS, positive margins and distant metastasis were significantly associated with a higher risk of LR. Tumor grade, LR, positive margins and distant metastases were significant predictors of overall survival poor prognosis

Nasopharyngeal cancer (NPC) is endemic in Southern China and Hong Kong. It has traditionally been treated by local radiotherapy with great success especially for early stage disease. However the treatment outcome in advanced stage disease is unsatisfactory. / Results from this series of combined clinical, translational and laboratory studies have redefined the role of hypoxia, angiogenesis and metastasis as new therapeutic targets in NPC. Novel biomarkers and new therapeutic approaches were developed based on these targets. / To develop new therapies in NPC, we demonstrated in a randomized controlled phase 2 clinical trial that sequential therapy of neoadjuvant chemotherapy followed by chemoradiotherapy was well tolerated with a manageable toxicity profile that allowed subsequent delivery of full dose chemoradiotherapy. This strategy reduced distant metastasis which translated into improved patient survival. In preclinical studies, the antiangiogenesis agent sunitinib demonstrated potent in vitro and in vivo growth inhibition in NPC. In a phase 2 clinical trial, sunitinib demonstrated modest clinical activity in heavily pretreated NPC patients. However, the unexpected high incidence of severe hemorrhage from upper aero-digestive tract in NPC patients who received prior high dose RT to the region is of concern. We propose to exclude NPC patients with disease recurrence within previous radiation field and/or with vascular invasion from future antiangiogenesis therapy. / To investigate potential new therapeutic targets and biomarkers in NPC, we first confirmed from the Hong Kong NPC study group of 2915 patients' database that distant metastasis was the leading cause of NPC failure after primary radiotherapy. We further showed that hypoxia induced broad changes of both up- and down-regulated gene expressions involved in diverse biological processes in NPC cells. Over-expression of biomarkers of hypoxia and angiogenesis (including HIF-1alpha, CA IX and VEGF) is common in NPC and is associated with poor prognosis. Elevated plasma osteopontin is a biomarker of distant metastasis, and pre-treatment plasma osteopontin level may be a useful biomarker of response to radiotherapy in NPC. / Hui, Pun. / "September 2010." / Adviser: Anthony Chan. / Source: Dissertation Abstracts International, Volume: 73-04, Section: B, page: . / Thesis (M.D.)--Chinese University of Hong Kong, 2011. / Includes bibliographical references (leaves 269-293). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.

Ngar, Yuen Kan. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 157-159). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.

Chemokines are responsible for the directed migration of leukocyte chemotactic cytokines, coordinating cell movement during inflammation and the transport of hematopoietic cells. In addition to leukocytes, chemokine receptors are also found in neoplastic cells and tumors associated with stromal cells. Among chemokines, and the CXCR4/CXCL12 CCR7/CCL21 systems have been shown the involvement of lymph node metastases or distant metastases in different cancers. Thus, aim of this study was to evaluate the expression of CXCR4, CXCL12, CCR7, CCL21 and Ki-67 in oral squamous cell carcinoma (SCC) and to correlate these markers with clinicopathological indicators, lymph node metastasis and survival. We conducted a survey of reports and paraffin blocks of excisional biopsies of patients with SCC treated at the Hospital Haroldo JuaÃaba (2001-2009). Data on anatomic location of the lesion, sex, age, patient survival, degree of histological differentiation of the tumor, tumor stage and presence or absence of lymph node metastasis, lymphovascular and perineural invasion, nuclear grade and depth of invasion were collected. For immunohistochemical analysis, followed by the technique of streptavidin-biotin-peroxidase using the anti-CXCR4, anti-CXCL12, anti-CCR7, anti-CCL21 and Ki-67 antibody. Histological sections were photomicrographed in 10 fields chosen randomly and measured for the number of labeled tumor cells and determined the percentage of each labeling antibody. The marking of CXCR4 was detected in the cytoplasm and nucleus, CXCL12, CCR7 and CCL21 were only cytoplasmic, their expression was observed in 18 (60%) 8 (22.66%) 16 (53.3%) and 3 (12%) cases, respectively. We found a significant positive association between lymphovascular invasion and immunostaining of CXCR4 (p = 0.007) and CCR7 (P = 0.01) and among these cases metastasis was present in 62.5% and 37.5%, respectively. When in combination with Ki67, we found a significant positive correlation between CXCR4 (p = 0.0086), CXCL12 (p = 0.036) and CCR7 (p = 0:04). Among patients CXCR4 + over 111 months, only 38.4% were alive (p = 0.845), whereas both patients CCR7 + (p = 0.398) as well as CXCR4 +, and CCR7 + (p = 0.441) after 62 months, everyone had already died. We conclude that these chemokines are associated with lymphovascular invasion and cell proliferation, perhaps favoring the development of metastasis and poor prognosis. / As quimiocinas sÃo citocinas quimiotÃticas responsÃveis pela migraÃÃo direcionada de leucÃcitos, coordenando o movimento celular durante a inflamaÃÃo e o transporte de cÃlulas hematopoiÃticas. AlÃm dos leucÃcitos, os receptores de quimiocinas tambÃm sÃo encontrados em cÃlulas neoplÃsicas e em tumores associados com cÃlulas estromais. Dentre as quimiocinas, os sistemas CXCR4/CXCL12 e CCR7/CCL21 tÃm sido demonstrado no envolvimento de metÃstases linfonodais ou à distÃncia em diferentes tipos de cÃncer. Dessa forma, foi objetivo desse trabalho avaliar a expressÃo de CXCR4, CXCL12, CCR7, CCL21 e Ki-67 em carcinoma de cÃlulas escamosas orais (CEC) e correlacionar estes marcadores com indicadores clÃnicopatolÃgicos, metÃstase linfonodal e sobrevida. Realizou-se um levantamento de laudos e blocos parafinados de biopsias excisionais de pacientes portadores de CEC tratados no Hospital Haroldo JuaÃaba (2001 a 2009). Foram coletados dados sobre localizaÃÃo anatÃmica da lesÃo, sexo, idade, sobrevida do paciente, grau de diferenciaÃÃo histopatolÃgica do tumor, estadiamento tumoral e presenÃa ou ausÃncia de metÃstase linfonodal, invasÃo linfovascular e perineural, grau nuclear e profundidade de invasÃo. Para reaÃÃo de imunohistoquÃmica, seguiu-se a tÃcnica da estreptavidina-biotina-peroxidase, utilizando os anticorpos anti-CXCR4, anti-CXCL12, anti-CCR7, anti-CCL21 e Ki-67. As secÃÃes histolÃgicas foram fotomicrografadas em 10 campos escolhidos aleatoriamente e quantificadas quanto ao nÃmero de cÃlulas tumorais marcadas e determinado o percentual de marcaÃÃo de cada anticorpo. A marcaÃÃo de CXCR4 foi detectada em citoplasma e nÃcleo, CXCL12, CCR7 e CCL21 tiveram marcaÃÃo apenas citoplasmÃtica, sendo observada suas expressÃes em 18 (60%), 8 (22,66%), 16 (53,3%) e 3 (12%) casos, respectivamente. Encontrou-se uma associaÃÃo significativa positiva entre a invasÃo linfovascular e a imunomarcaÃÃo do CXCR4 (p=0.007) e CCR7 (p=0.01) e dentre esses casos a metÃstase esteve presente em 62,5% e 37,5%, respectivamente. Quando em associaÃÃo com o Ki67, encontrou-se uma correlaÃÃo positiva significante entre o CXCR4 (p=0.0086), CXCL12 (p=0.036) e CCR7 (p=0.04). Dentre os pacientes CXCR4+, ao longo de 111 meses, apenas 38,4% estavam vivos (p=0.845), ao passo que tanto para pacientes CCR7+ (p = 0.398), quanto CXCR4+ e CCR7+ (p = 0.441), apÃs 62 meses, todos haviam ido a Ãbito. Conclui-se que essas quimiocinas estÃo associadas com a invasÃo linfovascular e proliferaÃÃo celular, talvez favorecendo o desenvolvimento de metÃstases e um pior prognÃstico.

The Ras signaling cascade is a vital component in the processes that mediate cell survival, growth, differentiation and transformation through activation of MAP kinase (mitogen-activated protein kinase). The recent discovery of a new scaffold of the Ras signaling pathway, Kinase Suppressor of Ras (KSR), is found to be a positive effector of Ras signaling which further contributes to proliferation and transformation in the ERK/MAPK pathway. This thesis describes the roles of Ras and Kinase Suppressor of Ras 1 (KSR-1) in regulating the expression of tumor promoting genes such as urokinase plasminogen activator (uPA) in the development and progression of breast cancer in vitro and in vivo. Ras and KSR increase the proliferative capacity and migration of MDAMB-231 human breast cancer cells in vitro. In contrast, Ras and KSR decrease the invasiveness of MDA-MB-231 human breast cancer cells in vitro. Furthermore, uPA gene expression levels do not correlate with uPA protein expression levels suggesting a possible mutation induced by KSR and/or Ras. In vivo studies reveal that Ras and KSR increase tumor volume in mice, as well as more advanced osteolytic bone metastases. Collectively, these results indicate that Ras and KSR play significant roles in breast cancer development and metastasis.

Thesis (Ph.D. in Cell Biology, Stem Cells, and Development) -- University of Colorado Denver, 2008. / Typescript. Includes bibliographical references (leaves 102-114). Free to UCD Anschutz Medical Campus. Online version available via ProQuest Digital Dissertations;

Thesis (Ph. D.)--University of Alabama at Birmingham, 2006. / Title from first page of PDF file (viewed Feb. 19, 2009). Includes bibliographical references.