Introdução: A escolha da via de acesso para tratamento paliativo da obstrução biliar nos tumores da confluência biliopancreática (TCBP) permanece incerta para os pacientes com baixo risco anestésico-cirúrgico ou longa expectativa de vida. Objetivo: Estudar a influência da derivação biliar mediante abordagem laparotômica e endoscópica nos resultados assistenciais e nos custos do tratamento paliativo dos TCBP. Método: Estudo coorte retrospectivo de prontuários dos pacientes portadores de TCBP submetidos ao tratamento paliativo endoscópico ou cirúrgico no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), no período de 2002 a 2013, com análise de variáveis epidemiológicas, clínicas e assistenciais e dos custos. Resultados: Dentre os 150 pacientes com TCBP estudados, 92 (61,33%) foram submetidos à derivação das vias biliares por laparotomia (TL) e 58 (38,66%) por via endoscópica (TE), onde a prótese plástica foi utilizada na maioria dos casos (N = 38, 65,51%). Os grupos foram homogêneos para a maioria das variáveis epidemiológicas e clínicas antes dos procedimentos. As taxas de complicações precoces foram equivalentes na comparação dos grupos (55,17% para TE e 40,1% para TL), porém as complicações tardias foram mais frequentes no grupo TE (20,68% para TE e 10,34% para TL), o que se associou principalmente às recorrências das obstruções biliares. As curvas de sobrevida foram menores para TE. Não houve diferença significativa entre o custo mediano por procedimento no grupo TE (R$2.861,00) e TL (R$3.427,00) (p=0,3253). Por outro lado, o custo mediano total para o grupo TE (R$8.586,00) foi menor que o do grupo TL (R$12.810,00) (p=0,0001). Conclusão: a combinação das vantagens das duas modalidades de tratamento paliativo para os TCBP (maior sobrevida e eficácia na redução da colestase no grupo TL e menores tempo de internação e custo global no grupo TE) é uma meta a ser atingida e o acesso videolaparoscópico é uma alternativa a ser explorada. / Introduction: the advanced tumors of the biliopancreatic confluence (TCBP) often present with biliary obstruction, which can receive palliative treatment, through laparotomy, laparoscopic or endoscopic. Objective: to study the influence of laparotomy and endoscopic approaches in care results and costs of the palliative treatment of TCBP. Method: retrospective coorte study of medical records of patients with TCBP undergoing to the endoscopic and / or laparotomic palliation at the Hospital of Clinics of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP), from 2002 to 2013 with analysis of epidemiological variables, clinical, care and treatment costs. Results: among the 150 patients with TCBP studied, 92 (61.33%) underwent biliary bypass by laparotomy (TL) and 58 (38.66%) endoscopically (TE). The groups were homogeneous for most of the epidemiological and clinical variables before the procedures. The rates of early complications were similar between the groups (55.17% for TE and 40.1% for TL), but late complications were more frequent in the TE group (20.68% for TE and 10.34% for TL), which was mainly associated with the recurrence of biliary obstruction. The survival curves were lower for TE. The median cost of the procedure in the TE group (R$ 2,861.00) wasn´t different from TL (R$ 3,427.00) (p = 0,3253). On the other hand, the median total cost for the TE group (R$ 8,586.00) was lower than the TL group (R$ 12,810.00) (p = 0,0001). Conclusion: the combination of the advantages of the two methods of palliative treatment for TCBP (greater efficacy in reducing cholestasis in the TL group and lower length of stay and the overall costs in the TE group) is a goal to be achieved, and the laparoscopic access is an alternative to be explored.

L'adénocarcinome canalaire pancréatique (PDAC) est une maladie agressive dans le monde. En raison du manque d'outils de détection hautement sensibles et spécifiques à un stade précoce de la maladie et de traitements peu curatifs, la plupart des patients sont diagnostiqués à un stade incurable avec une mortalité élevée. Comprendre la pathologie moléculaire, en particulier le stade précoce de cette maladie mortelle, est d’une importance capitale pour améliorer les bons pronostics de ces patients. La première et principale partie de mes travaux reposait sur une analyse de profilage génétique dans laquelle ils mettaient en évidence le rôle de la signalisation TGFβ / Activine et du récepteur ALK4 au cours du développement de la PDAC, en plus des quatre gènes oncogéniques courants (KRAS, CDKN2A, TP53 et SMAD4). ). D'autre part, INHBA (codant pour ActivinA) en tant que membre clé des ligands de la superfamille TGFβ est une cible de l'activation oncogénique de Kras dans les cellules du canal pancréatique et a été désigné comme composant potentiel de la SASP par une analyse au sécrétome de cellules subissant une sénescence induite par Kras. . Le but de mes travaux est donc d’étudier l’impact de la signalisation ActivinA lors de l’initiation de la PDAC. Dans la première partie de mon projet, j'ai démontré qu'ActivinA était un facteur SASP protecteur de la tumeur, produit par les cellules sénescentes d'ADM / PanIN, qui limitent leur prolifération et leur expansion dans les lésions hautement prolifératives via son récepteur ALK4 lors de l'initiation du PDAC. De plus, nos travaux ont révélé que les cellules sénescentes Dclk1 + limitent l'expansion des lésions prénéoplasiques et ont un impact partiel sur le composant stromal soutenu par la signalisation ActivinA. En outre, j'ai également exploré les fonctions autocrines et paracrines de la signalisation ActivinA au dernier stade de la PDAC. Nous avons constaté que le manque de signalisation ActivinA-ALK4 chez la souris entraînait une augmentation de la capacité de prolifération des cellules tumorales et une accumulation réduite de cellules stromales, ce qui pourrait aider à expliquer leurs métastases variées et un temps de survie relativement plus long. En conclusion, mon travail donne un autre aperçu de la signalisation ActivinA et Dclk1 dans l'initiation de la PDAC et leur existence dans des cellules sénescentes au sein de lésions précurseurs pancréatiques de bas grade devrait être considérée comme une étape cruciale pour développer de nouvelles stratégies diagnostiques et thérapeutiques pour les patients atteints de PDAC / Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease worldwide and remains the ranking of 7th leading cause of cancer related death in the past 5 years. Because of the lack of highly sensitive and specific detective tools in an early stage of this disease and low curative treatments, most of the patients are diagnosed in an incurable stage and end up with a high mortality. Understanding the molecular pathology especially the early stage of this lethal disease is of great importance to improve the outcome of these patients. The first and major part of my work was based on gene profiling analysis in which they emphasized the role of TGFβ/Activin signalling and ALK4-receptor during the development of PDAC in addition to the four common oncogenic genes (KRAS, CDKN2A, TP53 and SMAD4). On the other hand, INHBA(encoding for ActivinA) as a key member of TGFβ-superfamily ligands is a target of Kras oncogenic activation in pancreatic duct cell and has been pointed a potential SASP candidate component through a secretome analysis of cells undergoing Kras induced senescence. Therefore, the aim of my work is to investigate the impact of ActivinA-signalling during PDAC initiation. In the first part of my project, I demonstrated that ActivinA as a tumour-protecting SASP factor, produced by ADM/PanINs senescent cells, that limit their proliferation and expansion into highly proliferative lesions through its ALK4 receptor in the initiation of PDAC. Furthermore, our work revealed that senescent Dclk1+ cells limit the expansion of preneoplastic lesions and partly impact the stromal component which is sustained by ActivinA-signalling. Besides, I also explored the autocrine and paracrine functions of ActivinA-signalling in the late stage of PDAC. We found that lack of ActivinA-ALK4 signalling in mice leads to an increased proliferative capacity in tumor cells and a reduced accumulation of stromal cells, which might help to explain their diverse metastasis and a relative longer survival time. To conclude, my work gives another insight of ActivinA-signalling and Dclk1 in the onset of pancreatic cancer and their existence in senescent cells within low grade pancreatic precursor lesions should be considered a crucial step for developing novel diagnostic and therapeutic strategies for PDAC patients

Ptf1a/p48 is a pancreas specific bHLH transcription factor that is required at early stages of embryonic development for pancreas formation and, during adulthood, for the proper exocrine pancreatic function. P48 also exerts an antiproliferative effect, which may exert a tumor suppressor activity. In this study, based on a yeast two-hybrid approach, we have identified new p48 partners that modulate the activity of p48. Among the newly identified putative interactors we found p/CAF, which is a coactivator that potentiates its transcriptional activity, and ICAT, an inhibitor of the β-catenin/TCF signaling pathway. ICAT binds to p48 and is coexpressed with it in the pancreas during development and postnatally. Using different cellular models, ICAT overexpression in acinar tumor cells resulted in changes of the pancreatic specific gene expression pattern. Furthermore, high levels of ICAT inhibited the interaction between p48 and p/CAF. While this hetero-oligomeric complex is required for the acinar gene expression, ICAT itself is shown to be present in a reconstituted PTF1 complex in vivo. Importantly, altered ICAT expression is demonstrated in several histological types of pancreatic tumors, possibly contributing to their differentiation phenotype and neoplastic properties. / Ptf1a/p48 es un factor de transcripción bHLH específico del páncreas necesario durante los estadios tempranos del desarrollo embrionario para la formación del mismo, y para el correcto funcionamiento del páncreas exocrino en el adulto. P48 desempeña también una función antiproliferativa, la cual puede resultar en una actividad de supresión tumoral. En el presente estudio, basado en una estrategia de cribado de doble-híbrido en levadura, han sido identificadas nuevas proteínas que interaccionan y que modulan la actividad específica de p48. Entre las posibles proteínas que interaccionan y han sido identificadas de novo se encuentra p/CAF, un co-activador que potencia la actividad transcripcional de p48, y ICAT, un inhibidor de la vía de señalización de la β-catenina. Se ha demostrado que ICAT se une a p48 y ambos son co-expresados en el páncreas durante el desarrollo y en el adulto. Utilizando diferentes modelos celulares, la sobreexpresión de ICAT en células tumorales acinares resultó en un cambio en el patrón de expresión de genes específicos del páncreas. Al mismo tiempo, se observó que niveles elevados de ICAT inhiben la interacción entre p48 y su co-activador p/CAF. Mientras que este complejo hetero-oligomérico es necesario para la expresión de los genes acinares, se demostró que ICAT está presente en un complejo PTF1 reconstituido in vivo. Finalmente, se observaron alteraciones en la expresión de ICAT en varios tipos histológicos de tumores pancreáticos, que posiblemente contribuyen a su fenotipo de diferenciación y propiedades neoplásicas.

No description available.

Background: Surgery remains the only curative option for the treatment of pancreatic adenocarcinoma (PDAC). The goal of this study was to investigate the clinical outcome and prognostic factors in patients after resection for ductal adenocarcinoma of the pancreatic head. Methods: The data from 195 patients who underwent pancreatic head resection for PDAC between 1993 and 2011 in our center were retrospectively analyzed. The prognostic factors for survival after operation were evaluated using multivariate analysis. Results: The head resection surgeries included 69.7% pylorus-preserving pancreatoduodenectomies (PPPD) and 30.3% standard Kausch-Whipple pancreatoduodenectomies (Whipple). The overall mortality after pancreatoduodenectomy (PD) was 4.1%, and the overall morbidity was 42%. The actuarial 3- and 5-year survival rates were 31.5% (95% CI, 25.04%-39.6%) and 11.86% (95% CI, 7.38%-19.0%), respectively. Univariate analyses demonstrated that elevated CEA (p = 0.002) and elevated CA 19–9 (p = 0.026) levels, tumor grade (p = 0.001) and hard texture of the pancreatic gland (p = 0.017) were significant predictors of a poor survival. However, only CEA >3 ng/ml (p < 0.005) and tumor grade 3 (p = 0.027) were validated as significant predictors of survival in multivariate analysis. Conclusions: Our results suggest that tumor marker levels and tumor grade are significant predictors of poor survival for patients with pancreatic head cancer. Furthermore, hard texture of the pancreatic gland appears to be associated with poor survival.

Backround: Oxidative stress (OS) has been implicated in pathogenesis of human disorders such as depressive disorder, sepsis, cardiovascular disease, acute and chronic pancreatitis, and cancer. Increased OS is result of imbalance between increased reactive oxygen and nitrogen species (RONS) production and / or insufficient activity of antioxidant defence system. Antioxidant system, which is composed of antioxidant enzymes such as superoxide dismutase, catalase, glutathione peroxidases (GPX), glutathione reductase (GR) and non- enzymatic antioxidant reduced glutathione (GSH) plays an important role in the protection of cells against enhanced OS. The aim of this study was to assess the OS markers and antioxidant enzymes in different pathophysiological states. Materials and methods: Activities of erythrocyte glutathione peroxidase (GPX1), GR and concentration of GSH as well as levels of OS markers were analysed in six different pathophysiologic states. These parameters were measured in 35 women with depressive disorder (DD), 40 patients with metabolic syndrome (MetS), 30 septic patients (S) followed up in the course of sepsis; 15 non-septic critically ill patients (NC), 13 patients with acute pancreatitis (AP), 50 with chronic pancreatitis (CP) and 50 patients with pancreatic cancer (PC), compared to...

Introduction: Intraperitoneal tumor seeding is a common form of recurrence after surgery for GI tumours. Early diagnosis and treatment may influence the course of disease. Hypothesis and objectives of the work The finding of free tumor cells and / or elevation of tumor markers in peritoneal fluid predicts intraperitoneal tumor recurrence. The results of these tests can be used to indicate HIPEC. Aim of this work is to determine the sensitivity and specificity of cytology and tumor markers levels and importance of these tests for early diagnosis and prognosis of recurrence. Another objective was to confirm the applicability of RT PCR for identification of free tumor cells. Patients and methods . Materials are sourced both during initial surgery (220 patients) and by the dispensary controls (25 patients). The peritoneal fluid was examined cytologically and biochemically too. 50 samples was exemined by RT PCR. Results Elevation of tumor markers or finding of free intraperitoneal tumor cells predicts recurrence. The prognosis of these patients corresponds to stage IV TNM classification, regardless of other parameters TNM. Low sensitivity of these tests (34% for cytology, 53% for tumor markers) does not allow its use as an indicator of HIPEC. Due to degradation of RNA we did not confirm the value of RT...

Introdução: A escolha da via de acesso para tratamento paliativo da obstrução biliar nos tumores da confluência biliopancreática (TCBP) permanece incerta para os pacientes com baixo risco anestésico-cirúrgico ou longa expectativa de vida. Objetivo: Estudar a influência da derivação biliar mediante abordagem laparotômica e endoscópica nos resultados assistenciais e nos custos do tratamento paliativo dos TCBP. Método: Estudo coorte retrospectivo de prontuários dos pacientes portadores de TCBP submetidos ao tratamento paliativo endoscópico ou cirúrgico no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), no período de 2002 a 2013, com análise de variáveis epidemiológicas, clínicas e assistenciais e dos custos. Resultados: Dentre os 150 pacientes com TCBP estudados, 92 (61,33%) foram submetidos à derivação das vias biliares por laparotomia (TL) e 58 (38,66%) por via endoscópica (TE), onde a prótese plástica foi utilizada na maioria dos casos (N = 38, 65,51%). Os grupos foram homogêneos para a maioria das variáveis epidemiológicas e clínicas antes dos procedimentos. As taxas de complicações precoces foram equivalentes na comparação dos grupos (55,17% para TE e 40,1% para TL), porém as complicações tardias foram mais frequentes no grupo TE (20,68% para TE e 10,34% para TL), o que se associou principalmente às recorrências das obstruções biliares. As curvas de sobrevida foram menores para TE. Não houve diferença significativa entre o custo mediano por procedimento no grupo TE (R$2.861,00) e TL (R$3.427,00) (p=0,3253). Por outro lado, o custo mediano total para o grupo TE (R$8.586,00) foi menor que o do grupo TL (R$12.810,00) (p=0,0001). Conclusão: a combinação das vantagens das duas modalidades de tratamento paliativo para os TCBP (maior sobrevida e eficácia na redução da colestase no grupo TL e menores tempo de internação e custo global no grupo TE) é uma meta a ser atingida e o acesso videolaparoscópico é uma alternativa a ser explorada. / Introduction: the advanced tumors of the biliopancreatic confluence (TCBP) often present with biliary obstruction, which can receive palliative treatment, through laparotomy, laparoscopic or endoscopic. Objective: to study the influence of laparotomy and endoscopic approaches in care results and costs of the palliative treatment of TCBP. Method: retrospective coorte study of medical records of patients with TCBP undergoing to the endoscopic and / or laparotomic palliation at the Hospital of Clinics of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP), from 2002 to 2013 with analysis of epidemiological variables, clinical, care and treatment costs. Results: among the 150 patients with TCBP studied, 92 (61.33%) underwent biliary bypass by laparotomy (TL) and 58 (38.66%) endoscopically (TE). The groups were homogeneous for most of the epidemiological and clinical variables before the procedures. The rates of early complications were similar between the groups (55.17% for TE and 40.1% for TL), but late complications were more frequent in the TE group (20.68% for TE and 10.34% for TL), which was mainly associated with the recurrence of biliary obstruction. The survival curves were lower for TE. The median cost of the procedure in the TE group (R$ 2,861.00) wasn´t different from TL (R$ 3,427.00) (p = 0,3253). On the other hand, the median total cost for the TE group (R$ 8,586.00) was lower than the TL group (R$ 12,810.00) (p = 0,0001). Conclusion: the combination of the advantages of the two methods of palliative treatment for TCBP (greater efficacy in reducing cholestasis in the TL group and lower length of stay and the overall costs in the TE group) is a goal to be achieved, and the laparoscopic access is an alternative to be explored.

Le pronostic est depuis longtemps un concept de base de la médecine. Hippocrate envisageait déjà le pronostic des maladies par l’étude des circonstances passées, l’établissement des faits présents, et enfin la prédiction des phénomènes à venir. Pour lui, tout l’art du pronostic était de savoir interpréter intelligemment ces informations, et ainsi moduler le pronostic en fonction de leur valeur relative. Une recherche à visée pronostique consiste toujours actuellement en l’examen des relations entre un état de santé connu au moment de l’investigation et un évènement futur. L’augmentation de l’espérance de vie implique que de plus en plus de personnes vivent avec une ou plusieurs maladies ou problèmes altérant leur santé. Dans ce contexte, l’étude du pronostic n’a jamais été aussi importante. Cependant, contrairement au domaine des essais cliniques randomisés dans lequel les recommandations CONSORT sont appliquées depuis plus de 20 ans et garantissent une recherche de qualité, la recherche pronostique commence seulement à se doter d’initiatives similaires. En effet, des recommandations TRIPOD ont été élaborées en 2015 et un groupe de travail, PROGRESS, s’est constitué en 2013 au Royaume-Uni et a fait le constat que les recherches a visée pronostique sont réalisées de façon très hétérogènes et malheureusement ne respectent pas toujours des standards de qualité nécessaires pour supporter leurs conclusions et garantir la reproductibilité des résultats (...) / Prognosis is historically a basic concept of medicine. Hippocrates already considered the prognosis of disease as the study of the past circumstances, the establishment of the present state of health and finally the prediction of future events. He presented the prognosis as the ability to interpret these elements and to adapt the prognosis regarding their relative values. Currently, the prognostic research is still based on the examination of the relationship between a well-established health condition at the time of the investigation and the occurrence of an event. The increase in life expectancy implies that more and more people are living with one or more diseases or with problems that can impair their health status. In this context, the study of the prognosis has never been more important. However, in comparison with the field of randomized clinical trials in which the CONSORT statement recommendations are implemented for more than 20 years in order to guarantee quality research, the prognostic research only begins to develop similar initiatives. Indeed, in 2015 the TRIPOD statement recommendations were provided and in 2013 a working group called PROGRESS was constituted in the United Kingdom and its members made the observation that prognostic researches are developed with considerable heterogeneity in the methodology used and unfortunately do not always meet the quality standards required to support their conclusions and their reproducibility (...)

Background: Surgery remains the only curative option for the treatment of pancreatic adenocarcinoma (PDAC). The goal of this study was to investigate the clinical outcome and prognostic factors in patients after resection for ductal adenocarcinoma of the pancreatic head. Methods: The data from 195 patients who underwent pancreatic head resection for PDAC between 1993 and 2011 in our center were retrospectively analyzed. The prognostic factors for survival after operation were evaluated using multivariate analysis. Results: The head resection surgeries included 69.7% pylorus-preserving pancreatoduodenectomies (PPPD) and 30.3% standard Kausch-Whipple pancreatoduodenectomies (Whipple). The overall mortality after pancreatoduodenectomy (PD) was 4.1%, and the overall morbidity was 42%. The actuarial 3- and 5-year survival rates were 31.5% (95% CI, 25.04%-39.6%) and 11.86% (95% CI, 7.38%-19.0%), respectively. Univariate analyses demonstrated that elevated CEA (p = 0.002) and elevated CA 19–9 (p = 0.026) levels, tumor grade (p = 0.001) and hard texture of the pancreatic gland (p = 0.017) were significant predictors of a poor survival. However, only CEA >3 ng/ml (p < 0.005) and tumor grade 3 (p = 0.027) were validated as significant predictors of survival in multivariate analysis. Conclusions: Our results suggest that tumor marker levels and tumor grade are significant predictors of poor survival for patients with pancreatic head cancer. Furthermore, hard texture of the pancreatic gland appears to be associated with poor survival.