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.

A genotipagem do vírus da hepatite C (VHC) é a principal ferramenta para prognóstico e tempo de tratamento. Dependendo do genótipo infectado existem diferentes esquemas e tempo de tratamento. O objetivo deste trabalho foi desenvolver padronizar e validar um método de genotipagem por PCR em tempo real com base na análise da região NS5B. Esta região apresenta um grau de polimorfismo que permite identificar de modo mais acurado tanto os tipos como os subtipos do VHC. Para isto foram desenhados dois conjuntos de primers e sondas. Neste trabalho desenvolvemos um método one-step modificado em uma reação triplex em que ocorre a identificação dos genótipos (1a, 1b, 3a) e em outro set a identificação dos genótipos (2a, 2b, 2c). Os resultados obtidos pelo método de genotipagem em tempo real concordaram em 100% com os resultados de seqüênciamento da região NS5B quando excluímos amostras que foram identificados como mistura de genótipos no método desenvolvido e classificados somente como um único genótipo no seqüênciamento. Houve uma boa concordância entre o método desenvolvido e o seqüênciamento da região NS5B pelo coeficiente de Kappa (k= 0,6222; p=0,0020). O método de desenvolvido conseguiu detectar 97,93% (190/194) do genótipo 1, 86,11% (31/36) do genótipo 2 e 100% (80/80) do genótipo 3. A média da sensibilidade foi de 97%. Quando comparamos a genotipagem por PCR em tempo real e LiPA nas 310 amostras analisadas não houve resultados discordantes em relação ao genótipo. Entretanto, 26,24% (79/301) das amostras analisadas apresentaram resultados discordantes em relação ao subtipo quando comparados os dois métodos. Foi determinada a sensibilidade analítica do método através de um ponto do painel da OptiQuant que foi diluído de modo seriado e a sensibilidade relativa foi realizada através de amostras de plasma de pacientes com carga viral determinada pelo Cobas Amplicor. O limite mínimo de detecção determinado foi de 125UI/ml para o genótipo 3a, 250 UI/ml para o genótipo 1b e 2b e 500 UI/ml para o genótipo 1a. Somados a isso, o método desenvolvido tem um custo de R$ 58,00, um valor nove vezes menor que o método comercial utilizado em nosso laboratório. Além disso, no método desenvolvido, o tempo trabalhado cai para menos de 2 horas sem a necessidade de manipulação constante em comparação com LiPA que necessita em torno de 16 horas, devido ao vários passos de hibridizações e lavagens. No presente trabalho o método de genotipagem por PCR em tempo real para o VHC mostrou-se eficiente e capaz de identificar de um modo acurado os diferentes genótipos e seus subtipos e contribuir para um entendimento melhor do verdadeiro papel dos genótipos e seus subtipos e da variabilidade genética na história natural da infecção do VHC. / Hepatitis C virus (HCV) genotyping is the most significant predictor of response to antiviral therapy. Depending on the infecting HCV genotyping different antiviral regimens have been proposed as well as the length of different treatment. The aim of this study was to develop and evaluate a new real time PCR of HCV genotyping based in NS5B region. This region has sequencing heterogeneity and can accurately identify both type and subtype of HCV. Furthermore, we compared the real time PCR with LiPA and sequencing of NS5B region. We developed a new one-step modified method in triplex reaction where we identified in two sets genotypes (1a, 1b, 3a) and (2a, 2b, 2c). Results obtained by real time PCR agreed 100% with those obtained by NS5B sequencing when excluded samples with mixed of HCV genotypes identified by real time PCR genotyping and in NS5B sequencing all samples were classified only as only one genotype. We found a good concordance for the analysis of genotype concordance between genotyping by real time and sequencing of NS5B region through the coefficient kappa (k= 0,6222; p=0,0020). The method developed detected 97,93% (190/194) of genotype 1, 86,11% (31/36) of genotype 2 and 100% (80/80) of genotype 3, with the overall sensitivity of this new method being 97%. Among 310 samples only two samples had discordant results at type level when comparing real time PCR and LiPA. However, 26,24% (79/301) had discordant results at subtype level when comparing LiPA and real time PCR genotyping of HCV. In order to measure the analytical sensitivity of the real time assay, one member of the panel OptiQuant HCV RNA was diluted. The relative sensitivity was determined by analysis the clinical specimens based upon the initial HCV RNA concentration determined by Cobas Amplicor. The lower limit of detection was estimated to be 125 IU/ml for genotype 3a, 250 IU/ml for genotype 1b and 2b, and 500 IU/ml for genotype 1a. Finally, the cost of each reaction are about R$ 58,00 nine fold lower than the commercial method available in Brazil. Manipulation time of real time PCR genotyping is about 2 hours, in comparison to LiPA that requires about 16 hours due to various hybridization steps and washing. This study was demonstrated an efficient method of identification in a accurate way. HCV genotyping which is important to understand the role of genotypes and subtypes, as well as of genomic variability in the natural history of HCV infection.

Os transtornos alimentares são doenças graves que podem cursar com comorbidades importantes se não tratadas com abordagens múltiplas do ponto de vista clínico, nutricional, psicológico e psiquiátrico. Sendo assim, o objetivo deste estudo foi investigar aspectos nutricionais e psicossociais dos indivíduos que foram portadores de anorexia e bulimia nervosas do Grupo de Assistência em Transtornos Alimentares - (GRATA) - do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo-USP , se trataram e obtiveram alta hospitalar. Para tanto, elaborou-se uma entrevista semi - estruturada com dados demográficos de saúde atual, além as principais mudanças após o tratamento. Avaliou-se também o estado nutricional, por aferição de peso, altura, pregas cutâneas e circunferência do braço. O hábito alimentar foi questionado por meio de recordatório alimentar de 24 horas e questionário de freqüência alimentar. Para avaliação do ajustamento psicossocial do indivíduo, utilizou-se os seguintes instrumentos auto-aplicáveis: Questionário de Saúde Geral de Goldberg (QSG), Inventário de Depressão de Beck, Escala Hospitalar de Ansiedade e Depressão (HAD), Teste de Atitudes Alimentares (EAT-26).Foram encontrados 10 sujeitos, 9 mulheres e 1 homem, com idade entre 21 e 34 anos.Por meio da entrevista semi-estruturada, observou-se mudanças significativas após a alta hospitalar como: 5 sujeitos já concluíram o ensino superior e contribuem com a renda da família, 3 sujeitos estão concluindo esses cursos, 5 sujeitos casaram-se e já presenciaram o nascimento do primeiro filho.Apenas 1 sujeito faz acompanhamento psiquiátrico,e nenhum deles tem acompanhamento nutricional. A presença de ciclos menstruais regulares constando em todos sujeitos do sexo feminino.Atualmente 1 sujeito usa medicação fitoterápica e chás diuréticos para manter o peso. A ingestão calórica se aproximou das Recomendações Diárias (RDA) em 9 sujeitos e excedeu a recomendação diária de proteína em 9 sujeitos. Algumas vitaminas e minerais se mostraram deficientes como ferro, cálcio e retinol em 6 indivíduos. O questionário de freqüência alimentar quando comparado com a pirâmide alimentar adaptada para a população brasileira, se mostrou adequado nos itens: grupo do leite, verduras e carboidratos. Alimentos hipocalóricos e dietéticos são consumidos com freqüência por 7 sujeitos.O QSG mostrou valores indicativos de normalidade em todos os fatores. O HAD classificou com ansiedade leve 4 sujeitos da amostra. O Inventário de Beck detectou depressão leve 1 sujeito da amostra. O EAT-26 não apresentou pontuação indicativa de comportamento alimentar anormal. Conclui-se que esses indivíduos após a doença, desenvolveram-se de maneira positiva para a vida familiar, profissionale emocional, com progresos significativos. / Eating disorders are serious diseases that can go along important comorbidities if not treated from a clinical, nutritional, psychological and psychiatric point of view. Thus, the aim of the study was to investigate nutritional and psychosocial aspects of individuals that carried anorexia nervosa and bulimia nervosa from the group of assistants in alimentary disorders – GRATA – of the clinic hospital of the University of Medicine of Ribeirão Preto, University of São Paulo – USP, which received treatment and were discharged from the hospital.For that, a semi-structured interview was elaborated, and the individuals studied were asked about their occupation, marital status, number of children and main changes that occurred after their treatment. Their nutritional state was also evaluated, by checking their weight, height, cutaneous fold and the arm circumference. We analyzed their eating habits through alimentary 24-hour records and questionnaire of alimentary frequency. In order to evaluate the psychosocial adjustment of the individual, the following auto-applicable instruments were utilized: The general health questionnaire of Goldberg, Beck’s Depression Inventory, the Hospital scale of Anxiety and Depression (HAD) and the Alimentary Attitude Test (EAT-26)We found 10 subjects, of which 9 were females and 1 was male with ages between 21 and 34 that felt euphoric. There was only 1 subject that was overweight. In the semi-structured interview, significant changes were observed after the discharge from the hospital, as follows: 5 subjects have already graduated from college and contribute to their family income, 3 subjects are still in college, 5 subjects have gotten married and have already had their first child, 1 subject has been getting a psychiatric follow-up, and none of them has been getting a nutritional follow-up. We noticed the presence of regular menstrual cycles in all of the female subjects. Currently, one subject uses phytotherapic medication and diuretic teas to maintain her weight. The caloric ingestion has become closer to the daily recommendations (RDA) for 9 subjects and was exceeded to the daily protein recommendations in 9 subjects. Some vitamins and minerals were deficient in 6 subjects, such as iron, calcium and retinol. The questionnaire of alimentary frequency, when compared to the alimentary pyramid adapted to the Brazilian populations was considered adequate in the following items: dairy group, vegetables and carbohydrates. Hypo caloric and diet aliments are frequently ingested by 7 subjects. The QSG shows values that indicate normality in all factors, HAD detected a slight anxiety in 4 subjects. Beck’s inventory detected a slight depression in 1 subject from the group. The EAT-26 didn’t present a negative score as to the indication of abnormal alimentary behavior. In conclusion, the group studied was within the adequate nutritional state as well as a psychosocial adjustment of what are considered normal boundaries. Therefore, further investigations are necessary with respect of the prognostics of the carriers of these disorders, in order to aid in more specific therapeutical approaches.

Introdução. O Papilomavírus humano (HPV), particularmente o tipo 16, têm sido associado com risco e prognóstico de tumores de cabeça e pescoço. Contudo, o papel do DNA do HPV e resposta sorológica na sobrevida neste grupo de pacientes ainda não está claro. Objetivos. Avaliar o efeito do HPV (resposta sorológica e detecção do DNA no tecido tumoral) na sobrevida de pacientes com carcinoma epidermóide de cabeça e pescoço, considerando-se as distintas localizações anatômicas (cavidade oral, orofaringe, hipofaringe e laringe). Material e métodos. Coorte de 1.475 pacientes com carcinoma epidermóide de cabeça e pescoço, oriundos de dois estudos multicêntricos, diagnosticados entre novembro de 1998 e dezembro de 2008 e acompanhados até 30 de junho de 2009. Detecção de DNA do HPV no tecido tumoral foi feita pela técnica de PCR (Polymerase Chain Reaction) em tecido fresco e material parafinado. Resposta sorológica às proteínas do HPV foi determinada pela técnica Multiplex Luminex. Sobrevida global e específica pela doença foram calculadas pelo método atuarial (tábuas de vida). Curvas de sobrevida de Kaplan-Meier e teste Log-rank para comparação de curvas de sobrevida foram calculados. Hazard ratio (HR) do efeito da infecção pelo HPV nos tumores de cabeça e pescoço e respectivo intervalo com 95 por cento de confiança (IC95 por cento ) foram calculados via modelo de regressão de Cox ajustado pelas variáveis: estudo de origem dos casos, sexo, idade, educação, consumo de tabaco e de álcool, estadiamento do tumor e tratamento, assim como hábitos sexuais para a subcoorte com esta informação. Resultados. Prevalência de DNA do HPV 16 no tecido tumoral foi de 6,7 por cento nos casos recentes (2003-2008) comparado com 1 por cento nos casos iniciais (1998-2002) para a subcoorte de São Paulo. Aumento da soropositividade para HPV 16 E7 nos casos do estudo mais recente (2003-2008) comparado com os casos do estudo inicial (1998-2002) resultou estatisticamente significante. Foi observada pobre concordância entre os resultados de sorologia e DNA do HPV. Pacientes mais jovens (50 anos), que não fumavam e com tumores de orofaringe apresentaram risco aumentado na resposta sorológica à proteína E6 do HPV 16. Prática de sexo oral associou-se com resposta sorológica conjunta às proteínas E6 e E7 do HPV 16. Pacientes soropositivos para HPV 16 E6 apresentaram maior sobrevida global (HR=0,62; IC95 por cento =0,44-0,87), adicionalmente observou-se que a resposta sorológica conjunta às proteínas E6 e E7 do HPV incrementou a sobrevida dos pacientes com tumores de cabeça e pescoço (HR=0,34; IC95 por cento 0,17-0,70) e de orofaringe (HR=0,17; IC95 por cento 0,05-0,59). Conclusões. A prevalência da infecção pelo HPV entre pacientes com tumores de cabeça e pescoço aumentou no período estudado. O estudo sugere que resposta sorológica conjunta às proteínas E6 e E7 do HPV 16 pode estar associada com maior sobrevida global nos tumores de cabeça e pescoço, especificamente nos pacientes com tumores de orofaringe / Introduction. Human papillomavirus (HPV), especially type 16, had been associated with risk and prognostic of head and neck cancer. However, the role of HPV DNA and serological response in survival of patients with head and neck cancer is not yet clear. Objectives. Evaluate the effect of HPV (serological response and HPV DNA tumor status) in survival of patients with squamous cell carcinoma of head and neck (SCCHN), according to anatomical sites (oral cavity, oropharynx, hypopharynx and larynx). Material and methods. Cohort of 1,475 patients with SCCHN, from two multicentre studies diagnosed between November 1998 and December 2008 and followed-up until 30 of June 2009. HPV DNA detection was evaluated by PCR (Polymerase Chain Reaction) in fresh tissue and paraffin blocks. Antibodies to HPV in the serum were determinated by Multiplex Luminex technique. Overall and disease specific survival were calculated by actuarial method. Kaplan-Meier survival curves and Log-rank test in order to compare survival curves were calculated. Hazard ratio (HR) and 95 per cent of interval confidence (95 per cent IC) for Cox model regression were used to evaluate the effect of HPV infection in SCCHN, adjusted by variables: study group, sociodemographics, tobacco and alcohol consumption, tumor clinical stage and treatment, and also sexual habits in the subcohort with available information. Results. HPV DNA 16 tumoral status prevalence was 6.7 per cent in recent cases (2003-2008) compared to 1 per cent in old cases (1998-2002), only for subcohort of São Paulo. Seropositivity to HPV 16 E7 increased in the late cases (2003-2008) compared to old cases (1998-2002) and was statistically significant. Poor concordance was showed between DNA HPV and serological response to HPV. Younger patients (50 years old), no smokers and with oropharyngeal tumors showed increased risk to HPV 16 E6 serological response. Oral sex was associated with HPV 16 E6 and E7 simultaneously. Seropositivity to HPV 16 E6 had longer overall survival (HR=0.62; 95 per cent CI=0.440.87), additionally HPV 16 E6 and E7 serological response increased the survival of head and neck cancers (HR=0.34; 95 per cent CI 0.17-0.70) and oropharyngeal cancer (HR=0.17; 95 per cent CI 0.05-0.59) Conclusions. Prevalence of HPV infection in patients with SCCHN had increased in the study period. The study suggests that HPV 16 E6 serological response could be associated with increased overall survival in patients with SCCHN tumors and specifically with oropharyngeal cancer

Introdução: A lombalgia gera altos custos, em todo o mundo, com tratamentos e perda de produtividade. Embora hoje existam vários tratamentos para lombalgia, não ocorrem estudos demonstrando a superioridade de um programa específico de reabilitação e o número de pacientes que recidiva da dor é alto, sobrecarregando os serviços públicos de saúde. Questionamos se uma lista de fatores prognósticos elaborada, em 2007, pelo Multinational Musculoskeletal Inception Cohort Study, poderiam servir também para identificar fatores prognósticos da resposta terapêutica à fisioterapia convencional, em pacientes com lombalgia crônica já estabelecida. Objetivos: Identificar fatores prognósticos para resposta ao tratamento fisioterápico em uma população de pacientes com lombalgia crônica. Materiais e métodos: Foram selecionados 130 pacientes com lombalgia mecânica comum crônica no Ambulatório de Doenças da Coluna da Reumatologia. Estes pacientes foram avaliados inicialmente, após realização de dez sessões de fisioterapia e três meses após a da última sessão. Os pacientes foram classificados como respondedores ao apresentarem melhora na escala numérica de dor (END) e redução no questionário de Roland Morris (QRM). Resultado: A ausência de dor extra- espinhal e medo evitação-trabalho aumentam a chance de melhora na END ao final do tratamento. Já a melhora pelo QRM, ao final de dez sessões, só é influenciada pela ausência de dor extra-espinhal. Após três meses do final do tratamento, a ausência de medo-evitação trabalho e dor extra-espinhal aumentam a chance de melhora na END. Conclusão: Identificamos que medo e evitação-trabalho, bem como a presença de dor extra-espinhal são características de subgrupos de pacientes que podem necessitar de programas de reabilitação especiais / Introduction: Low back pain causes high treatment expenses and productivity losses worldwide. Although several treatments are currently available for low back pain, no studies have demonstrated the superiority of any rehabilitation program, and the number of patients exhibiting relapse is notably high, which has the effect of overloading the public health services. We questioned whether the list of prognostic factors elaborated in 2007 by the Multinational Musculoskeletal Inception Cohort Study, could also serve to identify prognostic factors of therapeutic response to conventional therapy in patients with chronic LBP already established. Aim: To identify prognostic factors for the response to physiotherapy treatment in a population of patients with chronic low back pain. Materials and Methods: A total of 130 patients with chronic mechanical low back pain were selected at the spine disease outpatient clinic of the rheumatology unit of a hospital. These patients were assessed at recruitment, at the completion of 10 sessions of physiotherapy and three months later. Patients were classified as responders when they exhibited at least a two-point improvement on a numerical rating scale (NRS) and at least a four-point reduction on the Roland-Morris Disability Questionnaire (RMDQ). Results: According to the NRS, the absence of extra-spinal pain and fear avoidance work increased the odds of improvement at the end of treatment. Improvement in the RMDQ at the end of 10 sessions was only influenced by the lack of extra-spinal pain. Three months after the end of the treatment, as measured by the NRS, the absence of fear-avoidance with regard to work and the absence of extra-spinal pain increased the improvement odds. Conclusion: We identified fear-avoidance with regard to work and the presence of extra-spinal pain as characteristics of subgroups of patients who may require special rehabilitation programs

INTODUÇÃO: O carcinoma renal (CR) é uma doença agressiva, e sua incidência vem aumentando. A variante de células claras (CRCC) é a mais comum e apresenta comportamento biológico mais agressivo. Os recentes avanços no conhecimento da biologia molecular do tumor demonstram que a oncogênese dos diversos tipos histológicos é regida por mecanismos celulares diversos. Os modelos prognósticos atuais vêm procurando incorporar os recentes avanços da biologia molecular, com o intuito de melhorar sua capacidade de predizer a evolução e o desfecho destes pacientes. OBJETIVOS: Correlacionar a imunoexpressão dos marcadores selecionados com: 1) sobrevida global e, 2) com parâmetros prognósticos estabelecidos (estadio clínico TNM, tamanho tumoral, grau nuclear de Fuhrman, invasão microvascular e invasão de gordura perirrenal) em portadores de CRCC não metastático. MÉTODOS: Neste estudo de coorte retrospectivo, avaliamos 99 pacientes portadores de CRCC não metastático, quanto à expressão imunoistoquímica das seguintes proteínas: CA-IX, EGF-R, Ki-67, p53, PTEN, VEGF e VEGF-R. Os parâmetros analisados foram: Sobrevida global, estadio TNM, tamanho tumoral, grau nuclear de Fuhrman, invasão microvascular e invasão de gordura perirrenal. Utilizamos um tissue microarray construído exclusivamente para esta finalidade e realizamos a leitura da imunoexpressão por técnica digital utilizando o software Photoshop®. RESULTADOS: O tempo de seguimento médio foi de 7,9 anos. Com relação à sobrevida global, não observamos sua correlação com nenhum dos marcadores avaliados. Quanto à correlação da expressão dos marcadores com os parâmetros prognósticos convencionais, observamos que a expressão do EGF-R se correlacionou com estadio T (p= 0,049) e invasão da gordura perirrenal (p=0,020); e o VEGF-R se correlacionou com grau de Fuhrman (p=0,022) e invasão microvascular (p=0,005). Nos demais marcadores, não foi observada correlação significativa. CONCLUSÃO: Os fatores prognósticos moleculares EGF-R e VEGF-R apresentam-se como ferramentas úteis para avaliação do risco de prognóstico desfavorável em portadores de carcinoma renal de células claras não metastático / INTODUCTION: Renal cell carcinoma is an aggressive disease and its incidence is rising. The clear cell variant is the most common, and also the most aggressive. Recent advances in the understanding of the tumors molecular biology indicate that the oncogenesis of each histologic subtype is controlled by distinct cellular mechanisms. Current prognostic models are gradually incorporating the advances in molecular biology, in the hope to improve their predictive capacity. OBJECTIVES: To correlate the immunoexpression of selected markers with 1) overall survival, and 2) with established prognostic parameters (clinical TNM stage, tumor size, Fuhrman nuclear grade, microvascular invasion and perirenal fat invasion) in patients with non-metastatic ccRCC. METHODS: This is a retrospective cohort study, we evaluated 99 patients with non-metastatic clear cell renal cell carcinoma, as to the expression of the following proteins: CA-IX, EGF-R, Ki-67, p53, PTEN, VEGF e VEGF-R. The analyzed parameters where: overall survival, TNM stage, tumor size, Fuhrman nuclear grade, microvascular invasion, perirenal fat invasion. We utilized a custom built tissue microarray, and the immunoexpression was digitally quantified using the Photoshop® software. RESULTS: The mean follow-up time was 7,9 years. We found no correlation between the expression of the studied molecular markers and overall survival. As for the conventional prognostic parameters, we found the expression of EGF-R to correlate with T stage (p= 0,049) and perirenal fat invasion (p= 0,020), and VEGF-R to correlate with Fuhrman nuclear grade (p= 0,022) and microvascular invasion (p= 0,022). None of the other markers showed correlation with the studied parameters. CONCLUSIONS: The expression of EGF-R and VEGF-R may be useful tools in the prognostic evaluation of unfavorable risk in patients with non metastatic clear cell renal cell carcinoma

LLC-B é uma neoplasia hematológica derivada de uma população de linfócitos B maduros CD5+ localizados na zona do manto dos folículos linfóides e é a mais comum das doenças linfoproliferativas. É uma doença clinicamente heterogênea na qual certos pacientes apresentam quadros indolentes que durante muitos anos podem ser controlados com pouco ou nenhum tratamento. Relatos da literatura sugerem que os linfócitos T na LLC-B podem ser incapazes de iniciar, manter e concluir uma resposta imune para a célula B maligna e outros antígenos, e podem estar diretamente envolvidos na manutenção do tumor. Os linfócitos são ativados, proliferam e polarizam sua resposta para padrões pro-inflamatórios ou antiinflamatórios, aumentando sua população e tornando-se capazes para realizar suas funções efetoras. Embora o processo de ativação dos linfócitos Th seja indispensável para a defesa do hospedeiro, é necessário que haja um equilíbrio homeostático, onde as células auto-reativas ou recorrentemente ativadas sejam eliminadas. A esse último mecanismo de manutenção do equilíbrio imunológico, dá-se o nome de Tolerância Periférica, sendo que o processo de morte celular induzida por ativação (AICD) constitui um dos principais mecanismos para sua manutenção. Assim, neste estudo também foram analisados membros do grupo de receptores de membrana da superfamília dos receptores de fatores de necrose tumoral (tumor necrosis factor receptor, TNFR). Esta família TNFR inclui diversos receptores, entre eles o FAS (CD95) e seu ligante FASL. O objetivo central deste trabalho é investigar alterações no compartimentos de linfócitos T como, Th1, Th2, Th17 e Treg, bem como membros da via extrínseca de morte, FAS e FASL nos linfócitos T CD4+. Os resultados mostraram que o número absoluto dos linfócitos T CD4+, CD8+ e Th1 é heterogêneo, sendo que alguns pacientes apresentaram aumento e outros diminuição destas células quando comparados com o grupo controle do estudo. Em relação a expressão de FAS e FASL os resultados também apresentaram heterogeneidade. Sendo assim foi analisado cada paciente e comparados com os fatores de prognósticos e dados clínicos em cada caso. Ainda há muito para ser investigado, mas este trabalho tem como perspectivas buscar melhor entendimento da participação dos linfócitos T CD4+ nas LLC-B, expandindo as possibilidade de tratamento e busca de novos alvos terapêuticos. / B-CLL is a hematologic malignancy derived from a mature population of CD5+ Blymphocytes located in the mantle zone of the lymphoid follicles and is the most common lymphoproliferative disorders. It is a clinically heterogeneous disorder in which patients have certain frames idle for many years that can be controlled with little or no treatment. Literature reports suggest that T lymphocytes in B-CLL may be unable to initiate, sustain and complete an immune response to the malignant B cell and other antigens, and may be directly involved in tumor maintenance. The lymphocytes are activated, proliferate and polarize their response patterns to pro-inflammatory or anti-inflammatory, increasing its population and becoming able to perform their effector functions. Although the process of Th lymphocyte activation is essential for host defense, there must be a homeostatic balance, where autoreactive cells are eliminated or recurrently activated. The latter mechanism of maintenance of immune balance, gives the name of Peripheral Tolerance, and the process of activation-induced cell death (AICD) is a major mechanism for its maintenance. In this study group members of the superfamily of membrane receptors of tumor necrosis factor (tumor necrosis factor receptor, TNFR) receptors were also analyzed. The TNFR family includes many receptors, including FAS (CD95) and its ligand FasL. The central objective of this study is to investigate changes in T lymphocyte compartments as Th1, Th2, Th17 and Treg as well as members of the extrinsic death pathway, FAS and FASL in CD4+ lymphocytes. The results showed that the absolute number of CD4+, CD8+ and Th1 lymphocytes is heterogeneous, with some patients showed an increase and others decrease of these cells when compared with the control group of the study. Regarding the expression of FAS and FASL results also showed heterogeneity. Thus each patient was analyzed and compared to the prognostic factors and to clinical data in each case. Much remains to be investigated, but this work has the prospects look better understanding of the role of the B-CLL CD4+ T lymphocytes, expanding the possibilities of treatment and the search for new therapeutic targets.

Der Einfluß von Ovulationshemmern auf die Tumorbiologie und die Prognose des Mammakarzinoms Die Frage eines potentiellen Einflusses von Ovulationshemmern (OH) auf die Tumorbiologie und die Prognose des Mammakarzinoms stellt noch immer ein ungeklärtes Problem dar. Zur Untersuchung dieser Frage wurde eine Fall-Kontroll-Studie aufgelegt, die den Effekt der OH-Einnahme vor der Diagnose des Mammakarzinoms auf dessen Prognosefaktoren und den Verlauf der Erkrankung untersucht. Das mediane Follow-up belief sich auf 10 Jahre. Bei 471 Patientinnen wurde der Einfluß von OH auf konventionelle (Tumortyp, Grading, Tumorgröße, LK-Status, ER, PR) und molekularbiologische (PCNA, EGF-R, c-erbB-2, p53) Prognosefaktoren dargestellt. In Abhängigkeit von der Zeit seit der letzten Einnahme von OH konnten 2 Tumorentitäten charakterisiert werden. Bei OH-Einnahme bis zum Zeitpunkt der Diagnose fanden sich signifikant häufiger LK-positive (OR 2.14), schlecht differenzierte (OR 2.01) und stark proliferierende Tumoren (OR 2.13). Patientinnen mit langer Latenzperiode seit letzter OH-Einnahme zeigten signifikant häufiger ER-positive (OR 21.6-3.69) allerdings auch EGF-R-positive Tumoren (OR 1.73-2.0) mit moderater Proliferationsaktivität (OR 1.64-1.93). In multivaraiaten Überlebensanalysen hatten Patientinnen mit Langzeiteinnahme (mehr als 5 Jahre) und solche mit OH-Einnahme lange vor der Diagnose der Erkrankung (mehr als 96 Monate) ein signifikant besseres Überleben (HR 0.55, 95%CI 0.34-0.90; HR 0.49, 95%CI 0.26-0.92 respektive)als Patientinnen ohne OH-Einnahme. Dagegen hatte Patientinnen bei OH-Einnahme bis zur Diagnose oder Einnahme in den letzten beiden Jahren vor Diagnose ein signifikant schlechteres Überleben als solche ohne OH-Einnahme (HR 2.29, 95%CI 1.02-5.17; HR 3.80, 95%CI 1.45-9.97 respektive). Offenbar ist die OH-Einnahme während eines biologisch sensiblen Zeitraumes der Entwicklung des Mammakarzinomes von größerer Bedeutung als die Dauer der OH-Einnahme. Eine biologische Hypothese wird dargestellt. / Oral contraceptive use and breast cancer: Effect on tumorbiolgy and prognosis The question of whether oral contraceptive(OC) use before diagnosis has an effect on tumorbiology and prognosis of breast cancer remains a subject of discussion. Thus, a case-control study was conducted to investigate the effect of OC use on prognostic factors and the outcome of breast cancer patients. The median follow-up amounted to 10 years. In 471 breast cancer patients histomorphological (tumortype, grading, tumorsize, nodal status, ER, PR) and molecularbiological prognostic factors (PCNA, EGF-R, c-erbB-2, p53) and their association to OC use were studied. 297 (63%) patients were OC users, 113 were short-term users (less than 5 years) and 184 were long-term users. Dependend on the time since last OC use, two different biological tumor entities were characterised. In current users a significant increase in node-positive (OR 2.14) and poorly differentiated tumors (OR 2.01) and of tumors with a high proliferative fraction (OR 2.13) was observed. Past users with a long latency period had significantly more ER-positive (OR 2.16-3.69) but also EGF-R positive tumors (OR 1.73-2.0) with a moderate increase in proliferative activity (OR 1.64-1.93) compared to never users. In multivariate survival analyses long-term OC use (HR 0.55, 95%CI 0.34-0.90) and first OC use more than 96 months before diagnosis (HR 0.49, 95%CI 0.26-0.92) were associated with a significant improvement in survival, whereas current OC use ( HR 2.29, 95%CI 1.02-5.17) or last OC use during the last 2 years before diagnosis (HR 3.80, 95%CI 1.45-9.97) were related to a significant decrease in survival rates. OC use during a biologically sensitive time period seems to be more important than duration of use. A biological hypothesis is beeing suggested.

Contexte : L'insuffisance cardiaque (IC) est un syndrome aux étiologies variées, et hétérogène dans ses présentations cliniques, dont l'incidence augmente avec l'âge et dont le pronostic reste sombre. Les facteurs pronostiques dans l'IC ont été largement décrits dans la littérature, en particulier dans l'IC à fraction d'éjection réduite (ICFER), à plus ou moins long terme. Des interventions thérapeutiques médicamenteuses, chirurgicales, ou complexes sont recommandées pour traiter ce syndrome. Objectifs : Les objectifs de ce travail étaient d'évaluer la valeur pronostique des marqueurs de fibrose chez les patients hypertendus, de décrire la survie et d'identifier les facteurs pronostiques chez les patients en IC, à très long terme chez les ICFER, et à 1 an chez les IC à fraction d'éjection préservée (ICFEP), et de mesurer l'impact sur les hospitalisations de 2 interventions complexes recommandées. Méthodes : Une première étude de cohorte a été menée chez des patients hypertendus, avec un recueil à l'inclusion des dosages sériques des marqueurs du renouvellement de la matrice extracellulaire cardiaque (MRMEC) et un suivi pendant 6 ans. Deux autres études de cohorte ont permis d'identifier les facteurs pronostiques de décès à 15 ans chez des patients ICFER (EPICAL), et à 1 an chez les ICFEP (Odin). Enfin, les données du PMSI ont permis de mesurer l'impact pronostique de la prise en charge dans une unité spécialisée (UTIC) et d'une prise en charge de type disease management (ICALOR). Résultats : La première étude a mis en évidence la valeur pronostique des MRMEC chez des patients hypertendus. L'étude EPICAL a montré que l'âge avancé, le diabète, l'insuffisance rénale chronique, l'ancienneté de l'IC, les antécédents de décompensation, la tachycardie, une fraction d'éjection réduite, et une hyponatrémie étaient associés à une mortalité plus élevée à 15 ans chez les ICFER. L'étude ODIN a montré la valeur pronostique négative de facteurs sociaux comme le fait de vivre seul ou la limitation des activités, chez les ICFEP. Enfin, les prises en charge en UTIC et par le réseau ICALOR étaient associées à une diminution des hospitalisations pour IC, mesurable à l'échelle populationnelle. Conclusion : Ces travaux permettent d'envisager de nouvelles pistes de prévention primaire et secondaire, afin de diminuer l'incidence, la morbidité et la mortalité liées à l'IC / Context: Heart failure (HF) is a heterogeneous syndrome with various aetiologies. HF incidence increases with age, and the prognosis remains poor. Prognostic factors have been widely described in the literature, especially in HF with reduced ejection fraction with short-term or mid-term follow-up. Medications, surgical interventions, and complex interventions are part of the current guidelines. Objectives: To assess the prognostic value of fibrosis markers in hypertensive patients; to describe the survival and to detect prognostic factors, first at 15 years in HF patients with reduced ejection fraction (HFREF), and second at one year in HF patients with preserved ejection fraction (HFPEF); and to assess the prognostic impact of 2 complex interventions on HF hospitalisations. Methods: Cardiac extracellular matrix serum markers (CEMSM) were assessed at baseline in a first cohort of hypertensive patients followed-up for 6 years. Two other cohort studies were used to detect prognostic factors associated with very-long term mortality in HFREF (EPICAL), and with 1-year mortality in HFPEF (Odin). And the national diagnostic related group database was used to assess the prognostic impact of a HF unit (UTIC) and a disease management programme (ICALOR). Results: The first cohort study highlighted the prognostic value of CEMSM in hypertensive patients. In EPICAL study, older age, diabetes mellitus, chronic renal failure, time from HF onset, history of hospitalisations for worsening HF, tachycardia, a low left ventricular ejection fraction, and hyponatraemia were associated with a higher mortality in HFREF patients. In Odin study, we highlighted the negative prognostic impact of social factors, such as living alone or daily activity limitation, in HFPEF patients. Both UTIC and ICALOR were associated with a decrease in HF hospitalisations compatible with a population impact. Conclusion: These studies offer new insights for primary and secondary prevention strategies that could eventually lead to decrease HF incidence, HF morbidity, and HF mortality

Les protéoglycanes à héparane-sulfates (HSPGs) sont des macromolécules ubiquitaires situées à la surface des cellules et au sein des matrices extracellulaires jouant un rôle clé dans le contrôle des interactions cellules-matrice et du micro-environnement tumoral. Leur biosynthèse est assurée par une machinerie enzymatique complexe impliquant des glycosyltransférases et sulfotransférases, lesquelles ajoutent des motifs sulfatés en différentes positions des résidus de la chaîne glucidique. Ces modifications confèrent aux HSPGs la capacité d’interagir avec de nombreux ligands comme les facteurs de croissance et leurs récepteurs permettant de réguler divers processus physiopathologiques tels que la prolifération et la survie cellulaires, l’angiogenèse et le développement tumoral. J’ai focalisé mon étude sur une famille de sulfotransférases, les 3-O-sulfotransférases (3-OSTs) responsables d’une modification rare et terminale des chaînes de HS et en particulier sur l’isoforme 3A (3-OST3A) dont le rôle dans le développement tumoral a été précédemment mis en évidence par notre équipe. L’objectif de ce travail de thèse est d’explorer le rôle de la 3-OST3A dans la régulation du développement du cancer du sein. Ces travaux mettent en évidence que le gène 3-OST3A est régulé épigénétiquement dans un panel de lignées cellulaires cancéreuses mammaires. Les tests cellulaires de prolifération et d’apoptose montrent que la 3-OST3A exerce une action oncogénique ou suppresseur de tumeur dépendante de la signature moléculaire des cellules cancéreuses mammaires. Au niveau clinique, un fort taux d’expression de la 3-OST3A dans les tumeurs est corrélé négativement avec la survie des patientes atteintes d’un cancer du sein de sous-type HER2+. Ces travaux sont les premiers à mettre en évidence un rôle fonctionnel de la 3-OST3A en tant que régulateur du comportement tumoral des cellules cancéreuses mammaires et permettent de l’envisager comme marqueur pronostique de l’évolution du sous-type de tumeur mammaire HER2. La poursuite de cette étude a pour objectif de comprendre les mécanismes qui expliquent les conséquences délétères de la forte expression de la 3-OST3A sur l’agressivité du cancer du sein HER2+. Mes résultats suggèrent que la 3-OST3A induirait l’activation du récepteur HER2 par une voie dépendante de la formation du complexe ternaire HS 3-O-sulfatés/FGF-7/FGFR2IIIb dans les cellules SKBR3, un modèle de cellules cancéreuses mammaires surexprimant le récepteur HER2 responsable du caractère agressif du cancer du sein HER2+ / Heparan sulfate proteoglycans (HSPG) are ubiquitous macromolecules located at the cell plasma membrane and in extracellular matrices playing a key role in the control of cell-matrix interactions and in the tumor micro-environment. Their biosynthesis is performed by a complex enzymatic machinery involving glycosyltransferases and sulfotransferases, the latter adding a sulfate group at different residue positions of the polysaccharide chain. These modifications provide to the HSPG the ability to interact with many ligands such as growth factors and their receptors, and to regulate multiple pathophysiological processes such as cell proliferation and survival, angiogenesis and tumor development. I focused on a sulfotransferase family, the heparan sulfate 3-O-sulfotransferases (HS3STs) responsible for a rare, terminal modification of HS chains. Specifically, we investigated the HS3ST3A isoform whose role in tumor development has been previously demonstrated by our team. Here I explored the role of HS3ST3A in breast cancer. My studies demonstrate that HS3ST3A gene is epigenetically regulated in a panel of breast cancer cell lines. Cell proliferation and apoptosis assays in cellulo showed that HS3ST3A exerts an oncogenic or tumor suppressor effect in a cell-dependent context. A clinical study performed in a cohort of breast cancer patients showed that a high expression level of HS3ST3A in tumors is associated with reduced relapse-free survival in HER2+ patients. For the first time, we report a functional role of HS3ST3A as a tumor regulator of breast cancer cells behavior and this study allows considering it as a prognostic marker of the HER2 breast cancer evolution. The last part of my work attempted to understand the mechanisms that explain the deleterious consequences of the high expression level of HS3ST3A on the aggressiveness of HER2+ breast cancer. In this regard, my results suggested that the HS3ST3A may induce HER2 receptor activation following the formation of the ternary complex HS 3-O-sulphated/FGF-7/FGFR2IIIb in SKBR3 (HER2+) cells