Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

A cirurgia ainda é o principal método de tratamento do câncer do reto. Recentemente a quimio e radioterapia neo-adjuvantes têm sido preconizadas, com freqüência cada vez maior, com o intuito de reduzir os índices de recidiva e mortalidade. O objetivo desse estudo foi avaliar, retrospectivamente a sobrevida e a recidiva tumoral de pacientes submetidos a quimioterapia adjuvante, com e sem quimio e radioterapia neoadjuvantes. Foram avaliados retrospectivamente 36 pacientes submetidos a ressecção anterior baixa por adenocarcinoma do reto. Subdivididos em três grupos: grupo I (N=11), submetidos exclusivamente a tratamento cirúrgico; grupo II (N=8), submetidos a tratamento cirúrgico, seguido de quimioterapia adjuvante; grupo III (N=17), submetidos a tratamento cirúrgico com quimio e radioterapia neo-adjuvantes. O período de seguimento foi de 36 meses. Seis pacientes (16,6%) apresentaram recidiva, sendo 1 paciente do grupo I, 3 pacientes do grupo II e 2 pacientes do grupo III. A sobrevida global foi de 88,9%, assim distribuída: grupo I, 80,0%; grupo II, 100,0% e grupo III, 87,5%. Não houve diferença significante nos índices de recidiva nem na sobrevida entre os grupos. Concluiu-se que na amostra estudada os métodos terapêuticos tiveram resposta equivalente, não tendo sido possível demonstrar a interferência da quimio e ou radioterapia nos índices de sobrevida ou recidiva / Surgery continues to be the principal method for treating cancer of the rectum. Recently, chemo and neo-adjuvant radiotherapy have been considered, with increasing frequency, with the intention of reducing the rates of recurrence and mortality. The objective of this study was to evaluate, retrospectively, survival and tumor recurrence in patients submitted to adjuvant chemotherapy, with and without neo-adjuvant chemo and radiotherapy. A retrospective evaluation of 36 patients submitted to lower anterior resection for adenocarcinoma of the rectum was conducted, subdivided into three groups: Group I (n=11), submitted exclusively to surgical treatment; Group II (n=8), submitted to surgical treatment followed by adjuvant chemotherapy; Group III (n=17), submitted to surgical treatment with chemo and neo-adjuvant radiotherapy. The time period was 36 months. Six patients (16.6%) presented recurrence: 1 patient from Group I, 3 patients from Group II and 2 patients from Group III. Overall survival was 88.9%, distributed in the following way: Group I, 80.0%; Group II, 100.0% and Group III, 87.5%. No significant differences in the rates of recurrence and survival were observed between the groups. It is therefore concluded that within the sample the therapeutic methods had similar response, not having been possible to demonstrate the interference of chemo and radiotherapy in the rates of survival or recurrence

A cirurgia ainda é o principal método de tratamento do câncer do reto. Recentemente a quimio e radioterapia neo-adjuvantes têm sido preconizadas, com freqüência cada vez maior, com o intuito de reduzir os índices de recidiva e mortalidade. O objetivo desse estudo foi avaliar, retrospectivamente a sobrevida e a recidiva tumoral de pacientes submetidos a quimioterapia adjuvante, com e sem quimio e radioterapia neoadjuvantes. Foram avaliados retrospectivamente 36 pacientes submetidos a ressecção anterior baixa por adenocarcinoma do reto. Subdivididos em três grupos: grupo I (N=11), submetidos exclusivamente a tratamento cirúrgico; grupo II (N=8), submetidos a tratamento cirúrgico, seguido de quimioterapia adjuvante; grupo III (N=17), submetidos a tratamento cirúrgico com quimio e radioterapia neo-adjuvantes. O período de seguimento foi de 36 meses. Seis pacientes (16,6%) apresentaram recidiva, sendo 1 paciente do grupo I, 3 pacientes do grupo II e 2 pacientes do grupo III. A sobrevida global foi de 88,9%, assim distribuída: grupo I, 80,0%; grupo II, 100,0% e grupo III, 87,5%. Não houve diferença significante nos índices de recidiva nem na sobrevida entre os grupos. Concluiu-se que na amostra estudada os métodos terapêuticos tiveram resposta equivalente, não tendo sido possível demonstrar a interferência da quimio e ou radioterapia nos índices de sobrevida ou recidiva / Surgery continues to be the principal method for treating cancer of the rectum. Recently, chemo and neo-adjuvant radiotherapy have been considered, with increasing frequency, with the intention of reducing the rates of recurrence and mortality. The objective of this study was to evaluate, retrospectively, survival and tumor recurrence in patients submitted to adjuvant chemotherapy, with and without neo-adjuvant chemo and radiotherapy. A retrospective evaluation of 36 patients submitted to lower anterior resection for adenocarcinoma of the rectum was conducted, subdivided into three groups: Group I (n=11), submitted exclusively to surgical treatment; Group II (n=8), submitted to surgical treatment followed by adjuvant chemotherapy; Group III (n=17), submitted to surgical treatment with chemo and neo-adjuvant radiotherapy. The time period was 36 months. Six patients (16.6%) presented recurrence: 1 patient from Group I, 3 patients from Group II and 2 patients from Group III. Overall survival was 88.9%, distributed in the following way: Group I, 80.0%; Group II, 100.0% and Group III, 87.5%. No significant differences in the rates of recurrence and survival were observed between the groups. It is therefore concluded that within the sample the therapeutic methods had similar response, not having been possible to demonstrate the interference of chemo and radiotherapy in the rates of survival or recurrence

INTRODUÇÃO: O câncer do reto médio e distal ainda é assunto bastante controverso, especialmente no que se refere ao estadiamento locorregional e opções terapêuticas. Busca-se um método sensível e específico para a avaliação da profundidade de invasão da parede retal e o envolvimento linfonodal. O adequado estadiamento da neoplasia do reto extraperitoneal é de suma importância no manejo terapêutico e prognóstico do paciente. Diversos métodos têm sido descritos para a avaliação da disseminação locorregional das neoplasias do reto, que variam desde o toque retal até a ressonância magnética da pelve e a ultrassonografia endorretal bi e tridimensional. OBJETIVO: Correlacionar os achados da profundidade de invasão tumoral na parede retal (T), comprometimento linfonodal (N), extensão e porcentagem de acometimento da lesão à ultrassonografia endorretal tridimensional (USER-3D) com o exame anatomopatológico (AP) de pacientes portadores de neoplasia de reto extraperitoneal submetidos a procedimento cirúrgico após o diagnóstico e estadiamento clínico prévio. MÉTODO: Estudo prospectivo foi realizado com pacientes portadores de neoplasia de reto médio e distal seguidos no Instituto Central (IC) e no Instituto do Câncer do Estado de São Paulo (ICESP), do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) que foram submetidos a USER-3D pré-operatório. Os parâmetros analisados por meio do USER-3D foram comparados aos achados da anatomia patológica do espécime cirúrgico obtido após o procedimento. Os exames de USER-3D foram realizados pelo mesmo médico, sendo cego dos outros métodos diagnósticos e dos achados da patologia, a qual também não tinha os resultados do estadiamento clínico pré-operatório. Todos os pacientes foram submetidos a enema evacuatório no dia anterior e na manhã do exame. Foram avaliados a sensibilidade, especificidade, valores preditivos positivo e negativo, área sobre a curva e o índice Kappa do USER-3D em comparação ao anatomopatológico, considerado exame padrão ouro. O coeficiente de correlação intraclasse (CCI) foi utilizado para analisar a extensão e porcentagem de acometimento da lesão na parede retal. RESULTADOS: No período de 3 anos, 44 pacientes foram estudados, 27 mulheres, com idade média de 63,5 anos. Houve 12 lesões benignas e 32 malignas de reto, sendo 30 submetidas à ressecção local e 14 à radical. O USER-3D determinou a diferenciação da profundidade de invasão tumoral na submucosa com sensibilidade de 77,3% (CI95% - 54,6%-92,2%), especificidade de 86,4% (CI95% - 65.1%-97.1%), valor preditivo positivo de 85% (CI95% - 62,1%-96,8%), valor preditivo negativo de 79,2% (CI95% - 57,8%-92,9%) e área sobre a curva de 0,82% (CI95% - 0,7%-0,96%). O índice Kappa ponderado para profundidade de invasão da parede retal (T) foi de 0,672 (IC95%: 0,493; 0,850), considerado grau de concordância substancial. Para o envolvimento linfonodal (N) não houve concordância adequada entre o USER-3D e o anatomopatológico (k=-0,164) nos 14 casos analisados. A CCI calculada para extensão da lesão foi moderada (0,45) para a extensão em centímetros, mas adequada (0,66) para porcentagem de envolvimento da circunferência. O gráfico de Bland-Altman mostrou que lesões com extensão de até 5 cm e 50% de acometimento têm melhor correlação com o espécime cirúrgico. CONCLUSÕES: USER-3D foi eficaz para a determinação da invasão da parede retal, sendo seguro na determinação da extensão de lesões até 5 cm e porcentagem de acometimento da circunferência até 50%. O método mostrou baixa eficácia na avaliação linfonodal, em subgrupo limitado de pacientes / INTRODUCTION: Loco-regional staging and treatment of extra peritoneal rectal neoplasms is still a controversial subject. There is no perfect method, substantially sensitive and specific for staging rectal wall invasion and lymph node involvement. Adequate oncologic staging of rectal neoplasias has major importance in both, treatment and prognostic evaluation. Therefore, the use of supplementary diagnostic methods such as endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) of the pelvis can promote an accurate assessment of tumor invasion in the rectal wall and lymph node involvement. OBJECTIVE: To correlate the findings of three-dimensional (3D) ERUS with pathology specimen of extra peritoneal rectal neoplasia referred directly to surgery after diagnosis, in regards to depth of rectal wall invasion (T), lymph node involvement, percentage of circumferential rectal wall invasion and tumor extension. METHODS: A prospective study was performed in patients with middle and distal rectal tumors followed at University of São Paulo, School of Medicine and Cancer Institute of State of São Paulo (ICESP), who underwent 3D-ERUS for preoperative evaluation. The parameters analyzed with 3D-ERUS were compared with pathology findings of the surgical specimen obtained after the procedure. A single doctor who performed the exams reported the 3D-ERUS studies and was blind of other methods as well as the pathologic findings. All patients underwent retrograde bowel enema the day before and in the morning of the test. The authors evaluated sensitivity, specificity, positive and negative predictive values, area under curve and kappa index of the 3D-ERUS as compared to pathologic findings, considered the gold standard. For extension and percentage of tectal wall involvement intraclass correlation index was applied. RESULTS: At 3-years period, 44 patients were studied, 27 females, with a mean age of 63.5 years, who had 12 rectal adenomas and 32 adenocarcinomas and underwent local resection (30) or radical resection (14). Value for 3D-ERUS to determine depth of rectal wall invasion sensitivity was 77.3% (CI95% - 54.6%-92.2%), specificity was 86.4% (CI95% - 65.1%- 97.1%), positive predictive value was 85% (CI95% - 62.1%- 96.8%), negative predictive value was 79.2% (CI95% - 57.8%-92.9%) and area under curve was 0,82% (CI95% - 0.7%-0.96%). The weighted kappa index for the depth of invasion in the rectal wall (T) evaluation was 0.67 (IC95%: 0.49; 0.85), considered substantial agreement. For N involvement there was any agreement between 3D-ERUS and histopathology, with K=-0.164. Intraclass correlation was calculated for lesion extension and was moderate (0.45) for extension in centimeters and adequate (0.66) for percentage of circumference involvement. A Bland-Altman graph was performed and showed that tumor extensions until 5 cm and 50% of wall involvement have a good correlation to specimen size. CONCLUSION: 3D-ERUS was effective for determining rectal wall invasion and evaluation of extension of lesions until 5 cm and 50% of rectal wall involvement. However, this method showed a lack of efficacy for evaluation of lymph node involvement for early rectal tumors in this limited subset of patients

越來越多證據表明了煙酰胺腺嘌呤核苷酸磷酸（nicotinamide adenine dinucleotide phosphate, NADPH）代謝對腫瘤細胞增殖和生存的重要性。最近一項研究證實了一個p53調節基因，TP53誘導的糖酵解和凋亡調節因數（TP53-inducible glycolysis and apoptosis regulator, TIGAR），在抑制凋亡和誘導NADPH產生方面的作用。抗凋亡蛋白B細胞淋巴瘤2（B-cell lymphoma 2, Bcl-2）之前被報導能夠通過還未確定的機制誘導NADPH的產生。在這篇論文研究中，我們假設Bcl-2與TIGAR耦合從而調節NADPH的產生和細胞生存，並且TIGAR可能成為一個促進細胞生長的新生存因數。這篇論文研究的目的是：1）檢測在NADPH代謝中Bcl-2與TIGAR間的生物聯繫；2）探究在哺乳動物系統中TIGAR調節的分子機制；3）研究TIGAR在體外和體內調節正常及腫瘤細胞生存的作用。 / 這篇論文的第一部分結果顯示在正常小鼠胚胎成纖維細胞（MEFs）和缺少功能性p53的人非小細胞肺癌（NSCLC）細胞中存在Bcl-2/TIGAR/NADPH這樣一個新的信號通路軸，重要抗凋亡蛋白Bcl-2與TIGAR耦合後，以一個特有並持久的方式調節NADPH代謝和細胞生長。用特異的小干擾RNA（siRNA）靶向抑制Bcl-2能夠在NSCLC細胞中抑制TIGAR/NADPH/生長信號軸。用小分子抑制劑ABT-737對Bcl-2進行藥理學抑制也能夠顯示相似的作用，而這個作用能夠通過過表達TIGAR被部分逆轉。而且，敲除TIGAR能夠降低Bcl-2誘導的NADPH產生和細胞生長，表明了TIGAR在介導TIGAR/NADPH/生長信號軸中的關鍵作用。 / 為了第二個目的，我們研究了Bcl-2對TIGAR的機制調節。我們發現過表達Bcl-2不能改變TIGAR的mRNA水平，但是能誘導轉錄後的TIGAR蛋白累積。有趣的是，TIGAR似乎能通過一個正反饋回路誘導Bcl-2的表達，這進一步促進了由Bcl-2誘導的TIGAR表達上調。除了Bcl-2，許多致癌基因或生長調節因數也被證實參與了TIGAR的調節，包括信號轉導和轉錄啟動因數3（signal transducer and activator of transcription 3, STAT3, Bcl-2的上有調節因數），表皮生長因數受體（epidermal growth factor receptor, EGFR）和肝細胞生長因數受體（hepatocyte growth factor receptor, c-Met）。 / 這篇論文的第三部分證實了TIGAR在缺少功能性p53細胞模型中的致癌作用。TIGAR過表達能夠誘導一些癌症的標誌性特徵，包括細胞代謝調節異常，細胞生長增加和凋亡減少。重要的是，TIGAR的過表達在MEFs和缺少功能性p53的NSCLC細胞中直接促成了腫瘤形成，促進了腫瘤的生長。但是功能性p53的存在無論在體外還是體內都能夠消除TIGAR這種生長促進和成瘤的作用。這些發現表明當p53功能消失時TIGAR能成為一個致癌基因，促進腫瘤形成。 / 總的來說，我們發現了在腫瘤中Bcl-2/TIGAR/NADPH這樣一條新的信號通路。Bcl-2通過增加TIGAR蛋白累積的轉錄後機制調節TIGAR。我們也證實了TIGAR受到多種致癌基因或生長調節因數的調節，包括STAT3，EGFR和c-Met。並且，我們闡明了當p53功能消失時TIGAR能成為一個致癌基因，促進細胞轉化和腫瘤形成。 / Emerging evidences reveal the importance of nicotinamide adenine dinucleotide phosphate (NADPH) metabolism for cancer cell proliferation and survival. A recent study demonstrated the role of a p53-regulated gene, TP53-inducible glycolysis and apoptosis regulator (TIGAR), in inhibiting apoptosis and inducing NADPH production. The anti-apoptotic protein B-cell lymphoma 2 (Bcl-2) has previously been reported to induce NADPH generation through undefined mechanism. In this thesis study, we hypothesized that Bcl-2 is coupled to TIGAR for regulation of NADPH production and cell survival, and that TIGAR may serve as a novel survival factor contributing to cell growth. The objectives of the thesis study are: 1) to examine the biologic relationship between Bcl-2 and TIGAR in NADPH metabolism; 2) to investigate the molecular mechanisms of TIGAR regulation in mammalian systems; and 3) to examine the role of TIGAR in regulating normal and cancer cell survival in vitro and in vivo. / Findings in first part of the thesis revealed a novel signaling axis of Bcl-2/TIGAR/NADPH in normal mouse embryonic fibroblasts (MEFs) and human non-small cell lung cancer (NSCLC) cells lacking functional p53, coupling the major anti-apoptotic protein Bcl-2 to TIGAR regulation for NADPH metabolism and cell growth in a specific and sustained manner. Targeting of Bcl-2 by specific siRNA inhibited TIGAR/NADPH/growth axis in NSCLC cells. Pharmacologic inhibition of Bcl-2 by small molecule inhibitor ABT-737 also exhibited similar effects, which was partially reversed by the overexpression of TIGAR. In addition, TIGAR knockdown reduced Bcl-2-induced NADPH production and cell growth, implicating a critical role of TIGAR in mediating Bcl-2/NADPH/growth signaling axis. / For the second objective, we studied the mechanistic regulation of TIGAR by Bcl-2. We found that overexpression of Bcl-2 did not alter TIGAR mRNA expression but induced TIGAR protein accumulation post-transcriptionally. Interestingly, TIGAR seemed to induce Bcl-2 expression via a positive feedback loop, which may further contribute to the upregulation of TIGAR expression induced by Bcl-2. In addition to Bcl-2, a number of oncogene/growth regulators were demonstrated to be involved in TIGAR regulation, including signal transducer and activator of transcription 3 (STAT3, an upstream regulator of Bcl-2), epidermal growth factor receptor (EGFR) and hepatocyte growth factor receptor (c-Met). / The third part of the thesis demonstrated the oncogenic role of TIGAR in cell models lacking functional p53. TIGAR overexpression induced several hallmark features of cancer including deregulated cell metabolism, increased cell growth and inhibited apoptosis. Strikingly, overexpression of TIGAR directly drove tumor formation and promoted tumor growth in MEFs and NSCLC cells lacking functional p53. The growth stimulatory and tumorigenic activities of TIGAR were abolished in the presence of functional p53 both in vitro and in vivo. These findings revealed TIGAR as an oncogene capable of driving tumorigenesis when p53 function is lost. / In summary, we have identified a novel signaling pathway of Bcl-2/TIGAR/NADPH in cancer. TIGAR is regulated by Bcl-2 via a post-transcriptional mechanism by enhancing TIGAR protein accumulation. We also demonstrated the regulation of TIGAR by multiple oncogene/growth regulators including STAT3, EGFR and c-Met. Furthermore, we have demonstrated TIGAR as an oncogene capable of driving cell transformation and tumorigenesis when p53 function is lost. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Lam, Kai Yee. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 158-176). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese. / Abstract --- p.i / 摘要 --- p.iv / Declaration --- p.vi / Acknowledgements --- p.vii / Publications --- p.viii / Table of Content --- p.ix / List of Illustrations --- p.xii / List of Abbreviations --- p.xv / Chapter Chapter 1: --- Introduction / Chapter 1.1 --- Overview of tumor metabolism --- p.1 / Chapter 1.1.1 --- Glucose metabolism --- p.4 / Chapter 1.1.2 --- Glutamine metabolism --- p.6 / Chapter 1.1.3 --- De novo fatty acid synthesis --- p.7 / Chapter 1.1.4 --- Advantages of metabolic reprogramming in tumor cells --- p.8 / Chapter 1.2 --- Mechanisms regulating metabolic reprogramming in cancers --- p.11 / Chapter 1.2.1 --- Tumor suppressor p53 --- p.11 / Chapter 1.2.2 --- Hypoxia-inducible factor 1 (HIF-1) --- p.13 / Chapter 1.2.3 --- PI3K/Akt/mTOR signaling pathway --- p.15 / Chapter 1.2.4 --- Oncogenic Myc --- p.16 / Chapter 1.2.5 --- Oncogenic Ras --- p.18 / Chapter 1.3 --- TP53-Inducible Glycolysis and Apoptosis Regulator (TIGAR) --- p.22 / Chapter 1.3.1 --- TIGAR and oxidative stress --- p.25 / Chapter 1.3.2 --- TIGAR and carcinogenesis --- p.29 / Chapter 1.3.3 --- TIGAR and other diseases --- p.32 / Chapter 1.4 --- Hypotheses and Aims --- p.36 / Chapter Chapter 2: --- Materials and Methods / Chapter 2.1 --- Materials --- p.38 / Chapter 2.1.1 --- Chemicals and reagents --- p.38 / Chapter 2.1.2 --- Drugs --- p.41 / Chapter 2.1.3 --- Commercial detection kits --- p.41 / Chapter 2.1.4 --- Antibodies --- p.42 / Chapter 2.2 --- Cell culture --- p.43 / Chapter 2.3 --- Plasmids --- p.44 / Chapter 2.4 --- Transfection --- p.46 / Chapter 2.5 --- Retrovirus infection --- p.47 / Chapter 2.6 --- Drug treatment --- p.47 / Chapter 2.7 --- Cell viability assay --- p.48 / Chapter 2.8 --- Trypan blue exclusion assay --- p.49 / Chapter 2.9 --- NADPH assay --- p.49 / Chapter 2.10 --- Cell death detection ELISA --- p.50 / Chapter 2.11 --- Western blotting --- p.50 / Chapter 2.12 --- Reverse TranscriptionPolymerase Chain Reaction (RT-PCR) --- p.51 / Chapter 2.13 --- Cell cycle analysis --- p.52 / Chapter 2.14 --- Transwell migration and matrigel invasion assays --- p.53 / Chapter 2.15 --- In vivo studies --- p.54 / Chapter 2.16 --- Histology and immunohistochemistry --- p.55 / Chapter 2.17 --- Statistical analysis --- p.56 / Chapter Chapter 3: --- Indentification of Novel Bcl-2/TIGAR/NADPH Signaling Axis / Chapter 3.1 --- Introduction --- p.57 / Chapter 3.2 --- Results --- p.60 / Chapter 3.2.1 --- Bcl-2-induced NADPH production and cell growth is associated with TIGAR upregulation in p53-null MEFs --- p.60 / Chapter 3.2.2 --- Identification of Bcl-2/TIGAR/NADPH signaling axis in p53-negative NSCLC cells --- p.63 / Chapter 3.2.3 --- Bcl-2 targeting reduces TIGAR expression and NADPH production in MEFs and NSCLC cells --- p.66 / Chapter 3.2.4 --- Pharmacologic intervention of Bcl-2 alters TIGAR levels in MEFs and NSCLC cells --- p.71 / Chapter 3.2.5 --- Bcl-2 targeting inhibits TIGAR expression, NADPH production and cell growth in Bcl-2-amplified small cell lung cancer (SCLC) cells --- p.76 / Chapter 3.2.6 --- Bcl-2-induced TIGAR expression is highly specific compared to other pro-survival proteins --- p.78 / Chapter 3.2.7 --- Bcl-2/TIGAR/NADPH signaling axis is functionally intact in p53-positive NSCLC cells --- p.80 / Chapter 3.3 --- Discussion --- p.83 / Chapter Chapter 4: --- Mechanisms of TIGAR Regulation / Chapter 4.1 --- Introduction --- p.88 / Chapter 4.2 --- Results --- p.90 / Chapter 4.2.1 --- Bcl-2 regulates TIGAR by post-transcriptional mechanism --- p.90 / Chapter 4.2.2 --- Bcl-2-induced TIGAR expression is associated with upregulation of other pro-survival proteins --- p.94 / Chapter 4.2.3 --- STAT3 activation can serve as a biological signal for TIGAR induction --- p.97 / Chapter 4.2.4 --- Tyrosine kinase receptors contributes to TIGAR regulation --- p.100 / Chapter 4.2.5 --- The existence of TIGAR/Bcl-2 positive feedback loop --- p.102 / Chapter 4.3 --- Discussion --- p.104 / Chapter Chapter 5: --- TIGAR is Oncogenic / Chapter 5.1 --- Introduction --- p.107 / Chapter 5.2 --- Results --- p.109 / Chapter 5.2.1 --- Overexpression of TIGAR alters several hallmark features of cancer --- p.109 / Chapter 5.2.2 --- TIGAR drives tumor formation in vivo --- p.114 / Chapter 5.2.3 --- Tumorigenic activity of TIGAR is functionally counteracted by functional p53 --- p.123 / Chapter 5.3 --- Discussion --- p.134 / Chapter Chapter 6: --- Summary --- p.138 / Chapter Chapter 7: --- Future Prospective --- p.143 / Appendices --- p.148 / References --- p.158

Diss. (sammanfattning) Linköping : Univ., 2006. / Härtill 5 uppsatser.

Diss. (sammanfattning) Göteborg : Univ. , 2009. / Härtill 4 uppsatser.

INTRODUÇÃO: O câncer do reto médio e distal ainda é assunto bastante controverso, especialmente no que se refere ao estadiamento locorregional e opções terapêuticas. Busca-se um método sensível e específico para a avaliação da profundidade de invasão da parede retal e o envolvimento linfonodal. O adequado estadiamento da neoplasia do reto extraperitoneal é de suma importância no manejo terapêutico e prognóstico do paciente. Diversos métodos têm sido descritos para a avaliação da disseminação locorregional das neoplasias do reto, que variam desde o toque retal até a ressonância magnética da pelve e a ultrassonografia endorretal bi e tridimensional. OBJETIVO: Correlacionar os achados da profundidade de invasão tumoral na parede retal (T), comprometimento linfonodal (N), extensão e porcentagem de acometimento da lesão à ultrassonografia endorretal tridimensional (USER-3D) com o exame anatomopatológico (AP) de pacientes portadores de neoplasia de reto extraperitoneal submetidos a procedimento cirúrgico após o diagnóstico e estadiamento clínico prévio. MÉTODO: Estudo prospectivo foi realizado com pacientes portadores de neoplasia de reto médio e distal seguidos no Instituto Central (IC) e no Instituto do Câncer do Estado de São Paulo (ICESP), do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) que foram submetidos a USER-3D pré-operatório. Os parâmetros analisados por meio do USER-3D foram comparados aos achados da anatomia patológica do espécime cirúrgico obtido após o procedimento. Os exames de USER-3D foram realizados pelo mesmo médico, sendo cego dos outros métodos diagnósticos e dos achados da patologia, a qual também não tinha os resultados do estadiamento clínico pré-operatório. Todos os pacientes foram submetidos a enema evacuatório no dia anterior e na manhã do exame. Foram avaliados a sensibilidade, especificidade, valores preditivos positivo e negativo, área sobre a curva e o índice Kappa do USER-3D em comparação ao anatomopatológico, considerado exame padrão ouro. O coeficiente de correlação intraclasse (CCI) foi utilizado para analisar a extensão e porcentagem de acometimento da lesão na parede retal. RESULTADOS: No período de 3 anos, 44 pacientes foram estudados, 27 mulheres, com idade média de 63,5 anos. Houve 12 lesões benignas e 32 malignas de reto, sendo 30 submetidas à ressecção local e 14 à radical. O USER-3D determinou a diferenciação da profundidade de invasão tumoral na submucosa com sensibilidade de 77,3% (CI95% - 54,6%-92,2%), especificidade de 86,4% (CI95% - 65.1%-97.1%), valor preditivo positivo de 85% (CI95% - 62,1%-96,8%), valor preditivo negativo de 79,2% (CI95% - 57,8%-92,9%) e área sobre a curva de 0,82% (CI95% - 0,7%-0,96%). O índice Kappa ponderado para profundidade de invasão da parede retal (T) foi de 0,672 (IC95%: 0,493; 0,850), considerado grau de concordância substancial. Para o envolvimento linfonodal (N) não houve concordância adequada entre o USER-3D e o anatomopatológico (k=-0,164) nos 14 casos analisados. A CCI calculada para extensão da lesão foi moderada (0,45) para a extensão em centímetros, mas adequada (0,66) para porcentagem de envolvimento da circunferência. O gráfico de Bland-Altman mostrou que lesões com extensão de até 5 cm e 50% de acometimento têm melhor correlação com o espécime cirúrgico. CONCLUSÕES: USER-3D foi eficaz para a determinação da invasão da parede retal, sendo seguro na determinação da extensão de lesões até 5 cm e porcentagem de acometimento da circunferência até 50%. O método mostrou baixa eficácia na avaliação linfonodal, em subgrupo limitado de pacientes / INTRODUCTION: Loco-regional staging and treatment of extra peritoneal rectal neoplasms is still a controversial subject. There is no perfect method, substantially sensitive and specific for staging rectal wall invasion and lymph node involvement. Adequate oncologic staging of rectal neoplasias has major importance in both, treatment and prognostic evaluation. Therefore, the use of supplementary diagnostic methods such as endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) of the pelvis can promote an accurate assessment of tumor invasion in the rectal wall and lymph node involvement. OBJECTIVE: To correlate the findings of three-dimensional (3D) ERUS with pathology specimen of extra peritoneal rectal neoplasia referred directly to surgery after diagnosis, in regards to depth of rectal wall invasion (T), lymph node involvement, percentage of circumferential rectal wall invasion and tumor extension. METHODS: A prospective study was performed in patients with middle and distal rectal tumors followed at University of São Paulo, School of Medicine and Cancer Institute of State of São Paulo (ICESP), who underwent 3D-ERUS for preoperative evaluation. The parameters analyzed with 3D-ERUS were compared with pathology findings of the surgical specimen obtained after the procedure. A single doctor who performed the exams reported the 3D-ERUS studies and was blind of other methods as well as the pathologic findings. All patients underwent retrograde bowel enema the day before and in the morning of the test. The authors evaluated sensitivity, specificity, positive and negative predictive values, area under curve and kappa index of the 3D-ERUS as compared to pathologic findings, considered the gold standard. For extension and percentage of tectal wall involvement intraclass correlation index was applied. RESULTS: At 3-years period, 44 patients were studied, 27 females, with a mean age of 63.5 years, who had 12 rectal adenomas and 32 adenocarcinomas and underwent local resection (30) or radical resection (14). Value for 3D-ERUS to determine depth of rectal wall invasion sensitivity was 77.3% (CI95% - 54.6%-92.2%), specificity was 86.4% (CI95% - 65.1%- 97.1%), positive predictive value was 85% (CI95% - 62.1%- 96.8%), negative predictive value was 79.2% (CI95% - 57.8%-92.9%) and area under curve was 0,82% (CI95% - 0.7%-0.96%). The weighted kappa index for the depth of invasion in the rectal wall (T) evaluation was 0.67 (IC95%: 0.49; 0.85), considered substantial agreement. For N involvement there was any agreement between 3D-ERUS and histopathology, with K=-0.164. Intraclass correlation was calculated for lesion extension and was moderate (0.45) for extension in centimeters and adequate (0.66) for percentage of circumference involvement. A Bland-Altman graph was performed and showed that tumor extensions until 5 cm and 50% of wall involvement have a good correlation to specimen size. CONCLUSION: 3D-ERUS was effective for determining rectal wall invasion and evaluation of extension of lesions until 5 cm and 50% of rectal wall involvement. However, this method showed a lack of efficacy for evaluation of lymph node involvement for early rectal tumors in this limited subset of patients

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23075号 / 医博第4702号 / 新制||医||1049(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 川上 浩司, 教授 近藤 尚己, 教授 小川 修 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Introdução. O Fluxo Gerenciado FGC20 é um protocolo institucional que define as etapas do tratamento neoadjuvante para adenocarcinoma de reto, com quimioterapia e radioterapia concomitantes e posterior cirurgia. Sua implantação no Instituto do Câncer do Estado de São Paulo (ICESP), a partir de março de 2011, envolveu as áreas assistenciais médicas, multiprofissionais e administrativas, com o estabelecimento da sequência das etapas e intervalos desejáveis. Objetivos. Avaliar a implantação do modelo de gerenciamento do protocolo clínico institucional para o tratamento neoadjuvante do adenocarcinoma de reto, nomeado Fluxo Gerenciado FGC20, adotado no ICESP. Pacientes e métodos. Foi construído um modelo lógico operacional para descrever o processo de implantação do fluxo gerenciado FGC20. Indicadores de monitoramento foram definidos a partir do modelo lógico e comparados com o período prévio à implantação. Dois grupos foram comparados: grupo controle, de pacientes cuja entrada ocorreu entre 06/05/2008 a 11/05/2011(prévio à implantação, nomeado grupo PreFluxo); e grupo experimental, de pacientes com início de atendimento entre 12/05/2011 a 31/12/2013 (posterior à implantação, nomeado grupo FGC20). Foram incluídos pacientes consecutivos, com diagnóstico de câncer de reto, tratados com quimioterapia e radioterapia concomitantes e posterior realização de cirurgia, e excluídos pacientes metastáticos ao diagnóstico inicial, pacientes com tratamento prévio ao início do tratamento no serviço e pacientes que não realizaram o tratamento neoadjuvante. Foram observados os intervalos de tempo entre as etapas do tratamento e recursos utilizados, dentre consultas, exames, internações, quimioterapia, radioterapia e cirurgia. O estudo de descrição de custos foi apresentado em Reais de 2015 na perspectiva do serviço. Resultados. De um total de 624 pacientes, foram analisados 330 pacientes: 112 do grupo PréFluxo e 218 do grupo FGC20. Em relação aos indicadores de monitoramento da implantação, 66% dos pacientes do grupo FGC20 realizaram a 1ª consulta no intervalo < 15 dias, 75% dos pacientes ficaram dentro da meta esperada de 14 semanas para o intervalo entre o final da neoadjuvância e a cirurgia (mediana de 13,2 semanas grupo FGC20 e 20 semanas grupo PréFluxo) e 73% dos pacientes completaram todas as etapas do fluxo gerenciado no intervalo <189 dias (mediana de 176,4 dias grupo FGC20 e 261,5 dias grupo PréFluxo). No grupo PréFluxo, houve maior número de consultas com oncologistas clínicos, tomografias computadorizadas, ressonâncias magnéticas e sessões de radioterapia (p < 0,001), bem como maior média de eventos de passagens no Setor de Emergência e na Unidade de Terapia Intensiva, em relação ao grupo FGC20 (p<0,001) e a média de custo por paciente tratado no grupo PréFluxo foi de R$ 40.935,68 e mediana de R$ 37.948,05. No grupo Fluxo Gerenciado, a média de custo por paciente tratado foi de R$ 40.368,18 e a mediana de R$ 35.341,32 respectivamente. A média de sobrevida global foi de 5,99 (5,59-6,40) e de 7,01 (6,47-7,54) anos, para os grupos PreFluxo e FGC20, respectivamente (p=0,83). Conclusões. A implantação do fluxo gerenciado promoveu reduções em todos os intervalos de tempo entre as etapas do tratamento. Não houve diferenças estatisticamente significantes na sobrevida global e no custo por paciente tratado entre os grupos. Custos de diárias e consultas foram os segmentos mais representativos no custo total do tratamento do paciente com câncer de reto / Background. The FGC20 is an integrated care pathway started in May 2011 at Instituto do Cancer do Estado de Sao Paulo (ICESP) for neoadjuvant treatment of adenocarcinoma of rectum. The implementation involved a multidisciplinary team to standardize patient care and to define steps, interventions and goals. Objectives. To evaluate the implementation of a clinical care pathway of rectal cancer in a Brazilian tertiary academic oncology hospital. Patients and Methods: An operational logical model of the integrated care pathway was developed to describe the pathway implementation. Two cohorts of diagnosed rectal cancer patients were compared: a control cohort from May 06th, 2008 through May 11th, 2011 (before the implementation, named group Pre FGC20), and a cohort from May 12th, 2011 through December 31th, 2013 (after implementation, named group FGC20). We included consecutive patients treated with concomitant chemoradiotherapy (nCRT) followed by surgery. Patients with prior treatment or who have not performed the nCRT treatment or with metastatic disease at diagnosis were excluded. Time intervals between treatment steps and resources used, including consultations, exams, hospitalizations, chemotherapy, radiotherapy and surgery were assessed. Cost description study from the hospital perspective is presented in 2015 Reais. Results. From a total of 624 patients, 330 were included: 112 PreFGC20 and 218 FGC20. Implementation indicators of the group FGC20 were identified based on the logic model: 66% had the first consultation < 15 days, 75% < 14 weeks interval between the neoadjuvant treatment and surgery (Group PreFGC20: 20 weeks, median; group FGC20: 13.2 weeks, median) and 73% < 189 days to complete all treatment steps (Group PreFGC20: 261.5 days, median; group FGC20: 176.4 days, median). We found higher utilization of consultations with clinical oncologists, CT, MRIs and radiotherapy sessions in the Group PreFGC20 compared with the FGC20 Group (p < 0.001), and also more utilization of emergency room and intensive care unit in Group PreFGC20 (p < 0.001). Median cost per treated patient in Group PreFGC20 was R$ 37.948,05 and mean cost was R$ 40.935,68. Median cost per treated patient in Group FGC20 was R$ 35.341,32 and mean cost was R$ 40.368,18. The mean overall survival in the Pre-MFC20 group and MFC20 group were 5.99 (5.59-6.40) and 7.01 (6.47-7.54) years, respectively (p=0.83) Conclusions. The implementation of the ICP promoted reductions in all time intervals between treatment steps. There were no statistically significant difference in overall survival and cost per patient treated between the groups. Daily costs and consultations were the most representative segments in total cost of the rectal cancer patient treatment