A Síndrome de von Hippel-Lindau é uma doença hereditária multissistêmica, causada por mutações germinativas no gene VHL que predispõe o portador a manifestações benignas e malignas em diversos órgãos. Entre esses eventos, o carcinoma de células claras renais (CRC) é o de pior prognóstico, com uma penetração média de 25% e sendo a principal causa de morte nestes pacientes. Os CRCs são tumores agressivos, pouco responsivos à quimioterapia e imunoterapia, e muitas vezes são diagnosticados em estágios avançados. Podem estar associados a síndromes hereditárias como o VHL ou apresentar a forma esporádica. Caracteristicamente, o CRC é provocado pela inativação dos dois alelos do gene VHL. Nos casos associados ao VHL, um alelo do gene VHL sofre uma mutação germinativa e um segundo evento mutacional somático nas células do tumor. Por outro lado, na forma esporádica, o CRC é resultado de dois eventos somáticos adquiridos, que incluem uma combinação de metilação do promotor, mutações pontuais que afetam a sequência de leitura aberta (ORF) e rearranjos cromossômicos, principalmente perda de heterozigosidade (LOH). Embora os eventos somáticos nos CRCs esporádicos já tenham sido explorados em outros estudos, os mecanismos de inativação somáticos do gene VHL nos CRCs associados à síndrome ainda não foram bem descritos. Este estudo avaliou os eventos somáticos no gene VHL em CRCs retirados em procedimentos cirúrgicos de pacientes portadores da síndrome. Os eventos somáticos em vários tumores de um mesmo paciente foram comparados a fim de verificarmos se essas mutações são independentes e não clonais. Oito pacientes com amostras CRCs previamente armazenadas no BNT tiveram sua mutação germinativa no gene VHL caracterizada por sequenciamento ou MLPA. Todas as amostras foram submetidas a uma revisão da patologia e macrodissecadas sempre que necessário. Para a análise das manifestações somáticas do gene VHL, o DNA foi extraído de 30 CRCs conservados em RNA latter ou formaldeído (parafina). As amostras foram analisadas quanto à metilação da região promotora do gene pelo método MS-PCR e para mutações pontuais por sequenciamento. Fomos capazes de detectar a mutação somática em 25 dos 30 tumores, incluindo uma mutação pontual e dois tumores diferentes de um mesmo paciente, nenhuma microdeleção e 23 grandes deleções. Em contraste com a literatura, nenhum dos tumores apresentou metilação no promotor do VHL. Devido ao grande número de achados LOH e da resolução limitada da técnica de MLPA para avaliar a extensão dos rearranjos cromossômicos em 3p, não foi possível concluir a análise de clonalidade dos tumores. Um estudo exploratório para caracterizar ganhos e perdas genômicas utilizando a técnica CNV array está em andamento em nosso laboratório. / The von Hippel-Lindau syndrome (VHL) is a multissystemic hereditary disease, caused by germline mutations in the VHL gene that predisposes the carrier to benign and malignant manifestations in different organs. Among these events, the clear cell renal carcinoma (RCC) is the most fearful, with an average penetration of 25% being the leading cause of death in these patients. RCCs are aggressive tumors, poorly responsive to chemo- and immunotherapy that are often diagnosed in advanced stages. They can be associated with hereditary syndromes such as VHL or present in a sporadic form. Characteristically, RCCs carrier the inactivation of the two alleles of VHL gene. In cases associated with VHL, one allele of the VHL gene is mutated in the germline, and the second mutational event occurs in the somatic cells of the tumor. On the other hand, in the sporadic form, RCCs results of two acquired somatic events, which includes a combination of methylation of the promoter, point mutations affecting the ORF, and rearrangements mainly loss of heterozigosity (LOH). Although somatic events in sporadic RCC have been explored before by others, the mechanisms of somatic VHL gene inactivation in VHL-associated RCCs have been poorly characterized. This study evaluated the somatic mutational events in the VHL gene of RCCs removed from VHL patients in therapeutic surgical procedures. The somatic events in multiple tumors from the same patient were compared in order to analyze whether these mutations are independent and not clonal. Eight patients with RCCs samples previously stored at BNT had their germline VHL gene mutation characterized by sequencing or MLPA. All samples were submitted to a pathology review and macrodissected whenever necessary. For the analysis of somatic events of VHL gene, DNA from 30 RCCs were extracted from either RNA later or archival formalin-fixed, paraffin-embedded tissue sections. Samples were analyzed for VHL gene promoter methylation by MS-PCR, and for point mutation in the coding DNA by sequencing. We were able to detect the somatic mutation in 25 of the 30 tumors, including one point mutations in two different tumors of the same patient, no micro-deletions, and 23 large deletions. In contrast to the literature, none of the tumors have shown methylation on the VHL promoter. Because of the large number of LOH findings, and the limited resolution of MLPA to evaluate the extension of 3p chromosomal rearrangements, we could not conclude the analysis of tumor clonality. An exploratory study to characterize genomic gains and losses using CNV-array technique are ongoing in our laboratory.

La diffusion dans le sang des cellules tumorales circulantes (CTC) à partir de la tumeur primitive est un signe précoce d’invasivité tumorale et du risque de développer des métastases. Par conséquent, la capacité à les détecter de façon très sensible et spécifique est censée constituer un test cliniquement important pour le pronostic du cancer, le suivi des patients et la personnalisation de la thérapie. Les CTC sont des cellules rares, et plusieurs méthodes ont été proposées pour leur détection. La technique ISET (Isolation by Size of Epithelial/Tumor cells) se base sur la différence de taille des CTC par rapport aux cellules leucocytaires et a montré une très grande sensibilité d’isolement et spécificité d’identification des CTC. Elle permet l’analyse cytopathologique, immunologique et moléculaire des cellules isolées.Le cancer du rein représente 3% des cancers de l’adulte, dans 75% des cas il s’agit d’un carcinome rénal à cellules claires (RCC). Sur le plan génétique, il est un des rarissimes cancers solides caractérisé par des variations de l’ADN, il s’agit de mutations au niveau du gène VHL.Ce projet de recherche vise l’analyse comparative, moléculaire et cytopathologique, des CTC isolées à partir des patients avec RCC dans le but d’évaluer, par une approche moléculaire, les critères cytopathologiques diagnostiques des CTC. Notre étude a porté sur 29 patients ayant bénéficié de l’isolement des CTC par ISET avant toute intervention chirurgicale.L’analyse cytopathologique a été réalisée utilisant les critères décrits par l’équipe de P. Hofman pour définir les CTC (CNHC-MF) et les Cellules Atypiques Circulantes « CAC » (CNHC-UMF). L’analyse génétique par séquençage du gène VHL a été réalisée avec succès sur l’ADN de 205 cellules individuelles, sur l’ADN issu du tissu tumoral et sur l’ADN génomique de chaque patient.Sur les 29 tumeurs étudiées, 25 étaient caractérisées par des mutations du gène VHL. Cent soixante et une cellules, CTC et CAC, isolées à partir du sang de ces 25 patients, ont présenté des variations génétiques du gène VHL identiques à l’ADN issu du tissu tumoral. Il s’agit de 18 mutations différentes affectant les 3 exons de ce gène. Nous avons trouvé des CTC/CAC dans 29/30 des patients avec CCRC analysés. Des mutations VHL ont été trouvées dans 25 des 29 tumeurs CCRC correspondantes. Nous avons obtenu des résultats spécifiques VHL dans 205 des 327 CTC/CAC microdisséquées, comprenant 64 CTC et 141 CAC, selon l’analyse cytopathologique. Les mutations VHL ont été détectées en aveugle dans 57/64 CTC et dans 125/141 CAC. Cependant, nous avons observé que les 8 et 16 CTC et CAC restantes, respectivement, avaient été isolées de patients sans mutations VHL détectables dans le tissu tumoral.Conclusion : Ceci est la première étude comparative de diagnostic génétique et cytopathologique des CTC/CAC chez des patients avec un cancer solide, le CRCC. Nos résultats suggèrent que des critères cytopathologiques élargis pourraient être appliqués au diagnostic des CTC chez les patients avec CCRC. Bien que des études complémentaires et plus élargies soient maintenant nécessaires, cette méthode ouvre la voie à une approche génétique pour le diagnostic des Cellules Tumorales Circulantes / Dissemination in the circulating tumor cells (CTC) from the primary tumor is an early sign of tumor invasion and risk of metastases. Therefore, the ability to detect CTC through a very sensitive and specific test is expected to be clinically important for cancer prognosis, patient monitoring and customization of therapy. CTCs are rare cells, and several methods have been proposed for their detection. The ISET technique (Isolation by Size of Epithelial /Tumor cells) is based on the difference in size of CTC as compared to leucocytes and provides high sensitivity of CTC isolation and high specificity of CTC identification. This methods also allows cytopathological, immunological and molecular analyses of the isolated cellsKidney cancer accounts for 3% of adult cancers and is a clear cell renal cell carcinoma (RCC) in 75% of cases. RCC is one of very rare cancers characterized by a DNA mutations. IRCC tumor cells are in fact characterized by by mutations in the VHL gene. This research project aims at a comparative molecular and cytopathological analysis of, CTCs isolated from patients with RCC in order to evaluate, through a molecular approach, the diagnostic criteria used for cytopathological identification of CTC. Our study included 29 patients tested by the ISET technique before surgery.The cytopathological analysis was performed using the criteria described by the group of P. Hofman to define CTC (CNHC-MF) and Circulating Atypical Cells "CAC" (UMF-CNHC). Genetic analysis of the VHL gene was successfully performed by sequencing on DNA from 205 individual cells isolated by ISET, on DNA from tumor tissue and on genomic DNA from each patient. Of the 29 tumors studied, 25 were characterized by mutations in the VHL gene. One hundred and sixty-one cells, CTC and CAC, isolated from the blood of the 25 patients, with the tumor having VHL mutation, showed genetic variations in the VHL gene identical to those found in the DNA from the tumor tissue. We found 18 different mutations affecting the three exons of this gene.We found CTC/CAC in 29/30 analyzed patients with CCRC. VHL mutations were found in the tumor of 25 out of the corresponding 29 CCRC tumors. Among 327 microdissected CTC/CAC, we obtained VHL-specific results in 205 including 64 CTC and 141 CAC, according to the cytopathological analysis. VHL mutations were blindly detected in 57/64 CTC and in 125/141 CAC. However, we then observed that the 8 and 16 residual CTC and CAC, respectively, had been isolated from patients without detectable VHL mutations in the tumor tissue. Conclusion: This is the first study comparing genetic and cytopathological diagnosis of CTC/CAC in patients with a solid cancer, CRCC. Our results suggest that broaden cytopathological criteria could be applied to the diagnosis of CTC in patients with CCRC. Although further and larger studies are now needed, this approach opens the way to a genetic approach for the accurate diagnosis of Circulating Tumor Cells.