Nearly 80% of children treated for cancer are expected to survive, but not without cost. Survivors face unprecedented challenges associated with long-term consequences of treatment, also called late effects. Approximately half of children treated for cancer are at risk for experiencing cognitive late effects, which typically emerge several years post diagnosis. The nature and extent of cognitive late effects appear to be developmental and related to patient, disease, and treatment variables. However, the relationships between these variables is not well understood because there have been few prospective and longitudinal studies that report on the contributions of these variables over time. This dissertation examined the effects of patient, disease, and treatment variables, as well as their interactions over time on neurocognitive functioning in childhood cancer survivors. It comprises part of a large prospective, randomized clinical trial designed to examine changes in cognitive function over three years as a function of different levels of monitoring of school-based intervention based on individual educational plans (IEPs). This dissertation uniquely contributed a new measure (the Treatment Intensity Rating Scale) that was used to systematically classify treatment severity across different types of cancer and cancer treatments. Participants included 61 children ages 7 to 12 years at enrollment who were two to five years from completion of treatment for a brain tumor, leukemia, or lymphoma. Participants received yearly neuropsychological evaluations for a follow-up period of 3 years. Results of these evaluations were used to develop IEPs. Participants were randomized to have their IEPs monitored on a quarterly or annual basis for the duration of the study. Contrary to the progressive decline in neurocognitive functioning that is typically anticipated in pediatric cancer survivors, analyses revealed relative stability of performance on neurocognitive measures over time. Higher neurocognitive performance was noted in children whose IEPs were monitored more frequently versus less frequently. Results also supported gender-specific risk for late effects, with lower performance on select neurocognitive measures in females compared to males. Results of this study provide encouraging evidence of the positive effects of school-based interventions and their close monitoring. This has important implications for quality of life as these children survive well beyond childhood into adulthood.

The aims of the studies described in this thesis were to investigate the pharmacokinetics of and cellular resistance to chemotherapy as causes of treatment failure in childhood acute lymphoblastic leukemia (ALL). Leukemic cells from 370 children with newly diagnosed ALL were tested by the Fluorometric Microculture Cytotoxicity Assay to measure their resistance to each of ten standard cytotoxic drugs. In the high-risk group, increased in vitro resistance to each of the drugs dexamethasone, etoposide and doxorubicin was associated with a worse clinical outcome. Combining the results for these drugs yielded a drug resistance score, showing a relative risk of relapse in the most resistant group that was 9.8 times higher than in the most sensitive group. In the standard-risk and intermediate-risk groups, final evaluation must await longer follow-up. The new cytotoxic agent CHS 828 was equally active in vitro in samples from children with acute myeloblastic leukemia (AML) and ALL, with 50% cell kill at concentrations achievable in vivo. In AML samples CHS 828 also displayed high frequencies of synergistic interactions with four standard drugs. The well-known differences in clinical outcome between Down´s syndrome (DS) and non-DS children with acute leukemia may partly be explained by our finding of differences in drug resistance at the cellular level. Pharmacokinetic studies were performed at the start of induction treatment of ALL. Doxorubicin was assayed by reversed-phase liquid chromatography with fluorometric detection, and vincristine by high performance liquid chromatography with electrochemical detection. Plasma doxorubicin concentrations were measured in 107 children after 23 h of a 24-h infusion. The median steady-state concentration in children 4-6 years old, a group known to have a favorable outcome of treatment, was about 50% higher than in those 1-2 and >6 years old Vincristine pharmacokinetics was evaluated in 98 children. There was no correlation between age and total body clearance or any other pharmacokinetic parameters. In vitro testing of cellular drug resistance might be useful in predicting the outcome in high-risk ALL. The further exploration of CHS 828 in childhood leukemia seems warranted. There is no pharmacokinetic rationale for the common practice of administering relatively lower doses of vincristine to adolescents than to younger children.

Traditionally, response to treatment in hematological malignancies is evaluated by light microscopy of bone marrow (BM) smears, but due to more effective therapies more sensitive methods are needed. Today, detection of minimal residual disease (MRD) using immunological and molecular techniques can be 100 times more sensitive than morphology. The main aim of this thesis was to compare and evaluate three currently available MRD methods in childhood acute lymphoblastic leukemia (ALL): (i) real-time quantitative PCR (RQ-PCR) of rearranged antigen receptor genes, (ii) multicolor flow cytometry (FCM) of leukemia-associated immunophenotypes and (iii) real-time quantitative PCR of fusion gene transcripts (RT-PCR). In paper I, we assessed the applicability of RQ-PCR in a population-based cohort of childhood ALL diagnosed in Sweden between 2002-2006. Clonal IG/TCR rearrangements were identified in the 96% of the 279 ALL cases. Using RQ-PCR, the quantitative range of 10-3 was reached in 93% of B-cell precursor (BCP) ALL and 86% of T-cell ALL (T-ALL) by at least one target gene. In paper II, we compared MRD detection using both RQ-PCR and FCM in the context of NOPHO ALL-2000 protocol. By applying the stratification threshold of ≥0.1% MRD late during induction therapy (day 29), we could demonstrate that both methods can predict the risk of BM relapse but not extramedullary relapse. However, the threshold of ≥0.2% MRD appears to be more optimal using RQ-PCR in BCP ALL, whilst in T-ALL, the results indicate that RQ-PCR is preferable for MRD assessment. The stability of RNA in vitro is a critical factor when using sensitive molecular techniques such as MRD detection. In paper III, we evaluated the influence on MRD detection when blood is collected in tubes with RNA stabilization reagents (PAX gene Vacutatiner®) compared to collection in EDTA-tubes (non-stabilized). We analyzed 68 matched samples from chronic myeloid leukemia patients and the results indicated that non-stabilized blood processed within 30 hours is preferable for MRD detection. In paper IV, follow-up samples from eight children with Philadelphia positive (Ph+) ALL were evaluated with the three available MRD methods. MRD measured by the fusion gene transcripts (BCR-ABL1) appeared to be the most sensitive method, however, precise quantification can be difficult and the other methods are thus complementary. In conclusion, all three applied MRD methods are useful and correlate to each other, although not necessary exchangeable in individual patients. We also conclude that MRD assessment by RQ-PCR, based on rearranged IG/TCR genes and multicolor FCM are predictive for identification of high risk childhood ALL patients.

Acute lymphoblastic leukemia (ALL) is the most common type of cancer affecting children in the world and in our country. The exact molecular etiology of the disease still remains to be elucidated. This study hypothesized that four genes, namely CYP2E1*5B, *6, and *7B, NQO1*2 SNPs, GSTM1 null and GSTT1 null, alone or in combination, could contribute to the risk of development of childhood ALL. Also interactions of these polymorphisms with non-genetic risk factors were investigated. The genotyping of these polymorphisms were done on 209 healthy subjects, and 185 patients with childhood ALL, in Turkish population. Venous blood samples were collected and genomic DNA was isolated from these samples. Genotyping was done by PCR-RFLP techniques. In the case-control analyses for the risk of development of childhood ALL, only GSTT1 null was found to be associated with the development of disease (OR= 1.8, p=0.01). CYP2E1*5B and *6 combination showed an increased risk of 2.7 fold (p= 0.04). Also co-presence of CYP2E1*6-GSTT1 and CYP2E1*7B-GSTT1 polymorphisms increased the risk significantly above 4.0 fold. The risk increased more to 7.6 fold, when CYP2E1*5B,*6 and GSTT1 null were considered together, with borderline significance (p=0.04). When interaction of exposure to cigarette smoke and genetic polymorphisms were investigated, NQO1*2 and GSTM1 null were turned out to be significant risk factors for the development of disease when the parental or child&rsquo / s postnatal exposure to cigarette smoke was considered. This study presented several new findings to the literature in terms of genetic epidemiology of childhood ALL. The present work would also contribute to public health in determining the susceptibility of the Turkish population to childhood ALL.

No description available.

INTRODUCTION Des réponses thérapeutiques variables aux glucocorticoïdes (GCs) sont observées parmi les patients atteints de la leucémie lymphoblastique aiguë (LLA). Les protéines Bax et Bim ont déjà montré un rôle important dans l’apoptose des cellules leucémiques. L’expression de Bax était plus basse chez les patients leucémiques résistants au médicament, de même une sensibilité diminuée aux GCs a été associée avec une expression réduite de Bim. La différence dans l’expression pourrait être due à des polymorphismes présents dans ces gènes et donc être associés avec la résistance aux GCs. MÉTHODE Dix-huit polymorphismes en régions régulatrices, 2 polymorphismes exoniques et 7 polymorphismes en région 3’UTR de ces gènes ont été analysés chez les témoins (n=50) et ont permis de déterminer un nombre minimal de polymorphismes suffisants pour définir les haplotypes (tagSNPs). Ces 8 polymorphismes ont ensuite été génotypés chez 286 enfants atteints de la LLA et ont été testés pour l’issue de la maladie par l’analyse de survie. RÉSULTATS Une survie sans évènement et une survie sans rechute diminuées ont été observées pour l’haplotype 3 (p=0,03 et p=0,02). Une survie globale diminuée a été associée avec l’homozygotie pour l’allèle exonique T298C>T (p=0,03), de même que pour les haplotypes 1 et 4 (p=0,04 et p=0,02) du gène Bim. CONCLUSION Les polymorphismes ont été associés avec une survie diminuée chez des enfants atteints de LLA. Il reste à tester d’autres polymorphismes présents dans ces deux gènes ainsi qu’à définir leurs fonctions afin de comprendre leurs rôles dans la réponse aux GCs. / INTRODUCTION Variable therapeutic responses to glucocorticoids (GCs) are observed for acute lymphoblastic leukemia (ALL) patients. Proteins Bax and Bim have already shown to play a major role in mediating GC-induced apoptosis in leukemia cells. Bax expression was lower in drug-resistant leukemia samples; likewise lower sensitivity to GC was associated with reduced Bim expression. The difference in the expression can be due to polymorphisms in these genes and therefore associated to GC resistance. METHOD Eighteen polymorphisms in the regulatory region, two exonic polymorphisms and seven polymorphisms in 3’UTR of these genes were analysed in controls (n=50) and have permitted to determine a minimal number of polymorphisms sufficient to define haplotypes (tagSNPs). These 8 single nucleotide polymorphisms (SNPs) were then genotyped in 286 LLA children and were tested for disease outcome by survival analysis. RESULTS A diminished event free survival and a diminished relapse free survival were observed for haplotype 3 (p=0,03 and p=0,02). A diminished overall survival was associated with the exonic T298C>T allele (p=0,03) and with haplotypes 1 and 4 (p=004 and p=0,02) of Bim gene. CONCLUSION Bax and Bim were associated with a diminished survival in LLA children. We still have to test other polymorphisms located in these genes and to define their functions in order to understand their roles in GC response.

Neural tube defects (NTD) result from the failure of the neural tube to close properly very early in gestation. A child born with an NTD may experience an early death or life-long disability. In the 1990s, the critical role of folic acid in the prevention of NTDs was confirmed and as a strategy to increase blood folate concentrations of women of childbearing age, folic acid fortification programs were mandated in Canada and the US. However, this change impacted the entire population not just women of childbearing age and not everyone may benefit from the increased folate intake. The objective of this research was to investigate the impact of higher intakes of folates on the mortality rates of children with acute lymphoblastic leukemia (ALL) and the risk of colorectal cancer (CRC) in adult populations. To address the impact in children with ALL, a comparison of the mortality rates between the pre- and post-fortification time periods in Ontario was performed using data from the Pediatric Oncology Group of Ontario. A second comparison between the mortality rates in these children in non-folic acid fortifying countries and the US was also completed. These analyses suggest that folic acid fortification is not negatively impacting mortality. With respect to CRC, one systematic review and two meta-analyses were conducted investigating folate intake and the risk of CRC or adenoma recurrence. The first analysis, in observational studies, compared high versus low folate intake and the risk of CRC. The second examined folate intake within the various polymorphisms of the methylene tetrahydrofolate reductase enzyme. The final study examined the impact of supplementation of 1 milligram or more per day of folic acid and the risk of colorectal adenoma recurrence in those adults with a history of colorectal adenomas. The findings from the completed observational studies suggest that there is an associated risk reduction in colorectal cancer from the intake of higher levels of folates. The investigations into the impact of the folic acid fortification program suggest that the program is not associated with having a negative impact on mortality of children with ALL or on the risk of colorectal cancer.

Neural tube defects (NTD) result from the failure of the neural tube to close properly very early in gestation. A child born with an NTD may experience an early death or life-long disability. In the 1990s, the critical role of folic acid in the prevention of NTDs was confirmed and as a strategy to increase blood folate concentrations of women of childbearing age, folic acid fortification programs were mandated in Canada and the US. However, this change impacted the entire population not just women of childbearing age and not everyone may benefit from the increased folate intake. The objective of this research was to investigate the impact of higher intakes of folates on the mortality rates of children with acute lymphoblastic leukemia (ALL) and the risk of colorectal cancer (CRC) in adult populations. To address the impact in children with ALL, a comparison of the mortality rates between the pre- and post-fortification time periods in Ontario was performed using data from the Pediatric Oncology Group of Ontario. A second comparison between the mortality rates in these children in non-folic acid fortifying countries and the US was also completed. These analyses suggest that folic acid fortification is not negatively impacting mortality. With respect to CRC, one systematic review and two meta-analyses were conducted investigating folate intake and the risk of CRC or adenoma recurrence. The first analysis, in observational studies, compared high versus low folate intake and the risk of CRC. The second examined folate intake within the various polymorphisms of the methylene tetrahydrofolate reductase enzyme. The final study examined the impact of supplementation of 1 milligram or more per day of folic acid and the risk of colorectal adenoma recurrence in those adults with a history of colorectal adenomas. The findings from the completed observational studies suggest that there is an associated risk reduction in colorectal cancer from the intake of higher levels of folates. The investigations into the impact of the folic acid fortification program suggest that the program is not associated with having a negative impact on mortality of children with ALL or on the risk of colorectal cancer.

Submitted by Jos? Henrique Henrique (jose.neves@ufvjm.edu.br) on 2017-09-12T18:28:33Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) aline_bacelar_goncalves.pdf: 5988024 bytes, checksum: 24d09b3ca0a2e58cc7aee0ca7ca2528f (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2017-09-18T12:57:54Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) aline_bacelar_goncalves.pdf: 5988024 bytes, checksum: 24d09b3ca0a2e58cc7aee0ca7ca2528f (MD5) / Made available in DSpace on 2017-09-18T12:57:54Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) aline_bacelar_goncalves.pdf: 5988024 bytes, checksum: 24d09b3ca0a2e58cc7aee0ca7ca2528f (MD5) Previous issue date: 2017 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior (CAPES) / O tratamento das leucemias ? desafiador por v?rios aspectos, entre os quais podem ser destacados os efeitos adversos e a obten??o de op??es terap?uticas de alta qualidade e de custos razo?veis. A utiliza??o da enzima L-asparaginase como agente terap?utico, limita a fonte ex?gena de asparagina, da qual as c?lulas malignas dependem para o metabolismo celular e para a sobreviv?ncia. Essa ? uma op??o que oferece menores riscos ao paciente e ?s c?lulas sadias, que s?o capazes de sintetizar este amino?cido. Neste cen?rio o objetivo deste trabalho foi selecionar, entre fungos filamentosos, linhagens produtoras da enzima L-asparaginase. O estudo tamb?m buscou avaliar o efeito da varia??o da fonte de carbono e da raz?o carbono-nitrog?nio no crescimento e na express?o da atividade enzim?tica, a fim de desenvolver meios de cultivo para o processo produtivo. Realizou-se tamb?m um estudo do crescimento apical das tr?s linhagens selecionadas, duas do g?nero Penicillium sp. e uma do g?nero Fusarium sp., em diversos meios de cultivo. O conhecimento gerado sobre as linhagens produtoras e os demais estudos realizados permitiram a obten??o de um meio de cultivo que possibilitou a produ??o enzim?tica em at? 11,45 U.min-1.mL-1 com a linhagem de Fusarium sp. / Disserta??o (Mestrado) ? Programa de P?s-gradua??o em Ci?ncias Farmac?uticas, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2016. / The treatment of leukemia is challenging in many ways, including the adverse effects and obtaining treatment options of high quality and reasonable cost. The use of L-asparaginase enzyme as a therapeutic agent limits the exogenous source of asparagine, which the malignant cells depend for cellular metabolism and survival. This option offers lower risk to patients and healthy cells, which are able to synthesize this amino acid. Therefore, the objective of this work was to select among filamentous fungi, producing strains of L-asparaginase enzyme. The study also aimed at evaluating the effect of varying the carbon source and carbon-nitrogen ratio in the growth and expression of the enzymatic activity to develop culture media for the production process. It was also carried out a study of the apical growth of the three strains selected, two of the genus Penicillium sp. and one Fusarium sp., cultivated in various culture media. The knowledge about the growth of the strains studied in different nutritional sources and other studies allowed obtaining a culture medium that enabled the enzyme production of 11.45 U.min-1.mL-1 by Fusarium sp.

Made available in DSpace on 2016-04-04T12:26:00Z (GMT). No. of bitstreams: 2 14.pdf: 930696 bytes, checksum: 4334fa07716ed0ea4227a0d296d9310c (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Previous issue date: 2015 / Fundação Oswaldo Cruz. Instituto de Tecnologia em Fármacos/Farmanguinhos. Rio de Janeiro, RJ, Brasil. / A asparaginase de origem bacteriana é o principal medicamento para o tratamento da leucemia linfoblástica aguda, um câncer que afeta principalmente as crianças. Apesar de efetivo, o medicamento causa sérias reações imunológicas por ser produzido por um procarioto. Atualmente, o medicamento existente no mercado brasileiro é importado, o que acarreta dependência tecnológica, alto custo na obtenção do medicamento e dificuldade de abastecimento. As asparaginase II de Saccharomyces cerevisiae codificada pelo gene ASP3 apresenta, por suas características, potencial para uso como medicamento antileucêmico. Em trabalhos anteriores, este gene foi clonado e expresso em altos níveis na levedura Pichia pastoris. O presente trabalho teve como objetivo caracterizar as propriedades físico-químicas e bioquímicas da asparaginase periplásmica recombinante produzida por P. pastoris, tendo sido avaliados as melhores condições de estocagem da enzima após ressuspensão, o efeito de alguns íons e de alguns compostos na atividade asparaginásica, a afinidade da asparaginase pelos substratos D e L-asparagina e L-glutamina e os seus parâmetros cinéticos. Observou-se que a ressuspensão da asparaginase de levedura em água destilada e mantida a 4 °C reteve em torno de 98% da atividade original após 96 horas, na presença de sorbitol 0,1 M, mostrando ser esta a melhor condição de estocagem. Os valores do Km e da Vmáx foram determinados, obtendo-se 2,461 ± 0,170mM e 0,090 ± 0,0017mM min-1, respectivamente. A asparaginase de P.pastoris recombinante apresentou maior afinidade pela D-asparagina, de forma semelhante à asparaginase nativa de S. cerevisiae; e baixa atividade glutaminásica, o que favorece a sua utilização como medicamento pelo menor risco de efeitos tóxicos. O EDTA não apresentou efeito negativo sobre a asparaginase de levedura, indicando não ser a mesma uma metaloenzima. A influência negativa de agentes redutores sobre a atividade enzimática indica a presença de pontes de enxofre na estrutura proteica. Os resultados obtidos são de extrema importância para a continuidade dos estudos da utilização da asparaginase de Pichia pastoris recombinante como agente antileucêmico. / Bacterial asparaginase is the main medicament for the treatment of acute lymphoblastic leukemia, a cancer that primarily affects children. Although effective, the medicine causes serious immunological reactions due to its prokaryotic origin. Currently, the existing drug in the Brazilian market is imported, which carries a technological dependence, high cost and supply difficulties. The asparaginase II of Saccharomyces cerevisiae encoded by the ASP3 gene, given its characteristics, has potential to be used as an antileukemic drug. In previous work, this gene was cloned and expressed at high levels in the yeast Pichia pastoris. The present work aimed to characterize the physicochemical and biochemical properties of the recombinant periplasmic asparaginase produced by P. pastoris, having been assessed the best enzyme storage conditions after resuspension, the effect of some ions and some compounds in asparaginasic activity, asparaginase affinity for yhe substrates D- and L-asparagine and Lglutamine and its kinetic parameters. It was observed that the yeast asparaginase resuspension in distilled water and kept at 4 °C retained about 98% of the original activity after 96 hours in the presence of 0.1 M sorbitol, showing this to be the best storage condition. The values of Km and Vmax were determined to be 2,461 ± 0,170mM e 0,090 ± 0,0017mM min-1, respectively. The recombinant asparaginase showed higher affinity for D-asparagine, similarly to the native S. cerevisiae asparaginase; and low glutaminasic activity, which favors its use as a medicine due to the lower risk of toxic effects. EDTA showed no negative effect on the yeast asparaginase, indicating that it is not a metalloenzyme. The negative influence of reducing agents on the enzymatic activity indicates the presence of sulfur bridges in the protein structure. These results are extremely important for the further studies on the use of the recombinant Pichia pastoris asparaginase as antileukemic agent.