The c-Jun NH2-terminal kinase (JNK) group of kinases include ten members that are created by alternative splicing of transcripts derived from Jnk1, Jnk2 and Jnk3 genes. The JNK1 and JNK2 protein kinases are ubiquitously expressed while JNK3 is expressed in a limited number of tissues. The JNK signaling pathway is implicated in multiple physiological processes including cell transformation. There is growing evidence that JNK signaling is involved in oncogenesis. Nevertheless, the role that JNK plays in malignant transformation is still unclear. The aim of this thesis is to examine the role of JNK in malignant transformation. For this purpose, I used the Bcr/Abl oncogene as a transforming agent. Bcr/Abl is a leukemogenic oncogene that is created by reciprocal translocation between chromosome 9 and 22. The translocation breakpoint is variable and several different Bcr/Abl isoforms have been identified such as Bcr/AblP185 and Bcr/AblP210, whose expression is associated with different types of leukemia. Bcr/Abl activates the JNK signaling pathway in hematopoietic cells and increases AP-1 transcription activity. Furthermore, dominant negative approaches demonstrate that inhibition of c-Jun or JNK prevents Bcr/ Abl-induced cell transformation in vitro. These data implicate the JNK signaling pathway in Bcr/Abl transformation although the role that JNK might have in this process is unclear. Thus, I examined the importance of JNK signaling in Bcr/Abl-induced lymphoid or myeloid transformation. For this purpose I compared Bcr/AblP185- and Bcr/AblP210- induced transformation of wild-type and JNK1-deficient cells using three approaches: in vitro, in vivo and ex vivo. The results obtained with the in vitro approach suggest that both Bcr/AblP185 and Bcr/AblP210 require JNK activity to induce lymphoid transformation. While JNK1-deficiency inhibits Bcr/AblP210 oncogenic potential in lymphoid cells both in vitro and in vivo, pharmacological inhibition of JNK activity (JNK1 and/or JNK2) blocked Bcr/AblP185 induced malignant proliferation in vitro. The differential requirement for JNK observed in the two Bcr/Abl isoforms can be ascribed to the presence in Bcr/AblP210 of the Dbl domain which can activate the JNK pathway in vitro. In the case of Bcr/AblP210, JNK1 is critical for the survival of the ex vivo derived transformed lymphoblasts upon growth factor removal. This result correlates with the fact that mice reconstituted with Bcr/AblP210 transformed Jnk1-l- bone marrow showed normal malignant lymphoid expansion in the bone marrow yet they had reduced numbers of lymphoblast in the bloodstream and lacked peripheral organ infiltration. Thus JNK1 is essential for the survival of the transformed lymphoblast outside the bone marrow microenvironment in Bcr/AblP210induced lymphoid leukemia. Interestingly, while JNK1 is essential for lymphoid transformation, it is dispensable for the proliferation of transformed myeloblasts. Taken together these results indicate that the JNK signaling pathway plays an essential role in the survival of Bcr/AblP210 lymphoblasts and that JNK-deficiency decreases the leukomogenic potential of Bcr/AblP210 in vivo. Thus, cell survival mediated by JNK may contribute to the pathogenesis of proliferative diseases.

Chronic myeloid leukemia (CML) is a disease characterized by the expansion of granulocytic cells. The BCR-ABL tyrosine kinase inhibitor imatinib, the frontline treatment for Ph+ leukemias, can induce complete hematologic and cytogenetic response in most chronic phase CML patients. Despite the remarkable initial clinic effects, it is now recognized that imatinib will unlikely cure patients because a small cell population containing leukemic stem cells (LSCs) with self-renewal capacity is insensitive to tyrosine kinase inhibitors. In Chapter I, I briefly review the BCR-ABL kinase and its related signaling pathways. BCR-ABL kinase activates several signaling pathways including MAPK, STAT, and JNK/SAPK. BCR-ABL also mediates kinase-independent pathways through SRC family kinases. I will also discuss pathways involving β-catenin, hedgehog, FoxO and Alox5 are critical to the regulation of self-renewal and differentiation in LSC of CML. As detailed in Chapter II, I describe our work evaluating the effects of omacetaxine, a novel CML drug inducing cell apoptosis by inhibition of protein synthesis, on self-renewal and differentiation of LSCs and BCR-ABL-induced CML and acute lymphoblastic leukemia (B-ALL) in mice. We found that treatment with omacetaxine decreased the number of LSCs and prolonged the survival of mice with CML or B-ALL. In chapter III, I describe that Alox5 is an essential gene in the function of LSCs and CML development. We show evidence that Alox5 affects differentiation, cell division, and survival of long-term LSCs. Treatment of CML mice with a 5-LO inhibitor also impaired the function of LSCs similarly and prolonged survival. In chapter IV, I present evidence of our work showing a further dissection the Alox5 pathway by comparing the gene expression profiles of wild type and Alox5-/- LSCs. We show that Msr1 deletion causes acceleration of CML development. We also show that Msr1 affects CML development by regulating the PI3K-AKT pathway and β-catenin. Taken together, these results demonstrate that some pathways including Alox5 and Msr1 play an important role in regulating the self-renewal and differentiation of LSC. More efforts should be put into developing the novel strategies that may effectively target LSCs and thus cure CML.

A leucemia mielóide crônica (LMC) é caracterizada pela translocação (9;22) que dá origem ao gene quimérico BCR-ABL. Este gene codifica uma proteína com atividade tirosina quinase, p210, constitutivamente ativa. O três mecanismos envolvidos na patogênese da LMC são o aumento da proliferação celular, alteração da adesão celular ao estroma e matriz medular e inibição da apoptose. A introdução do mesilato de imatinibe (MI), um inibidor de tirosina quinase, revolucionou o tratamento da LMC levando pacientes em fase crônica a remissões duráveis, porém uma parcela destes não responde ou perde a resposta ao longo do tratamento. Os mecanismos de resistência ao MI podem ser classificados como independentes de BCR-ABL (a1- glicoproteína ácida e genes de resistência a múltiplas drogas) ou dependentes de BCR-ABL (superexpressão de BCR-ABL e mutações do domínio quinase do gene ABL). Objetivo: avaliar a presença de mutações no domínio quinase do gene ABL e a expressão dos genes de resistência a múltiplas drogas MDR1 e BCRP em amostras pré-tratamento com MI, acompanhar estes pacientes mensalmente através da quantificação de transcritos BCR-ABL e quando ocorrer resistência reavaliar a presença de mutações do domínio quinase do ABL e a expressão dos genes de resistência a múltiplas drogas. Material e Métodos: Foram avaliados 61 pacientes com LMC em fase crônica. A pesquisa de mutações do domínio quinase foi realizada pela técnica de seqüenciamento direto e a expressão relativa dos genes de resistência a múltiplas drogas foi avaliada por PCR em tempo real. A quantificação absoluta do número de transcritos BCR-ABL foi realizada pela técnica de PCR em tempo real utilizando-se o sistema Taqman de sondas de hibridização. Resultados: Nas amostras pré-tratamento dos 61 pacientes estudados não foram detectadas mutações. Quando relacionamos o aumento da expressão dos genes MDR1 e BCRP à resposta citogenética completa aos 12 meses de tratamento não houve diferença estatística significativa (p>0,05). Quanto ao número de transcritos BCR-ABL, observamos que os pacientes que apresentaram menos de 1% pela escala internacional aos 3 meses de tratamento atingiram a RMM em período menor (7 meses) do que os que apresentaram mais de 1% (12 meses) com diferença estatística significativa (p = 0,03). Conclusões: As mutações do domínio quinase do gene BCR-ABL nas amostras pré-tratamento não foram detectadas ou pela sensibilidade da técnica de seqüenciamento direto (10%) ou porque tais mutações são mais freqüentes nas fases acelerada e blástica. A expressão dos genes de resistência a múltiplas drogas (MDR1) e BCRP) em pacientes com LMC-FC ao diagnóstico não apresentou correlação com o aparecimento de resistência secundária ao MI. Além disso a quantificação mensal dos transcritos BCR-ABL aos 3 meses pode ser considerada um marcador com valor prognóstico. / Chronic myeloid leukemia is characterized by t(9;22) translocation. The chimeric gene BCR-ABL encodes a p210BCRABL protein with constitutive tyrosine kinase activity which is directly related to CML pathogenesis. The imatinib mesylate, a tyrosine kinase inhibitor, is the first-choice treatment for patients in chronic phase but some patients show primary resistance or relapse after initial response. The mechanisms of resistance to the imatinib mesylate treatment are BCR-ABL dependent (amplification of BCR-ABL and mutation of kinase domain of BCR-ABL) or independent of BCR-ABL (1-acid glycoprotein and expression of multidrug resistance genes). Objective: The objective of this work was to evaluate the mechanisms of resistance (kinase domain mutation and MDR1 and BCRP genes expression) to imatinib mesylate in pretreatment samples, quantify of BCR-ABL transcript on a monthly follow up plan, and to re-evaluate the mechanisms of resistance in the absence or loss of treatment response. Patients and Methods: We have evaluated 61 pretreatment samples derived from chronic phase CML patients. The number of BCR-ABL transcripts was quantified by RTQ-PCR with taqman probes and MDR1 and BCRP expression were evaluated by RTQ-PCR with Syber Green. Mutations within the BCR-ABL kinase domain were screened by direct sequencing and we also have screened the T315I mutation in pretreatment samples by allele-specific PCR. Results:We detected no mutations in the 61 pretreatment samples. The correlation analysis between the expression of MDR1/BCRP genes and the cytogenetic response at 12 months of treatment revealed no significant statistical difference (p = > 0.05). The results of BCR-ABL quantification in the follow up of our cohort indicated that patients who had transcripts <1% by the international scale at 3 months of therapy are more likely to achieve rapid MMR (median of 7 months) than those who had >1% (median of 12 months) (p = 0,03). Conclusions: As expected, the kinase domain mutations of BCR-ABL in pretreatment samples of CML chronic phase patients are not detectable by direct sequencing because of the sensitivity of the assay (10%) and also because these mutations are more common in accelerated phase and blast crisis. About the expression of multidrug resistance genes MDR1 and BCRP, they showed no correlation with secondary resistance to imatinib mesylate. And finally the number of BCR-ABL transcripts at 3 months of treatment can be considered a marker with prognostic value.

A leucemia mielóide crônica (LMC) é caracterizada pela translocação (9;22) que dá origem ao gene quimérico BCR-ABL. Este gene codifica uma proteína com atividade tirosina quinase, p210, constitutivamente ativa. O três mecanismos envolvidos na patogênese da LMC são o aumento da proliferação celular, alteração da adesão celular ao estroma e matriz medular e inibição da apoptose. A introdução do mesilato de imatinibe (MI), um inibidor de tirosina quinase, revolucionou o tratamento da LMC levando pacientes em fase crônica a remissões duráveis, porém uma parcela destes não responde ou perde a resposta ao longo do tratamento. Os mecanismos de resistência ao MI podem ser classificados como independentes de BCR-ABL (a1- glicoproteína ácida e genes de resistência a múltiplas drogas) ou dependentes de BCR-ABL (superexpressão de BCR-ABL e mutações do domínio quinase do gene ABL). Objetivo: avaliar a presença de mutações no domínio quinase do gene ABL e a expressão dos genes de resistência a múltiplas drogas MDR1 e BCRP em amostras pré-tratamento com MI, acompanhar estes pacientes mensalmente através da quantificação de transcritos BCR-ABL e quando ocorrer resistência reavaliar a presença de mutações do domínio quinase do ABL e a expressão dos genes de resistência a múltiplas drogas. Material e Métodos: Foram avaliados 61 pacientes com LMC em fase crônica. A pesquisa de mutações do domínio quinase foi realizada pela técnica de seqüenciamento direto e a expressão relativa dos genes de resistência a múltiplas drogas foi avaliada por PCR em tempo real. A quantificação absoluta do número de transcritos BCR-ABL foi realizada pela técnica de PCR em tempo real utilizando-se o sistema Taqman de sondas de hibridização. Resultados: Nas amostras pré-tratamento dos 61 pacientes estudados não foram detectadas mutações. Quando relacionamos o aumento da expressão dos genes MDR1 e BCRP à resposta citogenética completa aos 12 meses de tratamento não houve diferença estatística significativa (p>0,05). Quanto ao número de transcritos BCR-ABL, observamos que os pacientes que apresentaram menos de 1% pela escala internacional aos 3 meses de tratamento atingiram a RMM em período menor (7 meses) do que os que apresentaram mais de 1% (12 meses) com diferença estatística significativa (p = 0,03). Conclusões: As mutações do domínio quinase do gene BCR-ABL nas amostras pré-tratamento não foram detectadas ou pela sensibilidade da técnica de seqüenciamento direto (10%) ou porque tais mutações são mais freqüentes nas fases acelerada e blástica. A expressão dos genes de resistência a múltiplas drogas (MDR1) e BCRP) em pacientes com LMC-FC ao diagnóstico não apresentou correlação com o aparecimento de resistência secundária ao MI. Além disso a quantificação mensal dos transcritos BCR-ABL aos 3 meses pode ser considerada um marcador com valor prognóstico. / Chronic myeloid leukemia is characterized by t(9;22) translocation. The chimeric gene BCR-ABL encodes a p210BCRABL protein with constitutive tyrosine kinase activity which is directly related to CML pathogenesis. The imatinib mesylate, a tyrosine kinase inhibitor, is the first-choice treatment for patients in chronic phase but some patients show primary resistance or relapse after initial response. The mechanisms of resistance to the imatinib mesylate treatment are BCR-ABL dependent (amplification of BCR-ABL and mutation of kinase domain of BCR-ABL) or independent of BCR-ABL (1-acid glycoprotein and expression of multidrug resistance genes). Objective: The objective of this work was to evaluate the mechanisms of resistance (kinase domain mutation and MDR1 and BCRP genes expression) to imatinib mesylate in pretreatment samples, quantify of BCR-ABL transcript on a monthly follow up plan, and to re-evaluate the mechanisms of resistance in the absence or loss of treatment response. Patients and Methods: We have evaluated 61 pretreatment samples derived from chronic phase CML patients. The number of BCR-ABL transcripts was quantified by RTQ-PCR with taqman probes and MDR1 and BCRP expression were evaluated by RTQ-PCR with Syber Green. Mutations within the BCR-ABL kinase domain were screened by direct sequencing and we also have screened the T315I mutation in pretreatment samples by allele-specific PCR. Results:We detected no mutations in the 61 pretreatment samples. The correlation analysis between the expression of MDR1/BCRP genes and the cytogenetic response at 12 months of treatment revealed no significant statistical difference (p = > 0.05). The results of BCR-ABL quantification in the follow up of our cohort indicated that patients who had transcripts <1% by the international scale at 3 months of therapy are more likely to achieve rapid MMR (median of 7 months) than those who had >1% (median of 12 months) (p = 0,03). Conclusions: As expected, the kinase domain mutations of BCR-ABL in pretreatment samples of CML chronic phase patients are not detectable by direct sequencing because of the sensitivity of the assay (10%) and also because these mutations are more common in accelerated phase and blast crisis. About the expression of multidrug resistance genes MDR1 and BCRP, they showed no correlation with secondary resistance to imatinib mesylate. And finally the number of BCR-ABL transcripts at 3 months of treatment can be considered a marker with prognostic value.

Les cellules iNKT et T CDS innées sont présumées contribuer à l'irnmunosurveillance (IS) des cancers et sont fonctionnellement déficientes dans la leucémie myéloïde chronique (LMC). Notre hypothèse était que ces défauts résultent de l'incapacité des cellules dendritiques myéloïdes (mDC) à les activer. Des analyses par cytométrie en flux et microscopie confocale ont révélé une baisse de l'expression membranaire de CD 1 d, qui présente les antigènes aux cellules iNKT, à la surface des mDC des patients LMC, par comparaison aux sujets sains. Ce défaut n'est associé ni à un défaut de maturation des mDC, comme le montre l'expression normale de HLA-DR et de CDS6, ni à une baisse d'expression intracellulaire de CDld ou de son transcrit. Ces résultats sont conciliables avec une rétention intracellulaire. Le traitement in vitro des mDC des patients LMC avec un inhibiteur de la protéine ROCK restaure partiellement l'expression de surface de CD 1 d et la présentation antigénique par CD Id, alors qu'il n'a eu aucun effet sur les mDC des sujets sains. Nous proposons que la protéine ROCK, qui est activée par le domaine DH-PH de BCR-ABL, interfere avec la réponse immunitaire dépendant des lymphocytes iNKT au cours de la LMC par régulation négative de l'expression membranaire de CDld des mDC. Le fait que les cellules iNKT et T CDS innées retrouvent des fonctions normales après rémission complète de la LMC est en faveur d'une génération de cellules T CD8 innées dépendante des cellules iNKT, comme décrit chez la souris. Notre travail suggère une implication des cellules iNKT et T CD8 innées dans l'IS de la LMC et révèle l'axe ROCK/mDC comme une nouvelle cible thérapeutique dans la maladie. / CDld-restricted iNKT cells and innate CD8 T cells are believed to play a key role in cancer immune surveillance and are functionally deficient in chronic myeloid leukemia (CML). Herein, we have hypothesized that this defect might originate from BCR-ABL-dependent dysfunctions in myeloid dendritic cells (mDC). Indeed, flow cytometry and confocal microscopy revealed that cell-surface expression of CDld was downregulated in CML mDC, relative to healthy donor (HD) controls. The decreased cell-surface display of CDld could not be ascribed to defective mDC differentiation, as attested by normal expression of HLA-DR and the CD86 maturation marker. On the other hand, reduced membrane expression was not associated with decreased intracytoplasmic levels of CDld or its mRNA transcripts, consistent with intracellular retention. ln vitro treatrnent of CML mDC with the Rho-associated protein Kinase (ROCK) inhibitor Y-27632 partially restored both cell-surface CDld expression and CDld-mediated antigen presentation, while it had no effect on HD mDC. We propose that ROCK, which is most likely activated by the DH-PH domain of BCR-ABL, mediates iNKT-cell immune subversion in CML patients by downregulating CDld expression on CML mDC. Remarkably, both iNKT cells and innate CD8 T cells retumed to nonnal after complete CML remission, a finding consistent with a iN KT cell-dependent generation of innate CD8 T cells, similarly to the observations in mice. Ali in ali, our study supports the possible contribution of iNKT/innate CD8 T cells to tumor surveillance in CML, and reveals the ROCK/mDC axis as a new potential target to restore immune surveillance in CML.

Chronic myeloid leukemia (CML) is a clonal hematopoietic stem cell disorder associated with the Philadelphia chromosome (Ph) that arises from a reciprocal translocation between chromosomes 9 and 22, thereby resulting in the formation of the chimeric BCR-ABL oncogene encoding a constitutively activated tyrosine kinase. BCR-ABL tyrosine kinase inhibitors (TKIs) induce a complete hematologic and cytogenetic response in the majority of chronic phrase CML patients. However, TKIs cannot efficiently eradicate leukemia stem cells (LSCs) because of the insensitivity of LSCs to TKIs. Therefore, developing new strategies to target LSCs is necessary and critical for curing CML, and success of this approach depends on further understanding the molecular mechanisms by which LSCs survive and are maintained. In Chapter I, I briefly introduce CML disease, BCR-ABL oncoprotein, and TKIs. I also describe the identification and features of LSCs. Several key pathways in LSCs including Wnt/ß-catenin, hedgehog, FoxO, Bcl6 and HIF1, are discussed. I also propose our strategy to identify unique molecular pathways that are important for LSCs but not their normal stem cell counterparts. In Chapter II, I describe our finding about the function of the positive regulator, HIF1α, in CML development and LSC survival. I show that loss of HIF1α impairs the maintenance of CML through impairing cell cycle progression and inducing apoptosis of LSCs, and I also report that p16Ink4a and p19Arf mediate the effect of HIF1α on LSCs, as knockdown of p16Ink4a and p19Arf rescues the defective colony-forming ability of HIF1α-/- LSCs. As detailed in Chapter III and IV, through comparing the global gene expression profiles of LSCs and HSCs, I find two novel regulators, Blk and Scd1, which act as tumor suppressors in CML development. In Chapter III, I show that Blk is markedly down-regulated by BCR-ABL in LSCs, and that c-Myc and Pax5 mediate this down-regulation. Deletion of Blk accelerates CML development; conversely, Blk overexpression significantly delays the development of CML and impairs the function of LSCs. I also demonstrate that p27, as a downstream effector, is involved in the function of Blk in LSCs. Blk also functions as a tumor suppressor in human CML stem cells, and inhibits the colony-forming ability of human CML cells. In Chapter IV, I investigate the function of another negative regulator, Scd1, in CML LSCs, and find that expression of Scd1 is down-regulated in mouse LSCs and human CML cells. We report that Scd1 acts as a tumor suppressor in CML, as loss of Scd1 causes acceleration of CML development and overexpression of Scd1 delays CML development. Using a colony-forming assay, I demonstrate that Scd1 impairs the maintenance of LSCs due to the change of expression of Pten, p53 and Bcl2. Importantly, I find that both Blk and Scd1 do not affect normal hematopoietic stem cells (HSCs) or hematopoiesis. Taken together, our findings demonstrate that HIF1α is required for the maintenance of CML LSCs, and conversely that Blk and Scd1 suppress the function of LSCs, suggesting that combining TKI treatment with specific targeting of LSCs will be necessary for curing CML.

Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2015-10-26T10:38:27Z No. of bitstreams: 2 Tese - Adriana do Prado Barbosa - 2015.pdf: 900945 bytes, checksum: c7a5ed7dcaeb54e2967829169a9de269 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-10-26T13:18:13Z (GMT) No. of bitstreams: 2 Tese - Adriana do Prado Barbosa - 2015.pdf: 900945 bytes, checksum: c7a5ed7dcaeb54e2967829169a9de269 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-10-26T13:18:13Z (GMT). No. of bitstreams: 2 Tese - Adriana do Prado Barbosa - 2015.pdf: 900945 bytes, checksum: c7a5ed7dcaeb54e2967829169a9de269 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2015-04-10 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / The treatment of chronic myeloid leukemia (CML) has changed dramatically with the advent of imatinib mesylate (IM). Besides the convenience of oral use, other benefits were achieved with the new drug, with faster therapeutic responses and increased survival, giving the CML similar characteristics as chronic diseases. In this scenario, there was another challenge, drug compliance, since a significant proportion of patients fail to ingest all the prescribed doses of imatinib. The concern was to optimize the adherence of CML patients, the hematology ambulatory at the Clinical Hospital of the Federal University of Goias (HC-UFG), led the authoress to create a film cartoon, as a pro-adhesion educational intervention model. To investigate the effectiveness of this new educational material, we used in 65 patients three adherence measures, two indirect (Morisky Test and Molecular Response [MR]) and direct (plasma dosage of IM), before and after the screening of film. In univariate analysis, from the Morisky Test, the film was striking, with increased adherent patients, which increased from 15 (23.1%) to 43 (66.1%). The results of MR showed an improvement trend after the movie, because the positive molecular response (major MR or complete MR) increased from 81.5% to 86.1%. Regarding the serum levels of IM, with daily doses of 400-800 mg IM, the premovie samples showed higher average than the post-movie (2473.16 ± 1049.55 ng/ml versus 1414.72 ± 715 73 ng/ml), with a variation coefficients interpatients of 43.4% and 50.6%, respectively. This high dispersion index found has been reported by other authors. By multivariate analysis, patients were divided into three groups. The first brought together compliant patients before and after the film with a good therapeutic response (major MR) after the intervention. It was: patients over 53 years old, females, with associated diseases before and after the treatment of CML that use more than two drugs in addition to imatinib. The second group was marked by the change of not adherence pre to adherence post-film. Its features were younger than or equal to 53, the absence of other disease before the CML, the use of less than two drugs and complete molecular response after the film. In the third group, we observed patients without molecular response before and after the educational intervention and no medication adherence after the film. They had in common their age (less than or equal to 53 years), and drug discontinuation due to adverse reactions. The last represents the set of patients resistant to the educational film, drawing attention to the fact that only one pro-adhesion method may be insufficient for all individuals. It is concluded that medication adherence was higher among patients older than 53 years, the educational film is an effective proadhesion assistance and continuing education, if combined with another method, it could help maintain or enhance the benefits achieved in this work. / O tratamento da leucemia mielóide crônica (LMC) mudou radicalmente com o advento do mesilato de imatinibe (MI). Além da comodidade do uso oral, outros benefícios foram alcançados com o novo fármaco, como respostas terapêuticas mais rápidas e aumento da sobrevida, dando `a LMC características semelhantes `as de doenças crônicas. Neste cenário, surgiu outro desafio, a adesão medicamentosa, pois uma proporção significativa de pacientes deixa de ingerir a dose prescrita de imatinibe. A preocupação em otimizar a adesão dos pacientes com LMC, do Ambulatório de Hematologia do Hospital das Clínicas da Universidade Federal de Goiás (HC-UFG), motivou a autora a criar um filme em desenho animado, como modelo de intervenção educativa pró-adesão. Para investigar a eficácia deste novo material educativo, empregou-se, em 65 pacientes, três medidas de adesão, duas indiretas (Teste de Morisky e Resposta Molecular [RM]) e uma direta (dosagem plasmática do MI), antes e depois da exibição do filme. Em análise univariada, pelo teste de Morisky, o filme foi impactante, com aumento dos pacientes aderentes, que passaram de 15 (23,1%) para 43 (66,1%). Os resultados da RM indicaram uma tendência de melhora após o filme, pois a resposta molecular positiva (RM maior ou RM completa) passou de 81,5% para 86,1%. Em relação `a dosagem sérica do MI, com doses diárias entre 400-800 mg de MI, as amostras pré-filme apresentaram média superior `as do pósfilme (2.473,16 ± 1.049,55 ng/ml versus 1.414,72 ± 715,73 ng/ml), com coeficientes de variação interpaciente de 43,4% e 50,6%, respectivamente. Este elevado índice de dispersão encontrado tem sido relatado por outros autores. Pela análise multivariada, os pacientes foram separados em três grupos. O primeiro, reuniu os pacientes aderentes antes e após o filme e com boa resposta terapêutica (RM maior) após a intervenção. Foram eles: os doentes com mais de 53 anos, do gênero feminino, com doenças associadas antes e após o tratamento da LMC e que usam mais de dois medicamentos além do imatinibe. O segundo grupo foi marcado pela mudança de não adesão pré para adesão pós-filme. Suas características foram idade menor ou igual a 53, ausência de outra doença antes da LMC, uso de menos de dois medicamentos e resposta molecular completa pós-filme. No terceiro grupo, observou-se pacientes sem resposta molecular antes e depois da intervenção educativa, bem como não adesão medicamentosa após o filme. Eles tinham em comum a idade, menor ou igual a 53 anos, e suspensão do medicamento por reação adversa. Estes últimos representam o conjunto de pacientes resistentes ao filme educacional, chamando atenção para o fato de que somente um método pró-adesão pode ser insuficiente para todos os indivíduos. Conclui-se que a adesão medicamentosa foi maior entre os pacientes maiores de 53 anos, que o filme educativo é uma intervenção pró-adesão eficaz e que a educação continuada, aliada a outro método, poderia ajudar a manter ou ampliar os benefícios conquistados neste trabalho.