No description available.

Po radikalaus gydymo 20–50 proc. pacientų, kuriems nustatytas galvos–kaklo srities vėžys lokoregioninis atkrytis nustatomas per pirmus dvejus metus. Literatūroje paskelbtų tyrimų rezultatai taikant pakartotinę nuotolinę spindulinę terapiją dėl galvos-kaklo vėžio atkryčio prasti: 2-jų metų bendras išgyvenimas siekė 15,2–40 proc., vėlyvųjų 3-4 laipsnio komplikacijų dažnis buvo 1,4–47 proc., 5 laipsnio - 7,6 proc. Retrospektyvinių ir II fazės tyrimų rezultatai naudojant didelės dozės galios brachiterapiją galvos-kaklo srities vėžio atkryčiui gydyti: 2-jų metų bendras išgyvenimas siekė 19–63 proc., vėlyvųjų 3-4 laipsnio komplikacijų dažnis buvo 4–22,2 proc. Tyrimų metu skirtos 3–4 Gy frakcijos iki 30–40 Gy suminės dozės. Iki šiol neatlikti tyrimai lyginantys nuotolinės spindulinės terapijos ir didelės dozės galios brachiterapijos gydymo veiksmingumą ir saugumą. Šioje disertacijoje palyginti skirtingi spindulinio gydymo metodai gydant galvos-kaklo srities vėžio atkrytį: kontrolinei grupei taikytas nuotolinis konforminis spindulinis gydymas (25 frakcijos po 2 Gy, suminė dozė 50 Gy), tiriamajai grupei - hipofrakcionuota didelės dozės galios brachiterapija skiriant naują frakcionavimo režimą – po 2,5 Gy per frakciją po dvi frakcijas per dieną, iki 30 Gy suminės dozės. Toks frakcionavimo režimas pasirinktas siekiant sumažinti spindulinių reakcijų dažnį ir sunkumo laipsnį, o suminė dozė yra biologiškai ekvivalentiška suminėms dozėms, kurios buvo naudotos ankstesniuose tyrimuose. / After radical treatment of head and neck cancer 20–50% of patients are diagnosed with the locoregional recurrence during first two years. In the literature the results of studies, using reirradiation by three-dimensional radiotherapy for head and neck cancer recurrence, according to a 2-year overall survival and toxicity, are poor: overall survival reached 15.2–40%, the grade 3 - 4 toxicity reached 1.4–47% and grade 5 - 7.6%. The results of phase II and retrospective studies using the high-dose-rate brachytherapy for treatment of head and neck cancer relapse were: 2-year overall survival was 19–63%; grade 3 - 4 late toxicity 4–22.2%. In these studies 3–4 Gy per fraction up to 30–40 Gy total dose were administered. So far, the randomized study, comparing the high-dose-rate brachytherapy with the three-dimensional radiotherapy, treating head and neck cancer relapse, hasn’t been conducted. We compared different radiotherapy methods: three-dimensional conformal radiotherapy was administered to the control group (25 fractions of 2 Gy, total dose of 50 Gy); the hypofractionated high-dose-rate brachytherapy was administered to the experimental group, while applying a new regime of fractionation: 2.5 Gy per fraction, two fractions per day, up to 30 Gy total dose. Such fractionation regimen was selected in order to reduce the rate and grade of toxicity, while the total dose is biologically equivalent to the total doses, which have been used in previous studies.

Base teórica: O surgimento de bactérias multirresistentes levou a uma renovação no interesse de antigos antimicrobianos, como a polimixina B, medicamento que foi descartado no passado devido sua toxicidade. Nas últimas duas décadas, esse antimicrobiano tornou-se um dos mais importantes agentes terapêuticos para o tratamento de infecções causadas por bactérias multirresistentes; porém, ainda faltam estudos clínicos que avaliem a segurança da polimixina B, especialmente em altas doses. Objetivo: Avaliar eventos adversos graves relacionados à infusão e a falência renal nos pacientes que receberam altas doses de polimixina B intravenosa. Métodos: Realizamos um estudo de coorte retrospectivo, multicêntrico. Incluímos pacientes que receberam > 3mg/kg/ dia ou uma dose total ≥250mg/dia de polimixina B, no período de janeiro de 2013 a dezembro de 2015. Para a avaliação dos eventos relacionados a infusão, foram incluídos pacientes que receberam ≥ 1 dose de polimixina B e para avaliação de falência renal incluiu apenas os pacientes que receberam ≥ 48 horas de polimixina B. Os desfechos principais avaliados foram os eventos adversos graves relacionados à infusão de acordo com os Critérios de Terminologia Comuns para Eventos Adversos (CTCAE v4.0) e a falência renal, utilizamos os critérios RIFLE (Risk, Injury, Failure, Loss and End stage), para categorizar os diferentes graus de lesão renal aguda. As variáveis incluídas no estudo foram as variáveis demográficas (idade, sexo), as variáveis individuais (peso, comorbidades, escore de Charlson), os fatores de gravidade (internação em UTI, uso de vasopressor, uso de bloqueador neuromuscular), outras fármacos nefrotóxicas, dose de polimixina utilizada (total, média diária e em mg/kg/dia), associação com outros medicamentos, e características da infecção (sítio, isolamento microbiológico) foram avaliadas em análise bivariada. Variáveis com P≤0.2 foram incluídas uma a uma, em ordem crescente, em modelo de regressão de COX. Variáveis com P< 0.1 permaneceram no modelo final. Resultados: Foram incluídos 222 pacientes para análise de eventos graves relacionados à infusão. A dose média de polimixina B foi de 3.61± 0.97 mg/kg /dia (dose total media = 268 mg/kg). Ocorreram eventos adversos graves relacionados à infusão em dois pacientes, determinando uma incidência bruta de 0.9% (intervalo de confiança de 95%, 0.2-3.2): um 7 evento classificado como um risco ameaçador a vida (efeito adverso classe IV) ocorreu em um paciente, homem, de 40 anos, internado no Centro de Terapia Intensiva, com fibrose cística, que recebeu 3,3 mg / kg / dia de PMB e desenvolveu dor torácica súbita, dispnéia e hipoxemia, no quarto dia de tratamento e o outro evento adverso grave (classe III), ocorreu em um paciente, homem, 23 anos, internado na enfermaria, com linfoma, que recebeu 3,6 mg / kg / dia de PMB , que apresentou parestesia perioral, tonturas e dispnéia no primeiro dia de tratamento. A falência renal foi analisada em 115 pacientes que receberam ≥ 48 horas de polimixina B e que não estavam em diálise no início do tratamento com Polimixina B; Falência renal foi encontrada em 25 de 115 (21,7%) pacientes expostos as PMB. Nosso estudo identificou que 54 [47,0%] pacientes desenvolveram algum grau de lesão renal aguda, pelos critérios de RIFLE: risco, 15 (27,8%), injúria, 14 (25,9%) e falência, 25 (46,3%) dentro das categorias do RIFLE. Além disso, droga vasoativa, outros fármacos nefrotóxicos e clearance de creatinina foram fatores de risco independentes para falência renal. Nem a dose diária de polimixina B ajustada para o peso corporal, nem a dose diária total foram associadas a falência renal. A mortalidade intra-hospitalar foi de 60% (134 pacientes): 26% (57 pacientes) morreram durante o tratamento e nenhum óbito foi durante a infusão. Conclusão: Altas doses de polimixina B no tratamento de infecções por bactérias gramnegativo apresentaram incidência baixa de eventos adversos agudos no nosso estudo e incidência de nefrotoxicidade elevadas, mas semelhantes a alguns estudos prévios com doses usuais”. Portanto, doses elevadas podem ser testadas em ensaios clínicos, objetivando melhorar os desfechos dos pacientes gravemente doentes com infecções por bactérias multirresistentes e minimizar o surgimento da resistência a polimixina B. / Background: The emergence of multiresistant bacteria has led to a renewal in the interest of old antimicrobials, such as polymyxin B, a drug that has been discarded in the past due to its toxicity. However, at this time, this antimicrobial has become one of the most important therapeutic agents for the treatment of infections caused by multiresistant bacteria but there is still a lack of clinical studies that evaluate the safety of polymyxin B, especially in relation to the use of high doses. This strategy, high doses, may be necessary in the fight against Gramnegative bacteria with a high minimum inhibitory concentration. Patients and methods: A retrospective, multicenter cohort study; the period evaluated was from January 2013 to December 2015, included patients who received > 3mg/kg/day or a total dose of ≥250mg/day of polymyxin B. The study included the evaluation of infusion-related events, patients who received ≥ 1 dose of polymyxin B and patients who received ≥ 48 hours of PMB were included for evaluation of renal failure. Major outcomes were serious adverse events related to infusion according to the Common Terminology Criteria for Adverse Events (CTCAE v4.0) and categorized renal failure by the RIFLE criteria (Risk, Injury, Failure, Loss, End stage). Factors potentially related to nephrotoxicity or mortality in 30 days were: demographic variables (age, sex), individual variables (weight, comorbidities, Charlson score), severity factors (ICU admission, use of vasopressor, use of Neuromuscular blocker), nephrotoxicity (other nephrotoxic drugs), polymyxin dose (total, daily mean and mg / Kg / day), association of drugs and infection characteristics (site and microbiological isolate) were evaluated in bivariate analysis. Variables with P≤0.2 were included one by one, in ascending order, in a Cox regression model. Variables with P <0.1 remained in the final model. Results: Two of 222 patients presented a severe infusion-related adverse event during PMB infusion, resulting in a crude incidence of 0.9% (95% Confidence Interval [CI], 0.2-3.2); one was classified as life-threatening and one classified as severe (crude incidence of each adverse event, 0.45%; 95% CI, 0.08-2.5). The life-threatening adverse effect occurred in an ICU patient (crude incidence among ICU patients, 0.67%; 95% CI, 0.12-3.7), a 40-years old male with cystic fibrosis who used 3.3 mg/kg/day of PMB and developed sudden thoracic pain, dyspnea and hypoxemia, in the fourth day of treatment. The severe adverse effect occurred in a non-ICU patient (crude incidence among non-ICU patients, 1.3%; 95% CI, 0.2-7.2), a 23- years old male with lymphoma exposed to 3.6 mg/kg/day of PMB, who presented perioral 9 paresthesia, dizziness and dyspnea in the first day of treatment. Renal failure was analysed in 115 patients who received ≥48 hours of PMB and who were not previously in dialysis. A total of 54 [47.0%] patients developed any degree of AKI, categorised as Risk [27.8%]; Injury [25.9%] and Failure [46.3%]) and 25 of 115 (21.7%) patients presented renal failure Vasoactive drug, concomitant nephrotoxic drugs and baseline creatinine clearance were independent risk factors for renal failure. Neither PMB daily dose scaled by body weight nor total daily dose were associated with renal failure. In-hospital mortality was 60% (134 patients): 26% (57 patients) occurred during treatment and none during infusion. Conclusion: Results suggest that high dose regimens have similar safety profile of usual doses and could be further tested in clinical trials assessing strategies to improve patients’ outcomes and minimize the emergence of PMB resistance.

Base teórica: O surgimento de bactérias multirresistentes levou a uma renovação no interesse de antigos antimicrobianos, como a polimixina B, medicamento que foi descartado no passado devido sua toxicidade. Nas últimas duas décadas, esse antimicrobiano tornou-se um dos mais importantes agentes terapêuticos para o tratamento de infecções causadas por bactérias multirresistentes; porém, ainda faltam estudos clínicos que avaliem a segurança da polimixina B, especialmente em altas doses. Objetivo: Avaliar eventos adversos graves relacionados à infusão e a falência renal nos pacientes que receberam altas doses de polimixina B intravenosa. Métodos: Realizamos um estudo de coorte retrospectivo, multicêntrico. Incluímos pacientes que receberam > 3mg/kg/ dia ou uma dose total ≥250mg/dia de polimixina B, no período de janeiro de 2013 a dezembro de 2015. Para a avaliação dos eventos relacionados a infusão, foram incluídos pacientes que receberam ≥ 1 dose de polimixina B e para avaliação de falência renal incluiu apenas os pacientes que receberam ≥ 48 horas de polimixina B. Os desfechos principais avaliados foram os eventos adversos graves relacionados à infusão de acordo com os Critérios de Terminologia Comuns para Eventos Adversos (CTCAE v4.0) e a falência renal, utilizamos os critérios RIFLE (Risk, Injury, Failure, Loss and End stage), para categorizar os diferentes graus de lesão renal aguda. As variáveis incluídas no estudo foram as variáveis demográficas (idade, sexo), as variáveis individuais (peso, comorbidades, escore de Charlson), os fatores de gravidade (internação em UTI, uso de vasopressor, uso de bloqueador neuromuscular), outras fármacos nefrotóxicas, dose de polimixina utilizada (total, média diária e em mg/kg/dia), associação com outros medicamentos, e características da infecção (sítio, isolamento microbiológico) foram avaliadas em análise bivariada. Variáveis com P≤0.2 foram incluídas uma a uma, em ordem crescente, em modelo de regressão de COX. Variáveis com P< 0.1 permaneceram no modelo final. Resultados: Foram incluídos 222 pacientes para análise de eventos graves relacionados à infusão. A dose média de polimixina B foi de 3.61± 0.97 mg/kg /dia (dose total media = 268 mg/kg). Ocorreram eventos adversos graves relacionados à infusão em dois pacientes, determinando uma incidência bruta de 0.9% (intervalo de confiança de 95%, 0.2-3.2): um 7 evento classificado como um risco ameaçador a vida (efeito adverso classe IV) ocorreu em um paciente, homem, de 40 anos, internado no Centro de Terapia Intensiva, com fibrose cística, que recebeu 3,3 mg / kg / dia de PMB e desenvolveu dor torácica súbita, dispnéia e hipoxemia, no quarto dia de tratamento e o outro evento adverso grave (classe III), ocorreu em um paciente, homem, 23 anos, internado na enfermaria, com linfoma, que recebeu 3,6 mg / kg / dia de PMB , que apresentou parestesia perioral, tonturas e dispnéia no primeiro dia de tratamento. A falência renal foi analisada em 115 pacientes que receberam ≥ 48 horas de polimixina B e que não estavam em diálise no início do tratamento com Polimixina B; Falência renal foi encontrada em 25 de 115 (21,7%) pacientes expostos as PMB. Nosso estudo identificou que 54 [47,0%] pacientes desenvolveram algum grau de lesão renal aguda, pelos critérios de RIFLE: risco, 15 (27,8%), injúria, 14 (25,9%) e falência, 25 (46,3%) dentro das categorias do RIFLE. Além disso, droga vasoativa, outros fármacos nefrotóxicos e clearance de creatinina foram fatores de risco independentes para falência renal. Nem a dose diária de polimixina B ajustada para o peso corporal, nem a dose diária total foram associadas a falência renal. A mortalidade intra-hospitalar foi de 60% (134 pacientes): 26% (57 pacientes) morreram durante o tratamento e nenhum óbito foi durante a infusão. Conclusão: Altas doses de polimixina B no tratamento de infecções por bactérias gramnegativo apresentaram incidência baixa de eventos adversos agudos no nosso estudo e incidência de nefrotoxicidade elevadas, mas semelhantes a alguns estudos prévios com doses usuais”. Portanto, doses elevadas podem ser testadas em ensaios clínicos, objetivando melhorar os desfechos dos pacientes gravemente doentes com infecções por bactérias multirresistentes e minimizar o surgimento da resistência a polimixina B. / Background: The emergence of multiresistant bacteria has led to a renewal in the interest of old antimicrobials, such as polymyxin B, a drug that has been discarded in the past due to its toxicity. However, at this time, this antimicrobial has become one of the most important therapeutic agents for the treatment of infections caused by multiresistant bacteria but there is still a lack of clinical studies that evaluate the safety of polymyxin B, especially in relation to the use of high doses. This strategy, high doses, may be necessary in the fight against Gramnegative bacteria with a high minimum inhibitory concentration. Patients and methods: A retrospective, multicenter cohort study; the period evaluated was from January 2013 to December 2015, included patients who received > 3mg/kg/day or a total dose of ≥250mg/day of polymyxin B. The study included the evaluation of infusion-related events, patients who received ≥ 1 dose of polymyxin B and patients who received ≥ 48 hours of PMB were included for evaluation of renal failure. Major outcomes were serious adverse events related to infusion according to the Common Terminology Criteria for Adverse Events (CTCAE v4.0) and categorized renal failure by the RIFLE criteria (Risk, Injury, Failure, Loss, End stage). Factors potentially related to nephrotoxicity or mortality in 30 days were: demographic variables (age, sex), individual variables (weight, comorbidities, Charlson score), severity factors (ICU admission, use of vasopressor, use of Neuromuscular blocker), nephrotoxicity (other nephrotoxic drugs), polymyxin dose (total, daily mean and mg / Kg / day), association of drugs and infection characteristics (site and microbiological isolate) were evaluated in bivariate analysis. Variables with P≤0.2 were included one by one, in ascending order, in a Cox regression model. Variables with P <0.1 remained in the final model. Results: Two of 222 patients presented a severe infusion-related adverse event during PMB infusion, resulting in a crude incidence of 0.9% (95% Confidence Interval [CI], 0.2-3.2); one was classified as life-threatening and one classified as severe (crude incidence of each adverse event, 0.45%; 95% CI, 0.08-2.5). The life-threatening adverse effect occurred in an ICU patient (crude incidence among ICU patients, 0.67%; 95% CI, 0.12-3.7), a 40-years old male with cystic fibrosis who used 3.3 mg/kg/day of PMB and developed sudden thoracic pain, dyspnea and hypoxemia, in the fourth day of treatment. The severe adverse effect occurred in a non-ICU patient (crude incidence among non-ICU patients, 1.3%; 95% CI, 0.2-7.2), a 23- years old male with lymphoma exposed to 3.6 mg/kg/day of PMB, who presented perioral 9 paresthesia, dizziness and dyspnea in the first day of treatment. Renal failure was analysed in 115 patients who received ≥48 hours of PMB and who were not previously in dialysis. A total of 54 [47.0%] patients developed any degree of AKI, categorised as Risk [27.8%]; Injury [25.9%] and Failure [46.3%]) and 25 of 115 (21.7%) patients presented renal failure Vasoactive drug, concomitant nephrotoxic drugs and baseline creatinine clearance were independent risk factors for renal failure. Neither PMB daily dose scaled by body weight nor total daily dose were associated with renal failure. In-hospital mortality was 60% (134 patients): 26% (57 patients) occurred during treatment and none during infusion. Conclusion: Results suggest that high dose regimens have similar safety profile of usual doses and could be further tested in clinical trials assessing strategies to improve patients’ outcomes and minimize the emergence of PMB resistance.

No description available.

Mit der vorliegenden Habilitationsschrift habe ich den Versuch unternommen, die beiden Themenkomplexe meiner bisherigen wissenschaftlichen Tätigkeit als Beispiele für die Rolle von Modellen in der klinischen Forschung zu verwenden. Den Ansto§ dazu gaben Diskrepanzen, die mir in der Auseinandersetzung mit eigenen Ergebnissen und Beobachtungen im Umfeld dieser Themenkomplexe aufgefallen sind: der Rolle kontaminierender Tumorzellen in der Hochdosistherapie maligner Tumoren einerseits und dem Enzym Dipeptidylpeptidase IV (DPP IV) andererseits. Die beobachteten Diskrepanzen sind Ausdruck konkurrierender pathophysiologischer oder therapeutischer Modelle, und die Präferenz eines bestimmten Modells scheint nicht rein rational erklärbar. Welche Faktoren tragen jedoch zur Entscheidung für oder gegen ein bestimmtes Modell bei? Ich möchte den Umgang mit wissenschaftlichen Modellen anhand der genannten Themenkomplexe aus meiner Sicht erörtern. Anschlie§end soll ein Entwurf skizziert werden, in dem die der Entscheidung für oder gegen ein therapeutisches Modell zugrundeliegende Motivationslage besser verständlich wird und die Intentionalität klinischer Forschung auf den Patienten hin berücksichtigt. / In the thesis presented here, I have taken the challenge to use the topics of my scientific work to discuss the role that models appear to exert in clinical science. This decision arose from discrepancies that became evident in the comparative assessment of my own studies in relation with the surrounding scientific context: the role of tumor cells contaminating peripheral blood or progenitor cell harvests as part of a high-dose chemotherapy regimen on the one hand, and the enzyme dipeptidyl peptidase IV (DPP IV) on the other. The observed discrepancies appear to result from competing pathophysiological or therapeutic models, and the preference or rejection of one model apparently cannot be explained solely by rational factors. I will discuss the application of models in the context of the topics which my scientific work has been focusing on, and I will develop a draft proposal which will render the individual motivational status underlying the decision in favor of or against a distinct model easier to understand, with attention to the intentionality of clinical research towards the patient.

Das moderne Therapiekonzept der Hochdosischemotherapie von soliden Tumoren und hämatologischen Neoplasien erfordert die prätherapeutische Sammlung, die extrakorporale Reinigung und die nachfolgende Tieftemperaturlagerung von menschlichen Blutstammzellen zur späteren Retransplantation. Stammzellpräparate (Transplantate) von 22 Patienten wurden durch extrakorporale Trennung von peripheren Blut hergestellt. Von jedem Patienten wurde eine Probe mit Dimethylsulfoxid (DMSO) versetzt, bei - 196 oC gelagert und nach ca. 3 Wochen aufgetaut. Eine Vergleichsprobe jedes Patienten wurde ohne den Zusatz von DMSO und ohne einen Einfrierschritt untersucht. Die Exposition von DMSO, das Frieren und Auftauen der Zellen zeigte eine geringfügige des Zell- und Kerndurchmessers, eine konstante Anzahl an Mitochondrien und eine Reduktion der Vesikel. Ein markantes Merkmal der Schädigung nach Tieftemperaturlagerung war das Auftreten von Flüssigkeitseinlagerungen in die Kerndoppelmembran und die Ausbildung von zisternenartigen Erweiterungen des endoplasmatischen Retikulums. Regelmäßig konnten Mitochondrien von verringerter Größe und randständig kondensierter Cristae gefunden werden. Insgesamt konnten keine schwerwiegenden zellulären Schäden beim Vergleich der unbehandelten und der DMSO- versetzten , eingefrorenen und wieder aufgetauten Proben festgestellt werden. Die morphologischen Ergebnisse korrespondieren mit der vollständigen Restitution aller hämatopoetischer Zelllinien nach Transplantation. / The modern therapeutic concept of high-dose chemotherapy of solid tumors and hematologic neoplasias demands a pretherapeutic harvest, an extracorporal purification and an consecutive deep temperature storage of human blood stem cells which will be retransplanted later. Stem cell preparates (transplants) of 22 patients were produced by extracorporal separation of peripheral blood. From each patient a stem cell specimen was mixed with dimethylsulfoxide (DMSO), storaged at - 196 °C and thawed after about 21 days. A corresponding specimen of each patients material was investigated without DMSO addition and without freezing under native conditions. The DMSO exposed, frozed and again defrosted cells showed a mild increase of total cell and nucleus diameters, a constant number of mitochondrias and a reduction of vesicles. A markedly feature of deep temperature damage was the occurance of liquide storages in the nucleus double membrane and the forming of cisterne-like enlargement of the endoplasmatic reticulum. Persistantly we found mitochondrias with reduced size and marginal condensed cristae. Alltogether there were no severe cellular damages in the comparative investigated overlifed specimen cells of the same patient with and without DMSO and deep temperature storage. The morphological results correspond with clinical investigations of a sufficient restitution of all hematopoietic cell lineages in transplanted patients.

Patienten mit metastasierten Keimzelltumoren, die einen Progress oder ein Rezidiv ihrer Erkrankung nach einer cisplatinhaltigen Vortherapie erleiden, haben eine schlechte Prognose. Unter Verwendung einer erneuten konventionellen Chemotherapie können maximal 15-30% dieser Patienten geheilt werden, so dass die Mehrzahl der Patienten an ihrer Erkrankung verstirbt. Aus diesem Grund ist die Optimierung der therapeutischen Möglichkeiten ein wesentliches Ziel. Unsere Daten zeigen, dass die Hochdosischemotherapie (HDCT) eine wesentliche therapeutische Verbesserung darstellt und mittels dieser Therapie mit einem ereignisfreien Überleben von 30-60% zu rechnen ist. Eine "matched-pair" Analyse konnte im Hinblick auf das ereignisefreie und das Gesamtüberleben einen Vorteil von mehr als 10% zu Gunsten der HDCT feststellen. Darüber hinaus hat die zunehmende Erfahrung und die Verwendung von peripheren Blutstammzellen und hämatopoetischen Wachstumsfaktoren, den Einsatz der HDCT deutlich sicherer gemacht. Aus den genannten Gründen sollte alle Patienten mit Rezidiv oder Progress eines Keimzelltumors der HDCT zugeführt werden. Die operative Entfernung von residuellen Tumormanifestationen (RTR) nach primärere Chemotherapie ist heute Standard bei Patienten mit metastasierten Keimzelltumoren. Zwar findet sich in der histologischen Aufarbeitung bei den meisten Patienten ausschließlich nekrotisches Gewebe, doch werden bei einem Teil der Patienten auch Anteile von reifem Teratom und vitalen differenzierten und undifferenzierten Karzinomen gefunden. Während die Resektion von Nekrose keinen therapeutischen Benefit für den Patienten darstellt, ist die komplette Entfernung von reifem Teratom oder Zellen eines Karzinoms für die Prognose entscheidend. In Bezug auf die HDCT konnten bisher keine vergleichbaren Daten erhoben werden. Zur Evaluierung des Stellenwertes der RTR nach HDCT analysierten wir unser eigenes Patientenkollektiv und fanden, dass vergleichbar zur Primärtherapie alle Patienten nach Salvage-HDCT, die eine partielle markernegative oder markerpositive Remission erreicht haben, einer RTR zugeführt werden sollten. Bis auf intrazerebrale Reste sollten alle residuellen Tumormanifestationen komplett reseziert werden. Neben der Optimierung der therapeutischen Möglichkeiten ist auch die Minimierung der chemotherapieassoziierten Toxizitäten ein wesentlicher Bestandteil meiner wissenschaftlichen Arbeit. Aus diesem Grund evaluierten wir die Wirksamkeit der Substanz Amifostin im Hinblick auf die Verringerung von Toxizitäten, die Wirkung auf die Mobilisierung von peripheren Blutstammzellen und den Einfluß auf die Rekonstitution des Immunstatus bei Patienten mit rezidivierten oder progredienten Keimzelltumoren, die mittels einer konventionellen Chemotherapie und anschließender HDCT behandelt wurden. Der Einsatz von Amifostin erbrachte in diesem Zusammenhang und in diesem Patientenkollektiv keinen therapeutischen oder prophylaktischen Nutzen, so dass dessen Verwendung bei Patienten mit Keimzelltumoren nicht generell empfohlen werden kann. / Overall, patients with relapsed or progressive germ cell tumors (GCT) after cisplatin-based chemotherapy have a low chance of cure. Using conventional-dose chemotherapy as salvage treatment only 15-30% of the patients will become long-term survivors. It is well known that the majority of these patients will ultimately die of their disease. Therefore, improvment of standard treatment is clearly desirable. Our data has been established high-dose chemotherapy (HDCT) as an effective salvage modality with an event-free survival of 30-60%. A matched-pair analysis showed an advantage for HDCT compared with conventional-dose chemotherapy with improvement in event-free and overall survival of more than 10%. Furthermore, due to increasing clinical experience in the management of side-effects, the use of peripheral blood progenitor cells, and the availability of hematopoietic growth factors, HDCT has become relatively safe. In GCT patients with relapsed or rogressive disease HDCT has been demonstrated as a feasible and safe treatment concept which will be curative for a substantial proportion of these patients. Therefore, HDCT should be administered in patients with first relapse and unfavorable prognostic factors and as second or subsequent salvage treatment. Surgical resection of residual tumors (RTR) after first-line chemotherapy is recommended in patients with metastatic GCT. Necrosis will be the only histological finding in the majority of these patients. However, in others mature teratoma, viable cancer consisting of residual GCT, non germ-cell tumors, undifferentiated cancer or a combination of these histologies may be found. Whereas the resection of necrosis offers no therapeutic benefit, resection of mature teratoma or viable cancer adds to long-term event-free and overall survival in these patients. However, limited data exist on the results of surgery and the respective histologies in patients after first or subsequent salvage treatment with HDCT. To assess the contribution of RTR in this setting, we retrospectively analyzed a cohort of patients who had been treated with HDCT for relapsed or refractory GCT. Our data show that RTR contributes to the overall treatment outcome and should be offered to all patients with a partial remission after HDCT. Complete resections of all residual tumors outside the CNS should be attempted. Furthermore, we assessed the efficacy of amifostine for protection from chemotherapy-induced toxicities, for peripheral blood progenitor cell mobilization and for immune-reconstitution in patients treated with conventional-dose paclitaxel, ifosfamide, cisplatin (TIP) and high-dose carboplatin, etoposide and thiotepa (CET) followed by PBPC rescue. In conclusion, amifostine additional to conventional-dose chemotherapy or HDCT showed no unequivocal advantage in protection from treatment-related toxicities and had no effect neither on PBPC mobilization nor on immune-reconstitution.

Die Hochdosischemotherapie stellt für Patienten unter 60 Jahren die Standardtherapie des multiplen Myeloms dar. Nach 600 Hochdosischemotherapiezyklen mit autologer peripherer Stammzelltransplantation zeigten sich erstmals Grundkrankheit, Alter und Zahl der transplantierten Stammzellen als unabhängige Einflußfaktoren für die Rate der dokumentierten Infektionen. Die Dauer der schweren Mukositis beeinflußte sowohl die Rate der Infektionen, als auch die therapieassoziierte Mortalität signifikant. Die Angiogenese im Knochenmark stellte bei Patienten mit multiplem Myelom einen unabhängigen Prognosefaktor für das Überleben dar. Myelom-Patienten wiesen im Vergleich zu gesunden Probanden eine signifikant erhöhte bFGF(basic fibroblast growth factor)-Konzentration im Serum auf. Es zeigte sich ein signifikanter Anstieg der bFGF Konzentration parallel zur Progression der Erkrankung vom Stadium I bis zum Stadium III. Eine effektive Chemotherapie ging mit signifikanten Reduktionen der Serum-Konzentrationen von drei angiogen wirksamen Zytokinen VEGF (vascular endothelial growth factor), bFGF und HGF (hepatocyte growth factor) sowie der Angiogenese im Knochenmark einher. Die Induktion der Knochenresorption stellt eines der wichtigsten weiteren Charakteristika von malignen Plasmazellen dar. In einer vergleichenden Untersuchung zeigte sich, daß unter den Knochenstoffwechselparametern ICTP (carboxyterminales quervernetztes Typ I Kollagen Telopeptid), NTx (aminoterminales Kollagen Typ I Telopeptid) und DPD (Desoxypyridinolin) das erstgenannte sich am besten zur Kontrolle der Progression eignet und dieser Parameter auch einen signifikanten Prognosefaktor für die Überlebenszeit darstellt. Die Hinweise, daß eine frühzeitige Bisphosphonattherapie die Progression des multiplen Myeloms hemmen könnte, hat uns veranlaßt, die erste prospektiv randomisierte Studie einer Bisphosphonattherapie beim multiplen Myelom im Stadium I in Zusammenarbeit mit der Deutschen Studiengruppe Multiples Myelom zu initiieren. Darüber hinaus wird in dieser Arbeit auf die prognostische Relevanz zytogenetischer und molekulargenetischer Befunde beim multiplen Myelom sowie auf die Möglichkeit immunphänotypischer Untersuchungen zur Differenzierung zwischen multiplem Myelom und monoklonaler Gammopathie unbestimmter Signifikanz (MGUS) eingegangen. / High-dose chemotherapy is the standard treatment for patients with multiple myeloma younger than 60 years. In 600 cycles of high-dose chemotherapy with autologous blood stem cell transplantation, we found that the type of the malignant disease, age and number of transplanted stem cells were independent prognostic factors for the rate of documented infections. The duration of severe mucositis was significantly associated both with the rate of infections and treatment-related mortality. The angiogenesis in bone marrow was found to be an independent prognostic factor for survival in patients with multiple myeloma. Myeloma patients had significantly elevated serum bFGF (basic fibroblast growth factor) levels in comparison to healthy controls. Serum bFGF levels increased parallel to the progression of multiple myeloma from stage I to stage III. Effective chemotherapy was associated with significant reductions in serum levels of three angiogenic cytokines VEGF (vascular endothelial growth factor), bFGF and HGF (hepatocyte growth factor) and the bone marrow angiogenesis. The induction of bone resorption is one of the most important characteristics of malignant plasma cells. In a comparative analysis of bone resorption parameters ICTP (carboxy-terminal telopeptide of type-I collagen), NTx (amino-terminal collagen type-I telopeptide) and DPD (deoxypyridinoline) we found that ICTP was the most suitable marker for the detection of progression in multiple myeloma and that ICTP was a significant prognostic factor for survival in this disease. The findings that an early start of a treatment with bisphosphonates might delay the progression of multiple myeloma has lead us to start the first prospective randomized trial of bisphosphonate treatment in stage I in collaboration with the German Study Group Multiple Myeloma. Furthermore the prognostic relevance of cytogenetic and moleculargenetic findings in multiple myeloma and the use of immunophenotypic analysis for the differentiation of multiple myeloma and monoclonal gammopathy of undetermined significance (MGUS) was discussed in this work.

The event TC1507 maize with cry1F gene from the bacterium Bacillus thuringiensis Berliner (Bt) was approved for commercial release in Brazil in 2008. The evolution of pest resistance to Bt plants has been a great concern to preserve the lifetime of this technology. Therefore, in this study we assess the risk of evolution of resistance to Cry1F protein in Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae) populations from major maize-growing regions in Brazil. The baseline susceptibility to Cry1F was detemined with diet overlay bioassay for susceptible reference population and four field populations of S. frugiperda. Then, we monitored 43 populations of S. frugiperda sampled in nine different States of Brazil during 2010/2011, 2011/2012 and 2012/2013 crop seasons. Only 4-fold variation in susceptibility to Cry1F was detected among S. frugiperda from field populations in the baseline susceptibility study. Diagnostic concentration of 2,000 ng cm-2 was defined for monitoring the susceptibility to Cry1F in S. frugiperda populations. Survival at 2,000 ng cm-2 of Cry1F protein increased significantly throughout crop seasons in populations from São Paulo, Santa Catarina, Rio Grande do Sul, Bahia, Mato Grosso, Goiás, Mato Grosso do Sul, and Paraná, but not in Minas Gerais. We also sampled a population of S. frugiperda in TC1507 field failures in Bahia in October, 2011. This population was selected in laboratory with Cry1F protein up to 20,000 ng cm-2 and the resistance ratio of the selected resistant population (BA25R) was > 5,000-fold. This resistant population was able to survive in Cry1F maize from neonate till pupa and produce normal adult. The inheritance of S. frugiperda resistance to Cry1F protein was autosomal. To test the functional dominance, neonate larvae obtained from the cross of resistant and susceptible populations were tested in leaf bioassay, and around 8% of heterozygotes were able to survive and complete the larval development and produce normal adults on TC1507 leaves while susceptible larvae could not survive for up to five days after infestation. Dominance was estimated to be 0.15 ± 0.09, suggesting that resistance to Cry1F in TC1507 maize was incompletely recessive. We also conducted resistance selection studies in other seven S. frugiperda populations from six different Brazilian states to test whether the resistance alleles were at same locus or not. The F1 larvae obtained from the cross between resistant population (BA25R) and each of the seven selected resistant populations were able to survive at 2,000 ng cm-2 of Cry1F protein in diet bioassay, and therefore they shared the same locus of resistance to Cry1F protein. We estimated the frequency of resistance allele to Cry1F protein in populations of S. frugiperda of main crop season 2011/2012 from five states. We stablished 517 isofemale lines using F2 screen method. The total frequency of Cry1F resistance allele in Brazil was 0.088 with 95% confidence interval between 0.077 and 0.100. Based on results obtained in this study, the risk of resistance evolution to Cry1F protein by S. frugiperda is high in Brazil. / O evento de milho TC1507 com gene cry1F da bactéria Bacillus thuringiensis Berliner foi aprovado comercialmente no Brasil em 2008. A evolução da resistência de pragas a plantas Bt tem sido uma grande preocupação na preservação desta tecnologia. Portanto, neste estudo foi avaliado o risco de evolução da resistência à proteína Cry1F em populações de Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae) das principais regiões de cultivo de milho no Brasil. A linha-básica de suscetibilidade à proteina Cry1F foi determinada em bioensaio de aplicação superfícial na dieta para a população suscetível de referência e quatro populações de campo de S. frugiperda. Posteriormente, a suscetibilidade a Cry1F foi monitorada em 43 populações de S. frugiperda coletadas em nove Estados do Brasil nas safras agrícolas de 2010/2011, 2011/2012 e 2012/2013. A variação na suscetibilidade foi de apenas quatro vezes para Cry1F entre as populações de campo na linha-básica de suscetibilidade. A concentração diagnóstica de 2.000 ng cm-2 de proteína Cry1F foi definida para o monitoramento da suscetibilidade. A sobrevivência em 2.000 ng cm-2 de proteína Cry1F aumentou significativamente no decorrer das safras em populações de São Paulo, Santa Catarina, Rio Grande do Sul, Bahia, Mato Grosso, Goiás, Mato Grosso do Sul e Paraná, mas não em Minas Gerais. Além disso, uma população de S. frugiperda foi coletada em milho TC1507 com falha de controle na Bahia em outubro de 2011. Esta população foi selecionada no laboratório com a proteína Cry1F até 20.000 ng cm-2, obtendo-se uma população resistente (BA25R) com razão de resistência >5000 vezes. Esta população resistente foi capaz de sobreviver no milho TC1507 desde larva neonata até a fase de pupa e com emergência de adultos normais. O padrão de herança da resistência de S. frugiperda a Cry1F foi autossômica. Para testar a dominância funcional, as larvas neonatas do cruzamento entre a população resistente e suscetível foram testadas em folhas do evento TC1507 e cerca de 8% dos heterozigotos foram capazes de sobreviver, completar o desenvolvimento e produzir adultos normais, enquanto as larvas da linhagem suscetível não sobreviveram por mais de cinco dias após a infestação. A dominância foi estimada em 0,15 ± 0,09; portanto, a resistência à proteína Cry1F no milho TC1507 foi incompletamente recessiva. A resistência foi selecionada para outras sete populações de seis Estados brasileiros para testar se os alelos de resistência estavam no mesmo locus. As larvas F1 obtidas do cruzamento entre a população resistente (BA25R) e cada uma das sete populações selecionadas sobreviveram na concentração de 2,000 ng cm-2 de proteína Cry1F e, portanto, essas populações compartilharam o mesmo locus de resistência à proteína Cry1F. A freqüência do alelo resistente à proteína Cry1F foi estimada em populações de S. frugiperda coletadas em cinco Estados na safra 2011/2012. Foram estabelecidas 517 isolinhas utilizando o método de \"F2 screen\". A freqüência total do alelo de resistência à proteína Cry1F no Brasil foi de 0,088, com intervalo de confiança de 95% entre 0,077 e 0,100. Com base nos resultados, o risco de evolução da resistência à proteína Cry1F por S. frugiperda é elevada no Brasil.