Affinity-based proteomics offers opportunities for the discovery and validation of disease-associated proteins in human body fluids. This thesis describes the use of antibody-based immunoassays for multiplexed analysis of proteins in human plasma, serum and cerebrospinal fluid (CSF). This high-throughput method was applied with the objective to identify proteins associated to clinical variables. The main work in this thesis was conducted within the diseases of multiple sclerosis and malignant melanoma, as well as mammographic density, a risk factor for breast cancer. The suspension bead array (SBA) technology has been the main method for the work presented in this thesis (Paper I-IV). SBA assays and other affinity proteomic technologies were introduced for protein profiling of sample material obtained from clinical collaborators and biobanks. Perspectives on the validation of antibody selectivity by means of e.g. immuno-capture mass spectrometry are also provided. Paper I describes the development and application of a protocol for multiplexed pro- tein profiling of CSF. The analysis of 340 CSF samples from patients with multiple sclerosis and other neurological disease revealed proteins with potential association to disease progression (GAP43) and inflammation (SERPINA3). Paper II continued on this work with an extended investigation of more than 1,000 clinical samples and included both plasma and CSF collected from the same patients. Comparison of disease subtypes and controls revealed five plasma proteins of potential diagnostic relevance, such as IRF8 and GAP43. The previously reported associations for GAP43 and SERPINA3 in CSF was confirmed. Subsequent immunohistochemical analysis of post-mortem brain tissue revealed differential protein expression in disease affected areas. In Paper III, 150 serum samples from patients with cutaneous malignant melanoma were analyzed. Protein profiles from antibody bead arrays suggested three proteins (RGN, MTHFD1L, STX7) of differential abundance between patients with no disease recurrence and low tumor thickness (T-stage 1 and 2) compared to patients with high tumor thickness (T-stage 3 and 4) and disease recurrence. We observed MTHFD1L expression in tissue of a majority of patients, while expression of STX7 in melanoma tissue had been reported previously. Paper IV describes the analysis of protein in plasma in relation to mammographic breast density (MD), one of the strongest risk factors for the development of breast cancers. More than 1,300 women without prior history of breast cancer were screened. Linear associations to MD in two independent sample sets were found for 11 proteins, which are expressed in the breast and involved in tissue homeostasis, DNA repair, cancer development and/or progression in MD. In conclusion, this thesis describes the use of multiplexed antibody bead arrays for protein profiling of serum, plasma and CSF, and it shortlists disease associated proteins for further validation studies. / <p>QC 20170302</p>

INTRODUÇÃO: O primeiro passo na presença de derrame pleural maligno é a aspiração terapêutica do líquido para alívio dos sintomas e avaliar indicação de pleurodese. Infelizmente, em seres humanos a re-aeração e re- ventilação pulmonar após a retirada de líquido pleural foi avaliada apenas indiretamente. A tomografia de impedância elétrica (TIE) é uma técnica precisa que já foi extensivamente validada para quantificar aeração e ventilação pulmonar em tempo real e à beira-leito. O conhecimento das alterações em aeração e ventilação pulmonar após a retirada do líquido pleural é essencial para a compreensão da evolução clínica, objetivando novos esquemas de pleurodese e novos indicadores de reexpansão pulmonar. OBJETIVOS: Avaliar a aeração, ventilação e sincronia ventilatória antes e durante a primeira hora após a aspiração de um derrame pleural maligno. Objetivos secundários: correlacionar a re-aeração com variáveis que pudessem influenciá-la. Métodos: Critérios de inclusão: derrame pleural unilateral com necessidade de aspiração terapêutica e superior a 500 mL. Os sinais e imagens da TIE foram adquiridos em seis períodos diferentes: antes da aspiração pleural, imediatamente, 15, 30, 45 e 60 minutos após a aspiração. A re-aeração foi avaliada pela variação no valor da impedância (Z) ao final de uma expiração relaxada, enquanto a re-ventilação foi avaliada através da variação da impedância no volume corrente. Também medimos a sincronia entre os pulmões usando o ângulo de fase. Finalmente, correlacionamos à re-aeração final com o volume retirado, ângulo de fase inicial e elastância pleural. O pulmão afetado pelo derrame foi nomeado como ipsilateral e o não afetado como contralateral. RESULTADOS: Foram incluídos 22 pacientes. O volume médio aspirado foi 1438 ml. No pulmão ipsilateral, a média no final da expiração valor Z aumentou para 173,5 ± 122,3, imediatamente após a aspiração pleural (p <0,001), e a análise individual revelou que todos os pacientes ganharam re-aeracão pulmonar imediatamente, sem mais re-aerações após. O mesmo comportamento, mas com uma menor magnitude foi encontrado no pulmão contralateral. Na avaliação da re-ventilação, os pulmões ipsilateral e contralateral mostraram resultados heterogêneos, alguns aumentaram a ventilação, outros diminuíram ou mantiveram-na inalterada. Antes da aspiração pleural, a média do ângulo de fase foi de 93 ± 71 graus e diminuiu para 20 ± 30 graus, imediatamente após a aspiração pleural (p <0,001), sem outras alterações após. A re-aeração final correlacionou-se apenas com o volume de derrame aspirado (R2 = 0,49, p <0,01). CONCLUSÃO: Após a aspiração de derrame pleural unilateral neoplásico em pulmões não encarcerados, a re-aeração pulmonar ocorre imediatamente nos pulmões ipisilateral e contralateral, sem mais re-aeração durante a hora seguinte. As mudanças na re-ventilação mostram altas variações individuais. Há uma assincronia ventilatória entre os pulmões, que é imediatamente revertida pela aspiração pleural. A única variável correlacionada com a re-aeração do pulmão afetado é o volume de derrame drenado / INTRODUCTION: The first procedure in the management of a malignant pleural effusion is a therapeutic pleural aspiration to relieve symptoms and assess pleurodesis indication. Unfortunately, in humans the pulmonary re- aeration and re-ventilation after a pleural aspiration was evaluated only indirectly. Electrical impedance tomography (EIT) is an accurate, non- invasive and bedside method that has been extensively validated to quantify lung ventilation and aeration. The knowledge of changes in lung aeration and ventilation after a therapeutic pleural aspiration is essential to understand the clinical course, to propose new lung reexpansion predictors and pleurodesis schemas. OBJECTIVE: To measure the lung re-aeration, re-ventilation and ventilatory synchrony before and over the first hour after a therapeutic pleural aspiration for a malignant pleural effusion. As secondary objectives we correlate the lung re-aeration with variables that could influence them. METHODS: The inclusion criteria were the need of a therapeutic pleural aspiration of a unilateral effusion over 500 mL. EIT signals and images were acquired in six different periods: before the pleural aspiration, immediately and 15, 30, 45 and 60 minutes after the aspiration. The re-aeration was evaluated through the change in the end-expiratory lung impedance (Z), while the re-ventilation was evaluated through the change in tidal impedance. We also measure the ventilator synchrony between lungs using the phase angle. Finally we correlated the final re-aeration with the effusion volume drained, pleural elastances and baseline phase angle. The lung affected by the effusion was nominated as ipsilateral and the non-affected as contralateral. RESULTS: We included 22 patients. The mean volume of aspirated effusion was 1438 ml. In the ipsilateral lung, the mean end- expiratory Z value increased to 173.5 ± 122.3 immediately after the pleural aspiration (p < 0.001) and the individual analysis revealed that all patients re- aerated the lung immediately without further re-aeration thereafter. The same behavior but with a lower magnitude was found in the contralateral lung. The ipsilateral and contralateral lung re-ventilation showed heterogeneous results with patients increasing the ventilation, while others decreased or kept the ventilation unchanged. Before the pleural aspiration, the mean phase angle was 93 ± 71 degrees and decreased to 20 ± 30 degrees immediately after the pleural aspiration (p < 0.001), without further changes thereafter. The final re-aeration only correlated to the volume of effusion aspirated (R2 = 0.49; p < 0.01). CONCLUSION: In untrapped lungs, a pleural aspiration of a unilateral malignant pleural effusion causes an immediate re-aeration of the lung affected by the effusion and even of the contralateral lung, without further re-aeration over the next hour. The changes in ventilations show high individual variations. There is a ventilatory asynchrony between lungs that is immediately reversed by the aspiration. The only variable correlated to re- aeration of the affected lung is the effusion volume drained

Das Multiple Myelom (MM) ist eine hämatologische Erkrankung, welche sich durch eine Akkumulation von malignen Plasmazellen im Knochenmark auszeichnet und eine gestörte Hämatopoiese und Osteolyse zur Folge hat. Komplexe molekulare Interaktionen zwischen MM-Zellen und der Mikroumgebung/Nische im Knochenmark (bone marrow microenvironment, BMM) führen zu einer Aktivierung von verschiedenen Wachstums-, Überlebens- und anti-apoptotischen Signalwegen, die zur Entstehung bzw. Wirkstoffresistenz von MM-Zellen beitragen. IL-6R/STAT3, Ras/MAPK und PI3K/Akt sind die drei wichtigsten Signalwege, die mit dem Wachstum und der Entwicklung des MM assoziiert sind. Auf der anderen Seite sind Myelomzellen insensitiv gegenüber einer Blockade des IL6R/STAT3-Signalweges bzw. des Ras/MAPK-Signalwegs in der Gegenwart von Knochenmarksstromazellen (bone marrow stroma cells, BMSCs), was die Entbehrlichkeit dieser beiden Signalwege unter Ko-Kultur-Bedingungen nahelegt. Interessanterweise aber induziert die gleichzeitige Unterbrechung der IL6R/STAT3 und Ras/MAPK Signalwege Apoptose in MM-Zellen. Ziel der Arbeit war die Identifizierung und Analyse von Zielgenen, die von beiden Signalwegen und nicht durch einen Signalweg alleine reguliert werden. Genexpressionsanalysen zeigten eine deutliche Herunterregulierung der Proteine Hsp90alpha und Hsp90beta nach einer gleichzeitigen Inhibition der IL6R/STAT3 und Ras/MAPK Signalwege. In Hinblick auf die zentrale Rolle von Hsp90 in der Tumorbiologie fokussiert sich die vorliegende Arbeit auf die Erforschung der Rolle von Hsp90 im Multiplen Myelom. Die siRNA-vermittelte Herunterregulation der Proteinexpression von Hsp90-Proteinen zeigte, daß das Ausschalten von HsP90alpha alleine nur zu einer moderaten Apoptoseinduktion in INA-6- und MM.1s-Zellen führte. Die gleichzeitige Herunterregulation von HsP90beta hingegen führte zu einer Verstärkung dieses Effektes und deutet darauf hin, daß beide Proteine miteinander kooperieren. Die pharmakologische Inhibition der Hsp90-Funktion mittels eines neuen Hsp90-Inhibitors (17-DMAG) führte zu einer Verringerung von phospho-ERK1/2, zur Degradation von STAT3 und zu einem verminderten Überleben von MM-Zellen. Die pro-apoptotischen Effekte der gestörten Hsp90-Funktion konnten weder durch BMSCs und Osteoklasten noch durch ECs (??) abgeschwächt werden, obwohl für ECs beschrieben wurde, daß sie zum Wachstum und Überleben von MM-Zellen beitragen können. Diese Beobachtungen deuten auf einen positiven Rückkopplungskreislauf zwischen HsP90alpha/beta und den wichtigsten Signalwegen hin, welcher das Überleben von MM-Zellen gewährleistet. Desweiteren zeigten immunhistologische Analysen, daß Hsp90-Proteine im Vergleich zu MGUS (??) bzw. normalen Plasmazellen in MM-Plasmazellen hochreguliert sind. Zusammengefasst zeigen die Ergebnisse der vorliegenden Arbeit die essentielle Rolle von Hsp90-Proteinen für die Überlebensfähigkeit von MM-Zellen. Ein neuer Mechanismus der Hsp90-Regulation durch das Zusammenwirken der Signalwege IL6R/STAT3 und Ras/MAPK in MM-Zellen konnte gezeigt werden. Darüber hinaus deuten die Ergebnisse darauf hin, daß ein positiver Rückkopplungskreislauf zwischen Hsp90-Proteinen und den wichtigsten Signalwegen existiert, welcher zum Wachstum und zur Entwicklung von MM-Zellen beiträgt. Die Inhibition der Hsp90-Funktion durch den pharmakologischen Inhibitor 17-DMAG führte zum Absterben von MM-Zellen und der pro-apoptotische Effekt der Hsp90-Depletion konnte nicht durch unterstützende BMM-Zellen aufgehoben werden. Diese Beobachtungen untermauern die multifunktionelle Rolle von Hsp90 in der MM-Biologie und zeigen die Wichtigkeit der Entwicklung neuer therapeutischer Wirkstoffe zur Inhibition der Hsp90-Funktion bei der Behandlung des MM. / Multiple myeloma (MM) is a haematological malignancy characterised by the accumulation of malignant plasma cells in the bone marrow leading to impaired haematopoiesis and osteolytic bone destruction. Intricate molecular interactions between MM cells and the BMM activate a diverse set of growth, survival and anti-apoptotic signaling cascades that mediate tumor progression and drug resistance. IL-6R/STAT3, Ras/MAPK and PI3K/Akt are the three major signal transduction pathways that are associated with MM growth and progression. However, myeloma cells have shown independence from IL-6R/STAT3 blockade or insensitivity towards Ras/MAPK pathway inhibition in the presence of BMSCs, indicating the dispensability of both in co-culture conditions. Interestingly, concomitant disruption of both IL-6R/STAT3 and Ras/MAPK pathways was successful to drive MM cells into significant apoptosis. This study aimed to identify and analyse the downstream target genes that are regulated by both pathways and not by either pathway alone. Gene expression profiling revealed prominent downregulation of Hsp90alpha and Hsp90beta proteins after combined inhibition of the IL-6R/STAT3 and Ras/MAPK pathways. Owing to the important role played by Hsp90 in cancer biology, this study was narrowed down to investigate the role of Hsp90 in MM. Specific siRNA-mediated knockdown of Hsp90 proteins showed that although knockdown of Hsp90beta was sufficient to induce moderate apoptosis in INA-6 and MM.1s cells, the effect was more pronounced when both Hsp90 proteins were targeted, indicating co-operation between them. Pharmacological inhibition of Hsp90 function by using a novel Hsp90 inhibitor (17-DMAG) down-regulated the levels of pERK1/2 and led to degradation of STAT3 and decreased viability of MM cells. The pro-apoptotic effects of compromised Hsp90 function could not be alleviated by either BMSCs, OCs or ECs, which are well-known to support myeloma growth and survival. These observations point to the existence of a positive feedback loop consisting of Hsp90alpha/beta and major signaling pathways supporting MM cell survival. Furthermore, immunohistochemical analysis unveiled the up-regulated status of Hsp90 proteins in MM PCs as compared to MGUS or normal PCs. Taken together, the results of this study explain the critical contribution of Hsp90 proteins to MM cell survival. A novel mechanism of Hsp90 regulation by co-operation between the IL-6R/STAT3 and Ras/MAPK pathways was discovered in myeloma cells. There is also strong evidence of the existence of a positive feedback loop between Hsp90alpha/beta proteins and major signaling pathways supporting MM growth and progression. Inhibition of Hsp90 function by using the Hsp90 inhibitory drug 17-DMAG proved to be lethal for myeloma cells and the pro-apoptotic effects of Hsp90 blockade could not be reversed by the presence of cells from the supportive BMM. These observations highlight a multi-functional role of Hsp90 in MM biology and strongly strengthen the notion that therapeutic strategies targeting Hsp90 may open new perspectives for anti-myeloma drug development.

Apoptoseresistenzmechanismen spielen bei der Pathogenese maligner Lymphome eine zentrale Rolle. So konnte bei Hodgkin/Reed-Sternbergzellen eine Deregulation des Transkriptionsfaktors NF-_B beobachtet werden, die zu verstärkter Apotoseresistenz führt und so zum malignen Wachstum dieser Zellen wahrscheinlich entscheidend beiträgt. Es konnte gezeigt werden, dass die selektive Blockade von NF-_B sowohl zu erhöhter Apoptosesensitivität als auch zur Inhibition der Zellzyklusprogression in kultivierten Hodgkinzellen führt. Der genaue molekulare Mechanismus der NF-_B-Deregulation in Hodgkinzellen ist jedoch noch unklar. Apoptoseresistenzmechanismen sind nicht nur bei der Pathogenese maligner Lymphome, sondern auch bei der Entstehung von Therapieresistenz von Bedeutung. So konnte gezeigt werden, dass die Überexpression proapoptotischer Gene der bcl-2 Familie in resistenten malignen Zellen sowohl die Empfindlichkeit gegenüber Zytostatika als auch gegenüber Antikörperbehandlung wiederherstellen kann. Neben der bcl-2 Familie spielt wahrscheinlich auch das Apo-I/Fas-System eine wichtige Rolle bei der Entstehung von Zytostatikaresistenz und immunologischer Resistenz. Somit stellt neben der Überexpression des P-Glykoproteins (MDR1), das als transmembranes "Pumpenprotein" Zytostatika aus der Tumorzelle heraustransportieren kann, die Deregulation Apoptose-steuernder Gene einen weiteren wichtigen Therapie-Resistenzmechanismus dar. Eine Möglichkeit, intrazelluläre Resistenzmechanismen zu umgehen, stellt die indirekte Induktion von Zelltod mit Hilfe bispezifische Antikörper dar. Durch diese Moleküle kann eine T-Zell-vermittelte Zellyse von Lymphomzellen erreicht werden. / Resistance towards apoptosis plays an important role in the pathogenesis of malignant lymphomas. It could be demonstrated that deregulation of the transcription factor NF-kB is a common molecular defect of Hodgkin/Reed-Sternberg cells that leads to enhanced resistance towards apoptosis and therefore probabaly contributes to the malignant growth of these cells. It couldbe shown that blocking of NF-kB leads to increased sensitivity towards apoptosis and decreased cell cycle progression. The precise molecular mechanism that leads deregulation of NF-kB is still unknown. Besides its role in the pathogenesis of malignant lymphoma resistance towards apoptosis plays an important role in the development of drug resistance. It could be shown that overexpression of pro-apoptotic members of the bcl-2 family in resistant tumor cells can restore sensitivity towards both cytotoxic drugs as well as antibody treatment. In addition to the bcl-2 family the Apo-I/Fas system is also involved in the development of drug resistance. Thus, besides overexpression of p-glycoprotein (MDR-1) that might pump cytotoxic drugs out of a malignant cell deregulation of apoptosis regulating genes is another important mechanisms of drug resistance development. One possibility to overcome drug resistance is the induction of cell death via bispecific antibodies. These molecules can induce T cell mediated lysis of lymohoma cells.

Die vorliegende Arbeit ist eine retrospektive Kohortenstudie, welche alle Patienten einschloß, die im Zeitraum von 07/1988 bis 06/1997 aufgrund eines anaplastischen Astrozytoms oder eines Glioblastoma multiforme im damaligen Rudolf-Virchow-Klinikum in Berlin eine Strahlentherapie des Kopfes erhielten. Von den 111 Patienten erlitten im Beobachtungszeitraum 85 ein radiologisches Rezidiv. Die mediane Überlebenszeit betrug 9 Monate. 69 der Rezidive waren Zentralrezidive, 7 Randrezidive und 9 Fernrezidive. Auch die Rand- und Fernrezidive rezidivierten zusätzlich am Ort der Primärläsion. Es konnte gezeigt werden dass ein Sicherheitsabstand von 2-3 cm ausreicht um 90% der Rezidive vollständig zu erfassen und dass die lokale Kontrolle weiterhin das Hauptproblem bei der Behandlung dieser malignen Gliome ist. / This retrospective study reviews the data of 111 patients treated from 07/1988 to 06/1997 at the Rudolf-Virchow-Klinikum in Berlin. Both patients with anaplastic astrocytoma and glioblastoma multiforme were included. 85 patients showed radiological recurrence of tumour. Median survival was 9 months. 69 recurrences were central, 7 near and 9 distant recurrences. Near and distant recurrences were always multifocal, i. e. they recurred also at central locations. It was shown that a safety margin of 2-3 cm is sufficient to completely cover 90% of recurrent tumour. Local failure is still the primary difficulty in treating these malignant glioma.

INTRODUÇÃO: O câncer de pulmão é a principal causa de morte por câncer em todo o mundo e muitos pacientes apresentam derrame pleural em um estágio avançado da doença, com alta morbidade e mortalidade. Entretanto, a patogênese do derrame maligno é ainda pouco compreendida e as opções terapêuticas são limitadas. OBJETIVO: 1) Estudar a fisiopatologia do derrame pleural maligno em modelo animal com células de Lewis em diferentes concentrações; 2) Avaliar os efeitos da terapia intrapleural com anti-VEGF e anti-EGFR e a frequência de mutações de EGFR e KRAS neste modelo. MÉTODOS: Foi utilizado modelo de neoplasia pleural com camundongos C57BL/6 e células de Lewis (LLC) dividido em duas etapas: estudo com diferentes concentrações de células LLC (0,1, 0,5 e 1,5x105) e avaliação de terapias-alvo. Após a padronização do modelo, quatro grupos de camundongos receberam tratamento intrapleural com anti-VEGF, anti-EGFR, anti-VEGF+anti-EGFR ou solução fisiológica (não tratados) 3, 7, 10 e 14 dias após a indução da neoplasia pleural com 0,5x105 células LLC. Em vinte animais de cada grupo foi avaliada a curva de sobrevida. 160 animais foram submetidos à eutanásia 7, 10, 14 ou 21 dias após e avaliados peso, mobilidade, volume de líquido pleural, marcadores inflamatórios, imunológicos e bioquímicos no líquido, presença de tumores e alterações histológicas em pleura, pulmão, rim, fígado e baço. Através de imunohistoquimica avaliou-se apoptose, proliferação tumoral, VEGF e EGFR. Analisou-se a expressão gênica do EGFR, VEGF, KRAS e ALK e a frequência de mutações do EGFR e KRAS. Análise estatística: One Way ANOVA, Kaplan-Meier, p < 0,05. RESULTADOS: Na etapa de padronização do modelo observamos que a concentração que manteve os parâmetros de neoplasia pleural com maior sobrevida foi de 0,5x105 células LLC. Na segunda etapa do estudo, a carcinomatose pleural foi letal com sobrevida máxima de 25 dias, sem diferença entre os grupos. Redução de peso foi observada em todos os grupos após 21 dias. A mobilidade foi melhor nos grupos que receberam anti-EGFR. O volume de líquido pleural foi maior no grupo não tratado durante todo o estudo. Parâmetros imunológicos e bioquímicos aumentaram temporalmente sendo mais evidentes no grupo sem tratamento. Implantes tumorais na pleura foram mais evidentes no grupo não tratado após 14 dias. A inflamação pulmonar foi mínima em todos os grupos. No grupo não tratado observou-se implantes tumorais no pericárdio e músculo cardíaco após 21 dias, esteatose hepática e renal após 14 dias e hiperplasia de polpa branca do baço no 21º dia. Altos índices de apoptose e menores índices de proliferação tumoral foram observados nos grupos que receberam tratamento com anti-EGFR e anti-VEGF+anti-EGFR. Houve mutação do gene KRAS e superexpressão gênica tumoral do EGFR e do KRAS. CONCLUSÃO: As terapias-alvo reduziram significativamente o derrame pleural, morbidade e parâmetros histológicos, embora sem impacto na sobrevida dos animais neste modelo experimental. Nossos dados indicam que a linhagem tumoral LLC possui um fenótipo tumoral agressivo demonstrado através da mutação do KRAS e superexpressão do EGFR, o que pode estar associado ao pior prognóstico e menor resposta aos inibidores do EGFR / INTRODUCTION: Lung cancer is the leading cause of death by cancer in the world. Many patients have pleural effusion in an advanced stage of the disease, with high morbidity and mortality. However, the pathogenesis of malignant pleural effusion is still poorly understood and the treatment options are limited. OBJECTIVE: 1) To study the pathophysiology of malignant pleural effusion in animal model with Lewis cells in different concentrations; 2) Evaluate the effects of the intrapleural therapy with anti-VEGF and anti-EGFR and the frequency of EGFR and KRAS mutations in this model. METHODS: We used pleural neoplasm experimental model with mice C57BL/6 and Lewis cells (LLC) divided into two steps: study with different concentrations of LLC cells (0.1, 0.5 and 1.5x105) and evaluation of targeted therapies. After the standardization of the model, four groups of mice received intrapleural treatment with anti-VEGF, anti-EGFR, anti-VEGF+anti-EGFR or saline (untreated) 3, 7, 10 and 14 days after induction of pleural neoplasm with injection of 0.5x105 LLC cells. In 20 animals of each group was evaluated the survival curve. 160 animals underwent euthanasia 7, 10, 14 or 21 days after and assessed weight, mobility, volume of pleural fluid, inflammatory, immunological and biochemical markers in the liquid, presence of tumor and histological changes in pleura, lung, kidney, liver and spleen. It was evaluated, through immunohistochemistry, tumor apoptosis and proliferation, VEGF and EGFR. Gene expression of EGFR, VEGF, KRAS and ALK and frequency of mutations of EGFR and KRAS were also evaluated. Statistical analysis: One Way ANOVA, Kaplan-Meier, p < 0.05. RESULTS: In the standardization of the model we observed that the concentration that kept parameters of pleural neoplasm with higher survival rate was 0.5x105 LLC cells. In the second stage, target-therapies, pleural carcinomatosis was lethal with maximum survival of 25 days, with no difference between the groups. Weight decrease was observed in all groups after 21 days. Mobility was better in groups that receiving anti-EGFR. Pleural fluid volume was greater in the untreated group throughout the study. Immunological and biochemical parameters have increased temporarily being most evident in the untreated group. Tumor implants in pleura were more apparent in the untreated group after 14 days. The lung inflammation was minimal in all groups. The untreated group showed tumor implants in the pericardium and heart muscle after 21 days, hepatic and renal steatosis after 14 days and spleen white pulp hyperplasia in 21 day. High rates of apoptosis and smaller tumor proliferation indices were observed in groups that received treatment with anti-VEGF and anti-EGFR+anti-EGFR. We also found gene KRAS mutation and tumoral gene overexpression of EGFR and KRAS. CONCLUSION: Targeted therapies reduced significantly the pleural effusion, morbidity and histological parameters, although without an impact on survival rate in this experimental model. Our data indicate that the tumor lineage LLC has an aggressive tumor phenotype shown by KRAS mutation and overexpression of EGFR, which can be associated with a worse prognosis and a lower response to EGFR inhibitors

A leucoplasia verrucosa proliferativa (LVP) é classificada como um subtipo da leucoplasia oral (LO), de rara incidência e alto potencial de malignização. Acomete com maior frequência pacientes do gênero feminino, acima da sétima década de vida e apresenta altos índices de recorrência após a realização de qualquer modalidade de tratamento. Seu aspecto clínico inicial é caracterizado pela presença de lesão branca, homogênea, aparentemente inócua, que desenvolve áreas eritematosas, superfície verrucosa, comportamento agressivo e envolvimento multifocal com o passar do tempo. A evolução clínica é geralmente lenta, levando anos para que ocorra transformação maligna. Existem divergências na literatura quanto aos critérios utilizados em seu diagnóstico. Alguns autores preconizam aqueles descritos em seu primeiro relato em 1985, que exigiam o acompanhamento das lesões desde sua fase inicial até o desenvolvimento de áreas verrucosas enquanto outros acreditam que o aguardo de fases avançadas apenas atrasa o diagnóstico e a instituição de tratamentos, aumentando as chances de malignização e piora do prognóstico dos pacientes. O objetivo desse estudo foi avaliar as características clínicas e demográficas dos indivíduos diagnosticados com LVP e compará-las a de pacientes diagnosticados com LO. Também foi realizada uma revisão e discussão dos critérios diagnósticos encontrados na literatura. Em nosso estudo analisamos retrospectivamente prontuários de pacientes diagnosticados na Disciplina de Estomatologia da FOUSP. Foram encontrados 9 pacientes diagnosticados com LVP, no período de 2007 a 2011, e 29 com LO, entre 1997 e 2011. Observamos que a LVP apresentou maior incidência em pacientes do gênero feminino, sem hábitos de tabagismo ou etilismo, com idade média de 73 anos. Já dentre os indivíduos com LO não encontramos diferença entre o envolvimento dos gêneros feminino e masculino, a idade média foi 57 anos e a maioria era tabagista ou etilista. O tempo médio de evolução da LVP foi de 5,4 anos enquanto da LO foi de 19,6 meses. Clinicamente, nenhum dos pacientes com LVP apresentou lesão homogênea inicial, sendo que todas eram multifocais, de comportamento agressivo e disseminado, com aspecto que variava desde placas brancas lisas até as nãohomogêneas, de superfície verrucosa, papilífera, com áreas eritematosas. Os pacientes com LO apresentavam lesões uni e multifocais localizadas, sendo que a maioria possuía placas brancas, de aspecto homogêneo. O grupo da LVP demonstrou taxas mais altas de recidiva em comparação as LO. A exigência de se acompanhar a lesão desde sua fase inicial e desconsiderar aquelas que apresentam aspecto multifocal na primeira consulta pode levar ao diagnóstico errôneo de uma verdadeira LVP, assim como aguardar o desenvolvimento de áreas verrucosas pode causar atraso considerável no diagnóstico, levando a tratamentos tardios e piorando o prognóstico do paciente. Sugerimos que dentre os critérios de diagnóstico da LVP devam ser considerados a presença de lesões brancas multifocais, lesões de comportamento agressivo, longo período de evolução, recorrência após qualquer forma de tratamento e não necessariamente apresentem aspecto verrucoso no momento do diagnóstico. / The proliferative verrucous leukoplakia (PVL) is a rare entity and was classified as a subtype of oral leukoplakia (OL). It affects more commonly elderly females and tends to recur after any type of treatment. Initially, it presents inconspicuous white lesions that progress to non-homogenous areas and develop verrucous surface, aggressive behavior and multifocal involvement over time. The lesions show a high tendency to transform into squamous cell carcinomas, usually taking years or decades to develop malignancy. There are controversies in the literature regarding the diagnostic criteria for PVL. Some authors follow those proposed on the first PVL report in 1985 which claimed continued follow-up since initial stages until the development of verrucous areas. Others believe that waiting for later stages postpone the diagnosis, worsening the patient´s prognosis. The objective of this study was to evaluate clinical and demographic aspects of patients with PVL and to compare them to patients diagnosed with OL. The diagnostic criteria reported on the literature were also revised. A retrospective study was performed and we analyzed patient´s records of Stomatology Department at FOUSP. Nine files of patients with PVL, diagnosed between 2007 and 2011 and 29 files of individuals with OL between 1997 and 2011 were studied. PVL showed higher incidence among women with no smoking or drinking habits with an average age of 73 years old while OL affected smoking and drinking patients, with a median age of 57 years old, with no gender predilection. PLV lesions progressed over a 5.4-year period while OL lesions took 19.3 months. Clinically, none of the PVL patients presented unifocal homogenous white lesion at the time of diagnosis. All of them showed aggressive and multifocal lesions, varying from homogenous to non homogenous aspect with verrucous surface and erythematous areas. OL individuals showed uni or multifocal white lesions with more restricted behavior. PVL group presented higher recurrence rate when compared to OL group. It is believed that not taking into account patients with multifocal lesions on the first visit can misdiagnose real PVL cases and waiting for the development of verrucous areas postpones the diagnosis and worsens the prognosis. It is suggested that PVL diagnostic criteria should include the presence of multifocal white lesions with aggressive behavior, long-term evolution, recurrences after any type of treatment and excludes the obligation of verrucous aspect on the time of diagnosis.

INTRODUÇÃO: O primeiro passo na presença de derrame pleural maligno é a aspiração terapêutica do líquido para alívio dos sintomas e avaliar indicação de pleurodese. Infelizmente, em seres humanos a re-aeração e re- ventilação pulmonar após a retirada de líquido pleural foi avaliada apenas indiretamente. A tomografia de impedância elétrica (TIE) é uma técnica precisa que já foi extensivamente validada para quantificar aeração e ventilação pulmonar em tempo real e à beira-leito. O conhecimento das alterações em aeração e ventilação pulmonar após a retirada do líquido pleural é essencial para a compreensão da evolução clínica, objetivando novos esquemas de pleurodese e novos indicadores de reexpansão pulmonar. OBJETIVOS: Avaliar a aeração, ventilação e sincronia ventilatória antes e durante a primeira hora após a aspiração de um derrame pleural maligno. Objetivos secundários: correlacionar a re-aeração com variáveis que pudessem influenciá-la. Métodos: Critérios de inclusão: derrame pleural unilateral com necessidade de aspiração terapêutica e superior a 500 mL. Os sinais e imagens da TIE foram adquiridos em seis períodos diferentes: antes da aspiração pleural, imediatamente, 15, 30, 45 e 60 minutos após a aspiração. A re-aeração foi avaliada pela variação no valor da impedância (Z) ao final de uma expiração relaxada, enquanto a re-ventilação foi avaliada através da variação da impedância no volume corrente. Também medimos a sincronia entre os pulmões usando o ângulo de fase. Finalmente, correlacionamos à re-aeração final com o volume retirado, ângulo de fase inicial e elastância pleural. O pulmão afetado pelo derrame foi nomeado como ipsilateral e o não afetado como contralateral. RESULTADOS: Foram incluídos 22 pacientes. O volume médio aspirado foi 1438 ml. No pulmão ipsilateral, a média no final da expiração valor Z aumentou para 173,5 ± 122,3, imediatamente após a aspiração pleural (p <0,001), e a análise individual revelou que todos os pacientes ganharam re-aeracão pulmonar imediatamente, sem mais re-aerações após. O mesmo comportamento, mas com uma menor magnitude foi encontrado no pulmão contralateral. Na avaliação da re-ventilação, os pulmões ipsilateral e contralateral mostraram resultados heterogêneos, alguns aumentaram a ventilação, outros diminuíram ou mantiveram-na inalterada. Antes da aspiração pleural, a média do ângulo de fase foi de 93 ± 71 graus e diminuiu para 20 ± 30 graus, imediatamente após a aspiração pleural (p <0,001), sem outras alterações após. A re-aeração final correlacionou-se apenas com o volume de derrame aspirado (R2 = 0,49, p <0,01). CONCLUSÃO: Após a aspiração de derrame pleural unilateral neoplásico em pulmões não encarcerados, a re-aeração pulmonar ocorre imediatamente nos pulmões ipisilateral e contralateral, sem mais re-aeração durante a hora seguinte. As mudanças na re-ventilação mostram altas variações individuais. Há uma assincronia ventilatória entre os pulmões, que é imediatamente revertida pela aspiração pleural. A única variável correlacionada com a re-aeração do pulmão afetado é o volume de derrame drenado / INTRODUCTION: The first procedure in the management of a malignant pleural effusion is a therapeutic pleural aspiration to relieve symptoms and assess pleurodesis indication. Unfortunately, in humans the pulmonary re- aeration and re-ventilation after a pleural aspiration was evaluated only indirectly. Electrical impedance tomography (EIT) is an accurate, non- invasive and bedside method that has been extensively validated to quantify lung ventilation and aeration. The knowledge of changes in lung aeration and ventilation after a therapeutic pleural aspiration is essential to understand the clinical course, to propose new lung reexpansion predictors and pleurodesis schemas. OBJECTIVE: To measure the lung re-aeration, re-ventilation and ventilatory synchrony before and over the first hour after a therapeutic pleural aspiration for a malignant pleural effusion. As secondary objectives we correlate the lung re-aeration with variables that could influence them. METHODS: The inclusion criteria were the need of a therapeutic pleural aspiration of a unilateral effusion over 500 mL. EIT signals and images were acquired in six different periods: before the pleural aspiration, immediately and 15, 30, 45 and 60 minutes after the aspiration. The re-aeration was evaluated through the change in the end-expiratory lung impedance (Z), while the re-ventilation was evaluated through the change in tidal impedance. We also measure the ventilator synchrony between lungs using the phase angle. Finally we correlated the final re-aeration with the effusion volume drained, pleural elastances and baseline phase angle. The lung affected by the effusion was nominated as ipsilateral and the non-affected as contralateral. RESULTS: We included 22 patients. The mean volume of aspirated effusion was 1438 ml. In the ipsilateral lung, the mean end- expiratory Z value increased to 173.5 ± 122.3 immediately after the pleural aspiration (p < 0.001) and the individual analysis revealed that all patients re- aerated the lung immediately without further re-aeration thereafter. The same behavior but with a lower magnitude was found in the contralateral lung. The ipsilateral and contralateral lung re-ventilation showed heterogeneous results with patients increasing the ventilation, while others decreased or kept the ventilation unchanged. Before the pleural aspiration, the mean phase angle was 93 ± 71 degrees and decreased to 20 ± 30 degrees immediately after the pleural aspiration (p < 0.001), without further changes thereafter. The final re-aeration only correlated to the volume of effusion aspirated (R2 = 0.49; p < 0.01). CONCLUSION: In untrapped lungs, a pleural aspiration of a unilateral malignant pleural effusion causes an immediate re-aeration of the lung affected by the effusion and even of the contralateral lung, without further re-aeration over the next hour. The changes in ventilations show high individual variations. There is a ventilatory asynchrony between lungs that is immediately reversed by the aspiration. The only variable correlated to re- aeration of the affected lung is the effusion volume drained

Le canal cationique TRPV1 (Transient Receptor Potential Vanilloid 1) est activé par la capsaïcine, une acidose, de fortes températures ainsi que par les anesthésiques volatils (AV) dans les neurones sensoriels. Dans le muscle squelettique, TRPV1 est impliqué dans le métabolisme énergétique et l'exercice d'endurance. Grâce à des techniques d'immunomarquage et d'imagerie calcique, la première partie de la thèse vise à caractériser TRPV1 en tant que canal de fuite fonctionnel du réticulum sarcoplasmique (RS) dans les cellules musculaires squelettiques isolées de FDB (Flexor Digitorum Brevis) de souris. Par la suite, nous nous sommes intéressés à son rôle physiopathologique dans le muscle strié squelettique. Ainsi, dans une seconde partie nous supposons une implication de TRPV1 dans les crises d'hyperthermie maligne (HM) chez l'homme. Cette pathologie musculaire correspond à une crise de métabolisme exacerbé du muscle strié squelettique menant à une brusque montée en température chez le patient (>42°C) endormi au moyen d'AV. Dans cette deuxième étude nous démontrons, à travers une approche combinant imagerie calcique et outils pharmacologiques spécifiques du canal, que TRPV1 est activé lors de l'exposition des cellules musculaires à l'isoflurane. TRPV1 est donc une cible des AV dans la cellule musculaire. Puis, des variants de TRPV1 (T612M et N394del) de patients susceptibles à l'HM ont été découvertes. Nous avons pu montrer, suite à la transfection in vivo de ces variants dans des souris déficientes en TRPV1 et grâce à la mesure de flux calciques intracellulaires, que les variants humains de TRPV1 rendent ces canaux plus sensibles aux anesthésiques volatils que le canal TRPV1 humain sauvage. La troisième partie de la thèse a pour but de déterminer le rôle de TRPV1 dans le muscle squelettique en conditions physiologiques par des études fonctionnelles (fonction locomotrice, consommation d'oxygène) sur animal entier. Les résultats préliminaires de cette étude tendent à montrer que l'entraînement physique est moins efficace sur la fonction musculaire des souris déficientes en TRPV1. En conclusion, l'ensemble de ces résultats révèlent pour la première fois que TRPV1 est un canal calcique de fuite fonctionnel du RS pouvant faire le lien entre le déclenchement de l'HM au cours des anesthésies et la présence des RyR1 mutés dans le muscle squelettique / TRPV1 (Transient Receptor Potential Vanilloid 1) cation channel is activated by capsaicine, acidosis, high temperature and by volatile anaesthetics (VA) in sensory neurons. In skeletal muscle, TRPV1 appears to be implied in exercice endurance and energy metabolism. The present work aims first to characterize the functionality of this channel using immnostaining and calcium imaging. We report that TRPV1 is functionally expressed in isolated mouse skeletal muscle cells of FDB (Flexor Digitorum Brevis). These experiments point out that TRPV1 acts as a SR calcium leak channel. In contrast to earlier reports, our analysis shows that TRPV1 is only located to the sarcoplasmic reticulum (SR) membrane. Subsequently, we have studied its physiological role in skeletal muscle. Thus, in a second part, we suppose that TRPV1 could be involved in malignant hyperthermia (MH) crisis in human. MH is a muscular pathology linked to an abrupt increase in body temperature (> 42°C) in patients. MH crisis is a severe and feared complication of anesthesia. Nevertheless, any studies have demonstrated that RyR1 mutants are activated by VA. If the triggering agents of MH are known, their targets remain to be determined. By combining calcium imaging and pharmacological agents, our data first demonstrate that TRPV1 is activated by isoflurane in skeletal muscle cells. TRPV1 is so a target of volatile anaesthetics in skeletal muscle. Afterwards, TRPV1 mutants (T612M and N394del), obtained from susceptibles MH patients, were discovered. In the second part of the work, using in vivo transfection of TRPV1 mutants in TRPV1-/- mice and intracellular calcium measurements we have been able to demonstrate that human TRPV1 mutants are more sensitive to VA than human wild type TRPV1. The last part of the work investigates the physiological role of TRPV1 in skeletal muscle, using a functional exploration (locomotor function, oxygen consumption) in TRPV1-/- mice. Preliminary data point out that training seems to be less effective on skeletal muscle function of TRPV1-/- mice. To conclude, these results indicate for the first time that TRPV1 is a functional SR calcium leak channel and that TRPV1 may be the missing link between MH induction and RyR1 mutants in skeletal muscle during anesthesia

Introdução: O tratamento para o derrame pleural maligno recidivado tem caráter paliativo, sendo a pleurodese o método mais utilizado. Contudo, nem todos os procedimentos são efetivos, em parte por um encarceramento do pulmão pela pleura visceral espessada que impede o contato entre os folhetos pleurais e subsequente pleurodese efetiva. A elastância pleural reflete o grau de encarceramento da pleura visceral, contudo sua correlação com a efetividade da pleurodese não é bem conhecido. Objetivo: Analisar a correlação entre a elastância pleural e a efetividade radiológica (quantificada por tomografia de tórax) da pleurodese realizada através de cateteres pleurais. Os objetivos secundários deste estudo são: correlacionar a elastância pleural com a qualidade de vida, graus de dispneia e dor após o procedimento, efetividade clínica, complicações e mortalidade. Correlacionar a posição da extremidade do cateter pleural com o sucesso radiológico e clínico da pleurodese. Métodos: Estudo prospectivo com 131 pacientes candidatos a pleurodese por instilação de nitrato de prata ou talco mineral por cateter pleural. As pressões pleurais foram aferidas através de manômetro hidrostático ou de transdutor eletrônico de pressão vascular durante o esvaziamento do líquido e usadas para calcular a elastância pleural, em cm H2O/L. A efetividade radiológica foi avaliada pelos volumes pleurais medidos por tomografias computadorizadas de tórax logo após a drenagem e 30 dias após a pleurodese. A efetividade clínica foi avaliada conforme a necessidade de procedimentos adicionais para controle de sintomas. A qualidade de vida foi avaliada através do questionário geral da OMS. A avaliação da dor foi feita pela quantificação na Escala Visual Analógica de Dor. A análise da dispneia foi realizada através da quantificação da funcionalidade na escala de dispneia do British Medical Research Council. Todos esses questionários foram aplicados antes da drenagem, 30 dias após pleurodese e, então, trimestralmente. Para a análise da segurança dos procedimentos foram considerados os tempos de internação e de drenagem e a ocorrência de complicações. Todos os pacientes foram seguidos até o óbito ou até o término do estudo, em novembro de 2014, registrando as complicações e as datas do óbito para a construção da curva de sobrevida. Resultados: Avaliamos 87 pacientes de um total de 131 recrutados. Não houve diferença entre os volumes pleurais nas duas tomografias realizadas. A efetividade clínica foi observada em 86,20% dos pacientes. Não houve diferença em nenhum dos domínios da qualidade de vida. Encontramos diferenças entre a dispneia e a dor aferidas 30 dias após a pleurodese e antes da drenagem. Complicações ocorreram em 14,94% dos casos. A mediana da sobrevida global foi de 16 meses. Não foram encontradas correlações entre as elastâncias pleurais em 400 ml, 800 ml e total com nenhum dos desfechos radiológicos, clínicos (efetividade clínica, qualidade de vida, dispneia, dor e complicações) ou com a sobrevida dos pacientes. A posição da ponta do cateter pleural não se correlacionou com o sucesso radiológico ou clínico da pleurodese. Conclusões: A elastância pleural não se mostrou, até o presente momento, capaz de predizer os defechos radiológicos, clínicos e a sobrevida em pacientes submetidos a pleurodese / Background: The treatment of recurrent malignant pleural effusion has a palliative purpose. Pleurodesis is the most used method. However, not all the procedures are effective, in part because of the lung entrapment by the visceral pleura, preventing the contact between the pleural surfaces and subsequente effective pleurodesis. The pleural elastance reflects the degree of entrapment of the visceral pleura, but its correlation with the effectiveness of pleurodesis is not well known. Objetive: To evaluate the correlation between pleural elastance and radiological effectiveness (measured by tomography) of bedside pleurodesis. The secondary objectives of this study are: correlating the pleural elastance with quality of life, degree of dyspnea and pain after the procedure, clinical effectiveness, complications and mortality. Evaluate the role of intrapleural position of the pleural catheter in early lung expansion and success of pleurodesis. Methods: Prospective study including 131 patients with recurrent malignant pleural effusion candidates for treatment with bedside pleurodesis with silver nitrate or mineral talc. Pleural pressures were measured through hydrostatic gauge or electronic pressure transducer during emptying of effusion and used to calculate the pleural elastance in cm H2O/L. Pleural volumes measured by CT scans of the chest after drainage and 30 days after pleurodesis were assess the radiological effectiveness. The clinical effectiveness was evaluated as the need for additional procedures to control symptoms. The quality of life was assessed using the WHO general questionnaire. Quantifying the Visual Analog Scale of Pain did pain assessment. Measuring the functionality in the British Medical Research Council dyspnea scale made the analysis of dyspnea. All these questionnaires were applied prior to drainage, 30 days after pleurodesis and then quarterly. Results: We evaluated 87 patients of a total of 131 recruited. There was no difference between the two pleural volumes CT scans performed. The clinical effectiveness was observed in 86.20% of patients. There was no difference in any of the domains of quality of life. We found differences between dyspnea and pain measured 30 days after pleurodesis and before draining. Complications occurred in 14.94% of cases. The median overall survival was 16 months. No correlations between pleural elastance in 400 ml, 800 ml and complete were found with all the imaging, clinical (clinical effectiveness, quality of life, dyspnea, pain and complications) or with patient survival outcomes. The tip of the pleural catheter was not correlated with the radiological or clinical success of pleurodesis. Conclusions: The pleural elastance was not, so far, able to predict the radiological outcomes, clinical outcomes and survival in patients undergoing bedside pleurodesis