L’objet de cette thèse est de réaliser une analyse économique du champ de l’aide informelle des personnes adultes jeunes vivant à domicile et atteintes de maladie neurologique grave. La question de recherche posée concerne l’articulation entre l’organisation de l’aide informelle et la cinétique de la pathologie neurologique. La méthodologie repose sur la construction de quatre modèles neuro-pathologiques et économiques d’une part, et sur la constitution de quatre cohortes représentatives, comportant chacune une centaine de binômes « aidant-aidés » d’autre part. Ainsi, les modèles de la pathologie brutale avec handicap résiduel stabilisé, de la pathologie progressive avec handicap croissant, de la pathologie à cinétique déficitaire rapide, de la pathologie dégénérative héréditaire sont-ils respectivement illustrés par le traumatisme crânien, la sclérose en plaques, la tumeur cérébrale et la maladie de Huntington. Nos travaux (1) mettent en évidence les caractéristiques sur le plan économique des aidants informels (conjoints jeunes) qui sont fortement impliqués dans la production du soin, experts d’un accompagnement complexe et déstabilisés dans leur trajectoire professionnelle (2) font la démonstration de la prédétermination forte de la cinétique de la pathologie neurologique sur les comportements d’aide informelle à travers différents indicateurs temporels dont la prise en compte s’avère incontournable pour l’analyse économique (3) montrent la nécessité d’avoir recours à une mesure bidimensionnelle (subjective et objective) dans l’analyse du fardeau des aidants informels. Une telle mesure souligne d’une part l’insuffisance du recours à l’aide professionnelle publique et d’autre part l’impact sur les aidants des troubles cognitivo-comportementaux (handicap invisible) et de la phase neuro-palliative à domicile d’une pathologie neurologique grave. Ces résultats ouvrent des perspectives pour la mise en place de mesures d’action publiques en France dans le champ complexe du handicap neurologique. / The purpose of this thesis is to achieve an economic analysis of informal caregiving of young adults living at home and suffering from a severe neurological disease. The research questions the relationship between the organization of informal care and kinetics of neurological pathology. The methodology is based on the construction of four neuro-pathological and economic models on the one hand, and on the constitution of four representative cohorts, each with a hundred pairs of "patients-caregivers" on the other. Thus, models of brutal disease stabilized with residual disability, progressive disease with increasing disability, fast kinetics disease and neuro-degenerative hereditary disease are respectively illustrated by traumatic brain injury, multiple sclerosis, malignant brain tumor and Huntington's Disease. Our work (1) highlights the economic characteristics of informal caregivers (young spouses) who are highly involved in the production of care, expert of complex care and therapeutic pathways and destabilized in their professional careers (2) demonstrates that the kinetics of neurological disease predicts the economic behavior of informal caregivers : taking account of different time indicators is crucial for economic analysis in neurodisability (3) shows that a two-dimensional subjective and objective outcome measure is necessary in the analysis of the burden of informal caregivers. Such a double indicator first stresses the inadequate use of publicly funded professional care ; it also points out the impact of cognitive-behavioral disorders (so-called “invisible disability”) and of the home neuro-palliative phase on caregivers in case of a severe neurological disease. These results open perspectives for the development of public action measures in France in the complex field of neurological disability.

Descreve-se os achados epidemiológicos e clínico-patológicos das clostridioses diagnosticadas no Setor de Patologia Veterinaria da Universidade Federal do Rio Grande do Sul no período 1996-março/2010. Este estudo incluiu uma pesquisa retrospectiva nos arquivos do SPV e uma etapa prospectiva, a qual também teve o objetivo de desenvolver exames complementares específicos para cada clostridiose. As clostridioses mais prevalentes foram tétano (em equinos, bovinos, ovinos e caprinos), botulismo (em bovinos, suínos e aves) e enterotoxemia (em caprinos). Também houve casos de edema maligno em equinos, bem como de carbúnculo sintomático e hemoglobinúria em bovinos. Adicionalmente, foram coletadas amostras de soro sanguíneo de animais afetados por tétano, em diferentes estágios de evolução da doença, para subsequente inoculação em camundongos (testes de bioensaio) e comprovação da técnica no diagnóstico da enfermidade. / This study describes the epidemiological and clinicopathological findings of clostridial diseases diagnosed in the 1996-March, 2010 period in the Setor de Patologia Veterinária da Universidade Federal do Rio Grande do Sul (SPV_UFRGS). A retrospective survey in the files of SPV was complemented with a prospective phase, which also aimed developing complementary diagnostic tests of clostridiosis. The most prevalent clostridiosis were tetanus (in horses, cattle, sheep and goats), botulism (in cattle, pigs and birds), and enterotoxemia in goats. There also were cases of malignant edema in horses, blackleg and bacillary hemoglobinuria in cattle. In addition, blood serum samples from animals affected by tetanus on different stages of the disease evolution were applied in mice bioassay, as a complementary diagnosing test for the disease.

Base teórica: O Acidente Vascular Cerebral (AVC) é a causa mais comum de novos diagnósticos de epilepsia no idoso. Embora a epilepsia pós-AVC seja um fenômeno clínico reconhecido há muito tempo, seguem muitas questões não resolvidas. Além disso, nas últimas duas décadas, o tratamento do AVC isquêmico sofreu mudanças radicais com a introdução da trombólise e da hemicraniectomia descompressiva (HD) para o tratamento do infarto maligno de artéria cerebral média (ACM). As consequências destas duas novas abordagens terapêuticas nas características da epilepsia pós-AVC ainda são pouco exploradas. Objetivo: Estudar as características e estimar fatores de risco para as crises epilépticas ou a epilepsia pós-AVC em pacientes submetidos ao tratamento agudo (Estudo 1) ou HD para infarto maligno de ACM (Estudo 2). Métodos: O estudo 1 é uma coorte de 153 pacientes submetidos a trombólise. Variáveis estudadas incluiram fatores de risco para o AVC e variáveis associadas ao AVC isquêmico agudo e trombólise. Utilizamos a análise de regressão de Cox para o estudo das variáveis que se associaram de forma independente com crises epilépticas, epilepsia pós-AVC e o desfecho do AVC. O estudo 2 é também uma coorte que retrospectivamente avaliou 36 pacientes com infarto maligno de ACM tratados com HD. Tempo, incidência e fatores de risco para crises epilépticas e desenvolvimento de epilepsia foram analisados. Resultados: Estudo 1: 74 pacientes (48,4%) eram mulheres; média de idade foi 67,2 anos (DP=13,1). Média do NIHSS na chegada foi 10,95 (DP=6,25) e 2,09 (DP=3,55) após 3 meses. Transformação hemorrágica ocorreu em 22 (14,4%) dos pacientes. Foi considerado desfecho bom classificação na escala modificada de Rankin (mRS) 0-1, sendo encontrado em 87 (56,9%) dos pacientes. Vinte e um pacientes (13,7%) tiveram crises epilépticas e 15 (9,8%) desenvolveram epilepsia após a trombólise. Crises epilépticas foram associadas de forma independente com transformação hemorrágica e desfecho não favorável (mRS ≥ 2) em três meses após o AVC. Transformação hemorrágica e mRS ≥ 2 avaliados em 3 meses, associaram-se de forma independente com epilepsia pós-AVC. Crises epilépticas surgiram como um fator de risco independente para desfecho pobre. Estudo 2. A média de seguimento dos pacientes foi de 1.086 (DP= 1.172) dias. Nove pacientes morreram antes de receberem alta hospitalar e no período de um ano, 11 pacientes haviam morrido. Quase 60% alcançaram mRS ≤ 4. Treze pacientes desenvolveram crises dentro da primeira semana após o AVC. No total, crises epilépticas ocorreram em 22 (61%) dos 36 pacientes. Dezenove pacientes (56%) dos 34, sobreviveram ao período agudo e desenvolveram epilepsia após infarto da ACM e HD. Questionamos aos pacientes ou responsáveis se eles se arrependeram de terem autorizado a HD no momento do AVC. Também foi perguntado se eles autorizariam a HD novamente. Trinta e dois (89%) não se arrependeram de ter autorizado a HD no momento do infarto agudo da ACM, e autorizaria novamente em retrospecto. Conclusão: Confirmamos que as frequências de crises ou epilepsia pós-AVC e trombolítico são comparáveis com as frequências das décadas da era pré-trombólise e confirmamos a alta incidência de crises epilépticas e epilepsia após infartos malignos de ACM submetidos a HD. Em nosso estudo, as crises epilépticas associaram-se de forma independente com pior prognóstico após terapia trombolítica. / Background: The most common cause of newly diagnosed epilepsies in the elderly is stroke. Although post-stroke epilepsy is a well-studied stroke complication, many questions remain unsolved. In addition, during the past two decades, the treatment of stroke has changed dramatically with the introduction of thrombolysis for treatment of acute ischemic stroke (AIS) and decompressive hemicraniectomy (DHC) for malignant middle cerebral artery infarction (MCA). The consequences of these two new therapeutic approaches for characteristics of post-stroke epilepsy remains poorly explored. Objective: To study characteristics and estimate risk factors for acute seizures or post-stroke epilepsy in patients submitted to thrombolysis for treatment of acute stroke (Study 1) or DHC for malignant MCA infarction. Methods: Study 1 is a cohort study of 153 patients submitted to thrombolysis. Variables studied included risk factors for stroke, and variables related to acute stroke and thrombolysis. Variables independently associated with seizures, pos-stroke epilepsy or stroke outcome were defined using Cox regression analysis. Study 2 is also a cohort study that retrospectively assessed 36 patients with malignant stroke of the MCA submitted to DHC. Timing, incidence and plausible risk factors for seizure and epilepsy development were analyzed in these patients. Results: Study 1. Seventy-four patients (48.4%) were female; mean age of patients was 67.2 years-old (SD=13.1). Initial NIHSS mean score was 10.95 (SD=6.25) and 2.09 (SD=3.55) after three months. Hemorrhagic transformation occurred in 22 (14.4%) patients. A good outcome, as defined by a modified Rankin Scale (mRS) of 0-1, was observed in 87 (56.9%) patients. Twenty one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation and with mRS ≥ 2 three months after stroke. Hemorrhagic transformation and unfavorable outcome, as measured by mRS ≥ 2 after three months, were variables independently associated with post-stroke epilepsy. Seizures emerged as an independent factor for poor outcome in stroke thrombolysis. Study 2. Mean patient follow-up time was of 1.086 (SD=1.172) days. Nine patients died before being discharged and after one year eleven patients died. Almost 60% had the modified Rankin score ≤ 4. Thirteen patients developed seizures within the first week after stroke. In total, seizures occurred in 22 (61%) of 36 patients. Nineteen patients (56%) out of 34 patients who survived the acute period developed epilepsy after MCA infarcts and DHC. Also, we asked patients or the person responsible for them whether they regretted, in retrospect, having authorized DHC at the time of the stroke. It was also asked whether they would authorize DHC again. Thirty- two (89%) did not regret having authorized DHC at the time of acute MCA infarct, and would authorize DHC again in retrospect. Conclusion: We confirm that seizures or post-stroke epilepsy rates after thrombolysis are comparable with rates from pre-thrombolysis decades and a high incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC. In our study, seizures were an independent risk factor associated with worst outcome after thrombolysis therapy.

A hipertensão essencial tem alta prevalência mundial, bem como, causas genéticas e ambientais. Na busca de correlações genéticas para a hipertensão, foi descrito um potencial papel do DARC (Duffy Antigen Receptor of Chemokines) como receptor de Interleucina-8 em endotélio e que essa interação poderia contribuir para a patogênese da pré-eclampsia. O DARC está expresso em vários tecidos além da linhagem eritróide, em especial nas células endoteliais. A glicoproteína DARC carreia determinantes antigênicos e também é receptora para Plasmodium vivax, tendo relevância biológica significante. Esse estudo teve como objetivo estudar a freqüência fenotípica e genotípica do Sistema de Grupo Sangüíneo Duffy comparando pacientes com hipertensão maligna com doadores de sangue normotensos. Foram estudadas 43 amostras de sangue de pacientes com diagnóstico de hipertensão maligna da Unidade de Hipertensão do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. O grupo controle foi constituído por 100 amostras de doadores de sangue da Fundação Pró-Sangue/Hemocentro de São Paulo. Em todas as amostras foi realizada a fenotipagem Duffy, a genotipagem DUFFY e a dosagem de IL-8 sérica. A fenotipagem foi realizada pela técnica em tubo. Na genotipagem DUFFY, foram estudadas as mutações 125G>A, 265C>T, 29 G>A e -33T>C pela técnica de PCR-RFLP. Na análise da freqüência alélica encontramos que o alelo FYB-33 foi o mais observado no grupo de pacientes com hipertensão maligna com diferença estatisticamente significante (p= 0,0191). Conseguimos demonstrar uma correlação entre níveis elevados de IL-8 em pacientes com hipertensão maligna e genótipo FYB- 33/FYB-33 (p=0,003). Também observamos níveis elevados de IL-8 nos pacientes com hipertensão maligna quando comparados com o grupo controle (doadores de sangue), p<0,001. Esses resultados indicam que a IL-8 tem papel potencial na fisiopatologia da hipertensão maligna por apresentar um efeito regulatório inibitório em pacientes Duffy negativo. / Essential hypertension has a high prevalence worldwide and the has genetic and environment causes. Searching genetics correlation for hypertension, a potential role of DARC (Duffy Antigen Receptor of Chemokines) was described as an Interleukine-8 receptor in endothelium and that this interaction might contribute for the pathogenesis of pre-eclampsia. DARC is expressed in many tissues beyond the erythrocyte lineage, in special endothelium cells. DARC glycoprotein carries antigens determinants and is also Plasmodium vivax receptor, with a significantly biological relevance. This study had as objective to verify the phenotypic and genetic frequencies of the Duffy Blood Group System in patients with malignant hypertension and, to compare them with norm tension blood donors. Forty three patients from the Hypertension Service of the InCor of Clinical Hospital of School of Medicine of the University of São Paulo and 100 blood donors from Fundação Pró-Sangue/Hemocentro de São Paulo were studied. Duffy phenotyping and genotyping and IL-8 serum dosage was performed in all samples. Phenotyping tests were performed by tube technique. We studied the 125 G>A, 265 C>T, 298 G>A and -33 T>C mutations by PCR RFLP genotyping. The FYB-33 allele was the most observed in the malignant hypertension patients group with p= 0.0191. We have shown a correlation in high between high levels of IL-8 in patients with malignant hypertension and FYB-33/FYB-33 genotype (p=0,003). We observed also high levels of IL-8 in patients with malignant hypertension when the control group (blood donors) was compared, p<0.001. This results indicate that IL-8 has a potential role in malignant hypertension physiopathology due to an regulatory inhibitory effect in Duffy negative patients.

Base teórica: O Acidente Vascular Cerebral (AVC) é a causa mais comum de novos diagnósticos de epilepsia no idoso. Embora a epilepsia pós-AVC seja um fenômeno clínico reconhecido há muito tempo, seguem muitas questões não resolvidas. Além disso, nas últimas duas décadas, o tratamento do AVC isquêmico sofreu mudanças radicais com a introdução da trombólise e da hemicraniectomia descompressiva (HD) para o tratamento do infarto maligno de artéria cerebral média (ACM). As consequências destas duas novas abordagens terapêuticas nas características da epilepsia pós-AVC ainda são pouco exploradas. Objetivo: Estudar as características e estimar fatores de risco para as crises epilépticas ou a epilepsia pós-AVC em pacientes submetidos ao tratamento agudo (Estudo 1) ou HD para infarto maligno de ACM (Estudo 2). Métodos: O estudo 1 é uma coorte de 153 pacientes submetidos a trombólise. Variáveis estudadas incluiram fatores de risco para o AVC e variáveis associadas ao AVC isquêmico agudo e trombólise. Utilizamos a análise de regressão de Cox para o estudo das variáveis que se associaram de forma independente com crises epilépticas, epilepsia pós-AVC e o desfecho do AVC. O estudo 2 é também uma coorte que retrospectivamente avaliou 36 pacientes com infarto maligno de ACM tratados com HD. Tempo, incidência e fatores de risco para crises epilépticas e desenvolvimento de epilepsia foram analisados. Resultados: Estudo 1: 74 pacientes (48,4%) eram mulheres; média de idade foi 67,2 anos (DP=13,1). Média do NIHSS na chegada foi 10,95 (DP=6,25) e 2,09 (DP=3,55) após 3 meses. Transformação hemorrágica ocorreu em 22 (14,4%) dos pacientes. Foi considerado desfecho bom classificação na escala modificada de Rankin (mRS) 0-1, sendo encontrado em 87 (56,9%) dos pacientes. Vinte e um pacientes (13,7%) tiveram crises epilépticas e 15 (9,8%) desenvolveram epilepsia após a trombólise. Crises epilépticas foram associadas de forma independente com transformação hemorrágica e desfecho não favorável (mRS ≥ 2) em três meses após o AVC. Transformação hemorrágica e mRS ≥ 2 avaliados em 3 meses, associaram-se de forma independente com epilepsia pós-AVC. Crises epilépticas surgiram como um fator de risco independente para desfecho pobre. Estudo 2. A média de seguimento dos pacientes foi de 1.086 (DP= 1.172) dias. Nove pacientes morreram antes de receberem alta hospitalar e no período de um ano, 11 pacientes haviam morrido. Quase 60% alcançaram mRS ≤ 4. Treze pacientes desenvolveram crises dentro da primeira semana após o AVC. No total, crises epilépticas ocorreram em 22 (61%) dos 36 pacientes. Dezenove pacientes (56%) dos 34, sobreviveram ao período agudo e desenvolveram epilepsia após infarto da ACM e HD. Questionamos aos pacientes ou responsáveis se eles se arrependeram de terem autorizado a HD no momento do AVC. Também foi perguntado se eles autorizariam a HD novamente. Trinta e dois (89%) não se arrependeram de ter autorizado a HD no momento do infarto agudo da ACM, e autorizaria novamente em retrospecto. Conclusão: Confirmamos que as frequências de crises ou epilepsia pós-AVC e trombolítico são comparáveis com as frequências das décadas da era pré-trombólise e confirmamos a alta incidência de crises epilépticas e epilepsia após infartos malignos de ACM submetidos a HD. Em nosso estudo, as crises epilépticas associaram-se de forma independente com pior prognóstico após terapia trombolítica. / Background: The most common cause of newly diagnosed epilepsies in the elderly is stroke. Although post-stroke epilepsy is a well-studied stroke complication, many questions remain unsolved. In addition, during the past two decades, the treatment of stroke has changed dramatically with the introduction of thrombolysis for treatment of acute ischemic stroke (AIS) and decompressive hemicraniectomy (DHC) for malignant middle cerebral artery infarction (MCA). The consequences of these two new therapeutic approaches for characteristics of post-stroke epilepsy remains poorly explored. Objective: To study characteristics and estimate risk factors for acute seizures or post-stroke epilepsy in patients submitted to thrombolysis for treatment of acute stroke (Study 1) or DHC for malignant MCA infarction. Methods: Study 1 is a cohort study of 153 patients submitted to thrombolysis. Variables studied included risk factors for stroke, and variables related to acute stroke and thrombolysis. Variables independently associated with seizures, pos-stroke epilepsy or stroke outcome were defined using Cox regression analysis. Study 2 is also a cohort study that retrospectively assessed 36 patients with malignant stroke of the MCA submitted to DHC. Timing, incidence and plausible risk factors for seizure and epilepsy development were analyzed in these patients. Results: Study 1. Seventy-four patients (48.4%) were female; mean age of patients was 67.2 years-old (SD=13.1). Initial NIHSS mean score was 10.95 (SD=6.25) and 2.09 (SD=3.55) after three months. Hemorrhagic transformation occurred in 22 (14.4%) patients. A good outcome, as defined by a modified Rankin Scale (mRS) of 0-1, was observed in 87 (56.9%) patients. Twenty one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation and with mRS ≥ 2 three months after stroke. Hemorrhagic transformation and unfavorable outcome, as measured by mRS ≥ 2 after three months, were variables independently associated with post-stroke epilepsy. Seizures emerged as an independent factor for poor outcome in stroke thrombolysis. Study 2. Mean patient follow-up time was of 1.086 (SD=1.172) days. Nine patients died before being discharged and after one year eleven patients died. Almost 60% had the modified Rankin score ≤ 4. Thirteen patients developed seizures within the first week after stroke. In total, seizures occurred in 22 (61%) of 36 patients. Nineteen patients (56%) out of 34 patients who survived the acute period developed epilepsy after MCA infarcts and DHC. Also, we asked patients or the person responsible for them whether they regretted, in retrospect, having authorized DHC at the time of the stroke. It was also asked whether they would authorize DHC again. Thirty- two (89%) did not regret having authorized DHC at the time of acute MCA infarct, and would authorize DHC again in retrospect. Conclusion: We confirm that seizures or post-stroke epilepsy rates after thrombolysis are comparable with rates from pre-thrombolysis decades and a high incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC. In our study, seizures were an independent risk factor associated with worst outcome after thrombolysis therapy.

Orientador: Albina Messias de Almeida Milani Altemani / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T19:08:01Z (GMT). No. of bitstreams: 1 Freitas_LeandroLuizLopesde_D.pdf: 4064664 bytes, checksum: d04222e584211904229193f280c217a9 (MD5) Previous issue date: 2006 / Resumo: O adenoma pleomórfico (AP) é a neoplasia mais freqüente das glândulas salivares e o carcinoma ex-adenoma pleomórfico (CXAP) é a sua forma de transformação maligna mais comum. Os trabalhos da literatura com séries exclusivas de CXAP são poucos e englobam, em sua maioria, carcinomas já em estádios avançados. Raros são os estudos realizados exclusivamente com tumores que apresentam os dois componentes (benigno e maligno) e em fases iniciais de malignização. Alterações nos genes p53 e c-erbB-2 parecem ser as principais vias envolvidas nesta transformação. Estas proteínas, além do marcador de proliferação celular Ki-67, podem ser importantes critérios no diagnóstico do CXAP, especialmente em sua fase precoce. O objetivo deste trabalho foi avaliar retrospectivamente a expressão imunoistoquímica de marcadores celulares (p53, c-erbB-2, Ki-67 e bcl-2, uma proteína antiapoptótica) em CXAP em diferentes fases de malignização (4 intracapsulares, 4 minimamente invasivos e 7 francamente invasivos), nas áreas benignas e malignas e em AP que não sofreram malignização (17 casos - grupo controle). A parótida foi a glândula mais acometida em ambos os grupos (CXAP 53%, grupo controle 88%), envolvendo mais mulheres que homens. A idade média dos pacientes com CXAP em qualquer fase evolutiva (63,3 anos) foi maior que no grupo controle (35,6 anos). A proteína p53 foi mais expressa nas áreas malignas (em média 35,71% nos CXAP precoces e 8,11% nos CXAP francamente invasivos, versus 12,76% e 4,58% nas áreas benignas, respectivamente) e principalmente em células luminais, enquanto os menores valores foram encontrados no grupo controle (1,71%). Fato semelhante ocorreu com o índice mitótico e a expressão de Ki-67. A expressão de c-erbB-2 foi observada quase que exclusivamente em células malignas com diferenciação luminal. A proteína bcl-2 teve positividade fraca e focal. Concluímos que as proteínas p53 e c-erbB-2 parecem estar envolvidas na transformação maligna do AP, já em fases precoces, sendo critérios mais objetivos do que a simples avaliação morfológica para o diagnóstico dos CXAP intracapsulares / Abstract: Pleomorphic adenoma (PA) is the commonest salivary gland tumor, and carcinoma ex pleomorphic adenoma (CXPA) is its most frequent malignant counterpart. There are few studies centering on CXPA only and most have been performed in frankly invasive carcinomas. Series of CXPA containing both morphological components (adenoma and carcinoma) at an early stage of carcinomatous transformation are extremely rare. p53 and c-erbB-2 appear to be the most important genes involved in this malignant change. These proteins, and the proliferative index marker Ki-67, could be valuable criteria for diagnosis of CXPA, specially at an early stage. The aim of this study was to assess retrospectively the expression of cell markers (p53, c-erbB-2, Ki-67 and bcl-2, an antiapoptotic protein) in CXPA in different phases of malignant progression (4 intracapsular, 4 minimally invasive and 7 frankly invasive), in benign and malignant areas and in PA without malignant transformation (17 cases - control group). The parotid was the most frequently involved gland in both groups (CXPA: 53%, control group: 88%), and women were more affected than men. The average age in the CXPA group (63.3 years) at any stage was higher than in the control group (35.6 years). p53 expression was highest in malignant areas (mean 35.71% in early CXPA and 8.11% in frankly invasive CXPA, versus 12.76% and 4.58% in benign areas, respectively) and mainly in luminal cells, while the lowest values (1.71%) occurred in the control group. Similar findings were obtained with the mitotic index and Ki-67 expression. c-erbB-2 positivity was observed almost exclusively in malignant cells of the luminal type. bcl-2 expression was weak and focal. In conclusion, both p53 and c-erbB-2 proteins appear to be involved in malignization of PA since an early stage, thus providing criteria more objetive than simple morphological evaluation for diagnosis of intracapsular CXPA / Doutorado / Anatomia Patologica / Doutor em Ciências Médicas

Made available in DSpace on 2014-08-20T14:37:54Z (GMT). No. of bitstreams: 1 tese_maria_cecilia_florisbal_dame.pdf: 53923 bytes, checksum: e82c085a8b324064158221bf46a754ba (MD5) Previous issue date: 2013-12-12 / This thesis is a continuation of a research project started with a diagnosis of dermatosis mechano-bullosa in a herd of buffaloes from a farm in southern Rio Grande do Sul. After this diagnostic it was created an experimental herd where several congenital defects and / or hereditary disorders have been diagnosed during more than two decades. These diseases were studied by a research group which the author of this thesis is a member. Thus, three papers are presented: the first one is a literature review about what has been diagnosed in Brazil on congenital defects and hereditary diseases in buffalo. It was concluded that undesirable genes are widespread in the population of buffaloes in the country; the second was a study conducted in partnership with UNESP / Jaboticabal, SP and UFCG / CSTR-Patos, PB to identify the mutation in the gene that determines the oculo-cutaneous albinism in Murrah buffalo. Another paper was accomplished to describe the occurrence of malignant melanoma in two albino buffalo. Although it is not a congenital or hereditary disease it was observed only in the buffalo with oculocutaneous albinism and probably the condition is associated with a predisposition of these animals to develop tumors in the skin. / Esta tese dá continuidade a um projeto de pesquisa iniciado com o diagnóstico de dermatose mecanobolhosa em 1985 em um rebanho de búfalos pertencente a uma propriedade da zona sul do Rio Grande do Sul. A partir desse diagnóstico foi criado um rebanho experimental no qual por mais de duas décadas foram diagnosticados diversos defeitos congênitos e/ou hereditários que foram estudados por um grupo de pesquisa do qual faz parte a autora desta tese. Assim sendo, são apresentados três artigos científicos: o primeiro trata-se de uma revisão bibliográfica sobre o que foi diagnosticado no Brasil em relação a defeitos congênitos/doenças hereditárias em bubalinos concluindo-se que alguns genes indesejáveis estão disseminados na população de búfalos no País; o segundo foi um trabalho realizado em parceria com a UNESP/Jaboticabal, SP e com a UFCG/CSTR-Patos, PB que identificou a alteração no gene que determina o albinismo óculo-cutâneo em búfalos da raça Murrah. O terceiro artigo trata-se da descrição de melanoma maligno observado em dois búfalos albinos. Embora não seja um defeito congênito ou hereditário este neoplasma ocorreu somente nos búfalos com albinismo óculo-cutâneo do rebanho e acredita-se que a condição esteja associada à predisposição desses animais a desenvolverem tumores de pele.

Les adénomes hépatocellulaires (AHC) sont des tumeurs bénignes rares qui se développent le plus souvent chez la femme jeune suite à la prise de contraceptifs oraux. Les complications principales sont l’hémorragie et plus rarement, la transformation maligne en carcinome hépatocellulaire (CHC). Des travaux récents ont permis d’identifier 3 groupes moléculaires principales d’AHC qui se définissent par (1) l’inactivation du facteur de transcription HNF1A (H-HCA), (2) l'activation de la voie Wnt/ß-caténine (bHCA) ou (3) la présence d’infiltrats inflammatoires (IHCA).Afin d’identifier les voies de tumorigenèse associées au développement d’AHC inflammatoires (IHCA), une analyse transcriptomique comparant des IHCA à des foies non tumoraux a été réalisée au laboratoire, ce qui a permis d’identifier dans ce groupe tumoral une activation de la voie IL-6/JAK/STAT3. Nous avons recherché de nouvelles altérations géniques et nous avons caractérisé le mécanisme d'activation de la voie IL-6/JAK/STAT dans les IHCA. Les conséquences fonctionnelles sur la voie STAT3 des différents mutants ont été analysées par une modélisation de leur expression dans des lignées hépatocellulaires. Par ailleurs, nous avons réalisé des études génomiques intégrées (analyse CGH-SNP, méthylome et séquençage exome) sur une large série de 250 AHC avec pour objectif d’affiner la classification moléculaire des AHC, d’identifier de nouveaux gènes altérés dans ces tumeurs et d’élucider les mécanismes de transformation maligne des AHC en CHC.Dans le groupe des IHCA, ces analyses nous ont permis d’identifier de nombreux oncogènes activés par mutation somatique ; de plus, trois de ces gènes n’avaient jamais été décrits comme étant mutés dans des tumeurs humaines. Nous avons identifié des mutations activatrices du récepteur à l’IL-6, gp130 dans 60% des IHCA. Nous avons aussi retrouvé des mutations de FRK, une src-like kinase, dans 10% des IHCA, du facteur de transcription STAT3 dans 5% des IHCA, du gène GNAS dans 5% des cas, et de la tyrosine kinase JAK1 dans 1% des cas. Toutes les mutations identifiées étaient somatiques, monoalléliques et mutuellement exclusives. Nous avons pu montrer, dans des systèmes de lignées cellulaires hépatocellulaires, que l'expression des formes mutées de ces gènes est capable d’activer la voie IL-6/STAT3 en absence du ligand IL-6, contrairement aux protéines sauvages. Nous avons identifié des inhibiteurs pharmacologiques qui permettent d’inhiber de façon spécifique ces mutants et qui pourraient être utilisés en clinique pour le traitement des IHCA.Grâce à une technique de CGH-SNP, nous avons identifié des événements récurrents de pertes et gains de chromosomes associés aux groupes moléculaires d’AHC. De façon similaire, l’étude de la méthylation dans les AHC a permis de mettre en évidence un pattern spécifique à chaque sous groupe. Nous avons montré que l’instabilité chromosomique augmente progressivement dans les lésions borderline et dans les CHC développés sur AHC comparés aux AHC classiques. Le séquençage exome de 5 transformations malignes de AHC en CHC a identifié un nombre plus important de mutations dans les AHC qui ont transformé comparé aux AHC classiques ; ce nombre est significativement augmenté dans la partie CHC des tumeurs. La comparaison de la partie bénigne et maligne des tumeurs a mis en évidence l'activation de ß-caténine comme un évènement précoce dans le processus de transformation et a révélé la présence de mutations somatiques fréquentes dans le promoteur de la télomèrase (TERT), identifiées principalement dans la partie maligne des tumeurs.En conclusion, cette étude a permis d’identifier des mécanismes distincts conduisant à l'activation de STAT3 dans les IHCA, renforçant le rôle de la voie JAK-STAT3 dans la tumorigenèse bénigne hépatocellulaire ainsi que le lien entre Src kinases et inflammation. Ces travaux ont permis d’affiner la classification moléculaire des AHC avec des corrélations étroites... / Hepatocellular adenomas (HCA) are rare benign tumors that develop most often in young women after taking oral contraception. The main complications are hemorrhage and rarely, malignant transformation to hepatocellular carcinoma (HCC). Recent work in the laboratory identified three main HCA molecular groups that are defined by (1) inactivation of the transcription factor HNF1A (H-HCA), (2) activation of the Wnt/ß-catenin pathway (bHCA) or (3) the presence of inflammatory infiltrates (IHCA).To identify tumorigenesis pathways associated with the development of inflammatory HCA (IHCA), a transcriptome analysis comparing IHCA to non-tumor liver was performed in the laboratory, leading to the identification of an activation of the IL-6/JAK/STAT3 pathway in these tumors. We sought new gene alterations and we characterized the activation mechanism of the IL-6/JAK/STAT pathway in IHCA. The functional consequences of the different mutants on the STAT3 pathway were analyzed by modeling their expression in hepatocellular cell lines. In addition, we performed integrated genomic studies (CGH-SNP analysis, methylome and exome sequencing) on a wide range of 250 HCA with the aim to refine the molecular classification of HCA, to identify new genes altered in these tumors and to elucidate the mechanisms of malignant transformation of HCA to HCC.In the group of the IHCA, we identified many oncogenes activated by somatic mutation; in addition, three of these genes were never been described as mutated in human tumors. We identified activating mutations in the IL-6 receptor gp130 in 60% of IHCA. We also found mutations in FRK, a src-like kinase, in 10% of IHCA, of the transcription factor STAT3 in 5% of IHCA, of the GNAS gene in 5% of cases, and of the tyrosine kinase JAK1 in 1% of the cases. All identified mutations were somatic and monoallelic and were mutually exclusive. We have shown in hepatocellular cell lines that the expression of mutated forms of these genes is able to activate the IL-6/STAT3 pathway in the absence of the IL-6 ligand, in contrast to wild-type proteins. We have identified pharmacological inhibitors that specifically inhibit the mutants and that could be used for the clinical treatment of IHCA.Using a CGH-SNP technique, we identified recurrent chromosomes gains and losses associated with the HCA molecular groups. Similarly, the study of methylation in HCA highlighted a specific pattern in each subgroup. We showed that chromosomal instability increases gradually in borderline lesions and in HCC developed on HCA compared to classical HCA. Exome sequencing of 5 malignant transformation of HCA to HCC identified a large number of mutations in the transformed HCA compared to classical HCA; and this number is significantly increased in HCC tumors counterpart. Comparison of benign and malignant tumors highlighted the activation of ß-catenin as an early event in the transformation process and revealed frequent somatic mutations in the promoter of the telomerase gene (TERT), identified mainly in the malignant part of tumors.In conclusion, this study has led to the identification of distinct mechanisms leading to the activation of STAT3 in IHCA, strengthening the role of the JAK-STAT3 pathway in benign hepatocellular tumorigenesis and the relationship between Src kinases and inflammation. This work helped to refine the molecular classification of HCA with tight correlations between genotype and phenotype, and led to advances in the identification of major genetic determinants involved in the process of malignant transformation.

Prostate cancer (PC) is the most common cancer in Sweden. Most patients have slow growing tumors that will not cause them any harm within their lifetime, but some have aggressive tumors and will die from their disease. The ability of current clinical practice to predict tumor behavior and disease outcome is limited leading to both over- and undertreatment of PC patients. The men who die from their disease are those that develop metastases. It is therefore of great value to find better and more sensitive prognostic techniques, so that metastatic spread can be detected (or predicted) at an early time point, and so that appropriate treatment can be offered to each subgroup of patients. The aim of this thesis was to investigate if, and by what means, highly aggressive prostate tumors influence extratumoral tissues such as the non-malignant parts of the prostate and regional lymph nodes (LN), and also if any of our findings could be of prognostic importance. Gene- and protein expression analysis were the main methods used to address these questions. Our research group has previously introduced the expression Tumor Instructed (Indicating) Normal Tissue (TINT), and we use the term TINT-changes when referring to alterations in non-malignant tissue due to the growth of a tumor nearby or elsewhere in the body. In the Dunning rat PC-model we found that MatLyLu (MLL)-tumors, having a high metastatic ability, caused pre-metastatic TINT-changes that differ from those caused by AT1-tumors who have low metastatic ability. Prostate-TINT surrounding MLL-tumors had elevated immune cell infiltration, and gene ontology enrichment analysis suggested that biological functions promoting tumor growth and metastasis were activated in MLL- while inhibited in AT1-prostate-TINT. In the regional LNs we found signs of impaired antigen presentation, and decreased quantity of T cells in the MLL-model. One of the downregulated genes in the MLL-LNs was Siglec1 (also known as Cd169), expressed by LN resident macrophages that are important for antigen presentation. When examining metastasis-free LN tissue from PC patients we found CD169 expression to be a prognostic factor for PC-specific survival, and reduced expression was linked to an increased risk of PC-specific death. Some of our findings in prostate- and LN-TINT could be seen already when the tumors were very small suggesting that differences in TINT-changes between tumors with different metastatic capability can be detected early in tumor progression. However, before coming of use in the clinic more research is needed to better define a suitable panel of prognostic TINT-factors as well as the right time window of when to use them. / Populärvetenskaplig sammanfattning Prostatacancer är den i särklass vanligaste cancerformen hos män i Sverige. De flesta patienter har en mycket långsamt växande tumör som inte orsakar dem några större besvär under deras livstid, men enbart i Sverige dör ca 2500 patienter/år av sjukdomen. Det är först vid uppkomst av metastaser som sjukdomen blir dödlig. Befintliga diagnos- och prognosmetoder är otillräckliga när det gäller att uppskatta och förutse tumörens aggressivitet och risk för att bilda metastaser. Detta gör att vissa patienter inte får tillräcklig behandling eller behandlas försent medan andra behandlas i onödan. Behovet av förbättrad diagnostik är därför stort. Om vi kan hitta markörer för potentiellt metastaserande sjukdom, och i bästa fall också behandla innan metastaser uppstår, skulle det förbättra chansen för överlevnad markant. För att kunna växa och spridas behöver en tumör inte bara förbereda närliggande vävnader utan förmodligen hela kroppen. Vår hypotes är att potentiell dödliga tumörer sannolikt är bättre på detta än mer ofarliga. Man vet från studier av andra cancerformer att farliga tumörer orsakar förändringar i det organ dit cancern senare sprids. Dessa förändringar sker för att de tumörceller som senare anländer ska kunna överleva, och processen har fått namnet pre-metastatisk nisch. Bl.a. har man sett att immunsystemet hämmas och nybildning av kärl ökar. Det är vanligt att metastaser uppstår i närliggande lymfkörtlar innan uppkomst av metastaser i andra organ. Dock är väldigt lite känt om pre-metastatiska förändringar i lymfkörtlar eftersom den forskning som hittills är gjord främst har tittat på andra organ. Inom prostatacancer finns det förvånande få studier av premetastatiska nischer överhuvudtaget, och man vet därför inte om de alls förekommer eller vilka förändringar som i så fall sker. Vår grupp har tidigare myntat uttrycket TINT som står för Tumor Instructed (Indicating) Normal Tissue (TINT är ett engelskt verb som betyder färga) och syftar på förändringar i normal vävnad som inducerats av tumören, dvs. att tumörer färgar av sig på omgivningen. Det kan vara förändringar i normal vävnad nära tumören, som i det här fallet resten av prostatan, eller i vävnad långt ifrån tumören som till exempel regionala lymfkörtlar, lungor och benmärg. Syftet med det här avhandlingsarbetet var att undersöka TINT-förändringar inducerade av aggressiv cancer och se om dessa skiljer sig från TINT-förändringar inducerade av mindre farliga tumörer, samt att utvärdera om någon TINT-förändring skulle kunna användas för att prognostisera vilka patienter som har hög risk att få metastaser. Vi har använt oss av en prostatacancer-modell i råtta där vi analyserat genoch proteinuttryck i pre-metastatiska regionala lymfkörtlar, tumörer och prostata-TINT (dvs. prostatavävnad utanför tumören). TINT-förändringar inducerade av MatLyLu (MLL), en tumör med hög metastaserande förmåga, jämfördes mot TINT-förändringar inducerade av AT1, en snabbväxande tumör men med låg förmåga att bilda metastaser. Vi kunde vi se flera skillnader mellan modellerna. Genuttrycket i MLL-prostata-TINT indikerade en aktivering av cellulära funktioner som visat sig stimulera tumörväxt och spridning såsom celldelning, viabilitet, migration, invasion, och angiogenes (nybildning av kärl). I AT1-prostata-TINT var genuttrycket kopplat till samma funktioner men verkade istället inhibera dessa. Genom att titta på vävnaderna i mikroskop kunde vi se att MLL-tumörer rekryterade färre T-celler (som har en viktig funktion i immunsvaret mot tumören), men istället fler makrofager och granulocyter till både tumören och prostata-TINT (dessa typer av immunceller har visats kunna hjälpa tumörer att växa och sprida sig). MLL-tumörer hade också fler blodkärl och lymfkärl strax utanför tumören. I de regionala lymfkörtlarna från djur med MLL-tumörer visade genuttrycket tecken på försämrad antigenpresentation, samt immunhämning och/eller induktion av immuntolerans. Immuntolerans innebär att immuncellen inte längre reagerar mot det specifika antigen den blivit tolerant emot. Detta är vanligt förekommande hos individer med cancer och är ett sätt för tumören att undkomma immunförsvaret. I vävnadsprover av lymfkörtlarna kunde vi se färre antigenpresenterande celler, och liksom i tumörerna fanns det färre T-celler i MLL-modellen, något vi kunde se redan när tumörerna var väldigt små. CD169 är ett protein som bl.a. uttrycks av sinus-makrofager i lymfkörtlar. Dessa makrofager har en central funktion i att aktivera ett tumör-specifikt immunsvar. I råttmodellen kunde vi se att regionala lymfkörtlar från djur med MLL-tumörer hade lägre nivåer av CD169 än regionala lymfkörtlar från djur med AT1-tumörer, och då antalet sinus-makrofager visat sig ha prognostiskt värde i t.ex. tjocktarmscancer, ville vi se om det kunde vara så även i prostatacancer. Därför kvantifierade vi uttrycket av CD169 i metastasfria regionala lymfkörtlar från prostatacancerpatienter och såg att låga nivåer av CD169 medförde en ökad risk för att dö i prostatacancer. Sammantaget tyder resultaten på att MLL-tumören jämfört med AT1- tumören bättre lyckas förbereda omgivande vävnad för att gynna tumörväxt och spridning, både lokalt i prostatan men också längre bort från tumören i de regionala lymfkörtlarna. Våra fynd stämmer väl överens med aktuell tumörbiologisk forskning om hur tumörer påverkar sin omgivning. Något som inte visats tidigare är att miljön utanför tumören verkar skilja sig drastiskt beroende på tumörens metastaserande förmåga, samt att dessa skillnader går att se relativt tidigt under sjukdomsförloppet och förmodligen även långt bort från tumören. Vi har också visat att särskilt aggressiv prostatacancer verkar inducera en pre-metastatisk nisch i tumördränerande lymfkörtlar likt det som beskrivits i andra modellsystem och i andra cancertyper, men hittills inte i prostatacancer. Fler studier behövs för att bättre karaktärisera de förändringar som en potentiellt dödlig prostatacancer orsakar i andra vävnader, och för att ta reda på hur denna kunskap kan användas för att förbättra diagnostik och behandling.

Les sarcomes épithélioides sont caractérisés dans 85% des cas par une perte d'expression nucléaire de la protéine SMARCB1, codée par un gène suppresseur de tumeurs situés en 22q11 impliqué dans la génèse des tumeurs rhabdoides malignes. L'exploration par BAC-FISH (Bacterial Artificial Chromosome- Fluorescence In Situ Hybridization) d'une série de 40 sarcomes épithélioides a permis d'établir que cette perte d'expression était secondaire dans 85% des cas à des délétions homozygotes et a mis en évidence le premier cas de sarcome épithélioide associé à une délétion germinale de SMARCB1, altération jusqu'alors uniquement identifiée dans les tumeurs rhabdoides malignes. Nous avons par la suite testé le gène suppresseur de tumeurs SMARCA4 comme gène candidat impliqué dans les sarcomes épithélioides SMARCB1-conservés à partir d'une série rétrospective de 16 cas. SMARCA4 code la sous-unité ATPase du complexe BAF dont SMARCB1 représente une sous unité. Ce screening initial a permis d'identifier 6 cas de sarcomes SMARCA4-inactivés dont la localisation était exclusivement thoracique et dont les caractéristiques clinique et anatomopathologique stéréotypées ont permis le recrutement prospectif et rétrospectif de nouveaux cas. L'étude par RNA-sequencing d'une fraction de notre cohorte (n=13/19) a confirmé leur homogénéité transcriptomique et souligné leur parenté avec les tumeurs rhabdoides SMARCB1 et SMARCA4 déficientes. L'absence de mutation germinale fréquente (n=1/11) a fait proposer le terme de sarcome thoracique SMARCA4-déficient (SMARCA4-DTS) en proscrivant l'utilisation du qualificatif « rhabdoide ». La parenté transcriptomique de ces tumeurs laisse entrevoir des vulnérabilités thérapeutiques communes qui restent à identifier / Epithelioid sarcomas (ES) display loss of SMARCB1 nuclear expression in 85% of cases. SMARCB1 is encoded by a tumor suppressor gene located in 22q11 which was first linked to cancer in malignant rhabdoid tumors. While investigating a series of 40 epithelioid sarcomas with BAC-FISH (Bacterial Artificial Chromosome-Fluorescence In Situ Hybridization), we demonstrated that SMARCB1 loss in ES occurred through genomic deletions in 85% of cases. We were also able to highlight the first case of ES associated with a heterozygous SMARCB1 deletion in the germ line, which feature was previously thought to be restricted to malignant rhadboid tumors (MRT). We subsequently investigated a series of 16 SMARCB1-retained ES to identify its underlying culprit gene with a focus on the candidate tumor suppressor gene SMARCA4. SMARCA4 encodes one of the ATPase subunit of BAF complexes. Interestingly, SMARCB1 is also a core submit of these complexes which regulate chromatin remodeling. We were able to identify a set of 6 cases displaying SMARCA4 inactivation with this discovery cohort. The review of medical records highlighted these cases had similar presentation : all tumors presented with large compressive and aggressive mediastinopulmonary masses. We further recruited 13 cases based on these characteristics including 5 prospective cases. The characterization of their transcriptomes by RNA-sequencing (n=13/19) confirmed their remarkable homogeneity, all our samples clustering together with MRT. However our variant diverge from malignant rhabdoid tumors as it lacks SMARCA4 alteration in the germline (n=0/11) and displays complex polyploidy genetic profiles. We therefore called this new tumor variant “SMARCA4-deficient thoracic sarcoma” (SMARCA4-DTS). The transcriptomic vicinity of SMARCA4-DTS and MRT let foresee they share common therapeutic vulnerabilities