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A introdução do Mesilato de Imatinibe (MI) como primeiro inibidor específico de BCR-ABL1 na prática clínica revolucionou o tratamento da Leucemia Mieloide Crônica (LMC), tornando-se a terapia padrão para o tratamento desta doença. Porém, cerca de 30% dos pacientes com LMC não respondem à terapia com MI e um número substancial destes casos de resistência não tem causa conhecida. O MI interage com transportadores de membrana ABCG2 e SLCO1A2. Este estudo teve como objetivo investigar a relação da expressão gênica de ABCG2 e de SLCO1A2 com marcadores de resposta ao tratamento com MI, em indivíduos com LMC e avaliar a influência dos polimorfismos ABCG2 c.421C>A e ABCG2 c.-19-99G>A na resposta ao MI. Foram incluídos 118 pacientes com LMC os quais foram classificados em dois grupos: Grupo Respondedor, constituído por 70 pacientes com resposta citogenética completa com a dose padrão de MI (400 mg/dia) por até 18 meses e, Grupo não Respondedor constituído por 48 pacientes sem resposta citogenética completa à dose inicial de 400 mg/dia de MI ou que perderam esta resposta ao longo do tratamento e foram reescalonados para doses de 600 ou 800 mg/dia. A resposta ao tratamento foi avaliada segundo os critérios da European LeukemiaNet. Foram excluídos pacientes com alterações citogenéticas diferentes do cromossomo Ph e mutações no gene BCR-ABL1. Amostras de sangue periférico foram utilizadas para: extração do RNA total para quantificação dos transcritos BCR-ABL1 e expressão gênica de ABCG2 e SLCO1A2; extração de DNA e análise citogenética de banda G. A expressão do gene ABCG2 e SLCO1A2 e as análises dos polimorfismos foram feitas por PCR em tempo real. A expressão de ABCG2 foi maior no grupo de não respondedores ao MI (P=0,028). Este resultado foi influenciado pelos pacientes com resistência primária (N= 34 P=0,029), mas não pelos que apresentaram resistência secundária (N=14 P=0,249) quando comparado com respondedores (N=70). A elevada expressão do gene ABCG2 foi também associada àqueles pacientes que não tiveram resposta molecular maior (número de transcritos BCR-ABL1 ≤ 0,1%) (P=0,027) quando todos os pacientes foram analisados. O gene estudado não foi associado com a resposta molecular completa (número de transcritos BCR-ABL1 ≤ 0,032%). Com relação ao gene SLCO1A2 não foi possível determinar sua expressão devido à baixa concentração do RNA obtido. Os polimorfismos c.421C>A e c.-19-99G>A não foram associados com a expressão do gene ABCG2 e a resposta ao MI. A RMC (no grupo de respondedores) foi associada com o genótipo 421CC e houve tendência a maior frequencia de portadores do genótipo -19-99GG neste mesmo grupo. Portadores do genótipo -19-99AA apresentaram tendência ao risco de ter LMC. Os resultados deste estudo nos permitem concluir que a maior expressão de ABCG2 está associada com a resistência primária ao MI podendo então ser um mediador da resistência ao MI. Os polimorfismos do gene ABCG2 não influenciaram na expressão gênica de ABCG2, mas impactaram na RMC no grupo respondedor ao MI. / The introduction of imatinib mesylate (IM) as the first specific inhibitor of BCR-ABL1 in clinical practice has revolutionized the treatment of chronic myeloid leukemia (CML), becoming the standard therapy for this disease. However, about 20% of CML patients do not respond to therapy with IM and a substantial number of these cases of resistance have no known cause. The MI interacts with membrane transporters ABCG2 and SLCO1A2. The aim of this study was to investigate the relationship of ABCG2 and SLCO1A2 gene expression with markers of response to MI in individuals with CML and evaluate the influence of polymorphisms ABCG2 c.421C> A and c. ABCG2-19-99G> A in response to the MI. One hundred and eighteen patients in chronic phase of CML were studied and classified in two groups: Responder Group comprised 70 patients who had a complete cytogenetic response within 18 months of treatment. The non-responder group comprised 48 patients who did not have a complete cytogenetic response with the initial dose (400 mg/day) of IM or who relapsed during treatment and were submitted to higher doses of 600 or 800 mg/day. Criteria of failed response to treatment were established by European LeukemiaNet. Patients with cytogenetic patterns other than the Philadelphia chromosome and patients with mutations in the BCR-ABL1 gene were excluded from this study. Blood samples were obtained for: total RNA extraction for quantification of BCR-ABL1 and gene expression of ABCG2 and SLCO1A2; genomic DNA extraction and band G cytogenetic analysis. The gene expression and the analysis of the polymorphisms were performed by real time PCR. Expression of ABCG2 in non-responder group was higher than in responder group (P=0.028). This result was influenced by patients with primary resistance (n= 34 P=0.029) but not secondary resistance (n=14 P=0.249) when compared with responders (n=70). The higher expression of ABCG2 gene was also associated with those patients who had major molecular response (number of BCR-ABL1 . 0.1%) (P=0.027) when all patients were analyzed. The studied gene was not associated with the complete molecular response (number of BCR-ABL1 .0.0032). Regarding to the gene SLCO1A2 was not possible to determine its expression due to low concentration of RNA obtained. The c.421C>A e c.-19-99G>A were not associated neither with the ABCG2 gene expression and MI response. CMR in responders group was associated with the 421CC genotype ant there was a trend for higher frequency of carriers of genotype -19-99GG in the same group. Carriers of 19-99AA genotype tended to the risk of having CML. The results of this study allow us to conclude that the higher expression of ABCG2 is associated with primary resistance to IM and may be a mediator of resistance to IM. The ABCG2 polymorphisms did not influence the gene expression of ABCG2 but impacted in CMR of the responders to IM.

FONSECA, Thiago de Sousa. Síntese quimioenzimática do Mesilato de Rasagilina (Azilect). 2013. 114 f. Dissertação (Mestrado em química)- Universidade Federal do Ceará, Fortaleza-CE, 2013. / Submitted by Elineudson Ribeiro (elineudsonr@gmail.com) on 2016-06-02T20:57:05Z No. of bitstreams: 1 2013_dis_tsfonseca.pdf: 1927032 bytes, checksum: 84f632bf5ae2356bf2323decdf5dbfd2 (MD5) / Approved for entry into archive by José Jairo Viana de Sousa (jairo@ufc.br) on 2016-07-20T20:39:45Z (GMT) No. of bitstreams: 1 2013_dis_tsfonseca.pdf: 1927032 bytes, checksum: 84f632bf5ae2356bf2323decdf5dbfd2 (MD5) / Made available in DSpace on 2016-07-20T20:39:45Z (GMT). No. of bitstreams: 1 2013_dis_tsfonseca.pdf: 1927032 bytes, checksum: 84f632bf5ae2356bf2323decdf5dbfd2 (MD5) Previous issue date: 2013 / Here we describe the synthesis of the chemoenzymatic Rasagilina mesylate (Azilect®), a drug used in monotherapy in patients with early stage Parkinson. One of the goals of this project was to carry out the introduction of chirality via biocatalysis processes. We studied two strategies: i) bioreduction of indanone in the presence of a series of yeast and ii) kinetic resolution of rac-indanol using lipases in organic solvent. In strategy (i) was conducted a screening with six yeasts. In all tests the (S)-indanol was obtained in low conversions (9.4 to 13.2%) and enantiomeric excesses of up to 97.6%. Due to low conversion rates, we decided to implement the strategy (ii). After screening of nine commercial lipases, was possible to verify that the Amano lipase AK from Pseudomonas fluorescens and Lipase from Thermomyces lanuginosus immobilized on immobead-150 were the most efficient in the kinetic resolution of rac- indanila acetate in aqueous medium with enantiomeric ratio equals 111.0 and 167.0 respectively. Thus, such lipases were selected for the kinetic resolution of rac-indanol in organic media. The best results of enzyme activity and selectivity were obtained using hexane as a solvent, reaction time of 15 minutes and 30ºC for Amano lipase AK (free enzyme) and 35ºC for Thermomyces lanuginosus, with enantiomeric ratio equals 200 for both cases. Were held assets of Amano AK (free enzyme) in various media and the best results were obtained selectivity and activity in hexane as organic solvent, reaction time of 6 hours and 30 º C using Amano Lipase AK immobilized chitosan in 2.5% low molecular weight; sodium alginate 2.5% and Amano AK lipase immobilized on chitosan 5.0% low molecular weight. The study was conducted reuse of immobilized lipase, Thermomyces lanuginosus being immobilized on immobead-150, the more efficiently compared to the others, since it has provided excellent results in higher reaction cycles. Subsequently, using a Mitsunobu reaction, (S)-indanol was converted to (R)-azidoindano with 70% yield. Then, the (R)-azidoindano was subjected to Staudinger reaction, producing (R)-indanamine in 60% yield. / Neste trabalho descrevemos a síntese quimioenzimática do Mesilato de Rasagilina (Azilect®), um fármaco utilizado na monoterapia de pacientes com Parkinson no estágio inicial. Um dos objetivos deste trabalho foi realizar a introdução da quiralidade via processos de biocatálise. Foram estudadas duas estratégias: i) biorredução da indanona na presença de uma série de leveduras e ii) resolução cinética do rac-indanol utilizando lipases, em solvente orgânico. Na estratégia (i) realizamos uma triagem com seis leveduras. Em todos os testes realizados o (S)-indanol foi obtido com baixas conversões (9,4-13,2%) e excessos enantioméricos de até 97,6%. Devido aos baixos valores de conversão, decidimos aplicar a estratégia (ii). Após uma triagem com nove lipases comerciais foi possível verificar que a Amano lipase AK a partir da Pseudomonas fluorescens e a Lipase a partir da Thermomyces lanuginosus imobilizada em immobead-150 foram as mais eficientes na resolução cinética do rac-acetato de indanila, em meio aquoso, com razão enantiomérica de 111,0 e 167,0, respectivamente. Com isso, tais lipases foram selecionadas para a resolução cinética do rac-indanol em meio orgânico. Os melhores resultados de seletividade e atividade enzimática foram obtidos utilizando hexano como solvente orgânico, tempo reacional de 15 minutos e temperatura de 30ºC para a Amano lipase AK (enzima livre) e 35ºC para a Thermomyces lanuginosus, com razão enantiomérica>200 para ambos os casos. Foram realizadas imobilizações da Amano AK (enzima livre) em vários suportes e os melhores resultados de seletividade e atividade foram obtidos em hexano como solvente orgânico, tempo reacional de 6 horas e temperatura de 30ºC empregando a Amano lipase AK imobilizada em quitosana 2,5% de baixo peso molecular; alginato de sódio 2,5% e a Amano lipase AK imobilizada em quitosana 5,0% de baixo peso molecular. Foi realizado o estudo de reuso das lipases imobilizadas, sendo a Thermomyces lanuginosus imobilizada em immobead-150, a mais eficiente comparada às demais, uma vez que proporcionou excelentes resultados em maiores ciclos reacionais. Posteriormente, empregando uma reação de Mitsunobu, o (S)-indanol foi convertido no (R)-azidoindano com rendimento de 70%. Em seguida, o (R)-azidoindano foi submetido a uma reação de Staudinger, produzindo a (R)-indanamina com 60% de rendimento.

A introdução do Mesilato de Imatinibe (MI) como primeiro inibidor específico de BCR-ABL1 na prática clínica revolucionou o tratamento da Leucemia Mieloide Crônica (LMC), tornando-se a terapia padrão para o tratamento desta doença. Porém, cerca de 30% dos pacientes com LMC não respondem à terapia com MI e um número substancial destes casos de resistência não tem causa conhecida. O MI interage com transportadores de membrana ABCG2 e SLCO1A2. Este estudo teve como objetivo investigar a relação da expressão gênica de ABCG2 e de SLCO1A2 com marcadores de resposta ao tratamento com MI, em indivíduos com LMC e avaliar a influência dos polimorfismos ABCG2 c.421C>A e ABCG2 c.-19-99G>A na resposta ao MI. Foram incluídos 118 pacientes com LMC os quais foram classificados em dois grupos: Grupo Respondedor, constituído por 70 pacientes com resposta citogenética completa com a dose padrão de MI (400 mg/dia) por até 18 meses e, Grupo não Respondedor constituído por 48 pacientes sem resposta citogenética completa à dose inicial de 400 mg/dia de MI ou que perderam esta resposta ao longo do tratamento e foram reescalonados para doses de 600 ou 800 mg/dia. A resposta ao tratamento foi avaliada segundo os critérios da European LeukemiaNet. Foram excluídos pacientes com alterações citogenéticas diferentes do cromossomo Ph e mutações no gene BCR-ABL1. Amostras de sangue periférico foram utilizadas para: extração do RNA total para quantificação dos transcritos BCR-ABL1 e expressão gênica de ABCG2 e SLCO1A2; extração de DNA e análise citogenética de banda G. A expressão do gene ABCG2 e SLCO1A2 e as análises dos polimorfismos foram feitas por PCR em tempo real. A expressão de ABCG2 foi maior no grupo de não respondedores ao MI (P=0,028). Este resultado foi influenciado pelos pacientes com resistência primária (N= 34 P=0,029), mas não pelos que apresentaram resistência secundária (N=14 P=0,249) quando comparado com respondedores (N=70). A elevada expressão do gene ABCG2 foi também associada àqueles pacientes que não tiveram resposta molecular maior (número de transcritos BCR-ABL1 ≤ 0,1%) (P=0,027) quando todos os pacientes foram analisados. O gene estudado não foi associado com a resposta molecular completa (número de transcritos BCR-ABL1 ≤ 0,032%). Com relação ao gene SLCO1A2 não foi possível determinar sua expressão devido à baixa concentração do RNA obtido. Os polimorfismos c.421C>A e c.-19-99G>A não foram associados com a expressão do gene ABCG2 e a resposta ao MI. A RMC (no grupo de respondedores) foi associada com o genótipo 421CC e houve tendência a maior frequencia de portadores do genótipo -19-99GG neste mesmo grupo. Portadores do genótipo -19-99AA apresentaram tendência ao risco de ter LMC. Os resultados deste estudo nos permitem concluir que a maior expressão de ABCG2 está associada com a resistência primária ao MI podendo então ser um mediador da resistência ao MI. Os polimorfismos do gene ABCG2 não influenciaram na expressão gênica de ABCG2, mas impactaram na RMC no grupo respondedor ao MI. / The introduction of imatinib mesylate (IM) as the first specific inhibitor of BCR-ABL1 in clinical practice has revolutionized the treatment of chronic myeloid leukemia (CML), becoming the standard therapy for this disease. However, about 20% of CML patients do not respond to therapy with IM and a substantial number of these cases of resistance have no known cause. The MI interacts with membrane transporters ABCG2 and SLCO1A2. The aim of this study was to investigate the relationship of ABCG2 and SLCO1A2 gene expression with markers of response to MI in individuals with CML and evaluate the influence of polymorphisms ABCG2 c.421C> A and c. ABCG2-19-99G> A in response to the MI. One hundred and eighteen patients in chronic phase of CML were studied and classified in two groups: Responder Group comprised 70 patients who had a complete cytogenetic response within 18 months of treatment. The non-responder group comprised 48 patients who did not have a complete cytogenetic response with the initial dose (400 mg/day) of IM or who relapsed during treatment and were submitted to higher doses of 600 or 800 mg/day. Criteria of failed response to treatment were established by European LeukemiaNet. Patients with cytogenetic patterns other than the Philadelphia chromosome and patients with mutations in the BCR-ABL1 gene were excluded from this study. Blood samples were obtained for: total RNA extraction for quantification of BCR-ABL1 and gene expression of ABCG2 and SLCO1A2; genomic DNA extraction and band G cytogenetic analysis. The gene expression and the analysis of the polymorphisms were performed by real time PCR. Expression of ABCG2 in non-responder group was higher than in responder group (P=0.028). This result was influenced by patients with primary resistance (n= 34 P=0.029) but not secondary resistance (n=14 P=0.249) when compared with responders (n=70). The higher expression of ABCG2 gene was also associated with those patients who had major molecular response (number of BCR-ABL1 . 0.1%) (P=0.027) when all patients were analyzed. The studied gene was not associated with the complete molecular response (number of BCR-ABL1 .0.0032). Regarding to the gene SLCO1A2 was not possible to determine its expression due to low concentration of RNA obtained. The c.421C>A e c.-19-99G>A were not associated neither with the ABCG2 gene expression and MI response. CMR in responders group was associated with the 421CC genotype ant there was a trend for higher frequency of carriers of genotype -19-99GG in the same group. Carriers of 19-99AA genotype tended to the risk of having CML. The results of this study allow us to conclude that the higher expression of ABCG2 is associated with primary resistance to IM and may be a mediator of resistance to IM. The ABCG2 polymorphisms did not influence the gene expression of ABCG2 but impacted in CMR of the responders to IM.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Neste trabalho descrevemos a sÃntese quimioenzimÃtica do Mesilato de Rasagilina (AzilectÂ), um fÃrmaco utilizado na monoterapia de pacientes com Parkinson no estÃgio inicial. Um dos objetivos deste trabalho foi realizar a introduÃÃo da quiralidade via processos de biocatÃlise. Foram estudadas duas estratÃgias: i) biorreduÃÃo da indanona na presenÃa de uma sÃrie de leveduras e ii) resoluÃÃo cinÃtica do rac-indanol utilizando lipases, em solvente orgÃnico. Na estratÃgia (i) realizamos uma triagem com seis leveduras. Em todos os testes realizados o (S)-indanol foi obtido com baixas conversÃes (9,4-13,2%) e excessos enantiomÃricos de atà 97,6%. Devido aos baixos valores de conversÃo, decidimos aplicar a estratÃgia (ii). ApÃs uma triagem com nove lipases comerciais foi possÃvel verificar que a Amano lipase AK a partir da Pseudomonas fluorescens e a Lipase a partir da Thermomyces lanuginosus imobilizada em immobead-150 foram as mais eficientes na resoluÃÃo cinÃtica do rac-acetato de indanila, em meio aquoso, com razÃo enantiomÃrica de 111,0 e 167,0, respectivamente. Com isso, tais lipases foram selecionadas para a resoluÃÃo cinÃtica do rac-indanol em meio orgÃnico. Os melhores resultados de seletividade e atividade enzimÃtica foram obtidos utilizando hexano como solvente orgÃnico, tempo reacional de 15 minutos e temperatura de 30ÂC para a Amano lipase AK (enzima livre) e 35ÂC para a Thermomyces lanuginosus, com razÃo enantiomÃrica>200 para ambos os casos. Foram realizadas imobilizaÃÃes da Amano AK (enzima livre) em vÃrios suportes e os melhores resultados de seletividade e atividade foram obtidos em hexano como solvente orgÃnico, tempo reacional de 6 horas e temperatura de 30ÂC empregando a Amano lipase AK imobilizada em quitosana 2,5% de baixo peso molecular; alginato de sÃdio 2,5% e a Amano lipase AK imobilizada em quitosana 5,0% de baixo peso molecular. Foi realizado o estudo de reuso das lipases imobilizadas, sendo a Thermomyces lanuginosus imobilizada em immobead-150, a mais eficiente comparada Ãs demais, uma vez que proporcionou excelentes resultados em maiores ciclos reacionais. Posteriormente, empregando uma reaÃÃo de Mitsunobu, o (S)-indanol foi convertido no (R)-azidoindano com rendimento de 70%. Em seguida, o (R)-azidoindano foi submetido a uma reaÃÃo de Staudinger, produzindo a (R)-indanamina com 60% de rendimento. / Here we describe the synthesis of the chemoenzymatic Rasagilina mesylate (AzilectÂ), a drug used in monotherapy in patients with early stage Parkinson. One of the goals of this project was to carry out the introduction of chirality via biocatalysis processes. We studied two strategies: i) bioreduction of indanone in the presence of a series of yeast and ii) kinetic resolution of rac-indanol using lipases in organic solvent. In strategy (i) was conducted a screening with six yeasts. In all tests the (S)-indanol was obtained in low conversions (9.4 to 13.2%) and enantiomeric excesses of up to 97.6%. Due to low conversion rates, we decided to implement the strategy (ii). After screening of nine commercial lipases, was possible to verify that the Amano lipase AK from Pseudomonas fluorescens and Lipase from Thermomyces lanuginosus immobilized on immobead-150 were the most efficient in the kinetic resolution of rac- indanila acetate in aqueous medium with enantiomeric ratio equals 111.0 and 167.0 respectively. Thus, such lipases were selected for the kinetic resolution of rac-indanol in organic media. The best results of enzyme activity and selectivity were obtained using hexane as a solvent, reaction time of 15 minutes and 30ÂC for Amano lipase AK (free enzyme) and 35ÂC for Thermomyces lanuginosus, with enantiomeric ratio equals 200 for both cases. Were held assets of Amano AK (free enzyme) in various media and the best results were obtained selectivity and activity in hexane as organic solvent, reaction time of 6 hours and 30  C using Amano Lipase AK immobilized chitosan in 2.5% low molecular weight; sodium alginate 2.5% and Amano AK lipase immobilized on chitosan 5.0% low molecular weight. The study was conducted reuse of immobilized lipase, Thermomyces lanuginosus being immobilized on immobead-150, the more efficiently compared to the others, since it has provided excellent results in higher reaction cycles. Subsequently, using a Mitsunobu reaction, (S)-indanol was converted to (R)-azidoindano with 70% yield. Then, the (R)-azidoindano was subjected to Staudinger reaction, producing (R)-indanamine in 60% yield.

Les tumeurs stromales gastrointestinales (GIST) sont les néoplasies mésenchymateuses les plus complexes du système gastrointestinal. Le traitement curatif standard de cette pathologie est la chirurgie avec l'obtention de marges microscopiques négatives. Les résultats impressionnants obtenus sur la prolongation de la survie avec l'administration d'imatinib (IM) chez les patients atteints de maladie métastatique et non-réséquable ont suggéré aux cliniciens que ce même médicament pourrait aussi collaborer à l'obtention de marges négatives plus aisément lors de cancer avancé. Jusqu'à présent, aucune étude prospective n'a caractérisée l'effet d'une thérapie néoadjuvante prolongée à l'IM sur la qualité de la résection chirurgicale subséquente. L'objectif de ce projet de maîtrise était d'évaluer l'efficacité de l'imatinib utilisé avant la chirurgie (néoadjuvant) jusqu'à l'obtention d'une réponse maximale, en vue d'augmenter le taux de résection microscopique complète (R0) dans le traitement chirurgical des GIST à haut risque de résection microscopique incomplète (R1) ou impossible (R2). Pour ce faire, une étude prospective multicentrique de phase II a été réalisée. Le traitement néoadjuvant à l'IM a été instauré chez des patients porteurs d'une GIST localement avancée ou métastatique. Au total, quatorze patients ont reçu une dose de 400-600 mg/d d'IM pour une durée de 6-12 mois avant la chirurgie. Quatorze patients ont été inclus dans l'étude. Onze ont eu une chirurgie à visée curative, un patient a démontré une maladie non-réséquable suite à une laparotomie exploratrice et deux patients ont refusé la chirurgie. Après un suivi moyen de 48 mois, tous les patients opérés étaient vivants et sept sans évidence de récidive. L'utilisation prolongée (12 mois) d'IM dans un contexte néoadjuvant est faisable, sécuritaire, efficace et comporte peu de toxicité. De plus, cette approche est associée à des hauts taux de résection complète (R0), tout en permettant une chirurgie moins extensive. Des études de phase III actuellement en cours sont nécessaires afin de confirmer nos résultats. / Gastrointestinal stromal tumor (GIST) is the most common mesenchymal malignancy of the GI tract. The current standard of care for GIST is surgical complete resection with negative margins. The agent response rate as well as survival advantages obtained with imatinib mesylate in patients with metastatic and/or non-resectable GIST has lead clinicians to evaluate this therapy as neoadjuvant treatment in patients with locally advanced or metastatic but potentially resectable GIST. This study was designed to evaluate the efficacy of neoadjuvant use of imatinib mesylate until maximal clinical response in potentially resectable GIST patients (locally advanced or metastatic), in order to provide preliminary data regarding the efficacy of this approach in the surgical treatment of GIST at high-risk of incomplete microscopic (R1) or macroscopic (R2) margins. A prospective multicenter phase II trial was designed. Fourteen consecutive patients diagnosed with advanced GIST received imatinib at dose of 400 mg/d to 600 mg/d, given from 6 to 12 months prior to surgery. Amoung the 14 patients included, 11 underwent surgery and had a complete microscopic resection (R0). After a median follow-up of 48 months, all operated patients were alive and 7 without evidence of recurrence. The prolonged use (12 months) of neoadjuvant imatinib is feasible, safe, eficient ans associated with low toxicity. Furthermore, it is associated with a high rate of microscopic resection (R0) and a less extensive surgical approach. Phase III study with higher cohorts are necessary to confirm our primary results.

Störungen im Bereich der Mikrozirkulation gelten als ursächlich für die Entstehung des Multiorganversagens bei Sepsis, wobei der Darm eine zentrale Rolle einnimmt. Aktivierte Leukozyten setzen u.a. Sauerstoffradikale frei, die entscheidend zur Zerstörung der endothelialen Integrität beitragen. Die Antagonisierung schädigender Mediatoren stellt ein Prinzip der adjunktiven Sepsis-Therapie dar, wobei die antioxidativ wirkenden Substanzen N-Acetylcystein (NAC) und Tirilazad Mesylat (TM) in mehreren Studien positive Effekte gezeigt haben. In einer tierexperimentellen Untersuchung an Ratten wurde der Effekt der kombinierten Gabe von NAC und TM auf die mesenteriale Mikrozirkulation, auf die Freisetzung von TNF-alpha, IL-1beta, IL-6, IL-10 und auf die Leukozytenzahl unter einer kontinuierlichen Lipopolysaccharidbelastung (LPS) von 10 mg/kg KG untersucht. Die Beurteilung der mesenterialen Mikrozirkulation erfolgte mittels Intravitalmikroskopie. Hierbei wurde das Ausmaß der Leukozytenadhärenz am Endothel der mesenterialen Venolen als Maß für die Leukozytenaktivierung und die Plasmaextravasation als Parameter für die Endotheldysfunktion bestimmt. Dabei konnte während zwei Stunden Endotoxinämie die Zunahme der Plasmaextravasation an mesenterialen Venolen durch die kombinierte Gabe von NAC und TM nicht signifikant beeinflusst werden (p>0,05). Eine tendenziell erhöhte Plasmaextravasation unterstützt die Hypothese, dass leukozytenunabhängige Mechanismen für die Plasmaextravasation existieren. Während zwei Stunden Endotoxinämie kam es zu einer signifikanten Reduktion der Anzahl der fest adhärenten Leukozyten in der NAC/TM-Gruppe im Vergleich zur LPS-Gruppe (p=0,001). Durch die kombinierte Gabe von NAC und TM konnte die endotoxininduzierte Freisetzung von TNF-alpha, IL-1beta, IL-6, IL-10 und die endotoxinbedingte Leukopenie nicht signifikant beeinflusst werden. / Disturbances of the microcirculation are causal for the pathophysiology of multiorgan failure related to sepsis in which the gut plays a central part. Activated leukocytes release i.e. oxygen radicals which decisively contribute to the destruction of the endothelial integration. To antagonize the damaging mediators is a principle of the adjunctive sepsis therapy in which the antioxidant agents N-acetylcysteine (NAC) and tirilazad mesylate (TM) showed positive effects in several studies. The effect of the combined administering of NAC and TM under continuous lipopolysaccharide (LPS) exposure of 10 mg/kg BW on the mesenteric microcirculation, on the release of TNF-alpha, IL-1beta, IL-6, IL-10 and on the number of leukocytes was examined in an animal study on rats. The appraisal of the microcirculation was done by intravital microscopy. The degree of leukocyte adherence on the endothelium of mesenteric venules was determined for the degree of leukocyte activation, and the plasma extravasation was the parameter for the endothelial dysfunction. The increase of plasma extravasation on mesenteric venules during 2 hours of endotoxemia could not be affected significantly by the combined administering of NAC and TM. The tendency of increased plasma extravasation supports the hypothesis of the existence of a leukocyte independent mechanism of plasma extravasation. During 2 hours of endotoxemia the NAC/TM group showed a significant decrease in the number of firmly adherent leukocytes in comparison to the LPS group. There was no significant effect on the endotoxin induced release of TNF-alpha, IL-1beta, IL-6, IL-10 and the endotoxin induced leukopenia by the combined administration of NAC and TM.

Les thérapies anticancéreuses ont apporté un gain largement reconnu en matière de réduction de la charge tumorale, de survie des patients et d’amélioration de leur qualité de vie, dans un certain nombre de cancers. Hélas, ces thérapies exercent un effet immunosuppresseur en détruisant les effecteurs ou en bloquant l’activité de certains facteurs biologiques impliqués dans le recrutement des acteurs du système immunitaire. D’autre part, plusieurs travaux ont permis de démontrer que ces traitements pouvaient avoir un effet contraire en générant ou en favorisant l’induction d’une réponse immunitaire anti-tumorale, soit par effet direct sur le recrutement et l’activation des effecteurs de l’immunité, soit en potentialisant les interactions cellulaires par des mécanismes biologiques. Ces derniers faisant intervenir les cytokines, la stimulation des TLR, l’augmentation des interactions entre cellules du SI; ce qui permet de passer d’une anergie immunologique vers un véritable système d’éradication des cellules cancéreuses.Dans notre laboratoire, nous avons essayé d’évaluer l’implication du système immunitaire dans la réponse thérapeutique induite par des agents cytotoxiques conventionnels. Ici, nous décrivons les effets d’un inhibiteur de cyclines kinases multi-cibles « CDKi PHA-793 887 » testé dans un essai de phase I mené sur deux sites en Europe. C’est le constat inattendu que 6 des 15 patients, traités par ce médicament (PHA-793887) ont développé de graves infections bactériennes et virales et que 6 d’entre eux ont présenté la réactivation du virus de l’herpès qui nous a conduit à étudier ces effets sur le système immunitaire et en particulier sur le dialogue entre cellules dendritiques (CD) et cellules natural killer (NK). Ce travail met en évidence que ce médicament inhibe le signalling des récepteurs toll-like (TLR) réduisant par conséquent l’interaction CD/NK in vitro. Enfin la stimulation des cellules des patients sous traitement démontre une réduction importante de ce signalling ex-vivo. Ainsi, cet effet immunosuppresseur inattendu a permis une réactivation virale chez 40% des patients. La deuxième partie de ce travail, concerne les effets du cyclophosphamide (CTX) utilisé à faible dose. L’injection d'une faible dose chez la souris ou d’un dosage métronomique chez l'homme, promeut la différenciation des cellules lymphocytaires vers Th17 (sécrétant de l’interleukine-17 (IL-17)) et Th1 (sécrétant de l’interféron-γ (IFN)). Ceux-ci ont été retrouvés dans le sang et dans des ascites carcinomateuses de patients. Ainsi, le CTX pourrait participer à la génération de réponses anti-tumorale via la différenciation Th 17 comme cela fut suggéré par de récentes études précliniques montrant l’existence d’une corrélation étroite entre le taux des lymphocytes Th17 infiltrant la tumeur et la destruction tumorale. / Cancer therapies have made a gain widespread recognition in the reduction of tumor burden, patient survival and improved quality of life in a number of cancers. Unfortunately, these therapies exert an immunosuppressive effect by killing effectors or blocking the activity of certain biological factors involved in recruiting of the immune system. On the other hand, several studies have shown that these treatments could have the opposite effect by generating or promoting the induction of antitumor immune response, either by direct effect on the recruitment and activation of effectors immunity, either by potentiating cellular interactions by biological mechanisms. The latter involving cytokines, TLR stimulation, increased interactions between cells of the IS; which toggles between immunological anergy to a real system to eradicate cancer cells. In our laboratory, we tried to evaluate the involvement of the immune system in the therapeutic response induced by conventional cytotoxic agents. Here, we describe the effects of an inhibitor of cyclin kinases multi-target "CDKIs PHA-793887" tested in a phase I trial conducted at two sites in Europe. This unexpected finding is that 6 of 15 patients treated with this drug (PHA-793887) developed severe bacterial and viral infections and six of them showed reactivation of the herpes virus that has led us to study these effects on the immune system and in particular on the dialogue between dendritic (DCs) and natural killer (NK) cells. This work shows that this drug inhibits the signaling of toll-like receptor (TLR) thereby reducing the interaction DC / NK in vitro. Finally, stimulation of the cells of treated patients demonstrated a significant reduction of this signaling ex vivo. Thus, this immunosuppressive effect has an unexpected viral reactivation in 40% of patients. The second part of this work concerns the effects of metronomic dose of cyclophosphamide (CTX). The injection of a low dose in mice or metronomic dosing in humans, markedly promotes the differentiation of CD4+ T helper 17 (Th17) cells that can be recovered in both blood and tumor beds. However, CTX does not convert regulatory T cells into Th17 cells and promotes cell differentiation into Th17 lymphocytes (secreting interleukin-17 (IL-17)) and Th1 (secreting interferon-γ (IFN)). These were found in blood and in ascites carcinoma patients. Thus, CTX may participate in the generation of antitumor responses through Th 17 differentiation as was suggested by recent preclinical studies showing the existence of a correlation between the rate of Th17 lymphocytes infiltrating the tumor and tumor destruction.

Les tumeurs stromales gastrointestinales (GIST) sont les néoplasies mésenchymateuses les plus complexes du système gastrointestinal. Le traitement curatif standard de cette pathologie est la chirurgie avec l'obtention de marges microscopiques négatives. Les résultats impressionnants obtenus sur la prolongation de la survie avec l'administration d'imatinib (IM) chez les patients atteints de maladie métastatique et non-réséquable ont suggéré aux cliniciens que ce même médicament pourrait aussi collaborer à l'obtention de marges négatives plus aisément lors de cancer avancé. Jusqu'à présent, aucune étude prospective n'a caractérisée l'effet d'une thérapie néoadjuvante prolongée à l'IM sur la qualité de la résection chirurgicale subséquente. L'objectif de ce projet de maîtrise était d'évaluer l'efficacité de l'imatinib utilisé avant la chirurgie (néoadjuvant) jusqu'à l'obtention d'une réponse maximale, en vue d'augmenter le taux de résection microscopique complète (R0) dans le traitement chirurgical des GIST à haut risque de résection microscopique incomplète (R1) ou impossible (R2). Pour ce faire, une étude prospective multicentrique de phase II a été réalisée. Le traitement néoadjuvant à l'IM a été instauré chez des patients porteurs d'une GIST localement avancée ou métastatique. Au total, quatorze patients ont reçu une dose de 400-600 mg/d d'IM pour une durée de 6-12 mois avant la chirurgie. Quatorze patients ont été inclus dans l'étude. Onze ont eu une chirurgie à visée curative, un patient a démontré une maladie non-réséquable suite à une laparotomie exploratrice et deux patients ont refusé la chirurgie. Après un suivi moyen de 48 mois, tous les patients opérés étaient vivants et sept sans évidence de récidive. L'utilisation prolongée (12 mois) d'IM dans un contexte néoadjuvant est faisable, sécuritaire, efficace et comporte peu de toxicité. De plus, cette approche est associée à des hauts taux de résection complète (R0), tout en permettant une chirurgie moins extensive. Des études de phase III actuellement en cours sont nécessaires afin de confirmer nos résultats. / Gastrointestinal stromal tumor (GIST) is the most common mesenchymal malignancy of the GI tract. The current standard of care for GIST is surgical complete resection with negative margins. The agent response rate as well as survival advantages obtained with imatinib mesylate in patients with metastatic and/or non-resectable GIST has lead clinicians to evaluate this therapy as neoadjuvant treatment in patients with locally advanced or metastatic but potentially resectable GIST. This study was designed to evaluate the efficacy of neoadjuvant use of imatinib mesylate until maximal clinical response in potentially resectable GIST patients (locally advanced or metastatic), in order to provide preliminary data regarding the efficacy of this approach in the surgical treatment of GIST at high-risk of incomplete microscopic (R1) or macroscopic (R2) margins. A prospective multicenter phase II trial was designed. Fourteen consecutive patients diagnosed with advanced GIST received imatinib at dose of 400 mg/d to 600 mg/d, given from 6 to 12 months prior to surgery. Amoung the 14 patients included, 11 underwent surgery and had a complete microscopic resection (R0). After a median follow-up of 48 months, all operated patients were alive and 7 without evidence of recurrence. The prolonged use (12 months) of neoadjuvant imatinib is feasible, safe, eficient ans associated with low toxicity. Furthermore, it is associated with a high rate of microscopic resection (R0) and a less extensive surgical approach. Phase III study with higher cohorts are necessary to confirm our primary results.

A leucemia mielóide crônica (LMC) é uma doença cujo marcador molecular é o rearranjo gênico BCR/ABL, original da translocação t(9;22), conhecida como cromossomo Philadelphia. Recentemente, os inibidores da enzima tirosina-quinase têm sido estudados e utilizados para o tratamento da LMC. Nesta classe, está o Mesilato de Imatinibe, uma pequena molécula que inibe competitivamente a BCR/ABL tirosina quinase, impedindo sua atividade. Por não possuir monografia publicada em compêndios oficiais, o objetivo deste trabalho foi avaliar o perfil in vitro de dissolução de comprimidos de mesilato em diferentes condições. A quantificação do fármaco foi feita utilizando a cromatografia líquida de alta eficiência em fase reversa (CLAE-FR) e as análises foram realizadas em uma coluna C18 Gemini Phenomenex®, utilizando como fase móvel tampão acetato de sódio 10,7 mmol/L, pH 3,0:metanol (40:60 v/v). O método foi validado e apresentou-se linear no intervalo de concentração de 10-150 µg/mL (r=0,9993). Os coeficientes de variação obtidos foram inferiores a 2,0 % e a exatidão próxima de 100 %. Também foram avaliados os parâmetros seletividade, robustez, estabilidade e limite de quantificação (10 µg/mL). A avaliação do perfil in vitro de dissolução foi realizada em três diferentes meios de dissolução (HCl 0,1 N, tampão acetato de sódio pH 4,5 e tampão fosfato de potássio monobásico pH 6,8), três velocidades de agitação (50, 75 e 100 rpm) e dois tipos de aparatos (pá e cesta). Os resultados obtidos neste teste indicaram que a forma farmacêutica em estudo é de liberação imediata, uma vez que foi verificada liberação de grande quantidade do fármaco em um curto período de tempo. A comparação dos perfis de dissolução, realizada através do cálculo da eficiência de dissolução, apresentou diferenças em relação à porcentagem do fármaco liberado. a condição mais adequada para avaliar o perfil in vitro de dissolução é o meio de dissolução HCl 0,1 N, aparato da pá e velocidade de agitação de 75 ou 100 rpm. / Chronic myeloid leukemia (CML) is a disease whose molecular marker is the BCR/ABL, original of the translocation t (9; 22), known as the Philadelphia chromosome. Recently, inhibitors of the enzyme tyrosine kinase have been studied and used for the treatment of CML. In this class, is the Imatinib mesylate, a small molecule that competitively inhibits BCR/ABL tyrosine kinase, preventing its activity. To do not have a monograph published in official compendia, the objective of this study was to evaluate the in vitro dissolution of tablets mesylate in different conditions. The quantification of the drug was made using high performance liquid chromatography on reversed phase (RP-HPLC) and analysis was performed on a Phenomenex® Gemini C18 column using a mobile phase of sodium acetate buffer 10.7 mmol/L pH 3.0:methanol (40:60 v/v). The method was validated and presented in a linear concentration range of 10-150 µg/mL (r=0.9993). The coefficients of variation obtained were below 2.0% and accuracy near 100%. We also evaluated the parameters selectivity, robustness, stability and limit of quantification (10 µg/mL). The evaluation of in vitro dissolution was conducted in three different dissolution media (0.1 N HCl, sodium acetate buffer pH 4.5 and potassium phosphate monobasic buffer pH 6.8), three agitation speeds (50, 75 and 100 rpm) and two types of devices (paddle and basket). The results of this tests indicated that the pharmaceutical form in question is immediate release, since it was observed release of large amounts of the drug in a short period of time. The comparison of dissolution profiles, conducted by calculating the dissolution efficiency, showed differences compared to the percentage of drug released. The best conditions to evaluate the in vitro profile of dissolution is the dissolution medium 0.1 N HCl, paddle apparatus and stirring speed of 75 or 100 rpm.