Résumé confidentiel / Résumé confidentiel

Le cancer colorectal est la première pathologie cancéreuse de la sphère digestive, tant en terme de fréquence que de mortalité par an. Chaque année, 41 000 nouveaux cas sont diagnostiqués et 17 000 décès sont dus à ce cancer en France. Deux paramètres cliniques expliquent la mortalité de ce cancer; d'une part le fait qu'un patient sur deux est diagnostiqué au stade métastatique ou va présenter des lésions métastatiques durant l'histoire de sa pathologie, d'autre part le fait que les patients après traitement vont fréquemment présenter une récidive de leur pathologie. L'utilisation de régimes de chimiothérapies avant et après résection métastatique améliore la survie sans récidive à court terme, mais à 2 ans post chirurgie l'avantage apporté est perdu. Ainsi, la compréhension des mécanismes d'échappement à la chimiothérapie et régissant la croissance tumorale est d'intérêt pour tenter de limiter la récidive tumorale. L'objectif de ce travail de thèse a consisté en l'analyse de sous-populations obtenues sous pression de chimiothérapie au 5-Fluorouracile (5FU) dérivées de la lignée cancéreuse colique HT29, ainsi que les mécanismes moléculaires associés. Notre clone le plus chimiorésistant isolé, le modèle cellulaire 5F31, quitte le compartiment prolifératif sous traitement à fortes doses de 5FU, ceci étant associé à une perturbation de la voie de signalisation de la Src kinase c-Yes et de son partenaire, le co-activateur transcriptionnel YAP. Sous traitement, les cellules chimiorésistantes entrent en quiescence, le complexe protéique entre c-Yes et YAP est perdu et la quantité totale et nucléaire de YAP diminue de manière significative (Igoudjil, Touil, Corvaisier et al. 2014 Clinical Cancer Research). Dès lors, la suite des travaux a consisté en l'étude du rôle potentiel de YAP sur la balance quiescence/prolifération sous 5FU. L'inhibition pharmacologique ou l'inhibition transitoire de l'expression de YAP et de son paralogue, la protéine TAZ, dans plusieurs lignées cancéreuses coliques induit l'augmentation de la fraction de cellules quiescentes, associée au ralentissement significatif de la croissance tumorale. A l'inverse, la surexpression d'une forme constitutivement active de YAP demeurant nucléaire sous 5FU maintient les cellules 5F31 en prolifération et sensibilise les cellules à la chimiothérapie. Au niveau des effecteurs protéiques, l'induction de quiescence (par traitement à la chimiothérapie ou inhibition de YAP/TAZ) est associée à la perte d'expression de la Cycline E1 et du facteur de transcription c-Myc. A l'inverse, la surexpression du dominant constitutivement actif de YAP dans les cellules 5F31 conduit à l'expression soutenue de la Cycline E1 sous 5FU, expression nécessitant l'activation du facteur de transcription CREB. L'inhibition de la Cycline E1 permet d'induire la quiescence cellulaire, proposant cette protéine comme l'un des effecteurs des protéines YAP/TAZ dans la régulation entre la quiescence et la prolifération cellulaire (Corvaisier et al, Oncotarget, 2016). En conclusion, nos données montrent l'importance du rôle des protéines YAP/TAZ dans le maintien des cellules en prolifération via l'expression notamment de la Cycline E1. Nos résultats sur cohorte de patients atteints de métastases hépatiques de cancers colorectaux montrent que l'expression des co-activateurs YAP/TAZ est liée à un index prolifératif plus important, confortant nos données sur le rôle de ces protéines dans la croissance tumorale. De plus, l'expression élevée de YAP et TAZ est associée en analyses multivariées à une récidive plus précoce et à une survie globale plus faible. Ainsi, l'étude de l'expression et du niveau d'activation de ces acteurs serait un marqueur pronostic intéressant dans l'anticipation de la récidive métastatique ; ainsi que des cibles thérapeutiques intéressantes pour tenter de limiter la rechute tumorale. / Colorectal cancer is the most frequent and lethal cancerous pathology from the digestive system. Each year in France, 41 000 new cases are diagnosed and 17 000 patients die due to this pathology. This high mortality is mainly due to the rate of patients with liver metastatic lesions and the early relapse of those metastases after treatment. The use of chemotherapy prior to surgery induces a decrease of early relapse, however 2 years after resection this advantage is lost. Thus, understanding the mechanisms underlying escape to treatment is required to try to delay or prevent tumor recurrence.The aim of this doctoral work was to analyze clonal chemoresistant subpopulations derived from the colorectal cancer cell line HT29 after chronic exposure to 5-Fluorouracil (5FU) and molecular mechanisms associated with chemoresistance. The most chemoresistant clonal subpopulation, 5F31, stops its proliferation after treatment with high dose of 5FU, this behavior being associated with the modulation of the c-Yes/YAP axis. After treatment, 5F31 cells enter quiescence, interaction between c-Yes and YAP is lost and total and nuclear YAP protein expression reduces significantly (Igoudjil, Touil, Corvaisier et al. 2014, Clinical Cancer Research). The next step was to study functions of YAP protein in this chemotherapy- induced quiescence.Pharmacological or transient inhibition of YAP and its homolog TAZ, induces quiescence and reduces cellular growth in several colorectal cancer cell lines. On the other hand, overexpression of a constitutively active form of YAP in 5F31 cells forces cells to remain proliferative under 5FU treatment, enhancing 5F31 cell chemosensitivity to 5FU.Regarding proteic effectors, quiescence (either induced by 5FU or YAP/TAZ inhibition) is associated with loss of expression of the transcription factor c-Myc and Cyclin E1. In 5F31 cells expressing the active mutant form of YAP, Cyclin E1 expression is sustained after 5FU treatment through the activation of the transcription factor CREB. Cyclin E1 inhibition is sufficient to induce quiescence, therefore introducing this protein as one of the final effectors of YAP/TAZ co-activators in the regulation of the proliferation/quiescence switch in colorectal cancer cells (Corvaisier et al. 2016, Oncotarget).To conclude, our work reveals the importance of YAP/TAZ proteins for the maintenance of colorectal cancer cells proliferation through Cyclin E1 expression. Our work on liver metastases from patients with colorectal cancer shows that high expression of YAP/TAZ is connected to a higher proliferative index in metastatic lesions. Moreover, high YAP/TAZ expression is associated with shorter patient progression-free survival and shorter overall survival. Studying the expression and level of YAP/TAZ activation could be an interesting prognosis marker to anticipate metastatic relapse and potent druggable target to delay tumoral recurrence.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-21T18:23:30Z No. of bitstreams: 1 robertawolpdiniz.pdf: 1863742 bytes, checksum: 6c164077a0182789343f2f09aa65af87 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T18:48:13Z (GMT) No. of bitstreams: 1 robertawolpdiniz.pdf: 1863742 bytes, checksum: 6c164077a0182789343f2f09aa65af87 (MD5) / Made available in DSpace on 2016-01-25T18:48:13Z (GMT). No. of bitstreams: 1 robertawolpdiniz.pdf: 1863742 bytes, checksum: 6c164077a0182789343f2f09aa65af87 (MD5) Previous issue date: 2014-09-12 / O câncer de mama é um problema de saúde pública, sendo o segundo mais frequente no mundo e o de maior incidência na população feminina, além de ser uma das principais causas de óbito por câncer em mulheres. O objetivo deste estudo foi analisar a sobrevida livre de doença (SLD) em cinco anos e fatores prognósticos em mulheres com câncer de mama invasivo não metastático diagnosticadas entre 2003 e 2005 e tratadas em centro de assistência oncológica de referência de cidade de porte médio do Sudeste do país. As pacientes foram identificadas através do registro hospitalar de câncer da instituição. O seguimento dos casos foi realizado através de consulta aos prontuários, complementado por busca no banco do Sistema de Informação sobre Mortalidade (SIM) e contato telefônico. As variáveis analisadas foram distribuídas nos seguintes blocos: sociodemográficas (idade ao diagnóstico, cor da pele, grau de escolaridade, história familiar de câncer de mama, etc.), características relativas ao tumor (tamanho tumoral, comprometimento linfonodal, estadiamento, invasão neurovascular, grau tumoral, perfil imunohistoquímico, etc.), características relativas ao tratamento (tipo de cirurgia, realização de quimioterapia, radioterapia e hormonioterapia, completude do tratamento quimioterápico, tempo entre a cirurgia e terapia complementar, etc.). As funções de sobrevida foram calculadas por meio do método de Kaplan-Meier e o modelo de riscos proporcionais de Cox foi utilizado para avaliação dos fatores prognósticos. O estudo mostrou uma sobrevida livre de doença em cinco anos de 72% (IC95%: 67,6 – 75,9). As principais variáveis associadas à SLD, de forma independente, foram o comprometimento linfonodal, a realização de hormonioterapia e nível de escolaridade. Esse estudo mostrou a importância do diagnóstico precoce na SLD. Reforça-se ainda a relevância dessa pesquisa no país haja vista a escassez de estudos a respeito de SLD na população brasileira. / Breast cancer is a public health problem, being the second most common in the world and the highest incidence in the female population, in addition to being a major cause of death from cancer in this population overall. The aim of this study was to analyze the disease-free survival (DFS) at five years and prognostic factors in women with non metastatic invasive breast cancer diagnosed between 2003 and 2005 and treated at a referencial center of cancer care on a medium sized town of Southeast. Patients were identified using the medical records and data from the cancer registries of the institution. The follow up of the cases were performed using hospital records, supplemented by searching the database of the Mortality Information System (SIM) and telephone contact. The variables analyzed were: sociodemographic (age at diagnosis, race, education level, family history of breast cancer and presence of diagnostic mammography), related to tumor characteristics (size, lymph node involvement, stage, neurovascular invasion, tumor grade, immunohistochemical profile), characteristics related to treatment (type of surgery, use of chemotherapy, radiotherapy and hormone therapy, completion of chemotherapy, time between surgery and adjunctive therapy). Survival functions were calculated using the Kaplan-Meier model while the Cox proportional hazards method was used to evaluate prognostic factors. The study showed a disease-free survival at 60 months 72% (95% CI 67.6 to 75.9). The main variables associated with SLD, independently, were lymph node involvement, use of hormone therapy and degree of schooling. This study showed the importance of early diagnosis in DFS. This research is relevant due the lack of studies regarding the DFS at the Brazilian population.

Le mélanome métastatique représente le plus mortel des cancers cutanés par sa forte résistance aux thérapies conventionnelles. Les cellules initiatrices de tumeurs (CIT) sont présentes dans de nombreux cancers dont le mélanome. Ces cellules, capables de s’autorenouveller, sont à l’origine de la récidive tumorale et des métastases représentant une cible pour le développement de nouveaux traitements. Les CIT sont confinées dans un microenvironnement tumoral dans lequel des facteurs sécrétés tels que l'Insulin-Like Growth Factor-1 (IGF-1) et le Transforming growth factor (TGF-β) favorisent la transition épithéliomésenchymateuse (TEM), un processus clef lié à l’émergence des CIT. En utilisant des cellules de mélanome métastatique, nous avons montré qu’une inhibition d’IGF-1 induit une diminution de la tumorigénicité des cellules en diminuant la capacité des B16-F10 à former des métastases pulmonaires. Outre son action sur la prolifération cellulaire, IGF-1 est impliqué dans le processus de TEM favorisant les propriétés migratoires et invasives des cellules B16-F10. Par ailleurs, IGF-1 joue un rôle majeur dans le maintien des CIT expliquant la forte résistance des mélanomes aux thérapies conventionnelles. Des expériences préliminaires suggèrent que ces activités induites par IGF-1 pourraient être médiées en partie par le facteur TGF-β, un facteur clef de la TEM. D'autres résultats confortent cette hypothèse en montrant une implication directe du TGF-β dans le caractère souche des cellules B16-F10. Ces travaux montrent que l’inhibition de la voie IGF-1/IGF-1R dans le microenvironnement tumoral pourrait être une bonne stratégie pour le développement de traitements anti-tumoraux contre le mélanome. / Metastatic melanoma is arguably the most virulent among human cancers, owing to its propensity to metastasize, and its resistance to conventional therapies. Like in many other cancers, tumor stem cells or tumor initiating cells (TIC), have been identified in melanoma. These cells have the unique ability to self-sustain and renew the tumor and thus represent an interesting target for the development of new therapeutic strategies. TIC are nested in a confined microenvironment where secreted-factors such as Insulin-Like Growth Factor- 1 (IGF-1) and transforming growth factor (TGF-β) promote epithelialmesenchymal transition (EMT), a key process in stemness features acquisition. In this context, we investigated the effects IGF-1 on TIC behavior. Using B16-F10 metastatic melanoma cell line, we show that IGF-1 downregulation curbs lung metastasis suggesting that IGF-1 plays a direct role in the intrinsic tumorigenic potential of these cells.markers associated with an increased expression of the epithelial marker E-cadherin and of the major regulator of melanocyte differentiation MITF. Most importantly, IGF-1 inhibition sharply decreased stemness features, reducing the expression of key stem markers and functional characteristics of MIC. This was associated with an important sensitivity to mitoxantrone treatment. Interestingly, our preliminary data suggest the EMT key component, TGF-β, conveys IGF-1-mediated effects. Indeed, TGF-β directly affects B16-F10 stemness phenotype and markers. In summary, we show that the IGF-1/IGF-1R nexus represents an interesting target for the development of novel therapeutic strategies against metastatic melanoma.

1. Abstract Pheochromocytoma/ paraganglioma (FEO/PGL) may be developed on the basis of an inherited genetic mutation of different genes. They are associated with a high risk of developing of secondary hypertension, organ damage and metastatic disease that can be fatal. The aim was to focus on the possibility of genetic testing in patients with FEO/PGL, especially in patients with malignant tumors. The issue FEO/PGL, however, concerns not only the examination and assessment of risks arising therefrom, as well as other therapies and monitoring, including appropriate recommendations for clinical practice. We demonstrated a 20% incidence of cardiovascular (CV) complications before determining the final diagnosis of FEO/PGL, mainly arrhythmic, followed by complications of myocardial ischemia and accentuate atherosclerosis. Elevated levels of vitamin C and decreased levels of malondialdehyde (MDA) following the successful removal of the tumor demonstrated reduction of oxidative stress postoperatively. We found that early postoperative testing of levels of plasma metanephrines to confirm the success of surgical removal of FEO/PGL is already possible, since there was no significant correlation between plasma levels of metanephrines and postoperative examination interval. Distribution of frequency of metastatic...

During the epithelial-to-mesenchymal transition, the intracellular cytoskeleton undergoes severe reorganization which allows epithelial cells to transition into a motile mesenchymal phenotype. Among the different cytoskeletal elements, the intermediate filaments keratin (in epithelial cells) and vimentin (in mesenchymal cells) have been demonstrated to be useful and reliable histological markers. In this study, we assess the potential invasiveness of six human breast carcinoma cell lines and two mouse fibroblasts cells lines through single cell migration assays in confinement. We find that the keratin and vimentin networks behave mechanically the same when cells crawl through narrow channels and that vimentin protein expression does not strongly correlate to single cells invasiveness. Instead, we find that what determines successful migration through confining spaces is the ability of cells to mechanically switch from a substrate-dependent stress fibers based contractility to a substrate-independent cortical contractility, which is not linked to their tumor phenotype.

Immune checkpoint blockade (ICB) shows remarkable clinical effects in patients with metastatic microsatellite-unstable (MSI) cancer. However, markers identifying potential non-responders are missing. We examined the prevalence of Beta-2-microglobulin (B2M) mutations, a common immune evasion mechanism, in stage IV MSI gastrointestinal cancer and its influence on metastatic pattern and patients’ survival under ICB. Twentyfive patients with metastatic, MSI gastrointestinal adenocarcinoma were included. Eighteen patients received ICB with pembrolizumab and one patient with nivolumab/ ipilimumab. Sequencing was performed to determine B2M mutation status. B2M mutations and loss of B2M expression were detected in 6 out of 25 stage IV MSI cancers. B2M mutations were strongly associated with exclusively peritoneal/peritoneal and lymph node metastases (p=0.0055). However, no significant differences in therapy response (25% vs. 46.6%, p>0.99) and survival (median PFS: 19.5 vs 33.0 months, p=0.74; median OS 39 months vs. not reached, p>0.99) were observed between B2Mmutant and B2M-wild type tumor patients. Among metastatic MSI GI cancers, B2Mmutant tumors represent a biologically distinct disease with distinct metastatic patterns. To assess ICB response in B2M-mutant MSI cancer patients, future studies need to account for the fact that baseline survival of patients with B2M-mutant MSI cancer may be longer than of patients with B2M-wild type MSI cancer.

Die Zytokine Interleukin-2 und Interferon-a2a nehmen eine zentrale Stellung bei der Behandlung von Patienten mit metastasierten Nierenzellkarzinomen ein. Im klinischen Teil der Arbeit wurde die Effektivität der Chemoimmuntherapie monozentrisch an 107 Patienten untersucht. Es zeigte sich eine Rate objektiver Remissionen von 22 % (95 % CI 14,6 - 31,3 %) mit einer zusätzlichen Rate an vorübergehenden Stabilisierungen von 46 %. Das mediane Überleben lag bei 19 Monaten mit einer kalkulierten 5-Jahres-Überlebensrate von 17 %. In der multivariaten Analyse zeigte sich eine hochsignifikante Abhängigkeit vom Karnofsky-Performance-Index der Patienten. Bei den 83 Patienten mit einem Karnofsky-Performance-Index von über 80 % lag das mediane Überleben bei 23 Monaten mit einer kalkulierten 5-Jahres-Überlebensrate von 21 %. Diese Untersuchungsergebnisse rechtfertigen eine weitere Prüfung der Kombination von Interleukin-2, Interferon-a2a und 5-Fluorourazil im Rahmen prospektiver klinischer Studien. In Weiterentwicklung der klinischen Aspekte zur Zytokin-basierten Immuntherapie war es die Aufgabenstellung des experimentellen Teils dieser Arbeit, die Bedeutung von 70 kDa Hitzeschockproteinen (HSP70) beim Nierenzellkarzinom zu untersuchen. Neben ihrer Funktion im Rahmen der zellulären Stressverarbeitung haben Mitglieder der HSP70-Familie (HSP72 und HSP73) eine außerordentliche Bedeutung für tumorimmunologische Fragestellungen erlangt, die sich aus der immunologischen Signalfunktion, der HSP72-vermittelten Interaktion von immunologischen Effektorzellen und Tumorzellen und der Beteiligung von HSP70 an der Peptidprozessierung in malignen Zellen ergeben. An einer Nierenkarzinomzelllinie und an Primärzellen von Nierenkarzinomen konnte die HSP72-Oberfächenexpression durchflusszytometrisch auf der Tumorzelloberfläche nachgewiesen und an der Zelllinie mit einer erhöhten Lyse der Tumorzellen durch Interleukin-2 stimulierte NK-Zellen korreliert werden. Im Gegensatz zu bisherigen Literaturbefunden zeigte sich in diesem Modell jedoch, dass die Membranexpression von HSP72 nicht nur auf maligne Zellen beschränkt, sondern auch bei renalen Zellen aus Normalgewebe nachzuweisen war. In einer immunhistochemischen Studie zur basalen, zytoplasmatischen HSP72-Expression zeigte sich univariat eine signifikante Korrelation einer hohen HSP72-Expression und dem Überleben der Patienten. In einer multivariaten Analyse konnte das Ausmaß der HSP72-Expression als unabhängiger prognostischer Parameter identifiziert werden, der auch mit dem Ansprechen auf eine Chemoimmuntherapie korreliert. Die klinische Etablierung spezifisch wirksamer Vakzinen nimmt eine zentrale Rolle bei der Entwicklung neuer Behandlungsmethoden des metastasierten Nierenzellkarzinoms ein. Dabei spielen Vakzinen auf der Basis von HSP-Peptid-Vakzinen eine besondere Rolle. Ein weiterer Bestandteil der experimentellen Arbeiten war daher in der Entwicklung einer Methode zur Aufreinigung von HSP70-Peptid-Komplexen. Mit der ADP-Affinitätschromatographie konnte eine Methode zur Anwendung gebracht und patentiert werden, durch die sich HSP70-Peptid-Komplexe aus Tumorzellen anreichern lassen. Die HSP70-Peptid-Komplexe sind einerseits für HSP-basierte Vakzinekonzepte verfügbar oder können andererseits für die Identifikation und Charakterisierung HSP70-gebundenener biologisch-aktiver (immunogener) Peptide genutzt werden. Die vorliegenden Untersuchungsergebnisse demonstrieren, dass HSP72 per se eine prognostische Bedeutung beim Nierenzellkarzinom besitzt und weisen auf die potentielle Bedeutung von HSP72 als immunologische Zielstruktur hin. Die Resultate stellen neue Ansätze zum tieferen Verständnis der immunogenen Eigenschaften des Nierenzellkarzinoms dar und liefern Ausgangspunkte für die Etablierung innovativer Vakzinationskonzepte bei der Behandlung des fortgeschrittenen Nierenzellkarzinoms. / The cytokines interleukin-2 and interferon-a2a are of central importance in the treatment of patients with metastatic renal cell cancer. In the clinical part of the thesis the efficacy of chemoimmunotherapy was investigated monocentrically on 107 patients. It appeared a rate of objective remissions of 22% (95% CI 14.6 - 31.3%) and an additional rate of temporary disease stabilisations of 46%. The median survival was 19 months, with a calculated 5-year survival rate of 17%. Multivariate analysis revealed a highly significant dependence on the Karnofsky-Performance-Index of the patients. In 83 patients with Karnofsky-Performance-Index over 80% the median survival was 23 months, with a calculated 5-year survival of 21%. These results justify the further investigation of the combination of interleukin-2, interferon-a2a, and 5-fluorouracil in prospective clinical studies. In the context of the clinical aspects of cytokine-based immunotherapy it was the task of the the experimental part of the study to investigate the importance of 70 kDa heat shock proteins (HSP70) in renal cell cancer. Besides their function in cellular stress processing, members of the HSP70 family (HSP72 and HSP73) are especially important for answering questions of tumor immunology resulting from their immunological signal function, the HSP72-mediated interaction of immunological effector cells with tumor cells, and from the involvement of HSP70 in peptide processing in malignant cells. On the basis of a renal cancer cell line and of primary cells of renal carcinomas the HSP72 expression on the surface of tumor cells could be demonstrated by flow cytometry and correlated with an increased lysis of tumor cells on the cell line by interleukin-2 stimulated natural killer cells. In contrast to the findings so far reported in the literature, the present model revealed that the membrane expression of HSP72 was not limited to malignant cells but was detectable in renal cells of normal tissue too. In an immunohistochemical study on basal cytoplasmatical HSP72 expression, a univariate analysis showed a significant correlation of high HSP72 expression and patient survival. In a multivariate analysis the extent of the HSP72 expression could be identified as an independent prognostic parameter that was also correlated with the response of patients to chemoimmunotherapy. The clinical establishment of specifically effective vaccines plays a central part in the development of new treatment strategies for metastatic renal cell cancer. In this context, vaccines on the basis of HSP-peptides are of special interest. Therefore, the experimental part of the work was also aimed at developing a method for enriching HSP70-peptide complexes. With ADP affinity chromatography a method for concentrating HSP70-peptide complexes from tumor cells was created, which proved to be usable and was patented. On the one hand, HSP70-peptide complexes can be used for HSP-based vaccine programmes, on the other hand, they can serve for identifying and characterizing HSP70-bound biologically active (immunogenic) peptides. The present findings demonstrate that HSP72 per se has a prognostic value in renal cell cancer and point to the potential importance of HSP72 as an immunological target structure. The results represent new approaches to a deeper understanding of the immunological properties of renal cell carcinoma and give a basis from which to establish innovative vaccination programmes for the treatment of advanced renal cell carcinoma.

Background: Drugs targeting angiogenic pathway remain the mainstay of treatment for metastatic renal cell carcinoma (mRCC). Tyrosine Kinase Inhibitors (TKI) as Sunitinib, Pazopanib as single agents and humanised monoclonal antibody bevacizumab (Bev) in combination with Interferon- α2a (IFN) have established as the first-line therapy for mRCC. Despite improvements in treatment, there are multiple questions which remain unanswered. In the combination of Bev and IFN, the respective role of each drug and whether any additional anti-angiogenic activity is gained by adding IFN to Bev remains unknown. As the clinical benefit obtained with these cytostatic agents does not always correlate with the conventional response assessment techniques as RECIST, it is necessary to reconsider the methods by which we assess benefit from these therapies. In this thesis, I report three studies aiming to answer these questions. Methods: With the clinical trial reported here, I explore whether Bev induced changes in vascular parameters measured by Dynamic Contrast Enhanced MRI (DCE-MRI) is significantly enhanced by the addition of IFN. In a phase II, randomised, open labelled, multicentre trial, treatment naïve mRCC patients were randomised to receive Bev on its own or in combination with a low dose (3MU) or standard dose (9MU) IFN. DCE-MRI was used to assess the changes in vascularity with the primary endpoint being, changes in transfer coefficient (Ktrans) after six weeks of treatment. I also report two retrospective imaging-based studies, using contrast-enhanced CT scans, performed to improve the methodology of response assessment for these antiangiogenic therapeutics. Here I explore the use of a) combining changes in size and arterial phase contrast enhancement measured using CT scan and b) changes in CT texture as methods of therapeutic response assessment in mRCC patients treated with TKI. Results: With the phase 2 clinical trial, we faced significant difficulty in recruitment as a result of restrictions in access to treatment in NHS, other competing studies and restrictions proposed by the DCE-MRI inclusion criteria. With slow recruitment, an unplanned analysis was performed after 21 patients were recruited. Analysis of primary endpoint showed no trend in the difference between arms with no correlation found between change in Ktrans and addition of IFN to bevacizumab. Effect size analysis performed due to the small numbers recruited failed to show any significance in the observed difference in Ktrans. Change in Ktrans and Kep may identify a group of patients likely to have PFS > 6 months, but this observation needs to evaluation in a larger sample size. Measuring size and change in arterial phase enhancement retrospectively using CT, a new criterion "modified" Choi, which prerequisite a combination of a decrease in arterial phase density by 15% and a decrease in size by 10% for response was proposed. Response assessment was measured with RECIST, Choi and modified Choi individually in 20 evaluable patients retrospectively and clinical benefit compared with Kaplan-Meier statistics and Log-Rank test. Response assessment as defined by the modified Choi criteria successfully identified patients who received clinical benefit from the treatment. Time to progression (TTP) was 448 days for the partial response and 89 days for stable disease as per the new criteria which were statistically significant with a p-value of 0.002. The second retrospective analysis explored the textural changes in enhanced CT scan. Performed in collaboration with researchers from Brighton University who developed the software algorithm used to assess changes in entropy and uniformity, 87 metastases from 39 patients with mRCC were analysed at baseline and after two cycles of TKI treatment. Textural parameters and response assessment criteria were correlated with TTP. After two cycles of TKI, the decrease in tumour entropy was 3%-45%, and increase in uniformity was 5%-21%. At a threshold change of -2% with uniformity, on a coarse scale of 2.5, the textural change was able to separate responders from non-responders. With Kaplan-Meier analysis comparing all four criteria, the percentage change in uniformity was statistically more significant than for RECIST, Choi, and Modified Choi criteria. Cox regression analysis showed that texture uniformity was an independent predictor of time to progression. Discussion: With the studies reported here, I was able to demonstrate the importance of improving the methodology in assessment of therapeutic response to targeted anti-angiogenic therapy in metastatic renal cell carcinoma. Even though the clinical trial, terminated early due to slow recruitment, did not reach its primary endpoint, changes in other vascular parameters as Kep combined with changes Ktrans showed tendency towards identifying a group of patients who derived clinical benefit of >6months with these therapies. This is particularly exciting as given the vascular stabilisation effect proposed for bevacizumab, the effusion parameter Kep may be a better tool in assessing response rather than Ktrans and warrants further assessment in a larger cohort. Modified choi criterion and textural analysis are two important methodological improvements in response assessment of cytostatic anti-angiogenic therapy. In the analyses reported here, both techniques have shown superiority over RECIST in response assessment and differentiating mRCC patients who is likely to gain clinical benefit by TKI therapy. Validation of these criteria on a larger patient cohort is important. As these criterions are assessed on standard enhanced CT scans, incorporating these criteria, especially modified choi criterion, as part of standard CT assessment could be performed and will provide a real world validation. Retrospective assessment using larger cohort of patients from previous phase 3 trials or inclusion of these parameters prospectively in phase 3 trials would also help us in evaluating these modalities further.

INTRODUÇÃO: A insuficiência respiratória acomete grande parte dos pacientes oncológicos levando a altos índices de mortalidade. A ventilação não invasiva (VNI) pode auxiliar seu manejo, mas seus efeitos ainda são pouco conhecidos sobre os mecanismos de defesa pulmonar. OBJETIVOS: Observar o efeito da VNI com máscara facial usando-se geradores de fluxo com pressão positiva contínua (CPAP) e ventilador microprocessado no modo pressão de suporte + pressão positiva ao final da expiração (PSV + PEEP), a fim de verificar impacto nas propriedades viscoelásticas do muco respiratório e o conforto proporcionado ao paciente. MÉTODOS: A VNI foi instalada após diagnóstico de insuficiência respiratória em dezenove pacientes, admitidos nas unidades de tratamento intensivo do Hospital A. C. Camargo, sendo nove submetidos ao CPAP e dez com PSV + PEEP. Foram colhidos antes e após uma hora de VNI: os dados clínicos, secreção nasal, gasometria, e o grau de conforto através de uma escala visual. As propriedades físicas do muco (transportabilidade in vitro, adesividade e wettabilidade ou hidrofobicidade) foram avaliadas respectivamente no palato de rã, máquina da tosse e ângulo de contato. RESULTADOS: Os grupos eram homogêneos entre si em relação à idade, sexo, tipo e estadiamento do tumor e SAPS II. Em relação às propriedades físicas do muco, houve um aumento da transportabilidade in vitro do muco nasal com o sistema PSV + PEEP (p = 0,04) e um aumento na wettabilidade no grupo CPAP (p = 0,06). Os dois sistemas foram eficazes em melhorar significativamente os sinais vitais, a PaO2/FiO2, o padrão e o conforto respiratório e em evitar a intubação traqueal nas primeiras 24 horas (p < 0,05). Entretanto, independentemente do tipo de sistema de VNI usado, foram encontrados altos índices de intubação endotraqueal e mortalidade no seguimento destes pacientes. CONCLUSÃO: As propriedades físicas do muco (transportabilidade in vitro e wettabilidade) se alteraram após uma hora de uso da VNI e parecem ser dependentes da temperatura e umidificação dentro da máscara. A VNI mostrou-se útil em reverter a insuficiência respiratória em pacientes selecionados, ou pelo menos em trazer conforto para pacientes hipoxêmicos que a princípio recusam a intubação endotraqueal / INTRODUCTION: Respiratory failure is a common situation among cancer patients leading to high rates of mortality. Noninvasive ventilation (NIV) can help its management, but its effects are still unknown regarding the pulmonary defense mechanisms. OBJECTIVES: Observe the effect of NIV with facial mask using a flow generator with continuous positive pressure (CPAP) and standard intensive care unit ventilator using pressure support ventilation + positive end expiratory pressure (PSV + PEEP), to verify impact on the physical properties of respiratory mucus and the comfort provided to the patient. METHODS: NIV was started after diagnosis of respiratory failure in nineteen patients, admitted in the intensive care unit of the A. C. Camargo Hospital. Nine patients were submitted to CPAP and ten to PSV + PEEP. Nasal mucus, blood gases, and the degree of comfort through a visual scale were accessed before and after one hour. The physical properties of nasal mucus (transportabilility in vitro, adhesivity and wettability or hydrofobicity) were evaluated respectively by frog palate, cough machine and contact angle. RESULTS: Groups had similar characteristics about age, sex, tumor and SAPS II score. Regarding the physical properties of the mucus, there was an increase in mucus transportability (by the frog palate model) with the system PSV + PEEP (p = 0.04) and an increase in the contact angle in the CPAP groupo (p = 0.06). The two systems were effective in improving the vital signs, the PaO2/FiO2, the respiratory pattern and comfort and avoiding endotracheal intubation in the first 24 hours (p < 0.05). However, regardless of the type of NIV system used, high rates of endotracheal intubation and mortality were found. CONCLUSION: The physical properties of the mucus (transportability in vitro and wettability) changed after an hour of use of the NIV as a result of temperature and humidification into the mask. NIV was useful in reversing the respiratory failure in selected patients, or at least in bringing comfort for those who refuse endotracheal intubation