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Diss. (sammanfattning) Umeå : Umeå universitet, 2006. / Härtill 4 uppsatser.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19569号 / 医博第4076号 / 新制||医||1017(附属図書館) / 32605 / 京都大学大学院医学研究科医学専攻 / (主査)教授 江藤 浩之, 教授 武藤 学, 教授 中畑 龍俊 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

OBJETIVO: Investigar o efeito da expressão de RNAm dos SMADs e de microRNAs (miRNAs) que possuem o TGFB1 como alvo na expressão gênica (RNAm e proteína) de TGF-β1 e seu papel na fisiopatologia da angiogênese em pacientes com mielofibrose (MF) e trombocitemia essencial (TE). MÉTODOS: Foram incluídos 21 pacientes com MF primária (MFP), 21 com MF pós-TE (MFPTE) e 24 com TE, além de 98 indivíduos controles pareados de acordo com gênero e idade com os pacientes. As análises realizadas no sangue periférico foram: quantificação das concentrações plasmáticas e de RNAm de TGFB1, VEGFA e FGF2; quantificação de RNAm de SMADs 1 a 7 e de miRNAs 193a-5p, 369-5p, 542-5p, 590-3p, e 590- 5p; e detecção das mutações JAK2V617F (com quantificação alélica), MPLW515K/L e CALR. Em 26 biópsias de medula óssea dos pacientes, foram determinados o grau de microvasculatura (angiogênese estimada - CD34), a imunoexpressão de TGF-b1 ativo, TGF-β1 latente e c-MPL. RESULTADOS: As concentrações de TGF- β1 plasmático foram semelhantes entre os pacientes e controles, enquanto o VEGFA plasmático foi maior em todos os grupos de pacientes comparados aos seus controles. O FGF2 plasmático também foi maior em todos os grupos de pacientes, e a expressão de seu RNAm foi maior nos pacientes com TE do que em seus controles. As expressões de SMADs e de miRNAs foram semelhantes entre pacientes e controles. TGF-β1 e FGF2 plasmáticos apresentaram correlações positivas nos pacientes com MFP, e correlações negativas nos seus controles, assim como nos controles de MFPTE. Em todos os grupos estudados foi observada correlação positiva entre TGF-β1 e VEGFA plasmáticos. Além disso, foram demonstrados diferentes perfis de correlações entre a expressão gênica de TGF-β1 e os diversos SMADs e miRNAs em cada grupo de pacientes e controles. Os pacientes com MFP com maior angiogênese (de acordo com a mediana da concentração plasmática de VEGFA e FGF2) apresentaram maiores concentrações plasmáticas de TGF-β1 do que aqueles com menor angiogênese. A angiogênese medular estimada (CD34) não foi diferente entre os três grupos de pacientes estudados. Além disso, não foram encontradas correlações entre a imunoexpressão de CD34 e as expressões de RNAm de TGFB1, VEGFA e FGF2 medulares nem em leucócitos de sangue periférico, ou a concentrações plasmáticas de TGF-β1, VEGFA e FGF2. As imunoexpressões de TGF-b1 ativo, TGF-β1 latente e c-MPL foram semelhantes entre os três grupos de pacientes. As frequências das mutações avaliadas foram similares às descritas na literatura. Os pacientes com MFPTE portadores de mutação CALR apresentaram menores concentrações plasmáticas de VEGFA e FGF2 do que os JAK2V617F positivos, enquanto os pacientes com TE portadores de mutação CALR exibiram menores concentrações plasmáticas de TGF-β1 do que os portadores de JAK2V617F. CONCLUSÕES: O presente trabalho permitiu confirmar a correlação positiva entre o TGF-β1 com outros dois marcadores de angiogênese (VEGFA e FGF2). As expressões de SMADs e de miRNAs estudados foram semelhantes entre pacientes e controles, visto não haver diferenças na expressão gênica de TGF-β1. Entretanto, disparidades encontradas nas correlações entre a expressão gênica de TGF-β1 e diferentes SMADs e miRNAs nos pacientes e controles poderiam indicar que a regulação da expressão gênica de TGF-β1 nas doenças estudadas seja distinta da apresentada nos indivíduos sem essas doenças. / AIM: To investigate the effects of the expression of SMADs mRNA and microRNAs (miRNAs) that target TGFB1 in TGF-β1 gene expression (mRNA and protein) and its role in the angiogenesis pathophysiology in myelofibrosis (MF) and essential thrombocythemia (ET) patients. METHODS: Twenty-one primary MF (PMF), twenty-one MF post-ET (MPET) and twenty-four ET patients were included, besides 98 controls matched for gender and age with patients. In peripheral blood were assessed: TGF-β1, VEGFA and FGF2 plasmatic levels and mRNA quantification; SMADs 1 to 7 mRNA quantification and miRNAs 193a-5p, 369-5p, 542-5p, 590-3p, and 590-5p quantification; and detection of JAK2V617F (and allele burden), MPLW515K/L and CALR mutations. Estimated angiogenesis (microvessel grade - CD34), active TGF-b1, latent TGF-β and c-MPL immunoexpression were determined in 26 bone marrow biopsies. RESULTS: Plasmatic TGF-β1 levels were similar in patients and controls, while all the patients groups had higher plasmatic VEGFA than controls. Plasmatic FGF2 was higher in all the patients groups, and its mRNA expression was higher in ET patients than in controls. No differences in SMADs and miRNAs expression were found between patients and controls. There was a positive correlation between plasmatic TGF-β1 and FGF2 in PMF, and a negative correlation between these variables in their controls, as well as in MPET controls. In all studied groups, there was a positive correlation between plasmatic TGF-β1 and VEGF. In addition, different profiles of correlations were demonstrated between TGF-β1 gene expression and the several SMADs and miRNAs studied in each group of patients and controls. PMF patients with higher angiogenesis (according to the median of VEGFA and FGF2 plasma levels) had higher plasmatic TGF-β1 levels than those with lower angiogenesis. Estimated angiogenesis (CD34) in bone marrow biopsies were not different among PMF, MPET and ET patients. Moreover, there were no correlation between CD34 immunoexpression and TGFB1, VEGFA and FGF2 mRNA bone marrow or peripheral blood expression or plasmatic levels, as well as latent TGF-β1, active TGF-b1, and c-MPL immunoexpression were similar in patients studied groups. The frequencies of evaluated mutations were similar to previously reported. MPET patients harboring CALR mutations had lower plasmatic VEGFA and FGF2 than JAK2V617F mutated, while ET patients carrying CALR mutations had lower plasmatic TGF-β1 than JAK2V617F mutated. CONCLUSIONS: This study confirmed the positive correlation among TGF-β1 and two other markers of angiogenesis (VEGFA and FGF2). SMADs and miRNAs expressions were similar between patients and controls, since there were no differences in TGF-β1 gene expression between patients and controls. However, disparities found in the correlations between TGF-β1 gene expression and different SMADs and miRNAs in patients and controls may indicate that TGF-β1 gene expression regulation in studied diseases is distinct from those presented by individuals without these diseases.

As neoplasias mieloproliferativas (NMPs) são um grupo de doenças derivadas de uma transformação clonal de célula tronco hematopoiéticas no qual a linhagem celular mielóide é predominantemente expandida no sangue periférico. As NMPs Philadelphia-negativas incluem policitemia vera (PV), trombocitemia essencial (TE) e mielofibrose primária (MFP) que compartilham muitas características hematológicas, clínicas e evolutivas. A mutação da JAK2 (JAK2V617F) está presente em cerca de 95% dos pacientes com PV, entre 50 a 70% com TE e 40 a 50% com MFP. No entanto, os testes moleculares para diagnóstico são muitas vezes um desafio devido ao alto custo e a disponibilidade de equipamentos especializados. Objetivo: Verificar o impacto do teste molecular da mutação JAK2V617F para o diagnóstico de NMPs nos pacientes atendidos no Hospital de Clínicas de Porto Alegre. Métodos: Foram avaliados 87 pacientes com suspeita de NMPs. As amostras de sangue periférico foram analisadas para a mutação JAK2V617F pelo método genético molecular de PCR alelo-específico e os resultados correlacionados com os dados clínico-laboratoriais. Para estabelecimento do diagnóstico, foram utilizados os critérios da Organização Mundial da Saúde (OMS) de 2016. Resultados: Dos 87 pacientes avaliados, 27,6% foram diagnosticados como PV, 39,1% como TE, 4,6% como MFP e 28,7% não contemplavam os critérios para o diagnóstico NMPs. A comparação da utilização do teste da mutação JAK2V617F mostrou que, apenas 41,7% dos pacientes com PV sem utilizar o teste, teriam sido diagnosticados comparados a 91,7% utilizando este teste como um dos critérios no diagnóstico final (p = 0,004). Na TE e na MFP, este critério não foi estatisticamente significativo. Conclusão: O teste molecular para a mutação de JAK2V617F no nosso hospital teve um impacto significativo no diagnóstico dos pacientes com PV, mostrando ser uma ferramenta importante para o diagnóstico final desta NMP. / Myeloproliferative neoplasms (MPNs) are a group of disorders derived from a clonal transformation of stem cell on which myeloid cell lineage is predominantly expanded in the peripheral blood. Philadelphia-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) which share many hematological, clinical, and evolutionary characteristics. The JAK2 mutation (JAK2V617F) is present in about 95% of patients with PV, between 50 to 70% with ET and 40 to 50% PMF. However, the molecular diagnostic tests are often a challenge due to the high cost and the availability of specialized equipment. Objective: To verify the impact of molecular testing of the JAK2V617F mutation for the diagnosis of MPNs in patients attended at Hospital de Clinics, Porto Alegre. Methods: A total of 97 patients were evaluated with suspected of MPNs. The peripheral blood samples were analyzed for the JAK2V617F mutation by the molecular genetic allelespecific PCR method and the results correlated with the clinical-laboratory data. To establish the diagnosis, the 2016 World Health Organization (WHO) criteria were used. Results: Of the 87 patients evaluated, 27.6% were diagnosed as PV, 39.1% as ET, 4.6% as PMF and 28.7% did not meet criteria for MPNs diagnosis. Comparison of the use of the JAK2V617F test showed that only 41.7% of patients with PV without the mutation test were diagnosed compared to 91.7% using this test as one of the criteria for the final diagnosis (p = 0.004). In the ET and the PMF, this criterion was not statistically significant. Conclusion: The molecular test for the JAK2V617F mutation in our hospital had a significant impact in the diagnosis of patients with PV, showing to be an important tool for the final diagnosis of this MPN.

La myélofibrose primitive (MFP) est un néoplasme myéloprolifératif (NMP) chronique BCR-ABL1-négatif associant une dérégulation de l’hématopoïèse (myéloprolifération, dysmégacaryopoïèse et migration des cellules souches et progéniteurs hématopoïétiques (CSH/PH)) à une altération du stroma médullaire et splénique (fibrose ostéomyélosclérose, néoangiogenèse). Le mégacaryocyte (MK) est un acteur majeur de sa pathogenèse, via la production de cytokines et facteurs fibrosants, dans un contexte inflammatoire. Plusieurs arguments suggèrent que les mutations JAK2V617F et MPL515L/K qui caractérisent les NMP ne sont pas les événements initiaux de la MFP car elles ne sont retrouvées que chez la moitié des patients. L’objectif de mon travail a été de rechercher si d’autres anomalies, géniques ou non, pouvaient expliquer la pathogenèse de la MFP. Pour cela, parallèlement à une démarche génomique (transcriptome et CGH array), nous avons développé une approche de biologie cellulaire ciblée sur le rôle du stroma hématopoïétique. Bien que n’ayant pas identifié d’autres anomalies génomiques que celles décrites dans la littérature et en particulier, la délétion 13q, les approches génomiques que nous avons développées nous ont permis de préciser les bornes de cette délétion dans les PH CD34+ et les polynucléaires des patients. Cette délétion (région chromosomique minimale 13q14-13q21) est située à 2 mégabases (télomérique) du cluster FLT où est localisé le gène FLT3. Plusieurs arguments nous ont ensuite conduits à rechercher si le couple Flt3-ligand/Flt3 était impliqué dans la dérégulation de l’hématopoïèse et plus particulièrement dans la dysmégacaryopoïèse observée chez les patients. Parmi ceux-ci, citons : 1) l’existence d’une modulation d’expression de gènes inclus dans la zone de délétion 13q et dans le cluster FLT, dont le gène FLT3 et 2) le fait que Flt3, un récepteur clé de la régulation de l’hématopoïèse primitive, soit souvent impliqué dans la pathogenèse d’hémopathies malignes et que son ligand, Flt3-ligand, soit majoritairement produit par le stroma hématopoïétique. Notre étude montre une dérégulation de Flt3 et des MAPKs p38 dans les PH CD34+ et les MK des patients atteints de MFP et ceci, quelque soit leur statut mutationnel Jak2. Elle démontre également que la persistance de la stimulation de l’axe Flt3/p38 en réponse à une production accrue de Flt3 ligand, participe à la dysmégacaryopoïèse qui caractérise la maladie. En effet, nous avons mis en évidence : 1) une augmentation du taux sérique de Flt3 ligand et de son expression par les cellules du stroma médullaire et splénique ainsi que par les PH des patients atteints de MFP, 2) une surexpression spécifique de son récepteur Flt3 et de sa phosphorylation dans les CSH/PH CD34+ et les progéniteurs mégacaryocytaires (MK), qui persistent au cours de la différenciation MK, quelque soit le statut mutationnel de Jak2 des patients, 3) une activation de Flt3 dans les progéniteurs MK en réponse au Flt3 ligand conduisant à la phosphorylation en cascade de la voie de signalisation des MAPKs p38 et à l’expression de ses gènes cibles tels que AP-1, p53, NFATc4, ATF2, IL-8, 4) une restauration de la mégacaryopoïèse et une inhibition de la migration (Flt3-ligand)-dépendante des progéniteurs MK des patients après inhibition de Flt3 ou de p38.Nos résultats confirment l’importance d’une altération des MAPKs dans une dérégulation de l’hématopoïèse et soulignent le rôle d’une activation persistante de la voie p38, via le couple Flt3-ligand/Flt3, dans la dysmégacaryopoïèse qui caractérise la myélofibrose primitive. Ils suggèrent également que cette dérégulation participe au processus inflammatoire à l’origine de la réaction stromale et « lit » d’une transformation leucémique potentielle. Ce dialogue altéré entre les cellules hématopoïétiques pathologiques (Bad seeds), en particulier mégacaryocytaires et les cellules stromales (Bad soil), conforte notre concept « Bad seeds in Bad soil ». / The primary myelofibrosis (PMF) is a chronic myeloproliferative neoplasm (NMP) BCR-ABL1-negative associating a dysregulation of hematopoiesis (myeloproliferation, dysmegacaryopoiesis and egress of hematopoietic stem and progenitor cells (HSC / PH)) from an altered bone marrow stroma (osteosclerosis, fibrosis, angiogenesis) to the spleen. The megakaryocyte (MK) is a major player in its pathogenesis through the production of cytokines and fibrotic factors in an inflammatory context. Several arguments suggest that mutations JAK2V617F and MPL515L / K which characterize the NMP are not the initial events of the PMF since they are found only in half of patients. The aim of my work was to investigate whether other abnormalities, genetic or otherwise, could explain the pathogenesis of the PMF. For this, a process parallel to genomics (transcriptome and CGH array), we developed a cell biology approach focused on the role of hematopoietic stroma.Although we have not identified other genomic abnormalities as those described in the literature and in particular, deletion 13q, by genomic approaches we have clarified the limits of this deletion in the PH CD34+ and polymorphonuclear patients. This deletion (chromosomal region 13q14-13q21 minimum) is located 2 megabases (telomeric) of the cluster where is located the FLT gene FLT3. Several arguments have then led to inquire whether the couple was involved in Flt3-ligand/Flt3 deregulation of hematopoiesis, especially in the dysmegakaryopoiesis observed in patients. Among these are: 1) the existence of an expression modulation of genes included in the area of deletion 13q and FLT in the cluster, as gene FLT3 and 2) the fact that Flt3, a key receptor the regulation of primitive hematopoiesis, is often implicated in the pathogenesis of hematologic malignancies and its ligand, Flt3-ligand, was predominantly produced by the hematopoietic stroma.Our study shows dysregulation of Flt3 and p38 MAPKs in CD34+ and PH MK from patients with PMF and this, whatever their Jak2 mutation status. It also shows that persistent stimulation of the axis Flt3/p38 in response to increased production of Flt3 ligand, participates in the dysmegacaryopoiesis that characterizes the disease. Indeed, we have highlighted: 1) an increase in serum Flt3 ligand and its expression by stromal cells and bone marrow and spleen by PH patients with PMF, 2) a specific overexpression of its receptor Flt3 and its phosphorylation in HSC / PH CD34+ and megakaryocytic progenitors (MK), which persist during the MK differentiation, regardless of the mutational status of Jak2 patients, 3) activation of Flt3 in MK progenitors by the Flt3 ligand leads to phosphorylation cascade signaling pathway, p38 MAPK and expression of its target genes such as AP-1, p53, NFATc4, ATF2, IL-8, 4) a restoration of megakaryopoiesis and inhibition of migration (Flt3-ligand)-dependent patients after of MK progenitors by Flt3 or p38 inhibitors.Our results confirm the importance of an alteration of MAPKs in a deregulation of hematopoiesis and highlight the role of a persistent activation of the p38 pathway, via the couple Flt3-ligand/Flt3 in the dysmegakaryopoiesis that characterizes idiopathic myelofibrosis. They also suggest that this dysregulation contributes to the inflammatory process at the origin of the stromal reaction and "bed" of a leukemic transformation potential. The dialogue among impaired hematopoietic cell disease (Bad Seeds), especially the stromal cells and megakaryocyte (Bad Soil), reinforces our concept of "Bad Seeds in Bad Soil". This work could help improve the dialogue with therapeutic approaches targeting the axis Flt3-ligand/Flt3 mediated by activation of p38 which, by reducing the inflammatory process, re-establish a link between the "seed" and the "Soil".

La myélofibrose (MF) est la plus agressive des néoplasies myéloprolifératives (NMP). Elle porte à elle seule le plus mauvais pronostic pour les patients puisqu’elle s’accompagne d’une fibrose de la moelle osseuse évoluant vers une insuffisance médullaire. Les inhibiteurs de la kinase JAK2 ont apporté de nouveaux espoirs pour le traitement des NPM mais leurs effets ont été essentiellement bénéfiques sur les symptômes et non sur la fibrose elle-même ni sur le cours de la maladie. Plus récemment, la protéine de choc thermique 90 (HSP90) - connue pour stabiliser JAK2 - est apparue comme une cible thérapeutique prometteuse pour les NMP. Cependant, les inhibiteurs de la HSP90 ont montré une toxicité importante accompagnée d’une expression compensatoire des HSPs inductibles (i.e HSP70, HSP27), connues pour favoriser l’émergence de phénomène de résistance. Par ailleurs, des études ont montré que HSP27 était fortement exprimée chez les patients présentant une fibrose pulmonaire idiopathique ou rénale montrant l’importance de HSP27 dans les processus fibrotiques. Sur la base de l’ensemble de ces données, nous avons évalué d’une part l'efficacité chez l’animal d'un oligonucléotide inhibiteur spécifique de HSP27 appelé OGX-427 (en essai clinique dans plusieurs cancers). D’autre part, nous avons déterminé le niveau d’expression intra- et extracellulaire de HSP27 chez des patients atteints de MF. L'effet de l'OGX-427 a été évalué dans deux modèles murins de myélofibrose, laquelle est induite soit par la sécrétion excessive de thrombopoïétine (TPOhigh) soit par la mutation JAKV617F. Nous avons mis en évidence dans les souris traitées par l’OGX-427, une réduction de la taille de la rate, de la prolifération mégacaryocytaire et de l’hématopoïèse extramédullaire par rapport aux souris contrôles, révélant ainsi un effet bénéfique de l’inhibition de HSP27 sur la progression de la maladie. De toutes récentes observations complémentaires à ce travail ont également montré une diminution de la fibrose réticulinique dans la moelle osseuse de souris JAKV617F. Au niveau moléculaire, nous démontrons que l'effet prolifératif induit par la voie de signalisation exacerbée - JAK2/STAT5 - est régulé par HSP27 via des interactions directes. Pour finir, nous avons détecté une augmentation de l'expression de HSP27 aussi bien dans les progéniteurs circulants CD34+ que dans le sérum des patients atteints de NMP avec MF. Ce travail révèle pour la première fois le rôle intra et extracellulaire de HSP27 dans la physiopathologie de la MF et le bénéfice thérapeutique potentiel de l’utilisation des inhibiteurs de HSP27 dans cette maladie. / Myelofibrosis (MF) is the most aggressive myeloproliferative neoplasms (MPN) with the highest degree of morbidity and mortality, including progressive bone marrow fibrosis resulting into bone marrow failure. JAK2 kinase inhibitors have been successfully used for a few years in MPN and more particularly for MF treatment. Nevertheless, their beneficial effects are mainly restricted on symptoms and not on the course of the disease. Recently, heat shock protein 90 (HSP90) - known to stabilize JAK2 - has been reported as a promising therapeutic target in MPN. However HSP90 inhibitors show toxicity and induce the expression of stress-inducible proteins such as HSP70 and, most likely HSP27 as previously shown in other cancers. In addition, we and others have shown that HSP27, was strongly expressed in patients with idiopathic pulmonary or kidney tubulointerstitial fibrosis, underlying a relevant role of HSP27 in fibrotic processes. Taking into account both the beneficial effects of HSP inhibitors in leukemia and in MPN, and the possible implication of HSP27 in fibrosis, we have evaluated here the status of HSP27 in MF patient’s samples and assess the effectiveness of an HSP27 oligonucleotide inhibitor called OGX-427 in murine models. We report here the effect of OGX-427 in two murine models of thrombopoietin- and JAKV617F-induced myelofibrosis. OGX-427 limited the progression of the disease associated with a reduction of spleen weight and of megakaryocytic expansion. And more recently, our additional results show a decrease of reticulin fibrosis in JAK2V617F’s bone marrow. We show that HSP27 regulates JAK2/STAT5 proliferative effect through direct interactions, and we report an increase expression of HSP27 both in CD34+ circulating progenitors and in the serum of patients with NMP with fibrosis. Taking altogether, this work supports that extra and intracellular HSP27 plays a key role of in the pathophysiology in MF and highlight the potential therapeutic benefit of HSP27 inhibitors in this disorder.

As neoplasias mieloproliferativas (NMPs) são um grupo de doenças derivadas de uma transformação clonal de célula tronco hematopoiéticas no qual a linhagem celular mielóide é predominantemente expandida no sangue periférico. As NMPs Philadelphia-negativas incluem policitemia vera (PV), trombocitemia essencial (TE) e mielofibrose primária (MFP) que compartilham muitas características hematológicas, clínicas e evolutivas. A mutação da JAK2 (JAK2V617F) está presente em cerca de 95% dos pacientes com PV, entre 50 a 70% com TE e 40 a 50% com MFP. No entanto, os testes moleculares para diagnóstico são muitas vezes um desafio devido ao alto custo e a disponibilidade de equipamentos especializados. Objetivo: Verificar o impacto do teste molecular da mutação JAK2V617F para o diagnóstico de NMPs nos pacientes atendidos no Hospital de Clínicas de Porto Alegre. Métodos: Foram avaliados 87 pacientes com suspeita de NMPs. As amostras de sangue periférico foram analisadas para a mutação JAK2V617F pelo método genético molecular de PCR alelo-específico e os resultados correlacionados com os dados clínico-laboratoriais. Para estabelecimento do diagnóstico, foram utilizados os critérios da Organização Mundial da Saúde (OMS) de 2016. Resultados: Dos 87 pacientes avaliados, 27,6% foram diagnosticados como PV, 39,1% como TE, 4,6% como MFP e 28,7% não contemplavam os critérios para o diagnóstico NMPs. A comparação da utilização do teste da mutação JAK2V617F mostrou que, apenas 41,7% dos pacientes com PV sem utilizar o teste, teriam sido diagnosticados comparados a 91,7% utilizando este teste como um dos critérios no diagnóstico final (p = 0,004). Na TE e na MFP, este critério não foi estatisticamente significativo. Conclusão: O teste molecular para a mutação de JAK2V617F no nosso hospital teve um impacto significativo no diagnóstico dos pacientes com PV, mostrando ser uma ferramenta importante para o diagnóstico final desta NMP. / Myeloproliferative neoplasms (MPNs) are a group of disorders derived from a clonal transformation of stem cell on which myeloid cell lineage is predominantly expanded in the peripheral blood. Philadelphia-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) which share many hematological, clinical, and evolutionary characteristics. The JAK2 mutation (JAK2V617F) is present in about 95% of patients with PV, between 50 to 70% with ET and 40 to 50% PMF. However, the molecular diagnostic tests are often a challenge due to the high cost and the availability of specialized equipment. Objective: To verify the impact of molecular testing of the JAK2V617F mutation for the diagnosis of MPNs in patients attended at Hospital de Clinics, Porto Alegre. Methods: A total of 97 patients were evaluated with suspected of MPNs. The peripheral blood samples were analyzed for the JAK2V617F mutation by the molecular genetic allelespecific PCR method and the results correlated with the clinical-laboratory data. To establish the diagnosis, the 2016 World Health Organization (WHO) criteria were used. Results: Of the 87 patients evaluated, 27.6% were diagnosed as PV, 39.1% as ET, 4.6% as PMF and 28.7% did not meet criteria for MPNs diagnosis. Comparison of the use of the JAK2V617F test showed that only 41.7% of patients with PV without the mutation test were diagnosed compared to 91.7% using this test as one of the criteria for the final diagnosis (p = 0.004). In the ET and the PMF, this criterion was not statistically significant. Conclusion: The molecular test for the JAK2V617F mutation in our hospital had a significant impact in the diagnosis of patients with PV, showing to be an important tool for the final diagnosis of this MPN.

As neoplasias mieloproliferativas (NMPs) são um grupo de doenças derivadas de uma transformação clonal de célula tronco hematopoiéticas no qual a linhagem celular mielóide é predominantemente expandida no sangue periférico. As NMPs Philadelphia-negativas incluem policitemia vera (PV), trombocitemia essencial (TE) e mielofibrose primária (MFP) que compartilham muitas características hematológicas, clínicas e evolutivas. A mutação da JAK2 (JAK2V617F) está presente em cerca de 95% dos pacientes com PV, entre 50 a 70% com TE e 40 a 50% com MFP. No entanto, os testes moleculares para diagnóstico são muitas vezes um desafio devido ao alto custo e a disponibilidade de equipamentos especializados. Objetivo: Verificar o impacto do teste molecular da mutação JAK2V617F para o diagnóstico de NMPs nos pacientes atendidos no Hospital de Clínicas de Porto Alegre. Métodos: Foram avaliados 87 pacientes com suspeita de NMPs. As amostras de sangue periférico foram analisadas para a mutação JAK2V617F pelo método genético molecular de PCR alelo-específico e os resultados correlacionados com os dados clínico-laboratoriais. Para estabelecimento do diagnóstico, foram utilizados os critérios da Organização Mundial da Saúde (OMS) de 2016. Resultados: Dos 87 pacientes avaliados, 27,6% foram diagnosticados como PV, 39,1% como TE, 4,6% como MFP e 28,7% não contemplavam os critérios para o diagnóstico NMPs. A comparação da utilização do teste da mutação JAK2V617F mostrou que, apenas 41,7% dos pacientes com PV sem utilizar o teste, teriam sido diagnosticados comparados a 91,7% utilizando este teste como um dos critérios no diagnóstico final (p = 0,004). Na TE e na MFP, este critério não foi estatisticamente significativo. Conclusão: O teste molecular para a mutação de JAK2V617F no nosso hospital teve um impacto significativo no diagnóstico dos pacientes com PV, mostrando ser uma ferramenta importante para o diagnóstico final desta NMP. / Myeloproliferative neoplasms (MPNs) are a group of disorders derived from a clonal transformation of stem cell on which myeloid cell lineage is predominantly expanded in the peripheral blood. Philadelphia-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) which share many hematological, clinical, and evolutionary characteristics. The JAK2 mutation (JAK2V617F) is present in about 95% of patients with PV, between 50 to 70% with ET and 40 to 50% PMF. However, the molecular diagnostic tests are often a challenge due to the high cost and the availability of specialized equipment. Objective: To verify the impact of molecular testing of the JAK2V617F mutation for the diagnosis of MPNs in patients attended at Hospital de Clinics, Porto Alegre. Methods: A total of 97 patients were evaluated with suspected of MPNs. The peripheral blood samples were analyzed for the JAK2V617F mutation by the molecular genetic allelespecific PCR method and the results correlated with the clinical-laboratory data. To establish the diagnosis, the 2016 World Health Organization (WHO) criteria were used. Results: Of the 87 patients evaluated, 27.6% were diagnosed as PV, 39.1% as ET, 4.6% as PMF and 28.7% did not meet criteria for MPNs diagnosis. Comparison of the use of the JAK2V617F test showed that only 41.7% of patients with PV without the mutation test were diagnosed compared to 91.7% using this test as one of the criteria for the final diagnosis (p = 0.004). In the ET and the PMF, this criterion was not statistically significant. Conclusion: The molecular test for the JAK2V617F mutation in our hospital had a significant impact in the diagnosis of patients with PV, showing to be an important tool for the final diagnosis of this MPN.

OBJETIVO: Investigar o efeito da expressão de RNAm dos SMADs e de microRNAs (miRNAs) que possuem o TGFB1 como alvo na expressão gênica (RNAm e proteína) de TGF-β1 e seu papel na fisiopatologia da angiogênese em pacientes com mielofibrose (MF) e trombocitemia essencial (TE). MÉTODOS: Foram incluídos 21 pacientes com MF primária (MFP), 21 com MF pós-TE (MFPTE) e 24 com TE, além de 98 indivíduos controles pareados de acordo com gênero e idade com os pacientes. As análises realizadas no sangue periférico foram: quantificação das concentrações plasmáticas e de RNAm de TGFB1, VEGFA e FGF2; quantificação de RNAm de SMADs 1 a 7 e de miRNAs 193a-5p, 369-5p, 542-5p, 590-3p, e 590- 5p; e detecção das mutações JAK2V617F (com quantificação alélica), MPLW515K/L e CALR. Em 26 biópsias de medula óssea dos pacientes, foram determinados o grau de microvasculatura (angiogênese estimada - CD34), a imunoexpressão de TGF-b1 ativo, TGF-β1 latente e c-MPL. RESULTADOS: As concentrações de TGF- β1 plasmático foram semelhantes entre os pacientes e controles, enquanto o VEGFA plasmático foi maior em todos os grupos de pacientes comparados aos seus controles. O FGF2 plasmático também foi maior em todos os grupos de pacientes, e a expressão de seu RNAm foi maior nos pacientes com TE do que em seus controles. As expressões de SMADs e de miRNAs foram semelhantes entre pacientes e controles. TGF-β1 e FGF2 plasmáticos apresentaram correlações positivas nos pacientes com MFP, e correlações negativas nos seus controles, assim como nos controles de MFPTE. Em todos os grupos estudados foi observada correlação positiva entre TGF-β1 e VEGFA plasmáticos. Além disso, foram demonstrados diferentes perfis de correlações entre a expressão gênica de TGF-β1 e os diversos SMADs e miRNAs em cada grupo de pacientes e controles. Os pacientes com MFP com maior angiogênese (de acordo com a mediana da concentração plasmática de VEGFA e FGF2) apresentaram maiores concentrações plasmáticas de TGF-β1 do que aqueles com menor angiogênese. A angiogênese medular estimada (CD34) não foi diferente entre os três grupos de pacientes estudados. Além disso, não foram encontradas correlações entre a imunoexpressão de CD34 e as expressões de RNAm de TGFB1, VEGFA e FGF2 medulares nem em leucócitos de sangue periférico, ou a concentrações plasmáticas de TGF-β1, VEGFA e FGF2. As imunoexpressões de TGF-b1 ativo, TGF-β1 latente e c-MPL foram semelhantes entre os três grupos de pacientes. As frequências das mutações avaliadas foram similares às descritas na literatura. Os pacientes com MFPTE portadores de mutação CALR apresentaram menores concentrações plasmáticas de VEGFA e FGF2 do que os JAK2V617F positivos, enquanto os pacientes com TE portadores de mutação CALR exibiram menores concentrações plasmáticas de TGF-β1 do que os portadores de JAK2V617F. CONCLUSÕES: O presente trabalho permitiu confirmar a correlação positiva entre o TGF-β1 com outros dois marcadores de angiogênese (VEGFA e FGF2). As expressões de SMADs e de miRNAs estudados foram semelhantes entre pacientes e controles, visto não haver diferenças na expressão gênica de TGF-β1. Entretanto, disparidades encontradas nas correlações entre a expressão gênica de TGF-β1 e diferentes SMADs e miRNAs nos pacientes e controles poderiam indicar que a regulação da expressão gênica de TGF-β1 nas doenças estudadas seja distinta da apresentada nos indivíduos sem essas doenças. / AIM: To investigate the effects of the expression of SMADs mRNA and microRNAs (miRNAs) that target TGFB1 in TGF-β1 gene expression (mRNA and protein) and its role in the angiogenesis pathophysiology in myelofibrosis (MF) and essential thrombocythemia (ET) patients. METHODS: Twenty-one primary MF (PMF), twenty-one MF post-ET (MPET) and twenty-four ET patients were included, besides 98 controls matched for gender and age with patients. In peripheral blood were assessed: TGF-β1, VEGFA and FGF2 plasmatic levels and mRNA quantification; SMADs 1 to 7 mRNA quantification and miRNAs 193a-5p, 369-5p, 542-5p, 590-3p, and 590-5p quantification; and detection of JAK2V617F (and allele burden), MPLW515K/L and CALR mutations. Estimated angiogenesis (microvessel grade - CD34), active TGF-b1, latent TGF-β and c-MPL immunoexpression were determined in 26 bone marrow biopsies. RESULTS: Plasmatic TGF-β1 levels were similar in patients and controls, while all the patients groups had higher plasmatic VEGFA than controls. Plasmatic FGF2 was higher in all the patients groups, and its mRNA expression was higher in ET patients than in controls. No differences in SMADs and miRNAs expression were found between patients and controls. There was a positive correlation between plasmatic TGF-β1 and FGF2 in PMF, and a negative correlation between these variables in their controls, as well as in MPET controls. In all studied groups, there was a positive correlation between plasmatic TGF-β1 and VEGF. In addition, different profiles of correlations were demonstrated between TGF-β1 gene expression and the several SMADs and miRNAs studied in each group of patients and controls. PMF patients with higher angiogenesis (according to the median of VEGFA and FGF2 plasma levels) had higher plasmatic TGF-β1 levels than those with lower angiogenesis. Estimated angiogenesis (CD34) in bone marrow biopsies were not different among PMF, MPET and ET patients. Moreover, there were no correlation between CD34 immunoexpression and TGFB1, VEGFA and FGF2 mRNA bone marrow or peripheral blood expression or plasmatic levels, as well as latent TGF-β1, active TGF-b1, and c-MPL immunoexpression were similar in patients studied groups. The frequencies of evaluated mutations were similar to previously reported. MPET patients harboring CALR mutations had lower plasmatic VEGFA and FGF2 than JAK2V617F mutated, while ET patients carrying CALR mutations had lower plasmatic TGF-β1 than JAK2V617F mutated. CONCLUSIONS: This study confirmed the positive correlation among TGF-β1 and two other markers of angiogenesis (VEGFA and FGF2). SMADs and miRNAs expressions were similar between patients and controls, since there were no differences in TGF-β1 gene expression between patients and controls. However, disparities found in the correlations between TGF-β1 gene expression and different SMADs and miRNAs in patients and controls may indicate that TGF-β1 gene expression regulation in studied diseases is distinct from those presented by individuals without these diseases.