Yes / The HOX genes encode a family of transcription factors that have key roles in both development and malignancy. Disrupting the interaction between HOX proteins and their binding partner, PBX, has been shown to cause apoptotic cell death in a range of solid tumors. However, despite HOX proteins playing a particularly significant role in acute myeloid leukemia (AML), the relationship between HOX gene expression and patient survival has not been evaluated (with the exception of HOXA9), and the mechanism by which HOX/PBX inhibition induces cell death in this malignancy is not well understood. In this study, we show that the expression of HOXA5, HOXB2, HOXB4, HOXB9, and HOXC9, but not HOXA9, in primary AML samples is significantly related to survival. Furthermore, the previously described inhibitor of HOX/PBX dimerization, HXR9, is cytotoxic to both AML-derived cell lines and primary AML cells from patients. The mechanism of cell death is not dependent on apoptosis but instead involves a regulated form of necrosis referred to as necroptosis. HXR9-induced necroptosis is enhanced by inhibitors of protein kinase C (PKC) signaling, and HXR9 combined with the PKC inhibitor Ro31 causes a significantly greater reduction in tumor growth compared to either reagent alone. / Funded in part through a grant to RA from the Cultural Bureau of the Kingdom of Saudi Arabia.

No description available.

Bcr-Abl é a tirosina quinase (TK) responsável por causar a Leucemia Mielóide Crônica (LMC). Os últimos estudos de follow-up mostram que apenas 50% dos pacientes tratados com a segunda geração de inibidores de TK atinge a remissão completa, o que significa que metade desses pacientes necessita de um algo melhor do que está disponível. Wiskott Aldrich Syndrome Protein (WASP) é um gene essencial para o bom desenvolvimento e função das células hematopoiéticas. Ante esse contexto, decidimos investigar se WASP poderia ter algum papel ou relevância na LMC. Em conclusão, Bcr-Abl suprime a expressão WASP por um mecanismo epigenético. A re-expressão de WASP torna as células mais suscetíveis à apoptose em resposta ao Imatinib. Sugerimos que a recuperação da expressão WASP deve ser discutida como estratégia para a terapia da LMC. / Bcr-Abl is the tyrosine kinase (TK) responsible for causing Chronic Myeloid Leukemia (CML). This fusion protein up- and down-regulates several genes and pathways, producing a strong resistance to apoptosis and a blockage of cell maturation in the hematopoietic compartment. The last follow-up studies provided that only 50% of the patients treated with second generation achieve complete remission, what means that one-half of these patients needs something better. Wiskott Aldrich Syndrome Protein (WASP) is an essential gene for the proper development and function of the hematopoietic cells. In the light of this background, we decided to investigate if WASP could have some role or relevance in the CML context. In conclusion, Bcr-Abl suppresses WASP expression by an epigenetic mechanism. The re-expression of WASP makes the CML cells more susceptible to apoptosis and contribute to respond to Imatinib. We suggest that recovery of WASP expression should be discussed as a new and additional strategy for CML therapy.

Introdução: O Transplante Alogênico de Célula Tronco Hematopoiética (TCTH alogênico) é um procedimento de alto potencial curativo para a Leucemia Mielóide Aguda (LMA), principalmente pelo efeito “graft versus leukemia” (GVL), que leva a redução do risco de recaída. Atualmente, os pacientes com LMA de risco intermediário são submetidos ao procedimento caso possuam doador aparentado. Pacientes sem doador aparentado disponível são submetidos a tratamento de consolidação com quimioterapia, com maior chance de recaída da doença. Acredita-se que os pacientes submetidos ao TCTH tenham maiores sobrevida global e livre de doença, a despeito das altas taxas de morbimortalidade. A classificação de risco é extremamente importante para escolha terapêutica pós remissão. Assim, a realização da pesquisa de marcadores moleculares, para refinar a estratificação prognóstica, tem importância especial no grupo de risco intermediário, complementando a avaliação citogenética, e auxiliando na decisão terapêutica, sendo cada vez mais necessária, apesar de não disponível em todos os centros. Material e métodos: Foram avaliados os pacientes com LMA de risco intermediário em primeira Remissão Completa (1RC) do Serviço de Hematologia e TCTH do Hospital de Clínicas de Porto Alegre do período de 01 de abril de 1999 a 01 de outubro de 2014, com pelo menos 1 ano de seguimento após o tratamento, através de revisão de prontuários. Os dados foram dispostos no programa Excel e posteriormente exportados para o programa SPSS v. 18.0 para análise estatística. Resultados: Foram avaliados 69 pacientes, sendo 45 pacientes submetidos a consolidação com quimioterapia (“QT”) e 24 submetidos a TCTH Alogênico (“TCTH Alogênico”). A média de idade do grupo “QT” foi de 47,8 anos e do grupo “TCTH Alogênico” foi de 35,5 anos, com diferença estatisticamente significativa (P<0,001). Não houve diferença na distribuição entre o sexo. A mediana de tempo de seguimento do grupo “QT” foi de 1,1 anos (intervalo interquartil de 0,4 a 2,5 ) e no grupo “TCTH Alogênico” foi de 2,7 anos (intervalo interquartil de 0,4 a 5,5), sem diferença estatisticamente significativa na distribuição dos tempos de seguimento entre os grupos (P=0,236). A sobrevida do grupo “QT” em 12 meses foi de 52,3% e no grupo “TCTH Alogênico” foi de 62,5%. Aos 24 meses, a sobrevida do grupo “QT” foi de 31,7% e no grupo “TCTH Alogênico” foi de 58,3% e em 5 anos de 21,1% e 53,8%, respectivamente. O teste do Long-Rank aponta uma diferença estatisticamente significativa nas sobrevidas entre os grupos após 5 anos, com Hazard Ratio (HR) para óbito de 2,2 (IC 95%: 1,1-4,2), P=0,027, porém ao ajustarmos a relação pela idade esta associação perde significância estatística (HR:1,6 IC95%:1 - 1,1; P=0,246) Discussão: Os dados evidenciaram melhor sobrevida no grupo submetido à TCTH alogênico, porém o grupo submetido ao procedimento apresentava média de idade menor. No entanto, apesar da perda da significância estatística, o HR corrigido para idade permanece maior para o grupo sem TCTH, o que pode dever-se ao “n” pequeno da amostra. Identificar quais pacientes terão benefício com TCTH torna-se cada vez mais um desafio. O uso de marcadores moleculares são importantes no refinamento da estratificação de risco do grupo de risco intermediário, podendo auxiliar nessa decisão. Além disso, com o advento da possibilidade de condicionamentos não mieloablativos como alternativa aos pacientes mais velhos e com escore de comorbidades pior e a melhor terapia de suporte, talvez possamos ser menos conservadores na indicação desse procedimento, identificando assim aqueles que poderão obter melhores resultados no tratamento de uma doença tão agressiva e grave. / Background: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is a high potentially curative procedure to Acute Myeloid Leukemia (AML), mainly by the “graft-versus-leukemia” (GVL) effect, which leads to reduced risk of relapse. Nowadays, intermediate risk AML patients are submitted to this procedure if a matched sibling donor is available. Patients without a sibling donor are submitted to consolidation with chemotherapy, with a greater chance of relapse. It is believed that patients submitted to allo-HSCT have a greater overall survival and disease-free survival, even though it presents high morbidity and mortality rates. Risk stratification is extremely important to post-remission treatment choice. Molecular markers research is especially important in intermediate risk group, complementing cytogenetic evaluation to a better prognostic stratification and, although it is still not available in all health centers, it is more and more necessary. Materials and Methods: We evaluated intermediate risk AML patients in first Complete Remission (CR1) at the Hematology Service and Bone Marrow Transplantation from Hospital de Clínicas de Porto Alegre from April 1st 1999 to October 1st 2014, and which had, at least, a one year follow-up after treatment, by conducting a medical record review. Data was inserted in Microsoft Excel 2010 spreadsheets and after exported to SPSS v. 18.0 to statistical analysis. Results: Among the 69 patients analyzed, 45 were submitted to consolidation with chemotherapy (Intermediate risk AML – non allo-HSCT) and 24 of then submitted to allo-HSCT (Intermediate risk AML – allo-HSCT). The average age of Intermediate risk AML – non allo-HSCT was 47.8 years old and Intermediate risk AML – allo-HSCT was 35.5 years old, with statistically significance difference (P<0,001). There was no difference regard sex of patients. The median follow-up in the Intermediate risk AML – non allo-HSCT was 1.1 years (interquartile rage of 0.4 to 2.5) and in the Intermediate risk AML – allo-HSCT was 2.7 years (interquartile rage of 0.4 to 5.5), with no statistically significance difference in follow-up time distribution between groups (P=0.236). Intermediate risk AML – non allo-HSCT survival in 12 months was 52.3% and in the Intermediate risk AML – allo-HSCT was 62.5%. In 24 months, Intermediate risk AML – non allo-HSCT survival was 31.7% and in Intermediate risk AML – allo HSCT survival was 58.3% and in 5 years it was 21.1% and 53.8% respectively. Long- Rank test indicates a statistically significant difference in survival between groups after 5 years, with hazard ratio (HR) for death of 2.2 (IC95% 1.1 – 4.2), P=0.027, but when we adjust the relation to age, this association loses statistical significance (HR:1.6 95%CI: 1 – 1.1; P=0.246). Discussion: Data showed a better survival rate to the group submitted to allo-HSCT, but the group presented a lower average age. However, despite de loss of statistical significance, Hazard Ratio (HR), adjusted to age remains higher to the non allo-HSCT group. It can be explained by the small number of the sample. Identifying which patients will benefit from allo-HSCT becomes increasingly challenging. The use of molecular markers are important in the refinement of risk stratification in intermediate risk group, assisting in the decision. Moreover, with the advent of the possibility of nonmyeloablative conditioning as an alternative to older patients and with worst rates of comorbidity, and the better supporting therapy, we may be less conservative in indicating this procedure, identifying the patients who may obtain better results during treatment of such aggressive and serious disease.

RUNX3是RUNX轉錄因子家族的其中一位成員。RUNX轉錄因子家族是負責調控細胞的增殖和分化。最近研究表明RUNX3可能在造血過程中扮演其中一個角色。可是，它在髓系細胞中的調節角色依然未明。此前，我們發現在核心結合因子急性骨髓性白血病中的融合蛋白RUNX1-ETO和CBFB-MYH11會抑制RUNX3基因表達，並且RUNX3表達水平對兒童急性骨髓性白血病的預後有顯著影響。本研究的目的是要調查RUNX3在成人急性骨髓性白血病的預後價值，並透過闡明RUNX3的轉錄調節去了解其在髓系細胞分化扮演的角色。 / 首先，我們透過實時定量聚合鏈反應去量化在174個成人急性骨髓性白血病的患者骨髓中的RUNX3表達，從而調查RUNX3表達與成人急性骨髓性白血病預後的關係。我們發現低RUNX3表達與較好預後的核型(P=0.045)，NPM1基因突變(P=0.014) 和較年青患者(P=0.084) 有關聯。在存活分析中，我們把有完整生存數據的非急性前骨髓性白血病病人分成高RUNX3表達和低RUNX3表達兩組。在成人急性骨髓性白血病中，高RUNX3表達和較差整體存活率(OS) (P=0.011)和無事件存活率(EFS) (P=0.003)有顯著的關聯，這和我們在兒童急性骨髓性白血病所觀察的一致。高RUNX3表達和較差存活率的關係在有野生型FLT3基因的病人中更為明顯(OS, P=0.004; EFS, P=0.001)。由於低RUNX3表達和較好預後核型有關聯，我們進一步只對擁有較差預後核型的病人作將存活分析，發現RUNX3表達仍是影響EFS的一個顯著因素(P=0.017)。在多元分析中，高RUNX3表達在所有病人(EFS, P=0.026, HR=2.433, 95%CI = 1.114-5.356)，野生v 型FLT3基因的病人(OS, P=0.016, HR=4.830, 95%CI = 1.335-17.481; EFS, P=0.007, HR=4.103, 95%CI = 1.480-11.372)和較差預後核型的病人(EFS, P=0.024,HR=2.339, 95%CI = 1.117-4.896) 中都是一個獨立的不利預後因素。 / 接著，我們研究RUNX3基因的表達調控。我們鑒定出一個最小啟動子區對於在髓系細胞的基因表達有關鍵作用。透過預測啟動子區和轉錄因子結合位點的分析，顯示這個活性區域含有PU.1，AP-1和Sp1轉錄因子結合位點。我們透過報告基因系統研究，染色質免疫沈澱技術及電泳遷移率改變分析去闡明PU.1，c-Jun及Sp1和相對的轉錄因子結合位點參與RUNX3基因的表達調控。我們進一步透過PU.1基因剔除去證實RUNX3是PU.1的直接下遊靶基因並發現PU.1與RUNX3表達在急性骨髓性白血病人中呈正相關性。 / 由於RUNX3基因表達受到PU.1, c-Jun及Sp1的控制，我們繼續研究RUNX3在髓系細胞分化的功用。我們透過實時定量聚合鏈反應及流式細胞儀檢測發現RUNX3過度表達誘導K562細胞株作單核細胞及粒細胞分化。RUNX3能激活髓系基因的啟動子。它在成熟髓系細胞的表達水平明顯比血幹細胞為高。根據以上結果，RUNX3也許在單核細胞及粒細胞分化中有一定功能。但是，有別於其他癌細胞，RUNNX3不能在髓系細胞誘導細胞凋亡和周期阻滯。 / 總括而言，RUNX3表達在成人急性骨髓性白血病中是一個獨立的預後因素。除此之外，本研究表明RUNX3受到PU.1，c-Jun及Sp1的表達調控並在單核細胞及粒細胞分化中有一定功能。 / RUNX3 is a member of Runt-related domain (RUNX) transcription factor family, which regulates cell proliferation and differentiation. Recent studies have suggested a role of RUNX3 in hematopoiesis. However, its regulatory function in myeloid cells remains unclear. Our group previously showed that RUNX3 expression was repressed by the fusion proteins RUNX1-ETO and CBFB-MYH11 in core-binding factor acute myeloid leukemia (CBF-AML) and had prognostic implication in childhood AML patients. The aim of this study is to investigate the prognostic value of RUNX3 in adult AML patients and its role in myeloid differentiation by elucidating its transcriptional control. / To investigate the relationship between RUNX3 expression and prognosis of adult AML, RUNX3 expression in the diagnostic bone marrow samples from 174 adult AML patients were quantified by real time quantitative PCR (RQ-PCR). Low RUNX3 expression was found to be associated with favorable cytogenetic group (P=0.045), NPM1 mutations (P=0.014) and younger age (P=0.084). For the survival analysis, 110 non-acute promyelocytic leukemia (non-APL) patients with complete survival data were dichotomized into high and low expression groups. Concordant with our previous observation in childhood AML, a significant association between high RUNX3 expression and poorer overall survival (OS) (P=0.011) and event-free survival (EFS) (P=0.003) was observed. The association between high RUNX3 expression and poorer survival was further strengthened in patients with wild-type FLT3 (P=0.004 and 0.001 for OS and EFS respectively). Since low RUNX3 expression was associated with favorable cytogenetics, the analysis was next restricted to patients with non-favorable cytogenetics and RUNX3 expression remained as a significant factor for EFS (P=0.017). In multivariate analysis, high RUNX3 expression was an independent adverse prognostic factor in the whole cohort (EFS, P=0.026, HR=2.433, 95%CI = 1.114-5.356), patients with wild-type FLT3 (OS, P=0.016, HR=4.830, 95%CI = 1.335-17.481; EFS, P=0.007, HR=4.103, 95%CI = 1.480-11.372) and patients with non-favorable genetics (EFS, P=0.024,HR=2.339, 95%CI = 1.117-4.896). / Next, the transcriptional regulation of RUNX3 in myeloid cells was investigated. A minimal promoter region was identified to be critical for myeloid-specific promoter activity. Sequence analysis of the fragment revealed potential transcription factor binding sites for PU.1, AP-1 and Sp1.The involvement of these putative binding sites and corresponding transcription factors in transcriptional regulation of RUNX3 was demonstrated by promoter reporter assay, chromatin immunoprecipitation (ChIP) and electrophoretic mobility shift assay (EMSA).Furthermore, PU.1 knockdown in U937 cells confirmed RUNX3 was a direct downstream target of PU.1 and a positive correlation between PU.1 and RUNX3 expression was observed in AML patient samples. / As RUNX3 was shown to be transcriptionally regulated by PU.1, c-Jun and Sp1, a role of RUNX3 in myeloid differentiation was postulated. Overexpression of RUNX3 induced both monocytic and granulocytic markers in K562 myeloid cells as detected by flow cytometry and RQ-PCR. RUNX3 was also found to activate myeloid-specific gene promoters and its expression was significantly higher in mature myeloid cells than in hematopoietic stem cells. This suggested a role of RUNX3 in both monocytic and granulocytic differentiation. However, unlike in other solid tumors, RUNX3 did not induce apoptosis and cell cycle arrest in myeloid cells. / In conclusion, RUNX3 expression was an independent prognostic factor in adult AML. Furthermore, our findings showed that RUNX3 was transcriptionally regulated by the master myeloid regulator PU.1 along with c-Jun and Sp1 and implicated a role in monocytic and granulocytic differentiation. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Kwan, Tsz Ki. / Thesis (Ph.D.) Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 171-202). / Abstracts also in Chinese.

Introdução: O Transplante Alogênico de Célula Tronco Hematopoiética (TCTH alogênico) é um procedimento de alto potencial curativo para a Leucemia Mielóide Aguda (LMA), principalmente pelo efeito “graft versus leukemia” (GVL), que leva a redução do risco de recaída. Atualmente, os pacientes com LMA de risco intermediário são submetidos ao procedimento caso possuam doador aparentado. Pacientes sem doador aparentado disponível são submetidos a tratamento de consolidação com quimioterapia, com maior chance de recaída da doença. Acredita-se que os pacientes submetidos ao TCTH tenham maiores sobrevida global e livre de doença, a despeito das altas taxas de morbimortalidade. A classificação de risco é extremamente importante para escolha terapêutica pós remissão. Assim, a realização da pesquisa de marcadores moleculares, para refinar a estratificação prognóstica, tem importância especial no grupo de risco intermediário, complementando a avaliação citogenética, e auxiliando na decisão terapêutica, sendo cada vez mais necessária, apesar de não disponível em todos os centros. Material e métodos: Foram avaliados os pacientes com LMA de risco intermediário em primeira Remissão Completa (1RC) do Serviço de Hematologia e TCTH do Hospital de Clínicas de Porto Alegre do período de 01 de abril de 1999 a 01 de outubro de 2014, com pelo menos 1 ano de seguimento após o tratamento, através de revisão de prontuários. Os dados foram dispostos no programa Excel e posteriormente exportados para o programa SPSS v. 18.0 para análise estatística. Resultados: Foram avaliados 69 pacientes, sendo 45 pacientes submetidos a consolidação com quimioterapia (“QT”) e 24 submetidos a TCTH Alogênico (“TCTH Alogênico”). A média de idade do grupo “QT” foi de 47,8 anos e do grupo “TCTH Alogênico” foi de 35,5 anos, com diferença estatisticamente significativa (P<0,001). Não houve diferença na distribuição entre o sexo. A mediana de tempo de seguimento do grupo “QT” foi de 1,1 anos (intervalo interquartil de 0,4 a 2,5 ) e no grupo “TCTH Alogênico” foi de 2,7 anos (intervalo interquartil de 0,4 a 5,5), sem diferença estatisticamente significativa na distribuição dos tempos de seguimento entre os grupos (P=0,236). A sobrevida do grupo “QT” em 12 meses foi de 52,3% e no grupo “TCTH Alogênico” foi de 62,5%. Aos 24 meses, a sobrevida do grupo “QT” foi de 31,7% e no grupo “TCTH Alogênico” foi de 58,3% e em 5 anos de 21,1% e 53,8%, respectivamente. O teste do Long-Rank aponta uma diferença estatisticamente significativa nas sobrevidas entre os grupos após 5 anos, com Hazard Ratio (HR) para óbito de 2,2 (IC 95%: 1,1-4,2), P=0,027, porém ao ajustarmos a relação pela idade esta associação perde significância estatística (HR:1,6 IC95%:1 - 1,1; P=0,246) Discussão: Os dados evidenciaram melhor sobrevida no grupo submetido à TCTH alogênico, porém o grupo submetido ao procedimento apresentava média de idade menor. No entanto, apesar da perda da significância estatística, o HR corrigido para idade permanece maior para o grupo sem TCTH, o que pode dever-se ao “n” pequeno da amostra. Identificar quais pacientes terão benefício com TCTH torna-se cada vez mais um desafio. O uso de marcadores moleculares são importantes no refinamento da estratificação de risco do grupo de risco intermediário, podendo auxiliar nessa decisão. Além disso, com o advento da possibilidade de condicionamentos não mieloablativos como alternativa aos pacientes mais velhos e com escore de comorbidades pior e a melhor terapia de suporte, talvez possamos ser menos conservadores na indicação desse procedimento, identificando assim aqueles que poderão obter melhores resultados no tratamento de uma doença tão agressiva e grave. / Background: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is a high potentially curative procedure to Acute Myeloid Leukemia (AML), mainly by the “graft-versus-leukemia” (GVL) effect, which leads to reduced risk of relapse. Nowadays, intermediate risk AML patients are submitted to this procedure if a matched sibling donor is available. Patients without a sibling donor are submitted to consolidation with chemotherapy, with a greater chance of relapse. It is believed that patients submitted to allo-HSCT have a greater overall survival and disease-free survival, even though it presents high morbidity and mortality rates. Risk stratification is extremely important to post-remission treatment choice. Molecular markers research is especially important in intermediate risk group, complementing cytogenetic evaluation to a better prognostic stratification and, although it is still not available in all health centers, it is more and more necessary. Materials and Methods: We evaluated intermediate risk AML patients in first Complete Remission (CR1) at the Hematology Service and Bone Marrow Transplantation from Hospital de Clínicas de Porto Alegre from April 1st 1999 to October 1st 2014, and which had, at least, a one year follow-up after treatment, by conducting a medical record review. Data was inserted in Microsoft Excel 2010 spreadsheets and after exported to SPSS v. 18.0 to statistical analysis. Results: Among the 69 patients analyzed, 45 were submitted to consolidation with chemotherapy (Intermediate risk AML – non allo-HSCT) and 24 of then submitted to allo-HSCT (Intermediate risk AML – allo-HSCT). The average age of Intermediate risk AML – non allo-HSCT was 47.8 years old and Intermediate risk AML – allo-HSCT was 35.5 years old, with statistically significance difference (P<0,001). There was no difference regard sex of patients. The median follow-up in the Intermediate risk AML – non allo-HSCT was 1.1 years (interquartile rage of 0.4 to 2.5) and in the Intermediate risk AML – allo-HSCT was 2.7 years (interquartile rage of 0.4 to 5.5), with no statistically significance difference in follow-up time distribution between groups (P=0.236). Intermediate risk AML – non allo-HSCT survival in 12 months was 52.3% and in the Intermediate risk AML – allo-HSCT was 62.5%. In 24 months, Intermediate risk AML – non allo-HSCT survival was 31.7% and in Intermediate risk AML – allo HSCT survival was 58.3% and in 5 years it was 21.1% and 53.8% respectively. Long- Rank test indicates a statistically significant difference in survival between groups after 5 years, with hazard ratio (HR) for death of 2.2 (IC95% 1.1 – 4.2), P=0.027, but when we adjust the relation to age, this association loses statistical significance (HR:1.6 95%CI: 1 – 1.1; P=0.246). Discussion: Data showed a better survival rate to the group submitted to allo-HSCT, but the group presented a lower average age. However, despite de loss of statistical significance, Hazard Ratio (HR), adjusted to age remains higher to the non allo-HSCT group. It can be explained by the small number of the sample. Identifying which patients will benefit from allo-HSCT becomes increasingly challenging. The use of molecular markers are important in the refinement of risk stratification in intermediate risk group, assisting in the decision. Moreover, with the advent of the possibility of nonmyeloablative conditioning as an alternative to older patients and with worst rates of comorbidity, and the better supporting therapy, we may be less conservative in indicating this procedure, identifying the patients who may obtain better results during treatment of such aggressive and serious disease.

Introdução: O Transplante Alogênico de Célula Tronco Hematopoiética (TCTH alogênico) é um procedimento de alto potencial curativo para a Leucemia Mielóide Aguda (LMA), principalmente pelo efeito “graft versus leukemia” (GVL), que leva a redução do risco de recaída. Atualmente, os pacientes com LMA de risco intermediário são submetidos ao procedimento caso possuam doador aparentado. Pacientes sem doador aparentado disponível são submetidos a tratamento de consolidação com quimioterapia, com maior chance de recaída da doença. Acredita-se que os pacientes submetidos ao TCTH tenham maiores sobrevida global e livre de doença, a despeito das altas taxas de morbimortalidade. A classificação de risco é extremamente importante para escolha terapêutica pós remissão. Assim, a realização da pesquisa de marcadores moleculares, para refinar a estratificação prognóstica, tem importância especial no grupo de risco intermediário, complementando a avaliação citogenética, e auxiliando na decisão terapêutica, sendo cada vez mais necessária, apesar de não disponível em todos os centros. Material e métodos: Foram avaliados os pacientes com LMA de risco intermediário em primeira Remissão Completa (1RC) do Serviço de Hematologia e TCTH do Hospital de Clínicas de Porto Alegre do período de 01 de abril de 1999 a 01 de outubro de 2014, com pelo menos 1 ano de seguimento após o tratamento, através de revisão de prontuários. Os dados foram dispostos no programa Excel e posteriormente exportados para o programa SPSS v. 18.0 para análise estatística. Resultados: Foram avaliados 69 pacientes, sendo 45 pacientes submetidos a consolidação com quimioterapia (“QT”) e 24 submetidos a TCTH Alogênico (“TCTH Alogênico”). A média de idade do grupo “QT” foi de 47,8 anos e do grupo “TCTH Alogênico” foi de 35,5 anos, com diferença estatisticamente significativa (P<0,001). Não houve diferença na distribuição entre o sexo. A mediana de tempo de seguimento do grupo “QT” foi de 1,1 anos (intervalo interquartil de 0,4 a 2,5 ) e no grupo “TCTH Alogênico” foi de 2,7 anos (intervalo interquartil de 0,4 a 5,5), sem diferença estatisticamente significativa na distribuição dos tempos de seguimento entre os grupos (P=0,236). A sobrevida do grupo “QT” em 12 meses foi de 52,3% e no grupo “TCTH Alogênico” foi de 62,5%. Aos 24 meses, a sobrevida do grupo “QT” foi de 31,7% e no grupo “TCTH Alogênico” foi de 58,3% e em 5 anos de 21,1% e 53,8%, respectivamente. O teste do Long-Rank aponta uma diferença estatisticamente significativa nas sobrevidas entre os grupos após 5 anos, com Hazard Ratio (HR) para óbito de 2,2 (IC 95%: 1,1-4,2), P=0,027, porém ao ajustarmos a relação pela idade esta associação perde significância estatística (HR:1,6 IC95%:1 - 1,1; P=0,246) Discussão: Os dados evidenciaram melhor sobrevida no grupo submetido à TCTH alogênico, porém o grupo submetido ao procedimento apresentava média de idade menor. No entanto, apesar da perda da significância estatística, o HR corrigido para idade permanece maior para o grupo sem TCTH, o que pode dever-se ao “n” pequeno da amostra. Identificar quais pacientes terão benefício com TCTH torna-se cada vez mais um desafio. O uso de marcadores moleculares são importantes no refinamento da estratificação de risco do grupo de risco intermediário, podendo auxiliar nessa decisão. Além disso, com o advento da possibilidade de condicionamentos não mieloablativos como alternativa aos pacientes mais velhos e com escore de comorbidades pior e a melhor terapia de suporte, talvez possamos ser menos conservadores na indicação desse procedimento, identificando assim aqueles que poderão obter melhores resultados no tratamento de uma doença tão agressiva e grave. / Background: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is a high potentially curative procedure to Acute Myeloid Leukemia (AML), mainly by the “graft-versus-leukemia” (GVL) effect, which leads to reduced risk of relapse. Nowadays, intermediate risk AML patients are submitted to this procedure if a matched sibling donor is available. Patients without a sibling donor are submitted to consolidation with chemotherapy, with a greater chance of relapse. It is believed that patients submitted to allo-HSCT have a greater overall survival and disease-free survival, even though it presents high morbidity and mortality rates. Risk stratification is extremely important to post-remission treatment choice. Molecular markers research is especially important in intermediate risk group, complementing cytogenetic evaluation to a better prognostic stratification and, although it is still not available in all health centers, it is more and more necessary. Materials and Methods: We evaluated intermediate risk AML patients in first Complete Remission (CR1) at the Hematology Service and Bone Marrow Transplantation from Hospital de Clínicas de Porto Alegre from April 1st 1999 to October 1st 2014, and which had, at least, a one year follow-up after treatment, by conducting a medical record review. Data was inserted in Microsoft Excel 2010 spreadsheets and after exported to SPSS v. 18.0 to statistical analysis. Results: Among the 69 patients analyzed, 45 were submitted to consolidation with chemotherapy (Intermediate risk AML – non allo-HSCT) and 24 of then submitted to allo-HSCT (Intermediate risk AML – allo-HSCT). The average age of Intermediate risk AML – non allo-HSCT was 47.8 years old and Intermediate risk AML – allo-HSCT was 35.5 years old, with statistically significance difference (P<0,001). There was no difference regard sex of patients. The median follow-up in the Intermediate risk AML – non allo-HSCT was 1.1 years (interquartile rage of 0.4 to 2.5) and in the Intermediate risk AML – allo-HSCT was 2.7 years (interquartile rage of 0.4 to 5.5), with no statistically significance difference in follow-up time distribution between groups (P=0.236). Intermediate risk AML – non allo-HSCT survival in 12 months was 52.3% and in the Intermediate risk AML – allo-HSCT was 62.5%. In 24 months, Intermediate risk AML – non allo-HSCT survival was 31.7% and in Intermediate risk AML – allo HSCT survival was 58.3% and in 5 years it was 21.1% and 53.8% respectively. Long- Rank test indicates a statistically significant difference in survival between groups after 5 years, with hazard ratio (HR) for death of 2.2 (IC95% 1.1 – 4.2), P=0.027, but when we adjust the relation to age, this association loses statistical significance (HR:1.6 95%CI: 1 – 1.1; P=0.246). Discussion: Data showed a better survival rate to the group submitted to allo-HSCT, but the group presented a lower average age. However, despite de loss of statistical significance, Hazard Ratio (HR), adjusted to age remains higher to the non allo-HSCT group. It can be explained by the small number of the sample. Identifying which patients will benefit from allo-HSCT becomes increasingly challenging. The use of molecular markers are important in the refinement of risk stratification in intermediate risk group, assisting in the decision. Moreover, with the advent of the possibility of nonmyeloablative conditioning as an alternative to older patients and with worst rates of comorbidity, and the better supporting therapy, we may be less conservative in indicating this procedure, identifying the patients who may obtain better results during treatment of such aggressive and serious disease.

Bcr-Abl é a tirosina quinase (TK) responsável por causar a Leucemia Mielóide Crônica (LMC). Os últimos estudos de follow-up mostram que apenas 50% dos pacientes tratados com a segunda geração de inibidores de TK atinge a remissão completa, o que significa que metade desses pacientes necessita de um algo melhor do que está disponível. Wiskott Aldrich Syndrome Protein (WASP) é um gene essencial para o bom desenvolvimento e função das células hematopoiéticas. Ante esse contexto, decidimos investigar se WASP poderia ter algum papel ou relevância na LMC. Em conclusão, Bcr-Abl suprime a expressão WASP por um mecanismo epigenético. A re-expressão de WASP torna as células mais suscetíveis à apoptose em resposta ao Imatinib. Sugerimos que a recuperação da expressão WASP deve ser discutida como estratégia para a terapia da LMC. / Bcr-Abl is the tyrosine kinase (TK) responsible for causing Chronic Myeloid Leukemia (CML). This fusion protein up- and down-regulates several genes and pathways, producing a strong resistance to apoptosis and a blockage of cell maturation in the hematopoietic compartment. The last follow-up studies provided that only 50% of the patients treated with second generation achieve complete remission, what means that one-half of these patients needs something better. Wiskott Aldrich Syndrome Protein (WASP) is an essential gene for the proper development and function of the hematopoietic cells. In the light of this background, we decided to investigate if WASP could have some role or relevance in the CML context. In conclusion, Bcr-Abl suppresses WASP expression by an epigenetic mechanism. The re-expression of WASP makes the CML cells more susceptible to apoptosis and contribute to respond to Imatinib. We suggest that recovery of WASP expression should be discussed as a new and additional strategy for CML therapy.

Indiana University-Purdue University Indianapolis (IUPUI) / Internal tandem duplications in FMS-like receptor tyrosine kinase (FLT3-ITDs) are seen in approximately 25% of all acute myeloid leukemia (AML) patients. FLT3-ITDs induce FLT3 ligand (FL)-independent cellular hyperproliferation, promiscuous and aberrant activation of STAT5, and confer a poor prognosis in patients; however, the molecular mechanisms contributing to FLT3-ITD-induced malignancy remain largely unknown. The protein tyrosine phosphatase, Shp2, is important for normal hematopoiesis as well as hematopoietic stem cell (HSC) differentiation, engraftment, and self-renewal. Furthermore, FLT3-ITD- or constitutive active STAT5-expressing CD34+ cells demonstrate enhanced hematopoietic stem cell self-renewal. Together with the previous findings that Shp2 is critical for normal hematopoiesis, that dysregulated Shp2 function contributes to myeloid malignancies, and that Shp2 has been shown to interact with WT-FLT3 tyrosine 599, which is commonly duplicated in FLT3-ITDs, a positive role for Shp2 in FLT3-ITD-induced signaling and leukemogenesis is implied. I demonstrated that Shp2 is constitutively associated with the reported FLT3-ITDs, N51-FLT3 and N73-FLT3, compared to WT-FLT3; therefore, I hypothesized that increased Shp2 recruitment to N51-FLT3 or N73-FLT3 contributes to hyperproliferation and hyperactivation of STAT5. I also hypothesized that Shp2 cooperates with STAT5 to activate STAT5 transcriptional targets contributing to the up-regulation of pro-leukemic proteins. Finally, I hypothesized that reduction of Shp2 would result in diminished N51-FLT3-induced hyperproliferation and activation of STAT5 in vitro, and prevent FLT3-ITD-induced malignancy in vivo. I found that genetic disruption of Ptpn11, the gene encoding Shp2, or pharmacologic inhibition of Shp2 with the novel Shp2 inhibitor, II-B08, resulted in significantly reduced FLT3-ITD-induced hematopoietic cell hyperproliferation and STAT5 hyperphosphorylation. I also demonstrated a novel role of Shp2 in the nucleus of FLT3-ITD-expressing hematopoietic cells where Shp2 and STAT5 co-localized at the promoter region of STAT5-transcriptional target and pro-survival protein, Bcl-XL. Furthermore, using a Shp2flox/flox;Mx1Cre+ mouse model, I demonstrated that reduced Shp2 expression in hematopoietic cells resulted in an increased latency to and reduced severity of FLT3-ITD-induced malignancy. Collectively, these findings demonstrate that Shp2 plays an integral role in FLT3-ITD-induced malignancy and suggest that targeting Shp2 may be a future therapeutic option for treating FLT3-ITD-positive AML patients.

published_or_final_version / Medicine / Doctoral / Doctor of Philosophy