Introdução: a ação antiestrogênica do tamoxifeno (TAM) é dependente da bioativação à endoxifeno (EDF) e 4-hidroxitamoxifeno (HTF). É bastante provável que sua eficácia terapêutica esteja relacionada ao alcance de um limiar nos níveis de EDF (>5,9 ng mL-1). Entretanto, as concentrações plasmáticas de EDF são altamente variáveis, em parte devido a polimorfismos no gene da CYP2D6 e ao uso de inibidores da enzima. A CYP3A4 também contribui para a formação do EDF e pode ser influenciada por interações medicamentosas e exposição solar. Recentemente, o polimorfismo CYP3A4*22 foi associado à redução da atividade da enzima. Entretanto, pouco se sabe sobre seu impacto na formação do EDF. Objetivo: Em virtude da alta variabilidade na resposta terapêutica e os múltiplos fatores associados ao metabolismo do TAM, o presente estudo objetivou avaliar o efeito dos polimorfismos da CYP2D6 e CYP3A4, interações medicamentosas e exposição à vitamina D na bioativação do TAM. Adicionalmente, dois métodos analíticos para a otimização do tratamento através da medida das razões metabólicas da CYP2D6 e quantificação do TAM e metabólitos em manchas de sangue seco (DBS) foram desenvolvidos. Patientes & métodos: Cento e dezesseis pacientes em tratamento adjuvante com o TAM forneceram amostras de plasma para dosagens do TAM, metabótilos e 25OHD3 no inverno e verão. As concentrações de TAM e metabólitos em plasma e DBS foram medidas por LCMS/ MS. Foram avaliados os genótipos da CYP2D6 e CYP3A4, bem como fenótipos obtidos pelas razões metabólicas determinadas após administração dos fármacos sonda dextrometorfano e omeprazol. As concentrações de vitamina D3 em plasma foram quantificadas por HPLC-UV. Foram obtidas informações sobre uso de inibidores ou indutores das enzimas e suplementação de vitamina D. Resultados: Cerca de 20% das pacientes apresentaram atividade metabólica reduzida para a CYP2D6 e 7% para a CYP3A4. Aproximadamente 30% das metabolizadoras lentas (ML), 56% das metabolizadoras intermediárias (MI) e 11.3% das metabolizadoras rápidas (MR) usavam fármaco inibidor da CYP2D6. As concentrações de EDF diminuiram proporcionalmente à redução da atividade metabólica da CYP2D6 (ML 2,79 ng mL-1, MI 5.36 ng mL-1 e MR 10,65 ng mL-1, P<0.01). A mediana das concentrações plasmáticas de TAM e HTF em pacientes CYP2D6 MI com metabolismo reduzido da CYP3A4 (161,50 ng mL-1 e 1,32 ng mL-1, respectivamente) foram superiores as encontradas nos pacientes CYP2D6 MI com metabolismo funcional da CYP3A4 (122,07 ng mL-1 e 0.61 ng mL-1, respectivamente, P<0.05). Adicionalmente, as concentrações de HTF e TAM foram aproximadamente 50% superiores em pacientes com genótipo CYP3A4*22 em comparação aos pacientes *1/*1. A sazonalidade também contribuiu para a variabilidade das concentrações dos metabólitos ativos, os níveis de EDF foram 24% e HTF 42% superiores no verão. Nas análises de DBS, foi possível identificar 96% dos pacientes com concentrações de EDF abaixo do limiar clínico, indicando seu potencial uso no monitoramento terapêutico do TAM. Conclusão: a CYP3A4 contribui para a bioativação do TAM através da formação de HTF, tornando-se mais importante em condições de atividade diminuída ou ausente da CYP2D6. Os níveis plasmáticos de EDF e HTF demonstraram ser influenciados pela sazonalidade, com aumento significativo no verão. Entretanto o mecanismo relacionado a associação da vitamina D, exposição solar e bioativação do TAM permanecem por ser elucidados. / Background: The therapeutic antiestrogenic effect of tamoxifen (TAM) requires metabolic activation to endoxifen (EDF) and 4-hydroxytamoxifen (HTF). Adequate therapeutic outcome seems to be dependent on the achievement of a threshold of EDF concentration (>5.9 ng mL-1). EDF plasma levels are highly variable among patients, which could be partly explained by polymorphisms in the CYP2D6 gene and the use of enzymes inhibitor drugs. In a lesser extent, CYP3A4 also contributes to EDF formation and can be influenced by drug interactions and sun exposure. From a genetic point of view, a recently described CYP3A4*22 polymorphism has been associated with reduced enzyme activity. However, there is little knowledge about the impact of CYP3A4 polymorphisms on EDF formation. Objective: In view of the large variability on therapeutic response and the multiple factors associated to TAM metabolic activation, the present study aimed to evaluate the effect of CYP2D6 and CYP3A4 polymorphisms, drug interactions and vitamin D exposure on TAM metabolic activation. Additionally, two analytical methods for optimization of TAM treatment by measurement of CYP2D6 metabolic ratios and quantification of TAM and metabolites in dried blood sopts (DBS) were developed. Patients & methods: One hundred and sixteen patients under TAM therapy provided blood samples for measurement of TAM, NDT, EDF, HTF and 25OHD3 at Winter and Summer. TAM and metabolites were measured in plasma and DBS by LC-MS/MS. CYP2D6 and CYP3A4 genotypes and phenotypes, given according to [DMT]/[DTP] and [OME]/[OMS] metabolic ratios after administration of probe drugs, were also evaluated. Vitamine D3 was measured in plasma by HPLC-UV. Data on use of CYP2D6 and CYP3A4 inhibitor or inducer drugs and vitamin D supplementation were recorded. Results: About 20% of patients had reduced CYP2D6 metabolic activity and 7% CYP3A4 impaired metabolism. Approximately 30% of CYP2D6 poor metabolizers (PM), 56% of intermediate metabolizers (IM) and 11.3% of extensive metabolizers (EM) were using CYP2D6 inhibitor drugs. EDF levels diminished proportionally to the reduction of CYP2D6 metabolic activity (PM 2.79 ng mL-1, IM 5.36 ng mL-1 and EM 10.65 ng mL-1, P<0.01). Median plasma levels of TAM (161.50 ng mL-1) and HTF (1.32 ng mL-1) in CYP2D6 IM patients with reduced CYP3A4 metabolism were higher (P<0.05) than those from CYP2D6 IM patients with functional CYP3A4 metabolism (122.07 ng mL-1 and 0.61 ng mL-1, respectively). Indeed, HTF and TAM plasma levels were approximately 50% higher in patients with CYP3A4*22 genotype compared to patients with alleles *1/*1. Seasonality also contributed to EDF and HTF variability, summer concentrations were 24% and 42% higher compared to winter. The DBS method was able to identify 96% of patients with plasma EDF concentrations below the clinical threshold and can be used in therapeutic monitoring of TAM. Conclusion: Our findings suggest that CYP3A4 contributes to the bioactivation of TAM through formation of HTF and becomes increasingly important in conditions of diminished or absent CYP2D6 activity. A significant variability on EDF and HTF exposure related to seasonality was identified, with considerable higher plasma concentrations during summer. The mechanism relating vitamin D status, seasonality and biotransformation of TAM still remains to be elucidated.

Introdução: a ação antiestrogênica do tamoxifeno (TAM) é dependente da bioativação à endoxifeno (EDF) e 4-hidroxitamoxifeno (HTF). É bastante provável que sua eficácia terapêutica esteja relacionada ao alcance de um limiar nos níveis de EDF (>5,9 ng mL-1). Entretanto, as concentrações plasmáticas de EDF são altamente variáveis, em parte devido a polimorfismos no gene da CYP2D6 e ao uso de inibidores da enzima. A CYP3A4 também contribui para a formação do EDF e pode ser influenciada por interações medicamentosas e exposição solar. Recentemente, o polimorfismo CYP3A4*22 foi associado à redução da atividade da enzima. Entretanto, pouco se sabe sobre seu impacto na formação do EDF. Objetivo: Em virtude da alta variabilidade na resposta terapêutica e os múltiplos fatores associados ao metabolismo do TAM, o presente estudo objetivou avaliar o efeito dos polimorfismos da CYP2D6 e CYP3A4, interações medicamentosas e exposição à vitamina D na bioativação do TAM. Adicionalmente, dois métodos analíticos para a otimização do tratamento através da medida das razões metabólicas da CYP2D6 e quantificação do TAM e metabólitos em manchas de sangue seco (DBS) foram desenvolvidos. Patientes & métodos: Cento e dezesseis pacientes em tratamento adjuvante com o TAM forneceram amostras de plasma para dosagens do TAM, metabótilos e 25OHD3 no inverno e verão. As concentrações de TAM e metabólitos em plasma e DBS foram medidas por LCMS/ MS. Foram avaliados os genótipos da CYP2D6 e CYP3A4, bem como fenótipos obtidos pelas razões metabólicas determinadas após administração dos fármacos sonda dextrometorfano e omeprazol. As concentrações de vitamina D3 em plasma foram quantificadas por HPLC-UV. Foram obtidas informações sobre uso de inibidores ou indutores das enzimas e suplementação de vitamina D. Resultados: Cerca de 20% das pacientes apresentaram atividade metabólica reduzida para a CYP2D6 e 7% para a CYP3A4. Aproximadamente 30% das metabolizadoras lentas (ML), 56% das metabolizadoras intermediárias (MI) e 11.3% das metabolizadoras rápidas (MR) usavam fármaco inibidor da CYP2D6. As concentrações de EDF diminuiram proporcionalmente à redução da atividade metabólica da CYP2D6 (ML 2,79 ng mL-1, MI 5.36 ng mL-1 e MR 10,65 ng mL-1, P<0.01). A mediana das concentrações plasmáticas de TAM e HTF em pacientes CYP2D6 MI com metabolismo reduzido da CYP3A4 (161,50 ng mL-1 e 1,32 ng mL-1, respectivamente) foram superiores as encontradas nos pacientes CYP2D6 MI com metabolismo funcional da CYP3A4 (122,07 ng mL-1 e 0.61 ng mL-1, respectivamente, P<0.05). Adicionalmente, as concentrações de HTF e TAM foram aproximadamente 50% superiores em pacientes com genótipo CYP3A4*22 em comparação aos pacientes *1/*1. A sazonalidade também contribuiu para a variabilidade das concentrações dos metabólitos ativos, os níveis de EDF foram 24% e HTF 42% superiores no verão. Nas análises de DBS, foi possível identificar 96% dos pacientes com concentrações de EDF abaixo do limiar clínico, indicando seu potencial uso no monitoramento terapêutico do TAM. Conclusão: a CYP3A4 contribui para a bioativação do TAM através da formação de HTF, tornando-se mais importante em condições de atividade diminuída ou ausente da CYP2D6. Os níveis plasmáticos de EDF e HTF demonstraram ser influenciados pela sazonalidade, com aumento significativo no verão. Entretanto o mecanismo relacionado a associação da vitamina D, exposição solar e bioativação do TAM permanecem por ser elucidados. / Background: The therapeutic antiestrogenic effect of tamoxifen (TAM) requires metabolic activation to endoxifen (EDF) and 4-hydroxytamoxifen (HTF). Adequate therapeutic outcome seems to be dependent on the achievement of a threshold of EDF concentration (>5.9 ng mL-1). EDF plasma levels are highly variable among patients, which could be partly explained by polymorphisms in the CYP2D6 gene and the use of enzymes inhibitor drugs. In a lesser extent, CYP3A4 also contributes to EDF formation and can be influenced by drug interactions and sun exposure. From a genetic point of view, a recently described CYP3A4*22 polymorphism has been associated with reduced enzyme activity. However, there is little knowledge about the impact of CYP3A4 polymorphisms on EDF formation. Objective: In view of the large variability on therapeutic response and the multiple factors associated to TAM metabolic activation, the present study aimed to evaluate the effect of CYP2D6 and CYP3A4 polymorphisms, drug interactions and vitamin D exposure on TAM metabolic activation. Additionally, two analytical methods for optimization of TAM treatment by measurement of CYP2D6 metabolic ratios and quantification of TAM and metabolites in dried blood sopts (DBS) were developed. Patients & methods: One hundred and sixteen patients under TAM therapy provided blood samples for measurement of TAM, NDT, EDF, HTF and 25OHD3 at Winter and Summer. TAM and metabolites were measured in plasma and DBS by LC-MS/MS. CYP2D6 and CYP3A4 genotypes and phenotypes, given according to [DMT]/[DTP] and [OME]/[OMS] metabolic ratios after administration of probe drugs, were also evaluated. Vitamine D3 was measured in plasma by HPLC-UV. Data on use of CYP2D6 and CYP3A4 inhibitor or inducer drugs and vitamin D supplementation were recorded. Results: About 20% of patients had reduced CYP2D6 metabolic activity and 7% CYP3A4 impaired metabolism. Approximately 30% of CYP2D6 poor metabolizers (PM), 56% of intermediate metabolizers (IM) and 11.3% of extensive metabolizers (EM) were using CYP2D6 inhibitor drugs. EDF levels diminished proportionally to the reduction of CYP2D6 metabolic activity (PM 2.79 ng mL-1, IM 5.36 ng mL-1 and EM 10.65 ng mL-1, P<0.01). Median plasma levels of TAM (161.50 ng mL-1) and HTF (1.32 ng mL-1) in CYP2D6 IM patients with reduced CYP3A4 metabolism were higher (P<0.05) than those from CYP2D6 IM patients with functional CYP3A4 metabolism (122.07 ng mL-1 and 0.61 ng mL-1, respectively). Indeed, HTF and TAM plasma levels were approximately 50% higher in patients with CYP3A4*22 genotype compared to patients with alleles *1/*1. Seasonality also contributed to EDF and HTF variability, summer concentrations were 24% and 42% higher compared to winter. The DBS method was able to identify 96% of patients with plasma EDF concentrations below the clinical threshold and can be used in therapeutic monitoring of TAM. Conclusion: Our findings suggest that CYP3A4 contributes to the bioactivation of TAM through formation of HTF and becomes increasingly important in conditions of diminished or absent CYP2D6 activity. A significant variability on EDF and HTF exposure related to seasonality was identified, with considerable higher plasma concentrations during summer. The mechanism relating vitamin D status, seasonality and biotransformation of TAM still remains to be elucidated.

Introdução: a ação antiestrogênica do tamoxifeno (TAM) é dependente da bioativação à endoxifeno (EDF) e 4-hidroxitamoxifeno (HTF). É bastante provável que sua eficácia terapêutica esteja relacionada ao alcance de um limiar nos níveis de EDF (>5,9 ng mL-1). Entretanto, as concentrações plasmáticas de EDF são altamente variáveis, em parte devido a polimorfismos no gene da CYP2D6 e ao uso de inibidores da enzima. A CYP3A4 também contribui para a formação do EDF e pode ser influenciada por interações medicamentosas e exposição solar. Recentemente, o polimorfismo CYP3A4*22 foi associado à redução da atividade da enzima. Entretanto, pouco se sabe sobre seu impacto na formação do EDF. Objetivo: Em virtude da alta variabilidade na resposta terapêutica e os múltiplos fatores associados ao metabolismo do TAM, o presente estudo objetivou avaliar o efeito dos polimorfismos da CYP2D6 e CYP3A4, interações medicamentosas e exposição à vitamina D na bioativação do TAM. Adicionalmente, dois métodos analíticos para a otimização do tratamento através da medida das razões metabólicas da CYP2D6 e quantificação do TAM e metabólitos em manchas de sangue seco (DBS) foram desenvolvidos. Patientes & métodos: Cento e dezesseis pacientes em tratamento adjuvante com o TAM forneceram amostras de plasma para dosagens do TAM, metabótilos e 25OHD3 no inverno e verão. As concentrações de TAM e metabólitos em plasma e DBS foram medidas por LCMS/ MS. Foram avaliados os genótipos da CYP2D6 e CYP3A4, bem como fenótipos obtidos pelas razões metabólicas determinadas após administração dos fármacos sonda dextrometorfano e omeprazol. As concentrações de vitamina D3 em plasma foram quantificadas por HPLC-UV. Foram obtidas informações sobre uso de inibidores ou indutores das enzimas e suplementação de vitamina D. Resultados: Cerca de 20% das pacientes apresentaram atividade metabólica reduzida para a CYP2D6 e 7% para a CYP3A4. Aproximadamente 30% das metabolizadoras lentas (ML), 56% das metabolizadoras intermediárias (MI) e 11.3% das metabolizadoras rápidas (MR) usavam fármaco inibidor da CYP2D6. As concentrações de EDF diminuiram proporcionalmente à redução da atividade metabólica da CYP2D6 (ML 2,79 ng mL-1, MI 5.36 ng mL-1 e MR 10,65 ng mL-1, P<0.01). A mediana das concentrações plasmáticas de TAM e HTF em pacientes CYP2D6 MI com metabolismo reduzido da CYP3A4 (161,50 ng mL-1 e 1,32 ng mL-1, respectivamente) foram superiores as encontradas nos pacientes CYP2D6 MI com metabolismo funcional da CYP3A4 (122,07 ng mL-1 e 0.61 ng mL-1, respectivamente, P<0.05). Adicionalmente, as concentrações de HTF e TAM foram aproximadamente 50% superiores em pacientes com genótipo CYP3A4*22 em comparação aos pacientes *1/*1. A sazonalidade também contribuiu para a variabilidade das concentrações dos metabólitos ativos, os níveis de EDF foram 24% e HTF 42% superiores no verão. Nas análises de DBS, foi possível identificar 96% dos pacientes com concentrações de EDF abaixo do limiar clínico, indicando seu potencial uso no monitoramento terapêutico do TAM. Conclusão: a CYP3A4 contribui para a bioativação do TAM através da formação de HTF, tornando-se mais importante em condições de atividade diminuída ou ausente da CYP2D6. Os níveis plasmáticos de EDF e HTF demonstraram ser influenciados pela sazonalidade, com aumento significativo no verão. Entretanto o mecanismo relacionado a associação da vitamina D, exposição solar e bioativação do TAM permanecem por ser elucidados. / Background: The therapeutic antiestrogenic effect of tamoxifen (TAM) requires metabolic activation to endoxifen (EDF) and 4-hydroxytamoxifen (HTF). Adequate therapeutic outcome seems to be dependent on the achievement of a threshold of EDF concentration (>5.9 ng mL-1). EDF plasma levels are highly variable among patients, which could be partly explained by polymorphisms in the CYP2D6 gene and the use of enzymes inhibitor drugs. In a lesser extent, CYP3A4 also contributes to EDF formation and can be influenced by drug interactions and sun exposure. From a genetic point of view, a recently described CYP3A4*22 polymorphism has been associated with reduced enzyme activity. However, there is little knowledge about the impact of CYP3A4 polymorphisms on EDF formation. Objective: In view of the large variability on therapeutic response and the multiple factors associated to TAM metabolic activation, the present study aimed to evaluate the effect of CYP2D6 and CYP3A4 polymorphisms, drug interactions and vitamin D exposure on TAM metabolic activation. Additionally, two analytical methods for optimization of TAM treatment by measurement of CYP2D6 metabolic ratios and quantification of TAM and metabolites in dried blood sopts (DBS) were developed. Patients & methods: One hundred and sixteen patients under TAM therapy provided blood samples for measurement of TAM, NDT, EDF, HTF and 25OHD3 at Winter and Summer. TAM and metabolites were measured in plasma and DBS by LC-MS/MS. CYP2D6 and CYP3A4 genotypes and phenotypes, given according to [DMT]/[DTP] and [OME]/[OMS] metabolic ratios after administration of probe drugs, were also evaluated. Vitamine D3 was measured in plasma by HPLC-UV. Data on use of CYP2D6 and CYP3A4 inhibitor or inducer drugs and vitamin D supplementation were recorded. Results: About 20% of patients had reduced CYP2D6 metabolic activity and 7% CYP3A4 impaired metabolism. Approximately 30% of CYP2D6 poor metabolizers (PM), 56% of intermediate metabolizers (IM) and 11.3% of extensive metabolizers (EM) were using CYP2D6 inhibitor drugs. EDF levels diminished proportionally to the reduction of CYP2D6 metabolic activity (PM 2.79 ng mL-1, IM 5.36 ng mL-1 and EM 10.65 ng mL-1, P<0.01). Median plasma levels of TAM (161.50 ng mL-1) and HTF (1.32 ng mL-1) in CYP2D6 IM patients with reduced CYP3A4 metabolism were higher (P<0.05) than those from CYP2D6 IM patients with functional CYP3A4 metabolism (122.07 ng mL-1 and 0.61 ng mL-1, respectively). Indeed, HTF and TAM plasma levels were approximately 50% higher in patients with CYP3A4*22 genotype compared to patients with alleles *1/*1. Seasonality also contributed to EDF and HTF variability, summer concentrations were 24% and 42% higher compared to winter. The DBS method was able to identify 96% of patients with plasma EDF concentrations below the clinical threshold and can be used in therapeutic monitoring of TAM. Conclusion: Our findings suggest that CYP3A4 contributes to the bioactivation of TAM through formation of HTF and becomes increasingly important in conditions of diminished or absent CYP2D6 activity. A significant variability on EDF and HTF exposure related to seasonality was identified, with considerable higher plasma concentrations during summer. The mechanism relating vitamin D status, seasonality and biotransformation of TAM still remains to be elucidated.

Orientador: Priscila Gava Mazzola / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T03:09:38Z (GMT). No. of bitstreams: 1 Cruz_AlineAparecidada_M.pdf: 2377605 bytes, checksum: b42d9527d3edb77d190453e2eb758d31 (MD5) Previous issue date: 2014 / Resumo: Objetivos: Avaliar o impacto do seguimento farmacoterapêutico sobre a adesão à hormonioterapia, qualidade de vida e nível de informação sobre a doença e o tratamento de mulheres com câncer de mama em uso de tamoxifeno. Casuística e métodos: Tratou-se de um estudo prospectivo longitudinal. O estudo foi realizado no Hospital da Mulher Prof. Dr. José Aristodemo Pinotti - Centro de Atenção Integral à Saúde da Mulher - CAISM / UNICAMP, Campinas ¿ SP (ambulatório de oncologia clínica) entre janeiro de 2012 e dezembro de 2013. Foi realizada amostragem por conveniência. O acompanhamento farmacoterapêutico foi realizado pelo período de 1 ano, utilizando-se como método o Pharmacotherapy Workup (PW). Foram aplicados questionários validados para a avaliação de qualidade de vida (QV) (EORTCQLQ-C30 3.0 e QLQ-BR23), avaliação da adesão ao tratamento medicamentoso (Teste de Morisky-Green (TMG)) e de avaliação do nível de informação sobre a doença e o tratamento (EORTCQLQ-INFO25) no início e ao final do acompanhamento. Resultados: Um total de 60 voluntárias foram incluídas inicialmente e 21delas permaneceram até o final do estudo. Estas apresentavam em média 2,0 ±1,4 Problemas Relacionados aos Medicamentos (PRMs) no início do acompanhamento, valor que diminuiu para 1,2 ±1,0 PRMs por voluntária (p<0,05) ao final do estudo. Os PRMs de segurança foram os mais numerosos e também foram aqueles que tiveram maior redução.A variação das pontuações dos 23 quesitos avaliados nos questionários de QV aplicados não foi significativa, oscilando pouco em torno da média inicial. Observou-se que os quesitos com maior pontuação inicialmente foram "Função social" (88,3 ± 30,6) e "Imagem corporal" (78,1 ± 31,2) e permaneceram com a melhor pontuação ao final do período de um ano. A adesão ao tratamento com tamoxifeno não apresentou diferença estatística ao final do período de estudo (p=0,289). A avaliação da quantidade de informação recebida pelas participantes quanto ao seu tratamento não apresentou diferenças significativas ao final do período de estudo para 7 dos 8 itens avaliados. Conclusão: O seguimento farmacoterapêutico foi efetivo na redução de PRMs deste grupo de mulheres, porém não modificou significativamente os parâmetros qualidade de vida, adesão ao tratamento com tamoxifeno e nível de informação sobre a doença e o tratamento / Abstract: Aims: To evaluate the impact of Pharmaceutical Care (PC) on adherence to hormonal therapy, quality of life (QOL) and level of information about the disease and treatment of breast cancer patients using tamoxifen. Methods: This was a longitudinal prospective study. It was conducted at Woman¿s Hospital Prof. Dr. José Aristodemo Pinotti - Centro de Atenção Integral à Saúde da Mulher - CAISM/UNICAMP, Campinas ¿ SP between January 2012 and December 2013. Sampling was done for convenience. Data for the study were collected during one year, using the Pharmacotherapy Workup method (PW). We used validated questionnaires to assess quality of life (EORTC QLQ - C30 3.0 and QLQ - BR23), adherence to medication (Morisky-Green test (TMG)) and level of information about the disease and treatment (EORTC QLQ - INFO25). Results: A total of 60 volunteers were included and 21 completed the study. We initially observed a 2.0 ± 1.4 (mean ± standard deviation) drug therapy problems (DTPs) per patient and this value decreased to 1.2 ± 1.0 DTPs per patient (p < 0.05) at the end of the study. The safety DTP were the most numerous of all and were also those who had the greatest reduction. The range of scores for the two QOL questionnaires used was small, oscillating slightly around the initial mean. It can be observed that questions with higher scores initially were "social function" (88.3 ± 30.6) and "body image" (78.1 ± 31.2) and remained with the highest score at the end of one year. Adherence to treatment with tamoxifen showed no statistical difference during the period (p=0,289). The evaluation of the amount of information received by patients on their treatment was not statistically significant at the end of the study period for most items assessed. Conclusion: The PC was effective in reducing drug therapy problems of this group, but was not able to cause a statistically significant impact on quality of life parameters, adherence to tamoxifen and level of information about the disease and the treatment for the group of patients studied / Mestrado / Ciencias Biomedicas / Mestra em Ciências Médicas

Orientadores: Luis Otavio Zanatta Sarian, Maria Salete Costa Gurgel, Carmem Silvia Passos Lima / Tese (Doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T11:21:21Z (GMT). No. of bitstreams: 1 CardosoFilho_Cassio_D.pdf: 1685855 bytes, checksum: 341644d7cc011e51bf31d1f4881e8878 (MD5) Previous issue date: 2012 / Resumo: Introdução: A terapêutica sistêmica para o câncer de mama envolve o uso do agente antiestrogênico tamoxifeno, fármaco metabolizado pelo fígado no sistema do citocromo P-450 (CYP). Este, por sua vez, é parcialmente codificado pelo gene CYP1A1, e alguns polimorfismos deste gene têm sido associados com interferências na sua eficácia metabólica. Além disso, diferenças interindividuais no CYP explicam parte das variações na resistência ao tamoxifeno e metabolismo dos estrogênios. Dentre esses polimorfismos, o A4889G (M2) e o T6235C (M1) são conhecidos por afetar a ativação da estrona e do estradiol, e por provocar a redução da concentração de metabólitos altamente ativos do tamoxifeno, reduzindo teoricamente o efeito antiestrogênico desta modalidade de hormonioterapia no tecido mamário. Embora plausíveis do ponto de vista biológico, as implicações clínicas dos polimorfismos do CYP1A1, ou seja, as características patológicas dos tumores e um pior prognóstico decorrente do aumento dos estrógenos circulantes e redução dos metabólitos ativos do tamoxifeno, não foram ainda avaliadas. Objetivo: Avaliar a associação entre os polimorfismos M1 e M2 do gene CYP1A1 e as características patológicas e clínicas de mulheres com câncer de mama esporádico, em duas abordagens: 1) determinar as associações entre estes polimorfismos e as características patológicas, clínicas e o padrão de sobrevida global em mulheres com câncer de mama esporádico e 2) determinar as associações entre estespolimorfismos e as caracteríasticas patológicas e o comportamento clínico de tumores de mama com receptores hormonais positivos na vigência do uso de tamoxifeno. Métodos: foram incluídas 741 mulheres com câncer de mama esporádico, 405 das quais com tumores positivos para receptores esteroides e que usaram tamoxifeno como terapia antiestrogênica primária, para as quais os dados referentes a cinco anos de seguimento estavam disponíveis. Foram avaliadas as associações de informações-chave patológicas e clínicas, incluindo a sobrevida geral em cinco anos, com as diferentes combinações de polimorfismos do gene CYP1A1. Resultados: Em mulheres portadoras de ambos os polimorfismos M1 e M2 do CYP1A1, a proporção de tumores grau histológico III (80,3%) foi significativamente menor que nas não-portadoras (89,6%); p ajustado <0,01. O mesmo ocorreu na análise restrita às mulheres com tumores RE+ usando tamoxifeno (76,1% vs. 85,9%; p ajustado= 0,02). Após 60 meses de seguimento, cerca de 75% das mulheres estavam vivas. Não houve diferença significativa na sobrevivência relacionada com o estado do gene CYP1A1. Conclusões: embora associados a tumores de menor grau histológico, não há nenhuma evidência da associação dos polimorfismos do CYP1A1 com prognóstico do câncer da mama / Abstract: Introduction: systemic therapy for breast cancer involves the use of the anti-estrogen agent tamoxifen, which is metabolized by the liver cytochrome P-450 (CYP). This, in turn, is partially encoded by CYP1A1, and some polymorphisms of this gene have been associated with metabolic disturbance at their effectiveness. Moreover, interindividual differences in efficiency of CYP explain part of the variations in resistance to tamoxifen and estrogen metabolism. Among these polymorphisms, the A4889G (M2) and T6235C (M1) are known to affect the activation of estrone and estradiol, and cause the reduction of the concentration of highly active metabolites of tamoxifen, theoretically reducing the anti-estrogenic effect of this form of endocrine therapy in breast tissue. Although plausible from the biological point of view, the clinical implications of polymorphisms of CYP1A1, ie, the pathologic features of tumors and a worse prognosis due to increased circulating estrogens and reduction of active metabolites of tamoxifen have not yet been evaluated. Objectives: To evaluate the association between CYP1A1 A4889G and T6235C gene polymorphisms and clinical and pathological characteristics of women with sporadic breast cancer in two approaches: 1) determine the associations between CYP1A1 A4889G and T6235C gene polymorphisms and the pathological characteristics of the tumors, and the clinical features, including overall survival, of women with sporadic breast cancer and 2) determine the associations between CYP1A1 A4889G and T6235C gene polymorphisms and the pathological characteristics and clinical behavior of estrogen receptor-positive breast tumors in patients using tamoxifen. Methods: We included 741 women with sporadic breast cancer, 405 of whom had tumors positive for steroid receptors and using tamoxifen as primary antiestrogen therapy, for which data on five years of follow-up were available. We evaluated the associations of key pathological and clinical features, including overall survival at five years, with different combinations of the CYP1A1 gene polymorphisms. Results: In women with both polymorphisms of the CYP1A1 gene, the proportion of grade III tumors (80.3%) was significantly lower than in non-carriers (89.6%), adjusted p <0.01. The same was true for women with ER + tumors using tamoxifen (76.1% vs. 85.9%; adjusted p = 0.02). After 60 months of follow up, 75% of the women were alive. There was no significant difference in survival related to the state of the CYP1A1 gene. Conclusions: Although associated with tumors of lower grade, there is no evidence of an association of CYP1A1 polymorphisms with breast cancer prognosis / Doutorado / Oncologia Ginecológica e Mamária / Doutor em Ciências Médicas

Nesse trabalho avaliamos a sensibilidade a drogas in vitro de alguns isolados obtidos de pacientes brasileiros com leishmaniose cutânea. O microteste de MTT modificado mostrou-se eficaz para avaliação da sensibilidade in vitro de promastigotas de Leishmania e macrófagos de medula como modelo de infecção por L. (V.) braziliensis. A atividade de tamoxifeno e anfotericina B foi similar entre os isolados de Leishmania avaliados. Foi observada uma variação maior da sensibilidade ao Glucantime®, sendo que os isolados de L. (V.) braziliensis apresentaram maior sensibilidade a essa droga. Não foi observada correlação da resposta clínica dos pacientes ao tratamento com a atividade in vitro. Avaliamos também a eficácia de tamoxifeno no tratamento de camundongos BALB/c infectados com L. (V.) braziliensis. Observamos que 20 ou 30 mg/kg/dia de tamoxifeno por 15 dias resultou em redução no tamanho das lesões e carga parasitária em comparação com animais controle.Um isolado apresentou morfologia flagelar distinta daquela observada em promastigotas típicos de Leishmania. / In this work we evaluated the in vitro sensitivity to drugs of some isolates from Brazilian patients with cutaneous leishmaniasis. The modified MTT microtest was effective for evaluation of in vitro sensitivity of Leishmania promastigotes and macrophages from bone marrow as a model of infection by L. (V.) braziliensis. The activity of tamoxifen and amphotericin B was similar among isolates of Leishmania evaluated. Sensitivity to Glucantime®, was more variable with isolates of L. (V.) braziliensis presenting higher sensitivity to the drug. There was no correlation between clinical response to treatment with in vitro activity. We have also evaluated the effectiveness of tamoxifen in the treatment of BALB/c mice infected with L. (V.) braziliensis and observed that 20 or 30 mg/kg/day of tamoxifen for 15 days resulted in reduction in the size of lesions and parasite load when compared with control animals. One of the isolates presented atypical flagellar morphology.

The microbes that inhabit the human body, our microbiota, greatly influence our physiology and propensity for disease. For instance, the gut microbiota metabolizes compounds from our diet to provide important nutrients. Similarly, the microbiota has the potential to impact drug response; directly by metabolizing drugs, or indirectly by providing metabolites to the host. The complexity of the mammalian microbiota, and the limited throughput of such models, prohibit a systematic interrogation of specific interactions between microbes and host drug response. Here, I use C. elegans and its bacterial diet as a suitable model with the scalability and genetic tractability to address these questions. In Chapter II, I describe host-bacteria-drug interactions involving the anti-pyrimidine drugs 5-FU and FUDR. In brief, we identified two main mechanisms by which bacteria affect the C. elegans response to anti-pyrimidines: (1) metabolic conversion into FUMP by uridine phospho-ribosyltransferase (upp) and (2) dietary supplementation of uracil. Chapter III will focus on a selective estrogen-receptor modulator, TAM, with no clear target in bacteria or C. elegans. I will describe my work characterizing a bacteria-dependent response to TAM involving fatty acid metabolism. Lastly, the Appendix will summarize my efforts to expand the sample space of tested host-microbe-drug interactions.

The resistance to tamoxifen, a drug used in the adjuvant therapy for hormone sensitive breast cancer, represents a major clinical obstacle. Although various mechanisms leading to tamoxifen resistance have been described and intensively studied, a significant number of patients still become resistant to the treatment and eventually relapse. Tamoxifen therapy has been shown to enrich tumors with cancer stem cells (CSCs), which are naturally resistant, and have self-renewal ability and the potential to form secondary tumors. Metabolic rewiring, altered iron metabolism and upregulation of ATP-binding cassette (ABC) transporters have been shown to be important in the maintenance of CSC phenotype. Therefore, we investigated these mechanisms as possible contributors to tamoxifen resistance in vitro in two tamoxifen resistant (Tam5R) cell lines that we established. We show that Tam5R cells have dramatically disassembled and less active mitochondrial supercomplexes (SCs) and higher level of mitochondrial superoxide, together with a fragmented mitochondrial network. Such dysfunction of mitochondria results in the AMP-activated protein kinase (AMPK) activation and metabolic rewiring towards glycolysis. Importantly, cells lacking functional mitochondria are significantly more resistant to tamoxifen, supporting...

The resistance to tamoxifen, a drug used in the adjuvant therapy for hormone sensitive breast cancer, represents a major clinical obstacle. Although various mechanisms leading to tamoxifen resistance have been described and intensively studied, a significant number of patients still become resistant to the treatment and eventually relapse. Tamoxifen therapy has been shown to enrich tumors with cancer stem cells (CSCs), which are naturally resistant, and have self-renewal ability and the potential to form secondary tumors. Metabolic rewiring, altered iron metabolism and upregulation of ATP-binding cassette (ABC) transporters have been shown to be important in the maintenance of CSC phenotype. Therefore, we investigated these mechanisms as possible contributors to tamoxifen resistance in vitro in two tamoxifen resistant (Tam5R) cell lines that we established. We show that Tam5R cells have dramatically disassembled and less active mitochondrial supercomplexes (SCs) and higher level of mitochondrial superoxide, together with a fragmented mitochondrial network. Such dysfunction of mitochondria results in the AMP-activated protein kinase (AMPK) activation and metabolic rewiring towards glycolysis. Importantly, cells lacking functional mitochondria are significantly more resistant to tamoxifen, supporting...

Introduction: Breast cancer is the second highest cause of cancer mortality in women worldwide. Hormonal therapy is considered one of the most effective therapies and is used against luminal-type malignancies. However, 40-50% of tumour cells can develop resistance, thereby limiting the success in breast cancer treatment. In this study, mechanisms of resistance were investigated using a novel multi-stable isotope labelled amino acids (SILAC) proteomics approach in phenotype-specific breast cancer cell lines resistant to endocrine treatment. Method: In vitro chemo-sensitivity (IC50) was determined for MCF7, T47D, MDA-MB-231, MDA-MB-468, MDA-MB-453, BT-20 and MCF-10A breast cell lines using four endocrine-based therapeutic agents (Tamoxifen, 4-Hydroxytamoxifen OHT, Raloxifene, Anastrozole) to select viable strains for resistance studies. MCF7 (luminal-type A) and MDA-MB-231 (triple negative breast cancer, TNBC) were selected and initially subject to OHT or raloxifene exposure with gradual increments for 10 months. WT cells were grown in the absence of drug in parallel as passage controls. Resistant cell lines were assessed by MTT and IF for comparison with parental cell lines. Resistant cell lines, along with the passage control and a SILAC control, were grown in “light” SILAC medium together with WT strains cultured in “heavy” SILAC medium. Proteins were extracted, concentrations determined and analysed by SDS PAGE for quality control. An aliquot of each “light” cell line (resistant, passage control or SILAC control) was combined with an equal amount of “heavy” WT, trypsin digested and analysed by nano-HPLC Orbitrap Fusion mass spectrometry (2D-LC MS/MS). Proteins were identified by database searching using MascotTM. Relative changes (resistant/WT ratio) in protein levels were determined and bioinformatics tools (STRING and UniProt) used to explore significantly changed pathways associated with resistance. Western blotting was used to verify selected target proteins. Results: Four consistently resistant sublines were generated MCF7 OHT Res (2.00-fold more resistant), MCF7 Ralx Res (2.00-fold), MDA-MB-231 OHT Res (1.90-fold change) and MDA-MB-231 Ralx Res (2.00-fold), in addition to two high passage controls. ER expression by IF was decreased in MCF7 OHT Res compared to the WT and MCF7 Ralx Res, whereas CD44 was increased. Proteomic analysis revealed 2247 and 2880 total proteins in MCF7 OHT Res and MCF7 Ralx Res whilst 3471 and 3495 total proteins were identified in MDA-MB-231 OHT Res and MDA-MB-231 Ralx Res, respectively. Bioinformatics tools identified significantly changed pathways included apoptosis, cytoskeleton, cell motility and redox cell homeostasis. Components of the MAPK-signalling cascade were consistently found to be upregulated in resistant cell lines. MAPK1 (ERK2), previously associated with tamoxifen resistance was increased in MDA-MB-231 Ralx Res cell lines by 4.45-fold and confirmed by Western blotting. Sorcin, which contributes to calcium homeostasis and is also linked to multidrug resistance was increased 4.11- and 2.35-fold in MCF7 OHT Res and Ralx Res sub cell lines, respectively. Some results, such as those for c-Jun, were inconsistent between proteomic analysis and Western blotting and require further investigation. Conclusion: The unique resistant cell lines generated here, as well the MCF7 OHT resistant line, provided novel data that give insights into the biological pathways involved in mechanisms of endocrine drug resistance in breast cancer. Proteomics analysis provided extensive data on common functionality and pathways across the resistant cell lines independent of phenotype or SERM. Overall, the results provided interesting targets for re-sensitising resistant breast cancer and the potential to investigate novel combination therapies in the future. / Al-Ahliyya Amman University scholaships