Análises celulares e moleculares dos efeitos do peptídeo vasoativo angiotensina-(1-7) no processo tumoral pulmonar e a atuação do microrna 21-5P

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

A tomografia por emissão de pósitrons com 2-[18F]-fluoro-2-desoxi-D-glicose é custo-efetiva em pacientes com câncer de pulmão não pequenas células no Brasil

OBJETIVO: Comparar a acurácia e a custo-efetividade do estadiamento metabólico (EM) com o FDG-PET em relação ao estadiamento convencional (EC) no estadiamento inicial de pacientes com câncer de pulmão não pequenas células (CPNPC). MATERIAIS E MÉTODOS: Noventa e cinco pacientes com diagnóstico inicial de CPNPC foram estadiados antes do início do tratamento. Os resultados do EC e EM foram comparados quanto a definição do tratamento e incidência de toracotomia fútil em cada estratégia. RESULTADOS: O EM com FDG-PET classificou 48,4% dos pacientes como estádio mais avançado e 5,3% como menos avançado. O resultado do EM modificaria o tratamento em 41% dos pacientes. A toracotomia foi considerada fútil em 47% dos pacientes com EC e em 19% dos casos com EM. O custo das toracotomias fúteis em oito pacientes no EM foi de R$ 79.720, enquanto em 31 pacientes no EC seria de R$ 308.915. Apenas esta economia seria mais que suficiente para cobrir os custos de todos os exames de FDG-PET nos 95 pacientes (R$ 126.350) ou de FDG-PET/CT (R$ 193.515). CONCLUSÃO: O EM com FDG-PET tem maior acurácia que o EC em pacientes com CPNPC. A FDG-PET e FDG-PET/CT são custo-efetivas e sua utilização se justifica economicamente na saúde pública no Brasil.

Ex vivo assessment of chemotherapy-induced apoptosis and associated molecular changes in patient tumor samples

BACKGROUND: There are inherent conceptual problems in investigating the pharmacodynamics of cancer drugs in vivo. One of the few possible approaches is serial biopsies in patients. However, this type of research is severely limited by methodological and ethical constraints. MATERIALS AND METHODS: A modified 3-dimensional tissue culture technique was used to culture human tumor samples, which had been collected during routine cancer operations. Twenty tumor samples of patients with non-small cell lung cancer (NSCLC) were cultured ex vivo for 120 h and treated with mitomycin C, taxotere and cisplatin. The cytotoxic activity of the anticancer agents was quantified by assessing the metabolic activity of treated tumor cultures and various assays of apoptosis and gene expression were performed. RESULTS: The proliferative activity of the tissue was maintained in culture as assessed by Ki-67 staining. Mitomycin C, cisplatin and taxotere reduced the metabolic activity of the tumor tissue cultures by 51%, 29% and 20%, respectively, at 120 h. The decrease in metabolic activity corresponded to the induction of apoptosis as demonstrated by the typical morphological changes, such as chromatin condensation and nuclear fragmentation. In addition, activated caspase-3 could be verified in apoptotic cells by immunohistochemistry. To verify functional aspects of apoptosis, the induction of chemotherapy-induced cell death was inhibited with the caspase inhibitor z-VAD.fmk. RNA was extracted from the tissue cultures after 120 h of ex vivo drug treatment and was of sufficient quality to allow quantitative PCR. CONCLUSION: The 3-dimensional ex vivo culture technique is a useful method to assess the molecular effects of pharmacological interventions in human cancer samples in vitro. This culture technique could become an important tool for drug development and for the prediction of in vivo drug efficacy.

Influence of comorbidity on outcome after pulmonary resection in the elderly

The aim of this study was to determine the influence of comorbidity on outcome after pulmonary resection in patients over 75 years old. Three hundred and thirty-three patients with non-small-cell lung cancer operated on between 1998 and 2002 were divided into 3 age groups: < 60 years (group 1), 60-75 years (group 2), > 75 years (group 3). Overall operative mortality was 0.3%; 30-day mortality was 1%. There were more major complications with re-operation in groups 1 and 2, but minor complications occurred significantly more frequently in group 3 (36% vs 16%). Overall mean hospital stay was 12 days, with no significant difference among groups. Three-year survival rates were: 80%, 70%, and 65% in groups 1, 2, and 3, respectively, with no significant difference among groups. Age or the presence of comorbidity should not be considered contraindications for lung resection. With proper patient selection and careful preoperative evaluation, many major complications after pneumonectomy are avoidable.

[Atypical case of bronchus carcinoma]

Bronchuscarcinoma ist the most frequent death cause with tumor patients. At time of diagnosis the stadium is often already advanced, the patient is inoperable. We present a patient (non-smoker) with polydipsia, visual troubles and polyuria. The lab results confirmed diabetes insipidus, but the following x-rays proved multiple intracerebral spots. And also multiple spots in the lungs, the mediastinum, in the liver, the coloumn and the adrenals. Histological diagnosis was non small cell lung cancer (NSCLC).

PET-CT-guided interventions in the management of FDG-positive lesions in patients suffering from solid malignancies: initial experiences

Positron emission tomography-computed tomography (PET-CT) has gained widespread acceptance as a staging investigation in the diagnostic workup of malignant tumours and may be used to visualize metabolic changes before the evolution of morphological changes. To make histology of PET findings without distinctive structural changes available for treatment decisions, we developed a protocol for multimodal image-guided interventions using an integrated PET-CT machine. We report our first experience in 12 patients admitted for staging and restaging of breast cancer, non-small cell lung cancer, cervical cancer, soft tissue sarcoma, and osteosarcoma. Patients were repositioned according to the findings in PET-CT and intervention was planned based on a subsequent single-bed PET-CT acquisition of the region concerned. The needle was introduced under CT guidance in a step-by-step technique and correct needle position in the centre of the FDG avid lesion was assured by repetition of a single-bed PET-CT acquisition before sampling. The metabolically active part of lesions was accurately targeted in all patients and representative samples were obtained in 92%. No major adverse effects occurred. We conclude that PET-CT guidance for interventions is feasible and may be promising to optimize the diagnostic yield of CT-guided interventions and to make metabolically active lesions without morphological correlate accessible to percutaneous interventions.

THE ROLE OF TYROSINE PHOSPHORYLATION IN THE FUNCTIONS OF THE TUMOR SUPPRESSOR GPRC5A

The retinoic acid inducible G protein coupled receptor family C group 5 type A (GPRC5A) is expressed preferentially in normal lung tissue but its expression is suppressed in the majority of human non-small cell lung cancer cell lines and tissues. This differential expression has led to the idea that GPRC5A is a potential tumor suppressor. This notion was supported by the finding that mice with a deletion of the Gprc5a gene develop spontaneous lung tumors. However, there are various tumor cell lines and tissue samples, including lung, that exhibit higher GPRC5A expression than normal tissues and some reports by other groups that GPRC5A transfection increased cell growth and colony formation. Obviously, GPRC5A has failed to suppress the development of the tumors and the growth of the cell lines where its expression is not suppressed. Since no mutations were detected in the coding sequence of GPRC5A in 20 NSCLC cell lines, it’s possible that GPRC5A acts as a tumor suppressor in the context of some cells but not in others. Alternatively, we raised the hypothesis that the GPRC5A protein may be inactivated by posttranslational modification(s) such as phosphorylation. It is well established that Serine/Threonine phosphorylation of G protein coupled receptors leads to their desensitization and in a few cases Tyrosine phosphorylation of GPCRs has been linked to internalization. Others reported that GPRC5A can undergo tyrosine phosphorylation in the cytoplasmic domain after treatment of normal human mammary epithelial cells (HMECs) with epidermal growth factor (EGF) or Heregulin. This suggested that GPRC5A is a substrate of EGFR. Therefore, we hypothesized that tyrosine phosphorylation of GPRC5A by activation of EGFR signaling may lead to its inactivation. To test this hypothesis, we transfected human embryo kidney (HEK) 293 cells with GPRC5A and EGFR expression vectors and confirmed that GPRC5A can be tyrosine phosphorylated after activation of EGFR by EGF. Further, we found that EGFR and GPRC5A can interact either directly or through other proteins and that inhibition of the EGFR kinase activity decreased the phosphorylation of GPRA5A and the interaction between GPRC5A and EGFR. In c-terminal of GPRC5A, There are four tyrosine residues Y317, Y320, Y347, Y350. We prepared GPRC5A mutants in which all four tyrosine residues had been replaced by phenylalanine (mutant 4F) or each individual Tyr residue was replaced by Phe and found that Y317 is the major site for EGFR mediated phosphorylation in the HEK293T cell line. We also found that EGF can induce GPRC5A internalization both in H1792 transient and stable cell lines. EGF also partially inactivates the suppressive function of GPRC5A on cell invasion activity and anchorage-independent growth ability of H1792 stable cell lines. These finding support our hypothesis that GPRC5A may be inactivated by posttranslational modification- tyrosine phosphorylation.

Evaluation of deformable image registration for improved 4D CT-derived ventilation for image guided radiotherapy

Recent treatment planning studies have demonstrated the use of physiologic images in radiation therapy treatment planning to identify regions for functional avoidance. This image-guided radiotherapy (IGRT) strategy may reduce the injury and/or functional loss following thoracic radiotherapy. 4D computed tomography (CT), developed for radiotherapy treatment planning, is a relatively new imaging technique that allows the acquisition of a time-varying sequence of 3D CT images of the patient's lungs through the respiratory cycle. Guerrero et al. developed a method to calculate ventilation imaging from 4D CT, which is potentially better suited and more broadly available for IGRT than the current standard imaging methods. The key to extracting function information from 4D CT is the construction of a volumetric deformation field that accurately tracks the motion of the patient's lungs during the respiratory cycle. The spatial accuracy of the displacement field directly impacts the ventilation images; higher spatial registration accuracy will result in less ventilation image artifacts and physiologic inaccuracies. Presently, a consistent methodology for spatial accuracy evaluation of the DIR transformation is lacking. Evaluation of the 4D CT-derived ventilation images will be performed to assess correlation with global measurements of lung ventilation, as well as regional correlation of the distribution of ventilation with the current clinical standard SPECT. This requires a novel framework for both the detailed assessment of an image registration algorithm's performance characteristics as well as quality assurance for spatial accuracy assessment in routine application. Finally, we hypothesize that hypo-ventilated regions, identified on 4D CT ventilation images, will correlate with hypo-perfused regions in lung cancer patients who have obstructive lesions. A prospective imaging trial of patients with locally advanced non-small-cell lung cancer will allow this hypothesis to be tested. These advances are intended to contribute to the validation and clinical implementation of CT-based ventilation imaging in prospective clinical trials, in which the impact of this imaging method on patient outcomes may be tested.

Radiomics of NSCLC: Quantitative CT Image Feature Characterization and Tumor Shrinkage Prediction

Radiomics is the high-throughput extraction and analysis of quantitative image features. For non-small cell lung cancer (NSCLC) patients, radiomics can be applied to standard of care computed tomography (CT) images to improve tumor diagnosis, staging, and response assessment. The first objective of this work was to show that CT image features extracted from pre-treatment NSCLC tumors could be used to predict tumor shrinkage in response to therapy. This is important since tumor shrinkage is an important cancer treatment endpoint that is correlated with probability of disease progression and overall survival. Accurate prediction of tumor shrinkage could also lead to individually customized treatment plans. To accomplish this objective, 64 stage NSCLC patients with similar treatments were all imaged using the same CT scanner and protocol. Quantitative image features were extracted and principal component regression with simulated annealing subset selection was used to predict shrinkage. Cross validation and permutation tests were used to validate the results. The optimal model gave a strong correlation between the observed and predicted shrinkages with . The second objective of this work was to identify sets of NSCLC CT image features that are reproducible, non-redundant, and informative across multiple machines. Feature sets with these qualities are needed for NSCLC radiomics models to be robust to machine variation and spurious correlation. To accomplish this objective, test-retest CT image pairs were obtained from 56 NSCLC patients imaged on three CT machines from two institutions. For each machine, quantitative image features with concordance correlation coefficient values greater than 0.90 were considered reproducible. Multi-machine reproducible feature sets were created by taking the intersection of individual machine reproducible feature sets. Redundant features were removed through hierarchical clustering. The findings showed that image feature reproducibility and redundancy depended on both the CT machine and the CT image type (average cine 4D-CT imaging vs. end-exhale cine 4D-CT imaging vs. helical inspiratory breath-hold 3D CT). For each image type, a set of cross-machine reproducible, non-redundant, and informative image features was identified. Compared to end-exhale 4D-CT and breath-hold 3D-CT, average 4D-CT derived image features showed superior multi-machine reproducibility and are the best candidates for clinical correlation.

Regulation of {\it neu\/} gene expression by the simian virus 40 large T antigen and tumor suppressors Rb and p53

The neu gene (also c-erbB-2 or HER2) encodes a 185 kilodalton protein that is frequently overexpressed in breast, ovarian and non-small cell lung cancers. Study of the regulation of neu indicates that neu gene expression can be modulated by c-myc or by the adenovirus 5 E1a gene product. This study demonstrates that the transforming protein, large T antigen, of the simian virus 40 represses neu promoter activity. Repression of neu by large T antigen is mediated through the region $-$172 to $-$79 (relative to first ATG) of the neu promoter--unlike through $-$312 to $-$172 for c-myc or E1a. This suggests a different pathway for repression of neu by large T antigen. The 10 amino acid region of large T required for binding the tumor suppressor, retinoblastoma gene product, Rb, is not necessary for repression of neu. Moreover, the tumor suppressors, Rb and p53 can independently inhibit neu promoter activity. Rb inhibits neu through a 10 base pair G-rich enhancer (GTG element) ($-$243 to $-$234) and also through regions close to transcription initiation sites ($-$172 to $-$79). Mutant Rb unable to complex large T is able to repress the region close to transcription initiation but not the GTG enhancer. Thus, Rb inhibits the two regulatory domains of the neu gene by different mechanisms. Both Rb and p53 can repress the transforming activity of activated neu in focus forming assays. These data provide evidence that tumor suppressors regulate expression of growth stimulatory genes such as neu. Therefore, one reason for the overexpression of neu that is frequently seen in breast cancer cells may be due to functional inactivation of Rb and p53 which is also a common occurrence in breast cancer cells. ^

Identificazione di miRNA correlati ad EGFR: nuovi potenziali biomarcatori di risposta alla terapia di 2a-3a linea in pazienti con NSCLC metastatico

La diagnosi di neoplasia epiteliale maligna polmonare è legata tradizionalmente alla distinzione tra carcinoma a piccole cellule (small-cell lung cancer, SCLC) e carcinoma non-a piccole cellule del polmone (non-small-cell lung cancer, NSCLC). Nell’ambito del NSCLC attualmente è importante di-stinguere l’esatto istotipo (adenocarcinoma, carcinoma squamocellulare e carcinoma neuroendocrino) perchè l’approccio terapeutico cambia a seconda dell’istotipo del tumore e la chemioterapia si dimostra molto spesso inefficace. Attualmente alcuni nuovi farmaci a bersaglio molecolare per il gene EGFR, come Erlotinib e Gefitinib, sono utilizzati per i pazienti refrattari al trattamento chemioterapico tradizionale, che non hanno risposto a uno o più cicli di chemioterapia o che siano progrediti dopo questa. I test per la rilevazione di specifiche mutazioni nel gene EGFR permettono di utilizzare al meglio questi nuovi farmaci, applicandoli anche nella prima linea di trattamento sui pazienti che hanno una maggiore probabilità di risposta alla terapia. Sfortunatamente, non tutti i pazienti rispondono allo stesso modo quando trattati con farmaci anti-EGFR. Di conseguenza, l'individuazione di biomarcatori predittivi di risposta alla terapia sarebbe di notevole importanza per aumentare l'efficacia dei questi farmaci a target molecolare e trattare con farmaci diversi i pazienti che con elevata probabilità non risponderebbero ad essi. I miRNAs sono piccole molecole di RNA endogene, a singolo filamento di 20-22 nucleotidi che svolgono diverse funzioni, una delle più importanti è la regolazione dell’espressione genica. I miRNAs possono determinare una repressione dell'espressione genica in due modi: 1-legandosi a sequenze target di mRNA, causando così un silenziamento del gene (mancata traduzione in proteina), 2- causando la degradazione dello specifico mRNA. Lo scopo della ricerca era di individuare biomarcatori capaci di identificare precocemente i soggetti in grado di rispondere alla terapia con Erlotinib, aumentando così l'efficacia del farmaco ed evitan-do/riducendo possibili fenomeni di tossicità e il trattamento di pazienti che probabilmente non ri-sponderebbero alla terapia offrendo loro altre opzioni prima possibile. In particolare, il lavoro si è fo-calizzato sul determinare se esistesse una correlazione tra la risposta all'Erlotinib ed i livelli di espressione di miRNAs coinvolti nella via di segnalazione di EGFR in campioni di NSCLC prima dell’inizio della terapia. Sono stati identificati 7 microRNA coinvolti nel pathway di EGFR: miR-7, -21, 128b, 133a, -133b, 146a, 146b. Sono stati analizzati i livelli di espressione dei miRNA mediante Real-Time q-PCR in campioni di NSCLC in una coorte di pazienti con NSCLC metastatico trattati con Erlotinib dal 1° gennaio 2009 al 31 dicembre 2014 in 2°-3° linea dopo fallimento di almeno un ciclo di chemioterapia. I pazienti sottoposti a trattamento con erlotinib per almeno 6 mesi senza presentare progressione alla malattia sono stati definiti “responders” (n=8), gli altri “non-responders” (n=25). I risultati hanno mostrato che miR-7, -133b e -146a potrebbero essere coinvolti nella risposta al trat-tamento con Erlotinib. Le indagini funzionali sono state quindi concentrate su miR-133b, che ha mo-strato la maggiore espressione differenziale tra i due gruppi di pazienti. E 'stata quindi studiata la capacità di miR-133b di regolare l'espressione di EGFR in due linee di cellule del cancro del polmone (A549 e H1299). Sono stati determinati gli effetti di miR-133b sulla crescita cellulare. E’ stato anche analizzato il rapporto tra miR-133b e sensibilità a Erlotinib nelle cellule NSCLC. L'aumento di espressione di miR-133b ha portato ad una down-regolazione del recettore di EGF e del pathway di EGFR relativo alla linea cellulare A549. La linea cellulare H1299 era meno sensibili al miR-133b up-regulation, probabilmente a causa dell'esistenza di possibili meccanismi di resistenza e/o di com-pensazione. La combinazione di miR-133b ed Erlotinib ha aumentato l'efficacia del trattamento solo nella linea cellulare A549. Nel complesso, questi risultati indicano che miR-133b potrebbe aumentare / ripristinare la sensibilità di Erlotinib in una frazione di pazienti.

Cirúrugia torácica videoassistida por porta única : um caso de adenocarcinoma do pulmão

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Angiogenesis in cancer - general pathways and their therapeutic implications

A vast amount of data shows that angiogenesis has a pivotal role in tumor growth, progression, invasiveness and metastasis. This is a complex process involving essential signaling pathways such as vascular endothelial growth factor (VEGF) and Notch in vasculature, as well as additional players such as bone marrow-derived endothelial progenitor cells. Primary tumor cells, stromal cells and cancer stem cells strongly influence vessel growth in tumors. Better understanding of the role of the different pathways and the crosstalk between different cells during tumor angiogenesis are crucial factors for developing more effective anticancer therapies. Targeting angiogenic factors from the VEGF family has become an effective strategy to inhibit tumor growth and so far the most successful results are seen in metastatic colorectal cancer (CRC), renal cell carcinoma (RCC) and non-small cell lung cancer (NSCLL). Despite the initial enthusiasm, the angiogenesis inhibitors showed only moderate survival benefit as monotherapy, along with a high cost and many side effects. Obviously, other important pathways may affect the angiogenic switch, among them Notch signaling pathway attracted a large interest because its ubiquitous role in carcinogenesis and angiogenesis. Herein we present the basics for VEGF and Notch signaling pathways and current advances of targeting them in antiangiogenic, antitumor therapy.

Inhibition of epidermal growth factor receptor expression by RNA interference in A549 cells

AIM: To investigate the biological features of A549 cells in which epidermal growth factor (EGF) receptors expression were suppressed by RNA interference (RNAi). METHODS: A549 cells were transfected using short small interfering RNAs (siRNAs) formulated with Lipofectamine 2000. The EGF receptor numbers were determined by Western blotting and flowcytometry. The antiproliferative effects of sequence specific double stranded RNA (dsRNA) were assessed using cell count, colony assay and scratch assay. The chemosensitivity of transfected cells to cisplatin was measured by MTT. RESULTS: Sequence specific dsRNA-EGFR down-regulated EGF receptor expression dramatically. Compared with the control group, dsRNA-EGFR reduced the cell number by 85.0 %, decreased the colonies by 63.3 %, inhibited the migration by 87.2 %, and increased the sensitivity of A549 to cisplatin by four-fold. CONCLUSION: Sequence specific dsRNA-EGFR were capable of suppressing EGF receptor expression, hence significantly inhibiting cellular proliferation and motility, and enhancing chemosensitivity of A549 cells to cisplatin. The successful application of dsRNA-EGFR for inhibition of proliferation in EGF receptor overexpressing cells can help extend the list of available therapeutic modalities in the treatment of non-small-cell lung carcinoma (NSCLC).

A new generation of companion diagnostics: cobas BRAF, KRAS and EGFR mutation detection tests

The cobas® (Roche) portfolio of companion diagnostics in oncology currently has three assays CE-marked for in vitro diagnostics. Two of these (EGFR and BRAF) are also US FDA-approved. These assays detect clinically relevant mutations that are correlated with response (BRAF, EGFR) or lack of response (KRAS) to targeted therapies such as selective mutant BRAF inhibitors in malignant melanoma, tyrosine kinases inhibitor in non-small cell lung cancer and anti-EGFR monoclonal antibodies in colorectal cancer, respectively. All these assays are run on a single platform using DNA extracted from a single 5 µm section of a formalin-fixed paraffin-embedded tissue block. The assays provide an ‘end-to-end’ solution from extraction of DNA to automated analysis and report on the cobas z 480. The cobas tests have shown robust and reproducible performance, with high sensitivity and specificity and low limit of detection, making them suitable as companion diagnostics for clinical use.