230 resultados para HER2
Resumo:
O cancro uma das principais causas de morte em todo o mundo. Entre as mulheres, o cancro da mama o mais frequente. A deteo precoce do cancro de extrema importncia na medida em que pode aumentar as possibilidades de cura dos pacientes e contribuir para a diminuio da taxa de mortalidade desta doena. Um mtodo que tem contribudo para a deteo precoce do cancro a anlise de biomarcadores. Biomarcadores associados ao cancro da mama, como o Recetor 2 do Fator de Crescimento Epidrmico Humano (HER2) e o Antignio Carbohidratado 15-3 (CA 15-3), podem ser detetados atravs de dispositivos como os biossensores. Neste trabalho foram desenvolvidos dois imunossensores eletroqumicos para a anlise de HER2 e CA 15-3. Para ambos os sensores foram utilizados, como transdutores, eltrodos serigrafados de carbono. A superfcie destes transdutores foi nanoestruturada com nanopartculas de ouro. Foram realizados imunoensaios no-competitivos (do tipo sandwich) em ambos os imunossensores, cuja estratgia consistiu na (i) imobilizao do respetivo anticorpo de captura na superfcie nanoestruturada dos eltrodos, (ii) bloqueio da superfcie com casena, (iii) incubao com uma mistura do analito (HER2 ou CA 15-3) e o respetivo anticorpo de deteo biotinilado, (iv) adio de estreptavidina conjugada com fosfatase alcalina (S-AP; a AP foi utilizada como marcador enzimtico), (v) adio de uma mistura do substrato enzimtico (3-indoxil fosfato) e nitrato de prata, e (vi) deteo do sinal analtico atravs da redissoluo andica, por voltametria de varrimento linear, da prata depositada enzimaticamente. Com as condies experimentais otimizadas, foi estabelecida a curva de calibrao para a anlise de HER2 em soro, entre 15 e 100 ng/mL, obtendo-se um limite de deteo de 4,4 ng/mL. Para o CA 15-3 a curva de calibrao (em soluo aquosa) foi estabelecida entre 15 e 250 U/mL, obtendo-se um limite de deteo de 37,5 U/mL. Tendo em conta o valor limite (cutoff value) estabelecido para o HER2 (15 ng/mL) pode-se comprovar a possvel utilidade do imunossensor desenvolvido para o diagnstico precoce e descentralizado do cancro da mama. No caso do CA 15-3 sero necessrios estudos adicionais para se poder avaliar a utilidade do imunossensor para o diagnstico do cancro da mama.
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Dissertao para obteno do Grau de Mestre em Gentica Molecular e Biomedicina
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INTRODUO: O carcinoma oculto uma entidade pouco frequente, que se define como a presena de metstases com tumor primrio indetetvel na altura da apresentao. O prognstico da maioria dos casos de tumor oculto reservado, no entanto, o desenvolvimento de tcnicas imunohistoqumicas que permitem a caracterizao do tumor, tornaram alguns subgrupos de tumor oculto potencialmente curveis. A presena de adenopatias axilares a forma de apresentao do cancro da mama em 0,3-1% das mulheres, sendo a origem mais provvel a mama ipsilateral. CASO CLNICO: Os autores relatam dois casos clnicos de tumor oculto da mama: Caso 1: Doente de 57 anos, com antecedentes familiares de primeiro e segundo grau de cancro da mama, com estudo gentico negativo. Recorreu consulta por adenopatia axilar direita.Exame objetivo (EO), mamografia + ecografia mamria normais. Microbipsia (MB) ganglionar:metstase de carcinoma compatvel com origem na mama, recetores de estrognios (RE) +, HER2 +, CK7 +, Ca125 +, CK20 (-). RMN mamria e PET no identificaram tumor primrio. Procedeu-se a disseco axilar: 10 gnglios sem metstases. Realizou teraputica adjuvante com quimioterapia (QT) e imunoterapia (IT). Manteve follow-up regular com EO, RMN e mamografia alternadas at aos 4 anos sem alteraes. Aos 4,5 anos detetou-se ao E.O. ndulo palpvel na mama direita e ndulo axilar. Mamografia + ecografia: leso slida suspeita (R5) cuja caracterizao histolgicademonstrouCDIG3, recetores hormonais (-) (RH), HER2 3+, Ki67 >30%. A TC TAP e a cintigrafia ssea no revelaram alteraes. Em reunio multidisciplinar de deciso teraputica (RMDT) decidiu-serealizar mastectomia total direita + mastectomia profiltica contralateral com reconstruo. Exame histolgico:CDI G3 com 22mm,confirmando-se a caracterizao imunohistoqumica, com invaso vascular e presena de 3 gnglios com metstase e extenso extracapsular (T2 N2). Realizou teraputica adjuvante com QT + IT+ Radioterapia (RT) da parede torcica e ganglionar. Um ano aps a mastectomia, a doente mantm-se em follow-up sem sinais de recidiva. Caso 2: Doente de 50 anos, com antecedentes familiares de primeiro grau de cancro da mama. Recorreu consulta por ndulo da axila esquerda e ndulo da mama direita com 2 meses de evoluo. EO: ndulo palpvel da mama direita e duas adenopatias axilares esquerda. Mamografia + eco: microcalcificaes atpicas da mama esquerda (R5) ealteraes benignas da mama direita (R2). Realizaram-se microbipsia por estereotaxia e bipsia assistida por vcuo da mama esquerda e citologia aspirativa de agulha fina (CAAF) de ndulo da mama direita:sem alteraes neoplsicas. A bipsia de adenopatia axilar revelou metstase ganglionar de carcinoma compatvel com origem na mama, RH (-), GCDFP15 (-),HER2 3+ e CK7 +.A RM mamria revelou apenas leses benignas. TC TAP, ecografia abdominal e cintigrafia ssea normais. PET: leso localizada na axila esquerda, nos trs nveis axilares. Por recusa da doente em realizar microbipsias adicionais ou mastectomia radical modificada, optou-se por realizar disseco axilar esquerda. Exame histolgico: 7 em 14 gnglios com metstases, morfologia e estudo imunohistoqumico concordantes com o anterior. Em RMDT foi decidida teraputicaadjuvante com RT, QT e IT que a doente se encontra no momento a realizar. DIAGNSTICOS DIFERENCIAIS/ DISCUSSO A presena de adenopatias axilares relaciona-se na maioria dos casos com processos benignos, mas naqueles em que se diagnostica uma neoplasia maligna, mais de 50% correspondem a carcinoma da mama. Outras neoplasias que se podem apresentar com metstases axilares so: linfoma, melanoma, sarcoma, tiride, pulmo, estmago, ovrio, tero. A avaliao diagnstica deve incluir alm do exame fsico, a bipsia ganglionar (para exame histolgico e caracterizao imunohistoqumica), mamografia, ecografia mamria e ressonncia magntica mamria, eventual TC toraco-abdominal, cintigrafia ssea nas mulheres sintomticas, existindo controvrsia sobre autilidade da PET. CONCLUSES O tumor oculto representa um problema diagnstico e um desafio teraputico. O carcinoma da mama apresentando-se sob a forma de metstase axilar sem tumor primrio identificvel e sem doena distncia, considera-se um dos casos potencialmente curveis, se for tratado de acordo com as guidelines para o estadio II do cancro da mama. A abordagem recomendada inclui disseco axilar, de importncia crucial pela informao prognstica que guiar o restante tratamento e por ajudar no controlo local da doena. A teraputica adequada da mama ipsilateral controversa, e pode passar pela mastectomia radical modificada ou RT. No existem at data estudos randomizados comparando a mastectomia versus RT mamria e os estudos retrospetivos disponveis no apresentam resultados consensuais. A deciso de RT da parede torcica ps-mastectomia e de teraputica adjuvante dever ser tomada tendo em conta as guidelines publicadas. BIBLIOGRAFIA 1- www.uptodate.com; Kaklamani, V., et al; Axillary node metastases with occult primary breast cancer; Mar 2012 2- Wang, J., et al; Occult breast cancer presenting as metastatic adenocarcinoma of unknown primary: clinical presentation, immunohistochemistry, and molecular analysis; Case Rep Oncol 2012;5:9-16 3- Takabatake, D.; Two cases of occult breast cancer in which PET-CT was helpful in identifying primary tumors; Breast Cancer (2008) 15:181-184 4- Kinoshita, S., et al.; Metachronous secondary primary occult breast cancer initially presenting with metastases to the contralateral axillary lymph nodes: report of a case; Breast Cancer (2010) 17:71-74 5- Bresser, J., et al; Breast MRI in clinically and mammographically occult breast cancer presenting with an axillary metastasis: a systematic review; EJSO 36 (2010) 114-119 6- Sharon, W., et al.; Benefit of ultrasonography in the detection of clinically and mammographically occult breast cancer; World J Surg (2008) 32:2593-2598 7- Masinghe, S.P., et al.; Breast radiotherapy for occult breast cancer with axillary nodal metastases does it reduce the local recurrence rate and increase overall survival?; Clinical Oncology 23 (2011) 95-100 8- Altan, E., et al.; Clinical and pathological characteristics of occult breast cancer and review of the literature; J Buon 2011 Jul-Sep;16(3):434-6
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Phage display technology is a powerful platform for the generation of highly specific human monoclonal antibodies (Abs) with potential use in clinical applications. Moreover, this technique has also proven to be a reliable approach in identifying and validating new cancer-related targets. For scientific or medical applications, different types of Ab libraries can be constructed. The use of Fab Immune libraries allows the production of high quality and affinity antigen-specific Abs. In this work, two immune human phage display IgG Fab libraries were generated from the Ab repertoire of 16 breast cancer patients, in order to obtain a tool for the development of new therapeutic Abs for breast cancer, a condition that has great impact worldwide. The generated libraries are estimated to contain more than 108 independent clones and a diversity over 90%. Libraries validation was pursued by selection against BSA, a foreign and highly immunogenic protein, and HER2, a well established cancer target. Preliminary results suggested that phage pools with affinity for these antigens were selected and enriched. Individual clones were isolated, however, it was not possible to obtain enough data to further characterize them. Selection against the DLL1 protein was also performed, once it is a known ligand of the Notch pathway, whose deregulation is associated to breast cancer, making it an interesting target for the generation of function-blocking Abs. Selection resulted in the isolation of a clone with low affinity and Fab expression levels. The validation process was not completed and further effort will have to be put in this task in the future. Although immune libraries concept implies limited applicability, the library reported here has a wide range of use possibilities, since it was not restrained to a single antigen but instead thought to be used against any breast cancer associated target, thus being a valuable tool.
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Part of this thesis will be published in the following: Gomes, B.C., Santos, B. 2015. Methods for studying microRNAs expression and their targets in formalin-fixed, paraffin-embedded (FFPE) breast cancer tissues. In Methods in Molecular Biology: Cancer Drug Resistance (Rueff, J. & Rodrigues, A.S. eds), Springer Protocols.
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RESUMO: Introduo: Tratamento do carcinoma da mama Este trabalho inicia-se com a histria do tratamento do carcinoma da mama, desde os primeiros documentos que descrevem doentes com carcinoma da mama at 1950. Desde 1950 at 2000 o diagnstico, risco e as modalidades teraputicas usadas no tratamento das doentes so mais detalhadas com nfase nas teraputicas locais, regionais e sistmicas. Parte 1:Quem tratar com teraputica sistmica adjuvante Captulo 1: A classificao TNM no est morta no carcinoma da mama Tem sido dito que a classificao TNM no adequada para usar como ferramenta de prognstico e deciso teraputica no carcinoma da mama, especialmente em doentes com carcinoma detectado atravs de rastreio, que tem geralmente menores dimenses. A razo desta classificao no ser adequada prendese com o facto de no estarem incluidos parmetros biolgicos na classificao TNM atual. Pusemos a hiptese de que numa populao com alta percentagem de carcinoma da mama no detectado em exames de rastreio, com uma mediana de idade baixa e com alta percentagem de estadios II e III, o estadiamento clssico, pela classificao TNM, mais descriminatrio que as caractersticas biolgicas na determinao do prognstico. Para isto analismos uma populao de doentes com carcinoma da mama tratados consecutivamente na mesma instituio, durante 10 anos. Caracterizmos os fatores de prognstico do estadiamento clssico includos na classificao TNM e as variantes biolgicas, presentemente no includas na classificao TNM. Quantificmos a capacidade de cada um dos factores de prognstico para para prever a sobrevivncia. A populao de 1699 doentes com carcinoma da mama que foram tratdos com teraputica sistmica adjuvante. Individualmente, cada um dos fatores de prognostico, clssicos ou biolgicos, diferem significativamente entre doentes que sobrevivem e que no sobrevivem. Explicitamente, como previsto, doentes com tumores maiores, envolvimento dos gnglios axilares, estadios TNM mais avanados, que no expressam recetor de esrogneo, com amplificao do gene Her2, triplos negativos ou de menor diferenciao tm menor sobrevida. Na anlise multivariada, s os fatores de prognostico da classificao TNM, o grau histolgico e a amplificao do gene Her2, esta ltima com menos significncia estatistica so preditores independentes de sobrevivncia. Captulo 2: Em busca de novos factores de prognostico: Poder preditivo e mecanismo das alteraes de centrossomas em carcinoma da mama Compilmos inmeros grupos de experincias de genmica feitas em tumores primrios de doentes com carcinoma da mama para as quais existe informao prognstica. Estas experincias so feitas com o objectivo de descobrir novos factores de prognstico. Reanalismos os dados, repetindo a mesma pergunta: Quais so os genes com expresso diferencial estatisticamente significativa entre doentes que recaram e doentes que no recaram. Identificmos 65 genes nestas condies e o MKI67, o gene que codifica a proteina Ki67, estava nesse grupo. Identificmos vrios genes que se sabe estarem envolvidos no processo de agregao de centrossomas. O gene que considermos mais promissor foi a kinesina KiFC1, que j tinha sido identificada como regulador da agregao de centrossomas. Anomalias cetrossomais numricas e estruturais tm sido observadas em neoplasias. H dados correlacionando anolmalias centrossomais estruturais e e numricas com o grau de malignidade e os eventos precoces da carcinognese. Mas estas anomalias centrossomais tm um peso para a clula que deve adapatar-se ou entrar em apoptose. Os nossos resultados sugerem que existe um mecanismo adaptativo, a agregao de centrossomas, com impacto prognstico negativo. O nosso objetivo foi quantificar o valor prognstico das anomalias centrossomais no carcinoma da mama. Para isto usmos material de doentes dos quais sabemos a histria natural. Avalimos os genes de agregao de centrossomas, KIFC1 e TACC3, nas amostras tumorais arquivadas em parafina: primeiro com PCR (polymerase chain reaction) quantitativa e depois com imunohistoqumica (IHQ). Apenas a protena KIFC1 foi discriminatria em IHQ, no se tendo conseguido otimizar o anticorpo da TACC3. Os nveis proteicos de KIFC1 correlacionam-se com mau prognstico. Nas doentes que recaram observmos, no tumor primrio, maior abundncia desta protena com localizao nuclear. Em seguida, demonstrmos que a agregao de centrossomas um fenmeno que ocorre in vivo. Identificmos centrossomas agregados em amostras de tumores primrios de doentes que recaram. Tecnicamente usmos microscopia de fluorescncia e IHQ contra protenas centrossomais que avalimos nos tumores primrios arquivados em blocos de parafina. Observmos agregao de centrossomas num pequeno nmero de doentes que recaram, no validmos, ainda, este fentipo celular em larga escala. Parte 2: Como tratar com teraputica sistmica os vrios subtipos de carcinoma da mama Captulo 3: Quantas doenas esto englobadas na definio carcinoma da mama triplo negativo? (reviso) O carcinoma da mama triplo negativo um tumor que no expressa trs protenas: recetor de estrognio, recetor de progesterona e o recetor do fator de crescimento epidermico tipo 2 (Her2). As doentes com estes tumores no so ainda tratadas com teraputica dirigida, possivelmente porque esta definio negativa no tem ajudado. Sabemos apenas as alteraes genticas que estes tumores no tm, no as que eles tm. Talvez por esta razo, estes tumores so o subtipo mais agressivo de carcinoma da mama. No entanto, na prtica clnica observamos que estas doentes no tm sempre mau prognstico, alm de que dados de histopatologia e epidemiologia sugerem que esta definio negativa no est a capturar um nico subtipo de carcinoma da mama, mas vrios. Avalimos criticamente esta evidncia, clnica, histopatolgica, epidemiolgica e molecular. H evidncia de heterogeneidade, mas no claro quantos subtipos esto englobados nesta definio de carcinoma da mama triplo negativo. A resposta a esta pergunta, e a identificao do fundamento molecular desta heterogeneidade vai ajudar a melhor definir o prognstico e eventualmente a definir novos alvos teraputicos nesta populao difcil. Captulo 4: Terapuica sistmica em carcinoma da mama triplo negativo (reviso) A quimioterapia a nica teraputica sistmica disponvel para as doentes com carcinoma da mama triplo negativo, ao contrrio dos outros dois subtipo de carcinoma da mama que tm com a teraputica antiestrognica e anti Her2, importantes benefcios. Apesar de terem surgido vrias opes teraputicas para estes doentes nennhuma teraputica dirigida foi validada pelos ensaios clnicos conduzidos, possivelmente porque a biologia deste carcinoma ainda no foi elucidada. Muitos ensaios demonstram que os tumores triplos negativos beneficiam com quimioterapia e que as mais altas taxas de resposta patolgica completa teraputica neoadjuvante so observadas precisamente nestes tumors. A resposta patolgica completa correlaciona-se com a sobrevivncia. Estamos a estudar regimes adjuvantes especficos para doentes com estes tumors, mas, neste momento, regimes de terceira gerao com taxanos e antraciclinas so os mais promissores. O papel de subgrupos de frmacos especficos, como os sais de platina, mantmse mal definido. Quanto s antraciclinas e taxanos, estes grupos no mostraram beneficio especfico em carcinoma da mama triplo negativo quando comparado com os outros subtipos. Os prprios carcinomas da mama triplos negativos so heterogneos e carcinomas da mama basais triplos negativos com elevada taxa de proliferao e carcinomas da mama triplos negativos surgidos em doentes com mutao germinal BRCA1 podero ser mais sensveis a sais de platino e menos sensveis a taxanos. Como a definio molecular ainda no foi explicada a busca de teraputica dirigida vai continuar. Captulo 5: Ensaio randomizado de fase II do anticorpo monoclonal contra o recetor do fator de crescimento epidrmico tipo 1 combinado com cisplatino versus cisplatino em monoterapia em doentes com carcinoma da mama triplo negativo metastizado O recetor do fator de crescimento epidrmico tipo 1 est sobre expresso nos tumores das doentes com carcinoma da mama triplo negativo metastizado, um subtipo agressivo de carcinoma da mama. Este ensaio investigou a combinao de cetuximab e cisplatino versus cisplatino isolado em doentes deste tipo. Doentes em primeira ou segunda linha de teraputica para doena metastizada foram randomizadas, num sistema de 2 para 1, para receber at 6 ciclos da combinao de cisplatino e cetuximab ou cisplatino isolado. s doentes randomizadas para o brao de monoterapia podiamos, aps progresso, acrescentar cetuximab ou trat-las com cetuximab isolado. O objetivo primrio foi a taxa de resposta global. Os objetivos secundrios foram a sobrevivncia livre de doena, a sobrevivncia global e o perfil de segurana dos frmacos. A populao em anlise foram 115 doentes tratadas com a combinao e 58 doentes tratadas com cisplatino em monoterapia, 31 destas em quem se documentou progresso passaram a ser tratadas com um regime que inclua cetuximab, isolado ou em combinao. A taxa de resposta global foi de 20% no brao da combinaao e de 10% no brao da monoterapia (odds ratio, 2.13). A sobrevivncia livre de doena foi de 3.7 meses no brao da combinao e de 1.5 meses no brao em monoterapia (hazard ratio, 0.67). A sobrevivncia global foi de 12.9 meses no brao da combinao versus 9.4 meses no brao de cisplatino. Conclui-se que, apesar de no ter sido alcanado o objectivo primrio, acrescentar cetuximab, duplica a resposta e prolonga tanto a sobrevivncia livre de doena como a sobrevivncia global. Captulo 6: Bloquear a angiognese para tratar o carcinoma da mama (reviso) A angiognese uma caracterstica que define a neoplasia, porque tumores com mais de 1mm precisam de formar novos vasos para poderem crescer. Desde que se descobriram as molculas que orquestram esta transformao, que se tm procurado desenvolver e testar frmacos que interfiram com este processo. No carcinoma da mama o bevacizumab foi o primeiro frmaco aprovado pela FDA em primeira linha para tratar doena metasttica. Depois foram estudados um grupo de inibidores de tirosina cinase associados aos recetores transmembranares envolvidos na angiognese como o VEGFR, PDGFR, KIT, RET, BRAF e Flt3: sunitinib, sorafenib, pazopanib e axitinib Neste captulo, analisaram-se e resumiram-se os dados dos ensaios clnicos das drogas anti-angiognicas no tratamaneto do carcinoma da mama. Os ensaios de fase III do bevacizumab em carcinoma da mama mostraram uma reduo na progresso de doena de 22 a 52% e aumento da sobrevivncia livre de doena de 1.2 a 5.5 meses mas nunca foi demonstrado prolongamento de sobrevivncia. Os ensaios de fase III em carcinoma da mama adjuvante com bevacizumab so dois e foram ambos negativos. O ensaio de fase III com o inibidor da tirosina cinase, sunitinib foi negativo, enquanto que os ensaios de fase II com os inibidores da tirosina cinase sorafenib e pazopanib melhoraram alguns indicadores de resposta e sobrevivncia. A endostatina foi testada no contexto neoadjuvante com antraciclinas e melhorou a taxa de resposta, mas, mais ensaios so necessrios para estabelecer este frmaco. A maioria dos ensaios clnicos dos agentes antiangiognicos em carcinoma da mama reportaram aumento da taxa de resposta e de sobrevivncia livre de doena mas nunca aumento da sobrevivncia global quando comparado com quimioterapia isolada o que levou ao cepticismo a que assistimos atualmente em relao ao bloqueio da angiognese. Ensaios clnicos selecionados em doentes especficas com objetivos translacionais relacionados com material biolgico colhido, preferefencialmente em diferentes intervalos da teraputica, sero cruciais para o bloqueio da angiognese sobreviver como estratgia teraputica em carcinoma da mama. Captulo 7: A resposta hipoxia medeia a resistncia primria ao sunitinib em carcinoma da mama localmente avanado O sunitinib um frmaco antiangiognico que nunca foi avaliado isolado em doentes com carcinoma da mama no tratadas. O nosso objetivo foi caracaterizar a atividade do sunitinib isolado e em combinao com o docetaxel em carcinoma da mama no tratado, localmente avanado ou opervel, mas de dimenso superior a 2 cm, para compreender os mecanismos de resposta. Doze doentes foram tratadas com duas semanas iniciais de sunitinib seguido de quatro ciclos de combinao de sunitinib e docetaxel. A resposta, a reistncia e a toxicidade foram avaliadas de acordo com parametros clnicos, ressonncia magntica nuclear, tomografia de emisso de positres, histopatologia e perfis de expresso genmica. Detetmos resistncia primria ao sunitinib na janela inicial de duas semanas, evidenciada em quatro doentes que no responderam. data da cirurgia, cinco doentes tinham tumor vivel na mama e axila, quatro tinahm tumor vivel na mama e trs foram retiradas do ensaio. No houve respostas patolgicas completas. A comparao dos perfis de expresso genmica entre os respondedores e os no respondedores, aos quinze dias iniciais, permitiu-nos identificar sobre expresso de VEGF e outras vias angiognicas nos no respondedores. Especificamente, em tumores resistentes ao sunitinib isolado detectmos uma resposta transcricional hipoxia caracterizada por sobre expresso de vrios dos genes alvo do HIF1. Neste ensaio de sunitinib isolado em doentes no tratadas com carcinoma da mama localmente avanado, encontrmos evidncia molecular de resistncia primria ao sunitinib possivelmente mediada por sobre expresso de genes que respondem hipoxia. Parte 3: Quando parar a teraputica sistmica s doentes com carcinoma da mama Captulo 8: Agressividade teraputica ns ltimos trs meses de vida num estudo retrospetivo dum centro nico Inclumos todos os adultos que morreram com tumores slidos na instituio em 2003 e foram tratados com quimioterapia para tratar neoplaias metastizadas. Colhemos dados detalhados relacionados com quimioterapia e toxicidade nos ltimos trs meses de vida a partir do processo clnico. Trezentas e dezanove doentes foram includos, a mediana de idade foi 61 anos. A mediana de sobrevivncia de doena metasttica foi de 11 meses. 66% (211) dos doentes foram tratados com QT nos ltimos 3 meses de vida, 37% foram tratados com QT no limo ms de vida e 21% nas ltimas duas semanas. Nos doentes que foram tratados com QT nos ltimos trs meses de vida, 50% comearam um novo regime teraputico neste perodo e 14% comearam um novo regime no ltimo ms. Identificmos como determinantes de tratamento com QT no fim de vida a idade jovem, o carcinoma da mama, do ovrio e do pncreas. Conclumos que administrmos QT no fim de vida frequentemente e inicimos novos regimes teraputicos no ltimo ms de vida em 14% dos casos. Precisamos de aprofundar este trabalho para compreender se esta atitude agressiva resulta em melhor paliao de sintomas e qualidade de vida no fim de vida dos doentes com neoplasias disseminadas. Captulo 9: O tratamento do carcinoma da mama no fim de vida est a mudar? Quismos caracterizar a modificao da tendncia no uso de QT e de estratgias paliativas no fim de vida das doentes com carcinoma da mama em diferentes instituies e em intervalos de tempo diferentes. Para isto selecionmos doentes que morreram de carcinoma da mama durante 6 anos, entre 2007 e 2012, num hospital geral e comparmos com as doentes que morreram de carcinoma da mama em 2003 num centro oncolgico. Avalimos um total de 232 doentes. O grupo mais recente tem 114 doentes e o grupo anterior tem 118 doentes. Usmos estatstica descritiva para caracterizar QT no fim de vida e o uso de estratgias paliativas. Ambas as coortes so comparveis em termos das caractersticas do carcinoma da mama. Observmos aumento do uso de estatgias paliativas: consulta da dor, consulta de cuidados paliativos e radioterapia paliativa no cuidado das doentes com carcinoma da mama metastizado. Evidencimos aumento do nmero de mortes em servios de cuidados paliativos. No entanto, a QT paliativa continua a ser prolongada at aos ltimos meses de vida, embora tenhamos mostrado uma diminuio desta prtica. Outros indicadores de agressividade como a admisso hospitalar tambm mostraram diminuio. Confirmmos a nossa hiptese de que h maior integrao da medicina paliativa multidisciplinar e menos agressividade na teraputica sistmica das doentes com carcinoma da mama nos ltimos meses de vida. Chapter 10: Porque que os nossos doentes so tratados com quimioterapia at ao fim da vida? (editorial) Este captulo comea por dar o exmeplo duma jovem de 22 anos que viveu trs meses aps comear QT paliatva. Este caso epitomiza a futilidade teraputica e usado como ponto de partida para explorar as razes pelas quais administramos QT no fim de vida aos doentes quando intil, txica, logisticamente complexa e cara. Ser que estamos a prescrever QT at tarde demais? Os oncologistas fazem previses excessivamente otimistas e tm uma atitude pr teraputica excessiva e so criticados por outros intervenientes nas instituies de sade por isto. Crescentemente doentes, familiares, associaes de doentes, definidores de polticas de sade, jornalistas e a sociedade em geral afloram este tema mas tornam-se inconsistentes quando se trata dum doente prximo em que se modifica o discurso para que se faam teraputicas sitmicas agressivas. H uma crescente cultura de preservao da qualidade de vida, paliao, abordagem sintomtica, referenciao a unidades de cuidados paliativos e outros temas do fim de vida dos doentes oncolgicos terminais. Infelizmente, este tema tem ganhado momentum no porque os oncologistas estejam a refletir criticamente sobre a sua prtica, mas porque os custos dos cuidados de sade so crescentes e incomportveis. Seja qual fr o motivo, as razes que levam os oncologistas a administrar QT no fim de vida devem ser criticamente elucidadas. Mas h poucos dados para nos guiar nesta fase delicada da vida dos doentes e os que existem so por vezes irreconciliveis, uma reviso destes dados que foi feita neste captulo. Concluso: A abordagem do carcinoma da mama no futuro? Na concluso, tenta-se olhar para o futuro e prever como ser a tomada a cargo dum doente com carcioma da mama amanh. Faz-se uma avaliao das vrias reas desde preveno, rastreio, suscetibilidade gentica e comportamental e teraputica. Na teraputica separa-se a teraputica locoregional, sistmica adjuvante e da doena metastizada. Nos trs ltimos pargrafos a histria duma mulher com um carcinoma localmente avanado que sobre expressa o recetor Her2, serve como ilustrao de como devemos estar preparados para incorporar evoluo, heterogeneidade e dinamismo no cuidado de doentes com carcinoma da mama. -------------------------------------------------------------------------------------------------- ABSTRACT: Introduction: Breast cancer care in the past This work starts with an overview of the treatment of breast cancer (BC). From the first reports of patients ill with BC until 1950. From 1950 until 2000, there is a more detailed account on how BC patients were treated with emphasis on the different modalities, local, regional and systemic treatments and their evolution. Part 1: Who to treat with adjuvant systemic therapy? Chapter 1: TNM is not dead in breast cancer It has been said that the current TNM staging system might not be suitable for predicting breast cancer (BC) outcomes and for making therapeutic decisions, especially for patients with screen detected BC which is smaller. The reason for this is also due to the non inclusion of tumor biology parameters in the current TNM system. We hypothesize that in a population where there is still a large abundance of non screen detected BC, with a low median age of incidence and abundance of high TNM staged lesions, biology is still second to classical staging in predicting prognosis. We analyzed a population of consecutive BC patients from a single institution during ten years. We characterized current established prognostic factors, classical staging variables included in the current TNM staging system and biological variables, currently not included in the TNM system. We quantified the capacity of individual prognostic factors to predict survival. We analyzed a population of 1699 consecutive BC patients. We found that individually both the TNM system prognostic factors and the biological prognostic factors are differing among BC survivors and dead patients in a statistically significant distribution. Explicitly, patients with larger tumors, positive nodes, higher stage lesions, ER negative, HER2 positive, TN or lower differentiation tumors show decreased survival. In the multivariate analysis we can conclude that in a population such as ours classical TNM staging variables, irrespective of tumor biological features, are still the most powerful outcome predictors. Chapter 2: Defining breast cancer prognosis: The predictive power and mechanism of centrosome alterations in breast cancer We performed a systematic analysis of the literature and compiled an extensive data set of gene expression data originated in primary tumours of BC patients with prognostic information. We analysed this data seeking for genes consistently up or down regulated in poor prognosis BC, i.e. that relapsed after initial treatment. In the course this bioinformatics analysis our lab identified 65 genes statistically significant across multiple datasets that can discriminate between relapsed and non-relapsed BC patients. Among the identified genes, we have detected genes such as MKI67, a marker of mitotic activity which is routinely used in the clinic. Unexpectedly, we also discovered several genes found to be involved in centrosome clustering, The most prominent of these is the kinesin KIFC1, also called HSET, and previously identified as regulator of centrosome clustering. Centrosome abnormalities (numerical, structural) have been observed in cancer. Indeed, compelling data has shown that cells from many cancers have multiple and abnormal centrosomes, that are either correlated with tumour malignancy or considered an early tumorigenesis event. However, extra centrosomes come at a cost and cells must be able to handle such abnormalities or otherwise die. Thus our results suggested a new mechanism of breast cancer progression with negative prognostic value. We aimed at quantifying the predictive power of centrosome clustering in BC clinical setting and at detecting this process in BC patient material. We validated the centrosome clustering genes KIFC1 and TACC3 in formalin fixed paraffin embedded (FFPE) BC patient material, using quantitative real-time PCR (RT-qPCR) technology. Our results indicate that the tested KIFC1 has a clear IHC signal (1) and that the protein expression patterns and levels correlate with prognosis, with relapsing patients having increased expression and nuclear localisation of this kinesin (2). Next we were able to show that centrosome clustering does occur in vivo. We identified centrosome amplification and clustering in breast cancer samples, and we established a fluorescence microscopy-based IHC approach by staining FFPE samples with centrosomal markers. Using this approach we have observed centrosome amplification and clustering in a small set of poor prognosis samples. By expanding the number of samples in which we have characterised the number of centrosomes, we were able to confirm our preliminary observation that centrosomes are clustered in relapsed BC. Part 2: How to treat breast cancer subtypes? Chapter 3: How many diseases is triple negative breast cancer? (review) Triple negative breast cancer is a subtype of breast cancer that does not express the estrogen receptor, the progesterone receptor and the epidermal growth factor receptor type 2 (Her2). These tumors are not yet treated with targeted therapies probably because no positive markers have been described to reliably classify them - they are described for what they are not. Perhaps for this reason, they are among the most aggressive of breast carcinomas, albeit with very heterogenous clinical behavior. The clinical observation that these patients do not carry a uniformly dismal prognosis, coupled with data coming from pathology and epidemiology, suggests that this negative definition is not capturing a single clinical entity, but several. We critically evaluate this evidence in this paper, reviewing clinical and epidemiological data, as well as molecular data. There is evidence for heterogeneity, but it is not clear how many diseases are grouped into triple negative breast cancer. Answering this question, and identifying the molecular basis of heterogeneity will help define prognosis and, eventually, the identification of new targeted therapies. Chapter 4: Systemic treatment for triple negative breast cancer (review) Chemotherapy remains the backbone of treatment for triple negative breast cancer (TNBC). Despite the appearance of new targeted and biologic agents there has been no targeted therapy validated for TNBC, possibly because the biology of TNBC has not been conclusively elucidated. Many studies have shown that TNBC derive significant benefit of chemotherapy in the neoadjuvant, adjuvant and metastatic treatment, possibly more benefit than other BC subtypes. Neoadjuvant chemotherapy studies have repeatedly shown higher response rates in TNBC than non-TNBC. Pathologic complete response has been shown to predict improved long term outcomes in BC. Although specific adjuvant regimens for TNBC are under study, third generation chemotherapy regimens utilizing dose dense or metronomic polychemotherapy are among the most effective tools presently available. The role of specific chemotherapy agents, namely platinum salts, in the treatment of TNBC remains undefined. Taxanes and anthracyclines are active in TNBC and remain important agents, but have not shown specific benefit over non-TNBC. TNBC is itself a heterogeneous group in which subgroups like basal like BC defined by higher proliferation and including those TNBC arising in BRCA1 mutation carriers may be more sensitive to platinum agents and relatively less sensitive to taxanes. The molecular characterization of TNBC is lacking and therefore the search for targeted therapy is still ongoing. Chapter 5: Randomized phase II study of the anti-epidermal growth factor receptor monoclonal antibody cetuximab with cisplatin versus cisplatin alone in patients with metastatic triple-negative breast cancer Epidermal growth factor receptor is overexpressed in metastatic triple-negative breast cancers, an aggressive subtype of breast cancer. Our randomized phase II study investigated cisplatin with or without cetuximab in this setting. Patients who had received no more than one previous chemotherapy regimen were randomly assigned on a 2:1 schedule to receive no more than six cycles of cisplatin plus cetuximab or cisplatin alone. Patients receiving cisplatin alone could switch to cisplatin plus cetuximab or cetuximab alone on disease progression. The primary end point was overall response rate (ORR). Secondary end points studied included progressionfree survival (PFS), overall survival (OS), and safety profiles. The full analysis set comprised 115 patients receiving cisplatin plus cetuximab and 58 receiving cisplatin alone; 31 patients whose disease progressed on cisplatin alone switched to cetuximab-containing therapy. The ORR was 20% with cisplatin plus cetuximab and 10% with cisplatin alone (odds ratio, 2.13). Cisplatin plus cetuximab resulted in longer PFS compared with cisplatin alone (median, 3.7 v 1.5 months; hazard ratio, 0.67. Corresponding median OS was 12.9 versus 9.4 months. While the primary study end point was not met, adding cetuximab to cisplatin doubled the ORR and appeared to prolong PFS and OS, warranting further investigation in mTNBC. Chapter 6: Blocking angiogenesis to treat breast cancer (review) Angiogenesis is a hallmark of cancer because tumors larger than 1mm need new vessels to sustain their growth. Since the discovery of the molecular players of this process and some inhibitors, that angiogenesis became a promising therapeutic target. Bevacizumab was the first molecular-targeted antiangiogenic therapy approved by the FDA and is used as first-line therapy in metastatic breast cancer. A second class of approved inhibitors (sunitinib, sorafenib, pazopanib and axitinib) include oral small-molecule tyrosine kinase inhibitors that target vascular endothelial growth factor receptors, platelet-derived growth factor receptors, and other kinases including KIT, Ret, BRAF and Flt-3, but none of these have gained approval to treat breast cancer. This review analyzes and summarizes data from clinical trials of anti-angiogenic agents in the treatment of BC. Phase III trials of bevacizumab in advanced BC have demonstrated a reduction in disease progression (2252%), increased response rates and improvements in progression-free survival of 1.2 to 5.5 months, but no improvements in OS. Bevacizumab phase III trials in early BC have both been negative. Bevacizumab combined with chemotherapy is associated with more adverse events. Phase III trials of the tyrosine kinase inhibitor sunitinib were negative, while randomized phase II trials of sorafenib and pazopanib have improved some outcomes. Endostatin has been tested in neoadjuvant clinical trials in combination with anthracyclinebased chemotherapy in treatment-naive patients and has increased the clinical response rate, but more trials are needed to establish this drug. Most trials of anti-angiogenic agents in BC have reported improved RR and PFS but no increase in OS compared to chemotherapy alone, leading to skepticism towards blocking angiogenesis. Selected trials in selected BC populations with translational endpoints related to harvested tumor tissue and other biological material samples, preferentially at several timepoints, will be crucial if antiangiogenesis is to survive as a strategy to treat BC. Chapter 7: Does hypoxic response mediate primary resistance to sunitinib in untreated locally advanced breast cancer? The antiangiogenic drug sunitinib has never been evaluated as single agent in untreated BC patients. We aimed to characterize the activity of sunitinib, alone and with docetaxel, in untreated locally advanced or operable BC, and, to uncover the mechanisms of response. Twelve patients were treated with an upfront window of sunitinib followed by four cycles of sunitinib plus docetaxel. Response, resistance and toxicity were evaluated according to standard clinical parameters, magnetic resonance imaging, positron emission tomography, pathology characterization and gene expression profiling. We detected primary resistance to sunitinib upfront window in untreated BC, as evidenced by four non-responding patients. At surgery, five patients had viable disease in the breast and axilla, four had viable tumor cells in the breast alone and three were taken off study due to unacceptable toxicity and thus not evaluated. Early functional imaging was useful in predicting response. There were no pathologic complete responses (pCR). Comparison of gene expression profiling tumor data between early responders and non-responders allowed us to identify upregulation of VEGF and angiogenic pathways in non responders. Specifically, in tumors resistant to the single-agent sunitinib we detected a transcriptional response to hypoxia characterized by over-expression of several HIF1 target genes. In this report of single-agent sunitinib treatment of untreated localized BC patients, we found molecular evidence of primary resistance to sunitinib likely mediated by up-regulation of hypoxia responsive genes. Part 3: When to stop systemic treatment of breast cancer patients? Chapter 8: The aggressiveness of cancer care in the last three months of life: a retrospective single centre analysis. All adult patients with solid tumors who died in our hospital in 2003 and received chemotherapy for advanced cancer, were included. Detailed data concerning chemotherapy and toxicity, in the last three months of life, were collected from patients clinical charts. A total of 319 patients were included. Median age was 61 years. Median time from diagnosis of metastatic disease to death was 11 months. The proportion of patients who received chemotherapy in the last three months of life was 66% (n=211), in the last month 37% and in the last two weeks 21%. Among patients who received chemotherapy in the last three months of life, 50% started a new chemotherapy regimen in this period and 14% in the last month. There was an increased probability of receiving chemotherapy in the last three months of life in younger patients and in patients with breast, ovarian and pancreatic carcinomas. There was a large proportion of patients who received chemotherapy in the last three months of life, including initiation of a new regimen within the last 30 days. Thus, further study is needed to evaluate if such aggressive attitude results in better palliation of symptoms at the end of life. Chapter 9: Is breast cancer treatment in the end of life changing? We aimed to characterize the shifting trends in use of anti-cancer chemotherapy and palliative care approaches in the end of life of BC patients in different institutions and times. For this, we selected women that died of BC during six years, from 2007 to 2012, and were treated in a central acute care general hospital and compared it with the BC patients that died in 2003 and were treated in a large cancer center. We analyzed a total of 232 patients: the more recent group has 114 women and the older cohort has 118. We used descriptive statistics to characterize CT in the EoL and use of palliative care resources. Both populations were similar in terms of BC characteristics. We observed more palliative care resources, pain clinic, palliative care teams and palliative radiotherapy, involved in the care of MBC patients and a shift towards more deaths at hospices. Systemic anti cancer treatments continue to be prolonged until very late in patients lives, notwithstanding, we could show a decrease in the use of such treatments. Other indicators of aggressiveness, namely hospital admissions, also show a decrease. We confirmed our hypothesis that there is more integration of multidisciplinary palliative care and less aggressiveness in the treatment of metastatic cancer patients, specifically, use of palliative anti-cancer treatment and hospital admissions. Nonetheless, we use systemic therapy until too late with underutilization of palliative medicine. Chapter 10: Why do our patients get chemotherapy until the end of life? (editorial) The editorial starts with a clinical case of a 21 year old patient that lives three months after starting palliative chemotherapy for the first time, a case that illustrates therapeutic futility at the end of life. Why are we not ceasing chemotherapy when it is useless, toxic, logistically complex and expensive? Are we prescribing chemotherapy until too late in solid tumor patients lives? Medical oncologists have overly optimistic predictions and, excessive, treatment-prone attitude and they are criticized by other health care providers for this. Increasingly, patients, their families, advocacy groups, policy makers, journalists and society at large dwell on this topic, which is a perplexing conundrum, because sometimes they are the ones demanding not to stop aggressive systemic anticancer treatments, when it comes to their loved ones. There is a growing culture of awareness toward preserving quality of life, palliative care, symptom-directed care, hospice referral and end of life issues regarding terminal cancer patients. Sadly, this issue is gaining momentum, not because oncologists are questioning their practice but because health care costs are soaring. Whatever the motive, the reasons for administering chemotherapy at the end of life should be known. There are few and conflicting scientific data to guide treatments in this delicate setting and we review this evidence in this paper. Conclusion: What is the future of breast cancer care? This work ends with a view into the future of BC care. Looking into the different areas from prevention, screening, hereditary BC, local, regional and systemic treatments of adjuvant and metastatic patients. The last three paragraphs are a final comment where the story of a patient with Her2 positive locally advanced breast cancer is used as paradigm of evolution, heterogeneity and dynamism in the management of BC.
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Triple negative breast cancer (TNBC) is a particular immunopathological subtype of breast cancer that lacks expression of estrogen and progesterone receptors (ER/PR) and amplification of the human epidermal growth factor receptor 2 (HER2) gene. Characterized by aggressive and metastatic phenotypes and high rates of relapse, TNBC is the only breast cancer subgroup still lacking effective therapeutic options, thus presenting the worst prognosis. The development of targeted therapies, as well as early diagnosis methods, is vital to ensure an adequate and timely therapeutic intervention in patients with TNBC. This review intends to discuss potentially emerging approaches for the diagnosis and treatment of TNBC patients, with a special focus on nano-based solutions that actively target these particular tumors.
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FUNDAMENTO: O trastuzumabe (TZB) um anticorpo monoclonal humanizado recombinante usado no tratamento do cncer de mama HER2-positivo, com reconhecida cardiotoxicidade associada. Os mtodos para sua deteco subclnica precoce no esto bem estabelecidos. OBJETIVO: Avaliar a cardiotoxicidade induzida por TZB em pacientes (pts) portadoras de cncer de mama acompanhadas por um perodo de 3 meses de tratamento. MTODOS: Estudo prospectivo de pts consecutivas em tratamento com TZB para cncer de mama HER2-positivo avanado, admitidas entre maio e setembro de 2010. Foram comparados dados clnicos, laboratoriais e ecocardiogrficos antes da introduo de TZB e 3 meses aps o incio do tratamento com a droga. Foram estudadas a deteriorao da funo sistlica do ventrculo esquerdo (segundo critrios do Comit de Avaliao e Reviso Cardaca) e a funo diastlica (classificao da Sociedade Americana de Ecocardiografia). RESULTADOS: Estavam disponveis dados de 51 pacientes, cuja idade mdia era de 55,414,0 anos. Nenhuma paciente apresentou insuficincia cardaca sintomtica no terceiro ms. No houve diferenas na frao de ejeo do ventrculo esquerdo (FEVE) aos 3 meses (69,3 7,4 contra 67,1 6,5%, p > 0,05), tendo sido observada reduo em 57,9% pts (em apenas uma a FEVE foi < 55%). Houve aumento significativo da relao E/e' (3,9 0,8 contra 8,0 1,9, p < 0,001) devido a uma reduo da velocidade e' (0,19 0,02 contra 0,10 0,03, p < 0,001). Os demais parmetros diastlicos permaneceram inalterados. Tanto o volume atrial esquerdo quanto o ventricular esquerdo permaneceram inalterados. No houve aumento dos nveis de peptdeo natriurtico tipo pr-B N-terminal. Durante o perodo de seguimento, duas pacientes morreram e duas foram internadas, todas por causas no cardiovasculares. CONCLUSO: Durante os trs primeiros meses de tratamento com TZB, nenhuma das pacientes apresentou insuficincia cardaca franca ou deteriorao significativa da FEVE. Detectou-se reduo significativa da relao e/e', porm sem alteraes importantes dos parmetros de carga e da FEVE.
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Les thrapies du cancer, comme la radiothrapie et la chimiothrapie, sont couramment utilises mais ont de nombreux effets secondaires. Ces thrapies invasives pour le patient ncessitent d'tre amliores et de nombreuses avances ont t faites afin d'adapter et de personnaliser le traitement du cancer. L'immunothrapie a pour but de renforcer le systme immunitaire du patient et de le rediriger de manire spcifique contre la tumeur. Dans notre projet, nous activons les lymphocytes Invariant Natural Killer T (iNKT) afin de mettre en place une immunothrapie innovatrice contre le cancer. Les cellules iNKT sont une unique sous-population de lymphocytes T qui ont la particularit de runir les proprits de l'immunit inne ainsi qu'adaptative. En effet, les cellules iNKT expriment leur surface des molcules prsentes aussi sur les cellules tueuses NK, caractristique de l'immunit inne, ainsi qu'un rcepteur de cellules T (TCR) qui reprsente l'immunit adaptative. Les cellules iNKT reconnaissent avec leur TCR des antignes prsents par la molcule CD1d. Les antignes sont des protines, des polysaccharides ou des lipides reconnus par les cellules du systme immunitaire ou les anticorps pour engendrer une rponse immunitaire. Dans le cas des cellules iNKT, l'alpha-galactosylceramide (αGC) est un antigne lipidique frquemment utilis dans les tudes cliniques comme puissant activateur. Aprs l'activation des cellules iNKT avec l'αGC, celles-ci produisent abondamment et rapidement des cytokines. Ces cytokines sont des molcules agissant comme des signaux activateurs d'autres cellules du systme immunitaire telles que les cellules NK et les lymphocytes T. Cependant, les cellules iNKT deviennent anergiques aprs un seul traitement avec l'αGC c'est dire qu'elles ne peuvent plus tre ractives, ce qui limite leur utilisation dans l'immunothrapie du cancer. Dans notre groupe, Stirnemann et al ont publi une molcule recombinante innovante, compose de la molcule CD1d soluble et charge avec le ligand αGC (αGC/sCD1d). Cette protine est capable d'activer les cellules iNKT tout en vitant l'anergie. Dans le systme immunitaire, les anticorps sont indispensables pour combattre une infection bactrienne ou virale. En effet, les anticorps ont la capacit de reconnatre et lier spcifiquement un antigne et permettent l'limination de la cellule qui exprime cet antigne. Dans le domaine de l'immunothrapie, les anticorps sont utiliss afin de cibler des antignes prsents seulement par la tumeur. Ce procd permet de rduire efficacement les effets secondaires lors du traitement du cancer. Nous avons donc fusionn la protine recombinante αGC/CD1d un fragment d'anticorps qui reconnat un antigne spcifique des cellules tumorales. Dans une tude prclinique, nous avons dmontr que la protine αGC/sCD1d avec un fragment d'anticorps dirig contre la tumeur engendre une meilleure activation des cellules iNKT et entrane un effet anti-tumeur prolong. Cet effet anti-tumeur est augment compar une protine αGC/CD1d qui ne cible pas la tumeur. Nous avons aussi montr que l'activation des cellules iNKT avec la protine αGC/sCD1d-anti-tumeur amliore l'effet anti- tumoral d'un vaccin pour le cancer. Lors d'expriences in vitro, la protine αGC/sCD1d-anti- tumeur permet aussi d'activer les cellules humaines iNKT et ainsi tuer spcifiquement les cellules tumorales humaines. La protine αGC/sCD1d-anti-tumeur reprsente une alternative thrapeutique prometteuse dans l'immunothrapie du cancer. - Les cellules Invariant Natural Killer T (iNKT), dont les effets anti-tumoraux ont t dmontrs, sont de puissants activateurs des cellules Natural Killer (NK), des cellules dendritiques (DC) et des lymphocytes T. Cependant, une seule injection du ligand de haute affinit alpha-galactosylceramide (αGC) n'induit une forte activation des cellules iNKT que durant une courte priode. Celle-ci est alors suivie d'une longue phase d'anergie, limitant ainsi leur utilisation pour la thrapie. Comme alternative prometteuse, nous avons montr que des injections rptes d'αGC charg sur une protine recombinante de CD1d soluble (αGC/sCD1d) chez la souris entranent une activation prolonge des cellules iNKT, associe une production continue de cytokine. De plus, le maintien de la ractivit des cellules iNKT permet de prolonger l'activit anti-tumorale lorsque la protine αGC/sCD1d est fusionne un fragment d'anticorps (scFv) dirig contre la tumeur. L'inhibition de la croissance tumorale n'est optimale que lorsque les souris sont traites avec la protine αGC/sCD1d-scFv ciblant la tumeur, la protine αGC/sCD1d-scFv non-approprie tant moins efficace. Dans le systme humain, les protines recombinantes αGC/sCD1d-anti-HER2 et anti-CEA sont capables d'activer et de faire prolifrer des cellules iNKT partir de PBMCs issues de donneurs sains. De plus, la protine αGC/sCD1d-scFv a la capacit d'activer directement des clones iNKT humains en l'absence de cellules prsentatrices d'antignes (CPA), contrairement au ligand αGC libre. Mais surtout, la lyse des cellules tumorales par les iNKT humaines n'est obtenue que lorsqu'elles sont incubes avec la protine αGC/sCD1d-scFv anti- tumeur. En outre, la redirection de la cytotoxicit des cellules iNKT vers la tumeur est suprieure celle obtenue avec une stimulation par des CPA charges avec l'αGC. Afin d'augmenter les effets anti-tumoraux, nous avons exploit la capacit des cellules iNKT activer l'immunit adaptive. Pour ce faire, nous avons combin l'immunothrapie NKT/CD1d avec un vaccin anti-tumoral compos d'un peptide OVA. Des effets synergiques ont t obtenus lorsque les traitements avec la protine αGC/sCD1d-anti-HER2 taient associs avec le CpG ODN comme adjuvant pour la vaccination avec le peptide OVA. Ces effets ont t observs travers l'activation de nombreux lymphocytes T CD8+ spcifique de la tumeur, ainsi que par la forte expansion des cellules NK. Les rponses, inne et adaptive, leves aprs le traitement avec la protine αGC/sCD1d-anti-HER2 combine au vaccin OVA/CpG ODN taient associes un fort ralentissement de la croissance des tumeurs B16- OVA-HER2. Cet effet anti-tumoral corrle avec l'enrichissement des lymphocytes T CD8+ spcifiques observ la tumeur. Afin d'tendre l'application des protines αGC/sCD1d et d'amliorer leur efficacit, nous avons dvelopp des fusions CD1d alternatives. Premirement, une protine αGC/sCD1d dimrique, qui permet d'augmenter l'avidit de la molcule CD1d pour les cellules iNKT. Dans un deuxime temps, nous avons fusionn la protine αGC/sCD1d avec un scFv dirig contre le rcepteur 3 du facteur de croissance pour l'endothlium vasculaire (VEGFR-3), afin de cibler l'environnement de la tumeur. Dans l'ensemble, ces rsultats dmontrent que la thrapie mdie par la protine recombinante αGC/sCD1d-scFv est une approche prometteuse pour rediriger l'immunit inne et adaptive vers le site tumoral. - Invariant Natural Killer T cells (iNKT) are potent activators of Natural Killer (NK), dendritic cells (DC) and T lymphocytes, and their anti-tumor activities have been well demonstrated. However, a single injection of the high affinity CD1d ligand alpha-galactosylceramide (αGC) leads to a strong but short-lived iNKT cell activation followed by a phase of long-term anergy, limiting the therapeutic use of this ligand. As a promising alternative, we have demonstrated that when αGC is loaded on recombinant soluble CD1d molecules (αGC/sCD1d), repeated injections in mice led to the sustained iNKT cell activation associated with continued cytokine secretion. Importantly, the retained reactivity of iNKT cell led to prolonged antitumor activity when the αGC/sCD1d was fused to an anti-tumor scFv fragments. Optimal inhibition of tumor growth was obtained only when mice were treated with the tumor-targeted αGC/CD1d-scFv fusion, whereas the irrelevant αGC/CD1d-scFv fusion was less efficient. When tested in a human system, the recombinant αGC/sCD1d-anti-HER2 and -anti-CEA fusion proteins were able to expand iNKT cells from PBMCs of healthy donors. Furthermore, the αGC/sCD1d-scFv fusion had the capacity to directly activate human iNKT cells clones without the presence of antigen-presenting cells (APCs), in contrast to the free αGC ligand. Most importantly, tumor cell killing by human iNKT cells was obtained only when co- incubated with the tumor targeted sCD1d-antitumor scFv, and their direct tumor cytotoxicity was superior to the bystander killing obtained with αGC-loaded APCs stimulation. To further enhance the anti-tumor effects, we exploited the ability of iNKT cells to transactivate the adaptive immunity, by combining the NKT/CD1d immunotherapy with a peptide cancer vaccine. Interestingly, synergistic effects were obtained when the αGC/sCD1d- anti-HER2 fusion treatment was combined with CpG ODN as adjuvant for the OVA peptide vaccine, as seen by higher numbers of activated antigen-specific CD8 T cells and NK cells, as compared to each regimen alone. The increased innate and adaptive immune responses upon combined tumor targeted sCD1d-scFv treatment and OVA/CpG vaccine were associated with a strong delay in B16-OVA-HER2 melanoma tumor growth, which correlated with an enrichment of antigen-specific CD8 cells at the tumor site. In order to extend the application of the CD1d fusion, we designed alternative CD1d fusion proteins. First, a dimeric αGC/sCD1d-Fc fusion, which permits to augment the avidity of the CD1d for iNKT cells and second, an αGC/sCD1d fused to an anti vascular endothelial growth factor receptor-3 (VEGFR-3) scFv, in order to target tumor stroma environment. Altogether, these results demonstrate that the iNKT-mediated immunotherapy via recombinant αGC/sCD1d-scFv fusion is a promising approach to redirect the innate and adaptive antitumor immune response to the tumor site.
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Although combination chemotherapy has been shown to be more effective than single agents in advanced esophagogastric cancer, the better response rates have not fulfilled their promise as overall survival times from best combination still range between 8 to 11 months. So far, the development of targeted therapies stays somewhat behind their integration into treatment concepts compared to other gastrointestinal diseases. Thus, the review summarizes the recent advances in the development of targeted therapies in advanced esophagogastric cancer. The majority of agents tested were angiogenesis inhibitors or agents targeting the epidermal growth factor receptors EGFR1 and HER2. For trastuzumab and bevacizumab, phase III trial results have been presented recently. While addition of trastuzumab to cisplatin/5-fluoropyrimidine-based chemotherapy results in a clinically relevant and statistically significant survival benefit in HER 2+ patients, the benefit of the addition of bevacizumab to chemotherapy was not significant. Thus, all patients with metastatic disease should be tested for HER-2 status in the tumor. Trastuzumab in combination with cisplatin/5-fluoropyrimidine-based chemotherapy is the new standard of care for patients with HER2-positive advanced gastric cancer.
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Breast cancer is the most common malignancy in women and a significant cause of morbidity and mortality. Sub-types of breast cancer defined by the expression of steroid hormones and Her2/Neu oncogene have distinct prognosis and undergo different therapies. Besides differing in their phenotype, sub-types of breast cancer display various molecular lesions that participate in their pathogenesis. BRCA1 is one of the common hereditary cancer predisposition genes and encodes for an ubiquitin ligase. Ubiquitin ligases or E3 enzymes participate together with ubiquitin activating enzyme and ubiquitin conjugating enzymes in the attachment of ubiquitin (ubiquitination) in target proteins. Ubiquitination is a post-translational modification regulating multiple cell functions. It also plays important roles in carcinogenesis in general and in breast carcinogenesis in particular. Ubiquitin conjugating enzymes are a central component of the ubiquitination machinery and are often perturbed in breast cancer. This paper will discuss ubiquitin and ubiquitin-like proteins conjugating enzymes participating in breast cancer pathogenesis, their relationships with other proteins of the ubiquitination machinery and their role in phenotype of breast cancer sub-types.
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Aquest estudi permet conixer les implicacions dels diferents subtipus de cncer de mama: luminal A, luminal B, HER2+, triple negatiu en el desenvolupament y pronostic de la carcinomatosi leptomenngea (CL). Es van identificar 38 pacients, major proporci: luminal B y HER2+, 53% va rebre quimioterpia sistmica (QTS). La mitjana de supervivencia post CL: 2,6 messos. A lanlisis univariat: ECOG de 0-2 y tractament amb QT van ser variables pronstiques i al multivariant noms QTS. En conclussi el subtipus de cncer de mama influiex en el temps daparici de la CL, no afectant la supervivencia desprs del diagnstic.
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Background: The purpose of the work reported here is to test reliable molecular profiles using routinely processed formalin-fixed paraffin-embedded (FFPE) tissues from participants of the clinical trial BIG 1-98 with a median follow-up of 60 months. Methods: RNA from fresh frozen (FF) and FFPE tumor samples of 82 patients were used for quality control, and independent FFPE tissues of 342 postmenopausal participants of BIG 1-98 with ER-positive cancer were analyzed by measuring prospectively selected genes and computing scores representing the functions of the estrogen receptor (eight genes, ER_8), the progesterone receptor (five genes, PGR_5), Her2 (two genes, HER2_2), and proliferation (ten genes, PRO_10) by quantitative reverse transcription PCR (qRT-PCR) on TaqMan Low Density Arrays. Molecular scores were computed for each category and ER_8, PGR_5, HER2_2, and PRO_10 scores were combined into a RISK_25 score. Results: Pearson correlation coefficients between FF- and FFPE-derived scores were at least 0.94 and high concordance was observed between molecular scores and immunohistochemical data. The HER2_2, PGR_ 5, PRO_10 and RISK_25 scores were significant predictors of disease free-survival (DFS) in univariate Cox proportional hazard regression. PRO_10 and RISK_25 scores predicted DFS in patients with histological grade II breast cancer and in lymph node positive disease. The PRO_10 and PGR_ 5 scores were independent predictors of DFS in multivariate Cox regression models incorporating clinical risk indicators; PRO_10 outperformed Ki-67 labeling index in multivariate Cox proportional hazard analyses. Conclusions: Scores representing the endocrine responsiveness and proliferation status of breast cancers were developed from gene expression analyses based on RNA derived from FFPE tissues. The validation of the molecular scores with tumor samples of participants of the BIG 1-98 trial demonstrates that such scores can serve as independent prognostic factors to estimate disease free survival (DFS) in postmenopausal patients with estrogen receptor positive breast cancer.
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BACKGROUND: Pancreatic carcinoma remains a treatment-refractory cancer with a poor prognosis. Here, we compared anti-epidermal growth factor receptor (EGFR) and anti-HER2 monoclonal antibodies (2mAbs) injections with standard gemcitabine treatment on human pancreatic carcinoma xenografts. MATERIALS AND METHODS: Nude mice, bearing human pancreatic carcinoma xenografts, were treated with either combined anti-EGFR (cetuximab) and anti-HER2 (trastuzumab) or gemcitabine, and tumor growth was observed. RESULTS AND CONCLUSION: In first-line therapy, mice survival was significantly longer in the 2mAbs group compared with gemcitabine (P < 0.0001 for BxPC-3, P = 0.0679 for MiaPaCa-2 and P = 0.0019 for Capan-1) and with controls (P < 0.0001). In second-line therapy, tumor regressions were observed after replacing gemcitabine by 2mAbs treatment, resulting in significantly longer animal survival compared with mice receiving continuous gemcitabine injections (P = 0.008 for BxPC-3, P = 0.05 for MiaPaCa-2 and P < 0.001 for Capan-1). Therapeutic benefit of 2mAbs was observed despite K-Ras mutation. Interestingly, concerning the mechanism of action, coinjection of F(ab')(2) fragments from 2mAbs induced significant tumor growth inhibition, compared with controls (P = 0.001), indicating that the 2mAbs had an Fc fragment-independent direct action on tumor cells. This preclinical study demonstrated a significant improvement of survival and tumor regression in mice treated with anti-EGFR/anti-HER2 2mAbs in first- and second-line treatments, compared with gemcitabine, independently of the K-Ras status.
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The development of orally active small molecule inhibitors of the epidermal growth factor receptor (EGFR) has led to new treatment options for non-small cell lung cancer (NSCLC). Patients with activating mutations of the EGFR gene show sensitivity to, and clinical benefit from, treatment with EGFR tyrosine kinase inhibitors (EGFR-TKls). First generation reversible ATP-competitive EGFR-TKls, gefitinib and erlotinib, are effective as first, second-line or maintenance therapy. Despite initial benefit, most patients develop resistance within a year, 50-60% of cases being related to the appearance of a T790M gatekeeper mutation. Newer, irreversible EGFR-TKls - afatinib and dacomitinib - covalently bind to and inhibit multiple receptors in the ErbB family (EGFR, HER2 and HER4). These agents have been mainly evaluated for first-line treatment but also in the setting of acquired resistance to first-generation EGFR-TKls. Afatinib is the first ErbB family blocker approved for patients with NSCLC with activating EGFR mutations; dacomitinib is in late stage clinical development. Mutant-selective EGFR inhibitors (AZD9291, CO-1686, HM61713) that specifically target the T790M resistance mutation are in early development. The EGFR-TKIs differ in their spectrum of target kinases, reversibility of binding to EGFR receptor, pharmacokinetics and potential for drug-drug interactions, as discussed in this review. For the clinician, these differences are relevant in the setting of polymedicated patients with NSCLC, as well as from the perspective of innovative anticancer drug combination strategies.
