Incidence of outer retinal tubulation in ranibizumab-treated age-related macular degeneration.

PURPOSE: To investigate the incidence of outer retinal tubulation (ORT) in ranibizumab-treated neovascular age-related macular degeneration patients. METHODS: We included 480 consecutive patients (546 eyes) with neovascular age-related macular degeneration, who were treated with variable-dosing intravitreal ranibizumab, evaluated with spectral domain optical coherence tomography, and followed-up for a minimum period of 6 months. Optical coherence tomographies were evaluated for the first appearance of ORT, precursor signs, and type of underlying lesion. Visual acuity was also recorded. RESULTS: Outer retinal tubulation was observed in 30% of eyes during a mean follow-up period of 26.7 months (SD, 13.5). Kaplan-Meier survival analysis revealed that the ORT incidence (2.5, 17.5, 28.4, and 41.6% at baseline, after 1, 2, and 4 years, respectively) continuously increased, despite visually effective anti-vascular endothelial growth factor treatment. Outer retinal tubulation was associated with a poorer functional benefit. Lower baseline visual acuity was associated with a higher risk of developing ORT. CONCLUSION: Incidence of ORT continuously increases despite visually optimal anti-vascular endothelial growth factor treatment of age-related macular degeneration. Outer retinal tubulation might be considered a prognostic factor for functional outcome and is relevant to avoid overtreatment.

Prospective evaluation of circulating VEGF in patients with advanced non-small cell lung cancer treated with bevacizumab, pemetrexed and cisplatin in the trial SAKK19/09.

Aim: Bevacizumab is a monoclonal antibody directed against the vascular endothelial growth factor (VEGF). The previous phase II trial ABIGAIL (Reck, 2010) suggested circulating VEGF as a prognostic, but not predictive, biomarker for patients (pts) with non-small cell lung cancer (NSCLC) treated with bevacizumab. We prospectively measured VEGF in the multicenter phase II trial SAKK19/09 (NCT01116219). Methods: SAKK19/09 enrolled 77 evaluable patients (pts) with previously untreated, advanced nonsquamous NSCLC and EGFR wild type. Pts received 4 cycles of cisplatin 75mg/m2 (or carboplatin AUC5), pemetrexed 500mg/m2 and bevacizumab 7.5mg/kg, followed by maintenance therapy with pemetrexed and bevacizumab until progression by RECIST1.1. Follow-up CT scans were performed every 6 weeks until week 54 and every 12 weeks thereafter. Baseline EDTA blood samples were sent by same-day courier to the central laboratory for centrifugation, aliquoting, and freezing. Upon completion of enrollment, aliquots were thawed, and VEGF quantification was performed centrally using Luminex® Performance Assay Human Base Kit A (R&D Systems, Abingdon, UK). The mean value was used to stratify pts into two groups (low versus high VEGF). Best response rate assessed by RECIST1.1 (CR + PR versus SD + PD). Results: Clinical results of the SAKK19/09 trial were reported previously (Gautschi, 2013). Baseline plasma VEGF was detectable in 71 of 77 (92%) evaluable patients treated with chemotherapy and bevacizumab. The mean value was 74.9 pg/ml, the median 47.5 pg/ml, and the range 3.55 to 310 pg/ml. Using the mean as a predefined cutoff value, 50 patients had low VEGF levels and 21 patients had high VEGF levels. High VEGF was significantly associated with shorter PFS (4.1 vs 8.3 months, HR = 2.56; 95%CI: 1.43- 4.57; p = 0.0015) and OS (8.7 vs 17.5 months, HR = 2.67; 95% CI: 1.37-5.20; p = 0.0041), but not with best response rate ( p = 0.2256). Conclusions: Consistent with the ABIGAIL trial, circulating VEGF was prognostic, but not predictive for response, in the current trial. Further work is ongoing to identify potentially predictive biomarkers for bevacizumab, using comprehensive proteomic analyses. Disclosure: S.I. Rothschild: I received honoraria for the participation in advisory boards from Eli Lilly and Roche and for presentations at scientific symposiums sponsored by Roche; O. Gautschi: Honoraria for advisory boards of Eli Lilly and Roche; R. Cathomas: Advisory board member: Eli Lilly. All other authors have declared no conflicts of interest.

Galactofuranose in Mycoplasma mycoides is important for membrane integrity and conceals adhesins but does not contribute to serum resistance.

Mycoplasma mycoides subsp. capri (Mmc) and subsp. mycoides (Mmm) are important ruminant pathogens worldwide causing diseases such as pleuropneumonia, mastitis and septicaemia. They express galactofuranose residues on their surface, but their role in pathogenesis has not yet been determined. The M. mycoides genomes contain up to several copies of the glf gene, which encodes an enzyme catalysing the last step in the synthesis of galactofuranose. We generated a deletion of the glf gene in a strain of Mmc using genome transplantation and tandem repeat endonuclease coupled cleavage (TREC) with yeast as an intermediary host for the genome editing. As expected, the resulting YCp1.1-Δglf strain did not produce the galactofuranose-containing glycans as shown by immunoblots and immuno-electronmicroscopy employing a galactofuranose specific monoclonal antibody. The mutant lacking galactofuranose exhibited a decreased growth rate and a significantly enhanced adhesion to small ruminant cells. The mutant was also 'leaking' as revealed by a β-galactosidase-based assay employing a membrane impermeable substrate. These findings indicate that galactofuranose-containing polysaccharides conceal adhesins and are important for membrane integrity. Unexpectedly, the mutant strain showed increased serum resistance.

Characterization and application of two RANK-specific antibodies with different biological activities.

Antibodies play an important role in therapy and investigative biomedical research. The TNF-family member Receptor Activator of NF-κB (RANK) is known for its role in bone homeostasis and is increasingly recognized as a central player in immune regulation and epithelial cell activation. However, the study of RANK biology has been hampered by missing or insufficient characterization of high affinity tools that recognize RANK. Here, we present a careful description and comparison of two antibodies, RANK-02 obtained by phage display (Newa, 2014 [1]) and R12-31 generated by immunization (Kamijo, 2006 [2]). We found that both antibodies recognized mouse RANK with high affinity, while RANK-02 and R12-31 recognized human RANK with high and lower affinities, respectively. Using a cell apoptosis assay based on stimulation of a RANK:Fas fusion protein, and a cellular NF-κB signaling assay, we showed that R12-31 was agonist for both species. R12-31 interfered little or not at all with the binding of RANKL to RANK, in contrast to RANK-02 that efficiently prevented this interaction. Depending on the assay and species, RANK-02 was either a weak agonist or a partial antagonist of RANK. Both antibodies recognized human Langerhans cells, previously shown to express RANK, while dermal dendritic cells were poorly labeled. In vivo R12-31 agonist activity was demonstrated by its ability to induce the formation of intestinal villous microfold cells in mice. This characterization of two monoclonal antibodies should now allow better evaluation of their application as therapeutic reagents and investigative tools.

The forced adoption of a fast-track appraisal process for a breast cancer treatment in UK

Trastuzumab (Herceptin ®, Roche) is approved in UK for the treatment of the metastatic breast cancer since 2001. As of 2005, concomitantly with the publication of 3 studies that showed it produces a 50% reduction of the recurrence rates of breast cancer, trastuzumab started to be prescribed in the earlt adjuvant treatrnent of this disease. Und June 2006, trastuzumab did not have both: 1) regulatory approval and 2) NICE [National Institute for Health and Clinical Excellence] recommendation for the use in early stages of breast cancer. During the period until June 2006, the trastuzumab use in those patients was not reimbursed and because the cost of trastuzumab is equal with the yearly UK average income, most of patients could not self fund their treatrnent. Before the publication of the final NICE guidance, the new data of trastuzumab in early breast cancer raised enormous patient and professional interest and expectations. A great volume of public and professional pressure was generated to transcend a system by which Primary Care Trusts can reimburse a treatment only after a formal guidance was issued. This paper draw on a case study depicting and analyzing the process by which regulatory approval and NICE recommendations were achieved in a record time and how trastuzumab became a standard treatment on early adjuvant breast cancer. According to the data we gathered in this work we were witnessing one of the fastest processes of adoption of a health care technology since the creation of NICE, in 1999. This study addresses the following research question: How and why does the adoption pattern of trastuzumab differ from the rational decision-making model of the reimbursement process in UK? [Author, p. 4]

HPV & head and neck cancer: a descriptive update

The incidence of head and neck squamous cell carcinoma (HNSCC) has been gradually increasing over the last three decades. Recent data have now attributed a viral aetiology to a subset of head and neck cancers. Several studies indicate that oral human papillomavirus (HPV) infection is likely to be sexually acquired. The dominance of HPV 16 in HPV+ HNSCC is even greater than that seen in cervical carcinoma of total worldwide cases. Strong evidence suggests that HPV+ status is an important prognostic factor associated with a favourable outcome in head and neck cancers. Approximately 30 to 40% of HNSCC patients with present with early stage I/II disease. These patients are treated with curative intent using single modality treatments either radiation or surgery alone. A non-operative approach is favored for patients in which surgery followed by either radiation alone or radiochemotherapy may lead to severe functional impairment. Cetuximab, a humanized mouse anti-EGFR IgG1 monoclonal antibody, improved locoregional control and overall survival in combination with radiotherapy in locally advanced tumours but at the cost of some increased cardiac morbidity and mortality. Finally, the improved prognosis and treatment responses to chemotherapy and radiotherapy by HPV+ tumours may suggest that HPV status detection is required to better plan and individualize patient treatment regimes.

Pró-fármaco ativado por enzima, uma estratégia promissora na quimioterapia

Strategies that promote selective activation of prodrugs by enzymes can be divided into two major classes: 1) deliver of a monoclonal antibody-enzyme immunoconjugate that can recognize a specific antigen and promote the prodrug to a citotoxic drug, with a high selectivity for the target cells, and 2) selective gene delivery encoding an enzyme that can promote the prodrug to a citotoxic drug for the target cells. In this article are discussed ADEPT (antibody-directed enzyme prodrug therapy), GDEPT (gene-directed enzyme prodrug therapy), VDEPT (virus-directed enzyme prodrug therapy), GPAT (genetic prodrug activation therapy) and PDEPT (polymer-directed enzyme prodrug therapy) approaches, their clinical trials, advantages, disadvantages and perspectives.

Role of ErbB2 and ErbB4 in Cancer Growth, Prognosis and as Targets for Immunotherapy

ErbB receptors (EGFR, ErbB2, ErbB3 and ErbB4) are growth factor receptors that regulate signals of cell differentiation, proliferation, migration and survival. Inappropriate activation of these receptors is associated with the development and severity of many cancers and has prognostic and predictive value in cancer therapy. Drugs, such as therapeutic antibodies, targeted against EGFR and ErbB2, are currently used in therapy of breast, colorectal and head and neck cancers. The role of ErbB4 in tumorigenesis has remained relatively poorly understood. Alternative splicing produces four different isoforms of one ErbB4 gene. These isoforms (JM-a, JM-b, CYT-1 and CYT-2) are functionally dissimilar and proposed to have different roles in carcinogenesis. The juxtamembrane form JM-a undergoes regulated intramembrane proteolysis producing a soluble receptor ectodomain and an intracellular domain that translocates into the nucleus and regulates transcription. Nuclear signaling via JM-a isoform stimulates cancer cell proliferation. This study aimed to develop antibodies targeting the proposed oncogenic ErbB4 JM-a isoform that show potential in inhibiting ErbB4 dependent tumorigenesis. Also, the clinical relevance of ErbB4 shedding in cancer was studied. The currently used monoclonal antibody trastuzumab, targeting ErbB2, has shown efficacy in breast cancer therapy. In this study novel tissues with ErbB2 amplification and trastuzumab sensitivity were analyzed. The results of this study indicated that a subpopulation of breast cancer patients demonstrate increased shedding and cleavage of ErbB4. A JM-a isoform-specific antibody that inhibited ErbB4 shedding and consequent activation of ErbB4 had anti-tumor activity both in vitro and in vivo. Thus, ErbB4 shedding associates with tumor growth and specific targeting of the cleavable JM-a isoform could be considered as a strategy for developing novel ErbB-based cancer drugs. In addition, it was demonstrated that ErbB2 amplification is common in intestinal type gastric cancers with poor clinical outcome. Trastuzumab inhibited growth of gastric and breast cancer cells with equal efficacy. Thus, ErbB2 may be a useful target in gastric cancer.

Evolution of Bioaffinity Reagents by Phage Display

Antibodies are natural binding proteins produced in vertebrates as a response to invading pathogens and foreign substances. Because of their capability for tight and specific binding, antibodies have found use as binding reagents in research and diagnostics. Properties of cloned recombinant antibodies can be further improved by means of in vitro evolution, combining mutagenesis with subsequent phage display selection. It is also possible to isolate entirely new antibodies from vast naïve or synthetic antibody libraries by phage display. In this study, library techniques and phage display selection were applied in order to optimise binding scaffolds and antigen recognition of antibodies, and to evolve new and improved bioaffinity reagents. Antibody libraries were generated by random and targeted mutagenesis. Expression and stability were mainly optimised by the random methods whereas targeted randomisation of the binding site residues was used for optimising the binding properties. Trinucleotide mutagenesis allowed design of defined randomisation patterns for a synthetic antibody library. Improved clones were selected by phage display. Capture by a specific anti- DHPS antibody was exploited in the selection of improved phage display of DHPS. Efficient selection for stability was established by combining phage display selection with denaturation under reducing conditions. Broad-specific binding of a generic anti-sulfonamide antibody was improved by selection with one of the weakest binding sulfonamides. In addition, p9 based phage display was studied in affinity selection from the synthetic library. A TIM barrel protein DHPS was engineered for efficient phage display by combining cysteinereplacement with random mutagenesis. The resulting clone allows use of phage display in further engineering of DHPS and possibly use as an alternative-binding scaffold. An anti-TSH scFv fragment, cloned from a monoclonal antibody, was engineered for improved stability to better suite an immunoassay. The improved scFv tolerates 8 – 9 °C higher temperature than the parental scFv and should have sufficient stability to be used in an immunoanalyser with incubation at 36 °C. The anti-TSH scFv fragment was compared with the corresponding Fab fragment and the parental monoclonal antibody as a capturing reagent in a rapid 5-min immunoassay for TSH. The scFv fragment provided some benefits over the conventionally used Mab in anayte-binding capacity and assay kinetics. However, the recombinant Fab fragment, which had similar kinetics to the scFv, provided a more sensitive and reliable assay than the scFv. Another cloned scFv fragment was engineered in order to improve broad-specific recognition of sulfonamides. The improved antibody detects different sulfonamides at concentrations below the maximum residue limit (100 μg/kg in EU and USA) and allows simultaneous screening of different sulfonamide drug residues. Finally, a synthetic antibody library was constructed and new antibodies were generated and affinity matured entirely in vitro. These results illuminate the possibilities of phage display and antibody engineering for generation and optimisation of binding reagents in vitro and indicate the potential of recombinant antibodies as affinity reagents in immunoassays.

Preparation and evaluation of atrazine immunoconjugate

In order to study the affinity reaction between the anti-atrazine antibody and atrazine, an enzyme was incorporated, as a marker, to an atrazine carboxylic derivative. The hapten and conjugate were synthesized and characterized by MS, IR and NMR. The interaction between monoclonal antibodies and hapten-HRP conjugate was investigated by enzyme linked immunosorbent assay (ELISA).

Biosynthesis of Yersinia enterocolitica serotype O:3 lipopolysaccharide outer core

Lipopolysacharide (LPS) present on the outer leaflet of Gram-negative bacteria is important for the adaptation of the bacteria to the environment. Structurally, LPS can be divided into three parts: lipid A, core and O-polysaccharide (OPS). OPS is the outermost and also the most diverse moiety. When OPS is composed of identical sugar residues it is called homopolymeric and when it is composed of repeating units of oligosaccharides it is called heteropolymeric. Bacteria synthesize LPS at the inner membrane via two separate pathways, Lipid A-core via one and OPS via the other. These are ligated together in the periplasmic space and the completed LPS molecule is translocated to the surface of the bacteria. The genes directing the OPS biosynthesis are often clustered and the clusters directing the biosynthesis of heteropolymeric OPS often contain genes for i) the biosynthesis of required NDP-sugar precursors, ii) glycosyltransferases needed to build up the repeating unit, iii) translocation of the completed O-unit to the periplasmic side of the inner membrane (flippase) and iv) polymerization of the repeating units to complete OPS. The aim of this thesis was to characterize the biosynthesis of the outer core (OC) of Yersinia enterocolitica serotype O:3 (YeO3). Y. enterocolitica is a member of the Gram-negative Yersinia genus and it causes diarrhea followed sometimes by reactive arthritis. The chemical structure of the OC and the nucleotide sequence of the gene cluster directing its biosynthesis were already known; however, no experimental evidence had been provided for the predicted functions of the gene products. The hypothesis was that the OC biosynthesis would follow the pathway described for heteropolymeric OPS, i.e. a Wzy-dependent pathway. In this work the biochemical activities of two enzymes involved in the NDP-sugar biosynthesis was established. Gne was determined to be a UDP-N-acetylglucosamine-4-epimerase catalyzing the conversion of UDP-GlcNAc to UDP-GalNAc and WbcP was shown to be a UDP-GlcNAc- 4,6-dehydratase catalyzing the reaction that converts UDP-GlcNAc to a rare UDP-2-acetamido- 2,6-dideoxy-d-xylo-hex-4-ulopyranose (UDP-Sugp). In this work, the linkage specificities and the order in which the different glycosyltransferases build up the OC onto the lipid carrier were also investigated. In addition, by using a site-directed mutagenesis approach the catalytically important amino acids of Gne and two of the characterized glycosyltranferases were identified. Also evidence to show the enzymes involved in the ligations of OC and OPS to the lipid A inner core was provided. The importance of the OC to the physiology of Y. enterocolitica O:3 was defined by determining the minimum requirements for the OC to be recognized by a bacteriophage, bacteriocin and monoclonal antibody. The biological importance of the rare keto sugar (Sugp) was also shown. As a conclusion this work provides an extensive overview of the biosynthesis of YeO3 OC as it provides a substantial amount of information of the stepwise and coordinated synthesis of the Ye O:3 OC hexasaccharide and detailed information of its properties as a receptor.

Characterization of Citrus tristeza virus isolates from grapefruit (Citrus paradisi Macf.) accessions of Citrus Active Germplasm Bank

Citrus tristeza virus (CTV) isolates from 35 grapefruit accessions belonging to Citrus Active Germplasm Bank of the "Instituto Agronômico de Campinas" located at the "Centro APTA Citros Sylvio Moreira", Cordeirópolis, São Paulo state, Brazil, were characterized and evaluated through symptoms in the trees, biological indexing, immunological diagnosis with different monoclonal antibodies and SSCP analysis (single-strand conformation polymorphism) of the coat protein gene. Symptomatology indicated that, in general, the group of plants with smaller canopy volume and severe stem pitting differed significantly from the group that presented greater vegetative development and mild to moderate stem pitting. However, the isolates from most of the accessions induced mild reaction on Mexican lime. The serological evaluation through the DAS-ELISA using monoclonal antibodies did not reveal any association between virus titer in the plant tissue and symptoms. The reaction with different monoclonal antibodies and the distinct electrophoresis patterns obtained through SSCP showed that there is a high degree of diversity among the isolates that infect these grapefruit accessions. High complexity within the same isolate was also observed in the SSCP profiles. This finding indicates that the CTV isolates from these plants are a complex mixture of CTV haplotypes. Similar SSCP banding patterns were observed among some plants with strong stem pitting symptoms, and among some plants with weak or moderate stem pitting symptoms.

Expressão da proteína P53 no adenocarcinoma gástrico: correlação clínica, anatomopatológica e significância prognostica

OBJETIVO: Avaliar a expressão da proteína p53 no adenocarcinoma gástrico e correlacioná-la com variáveis clínicas e anatomopatológicas, tais como: idade, sexo, infiltração da parede gástrica (T), tipo histológico (Laurén), grau de diferenciação histológica, comprometimento linfonodal, estadiamento (TNM) e sobrevida. MÉTODO: Foram analisados os registros médicos e reestudadas as lâminas de peças cirúrgicas de 45 doentes com adenocarcinomas gástricos submetidos à gastrectomia parcial e total no Serviço de Cirurgia Oncológica da Santa Casa de Misericórdia de Maceió-AL e no Hospital Universitário da Universidade Federal de Alagoas, no período de 1991 a 2002. A expressão da proteína p53 foi avaliada pelo método imunohistoquímico com o anticorpo monoclonal DO-7 e comparada com idade, sexo, infiltração na parede gástrica, tipo histológico, grau de diferenciação, comprometimento linfonodal, estadiamento e sobrevida. RESULTADOS: Dos 45 doentes, 27 eram do sexo masculino (60%). A média das idades foi 53,9 anos (26 - 75 anos), e mediana de 57 anos. Em 40 doentes (88,9%) o tumor foi classificado como bem diferenciado. Quanto à infiltração na parede gástrica, em 28 doentes (62,2%) foram classificados como profundos. Em 25 doentes (55,6%) não havia comprometimento linfonodal. O estudo histológico revelou que 29 doentes (64,4%) apresentavam tumores classificados como tipo intestinal de Laurén. O estadiamento TNM demonstrou que 33 (73,3%) doentes apresentavam tumores avançados. Quanto à expressão da p53, 18 doentes (40%) foram considerados positivos. O tempo médio de seguimento foi de 1020,4 dias (63 - 3920 dias) e mediana de 798 dias. Trinta e um (68,9%) doentes evoluíram para óbito. As variáveis: idade, estadiamento, comprometimento linfonodal e infiltração do tumor na parede gástrica, foram fatores prognósticos relacionados à sobrevida com significado estatístico (p<0,05). Não houve correlação estatística significativa da proteína p53 com as variáveis estudadas. A análise estatística multivariada identificou apenas o comprometimento linfonodal como fator prognóstico independente. CONCLUSÕES: Os autores concluíram que dezoito (40%) dos doentes expressaram a reação imunohistoquímica para p53. Não houve correlação estatística significativa da expressão da proteína p53 com os fatores prognósticos estudados. A expressão da proteína p53 não foi fator prognóstico independente.

Obstrução intestinal após uso de infliximab no tratamento de fístula êntero-cutânea na doença de Crohn

Crohn's disease is often complicated by the development of fistulas. Infliximab, a monoclonal antibody that binds tumor necrosis factor a have shown to be successful in the treatment of fistulizing Crohn's disease. It's possible complications and side effects have not been completely elucidated. Our objective is to report a case of a patient who developed intestinal obstruction after treatment of fistulizing Crohn's disease with infliximab. A 50 years-old female with Crohn's disease presented with spontaneous enterocutaneous fistula. She was successfully treated with the infusion of 5mg/kg infliximab at weeks 0, 2, and 6, with complete closure of the fistula after the first infusion. Eight weeks after treatment she developed small bowel obstruction secondary to stenosis of the ileum. She was subjected to exploratory laparotomy and resection of the stenotic ileum. The patient had good recovery, with no complications, and was discharged on the 5th postoperative day. Although a faster and complete healing of enterocutaneous fistula was induced by infliximab, this treatment may have caused intestinal obstruction in this case.

Influência da localização do tumor na expressão tecidual da proteína p53 em doentes com câncer colorretal: estudo de 100 casos

OBJETIVO: O objetivo do presente estudo foi verificar, se existem diferenças na expressão tecidual da proteína p53 segundo a localização do tumor em doentes com câncer colorretal. MÉTODO: Foram estudados 100 doentes (54 mulheres), com média de idade de 59,8 anos com adenocarcinoma colorretal. A expressão da proteína p53 foi analisada por imunoistoquímica, com anticorpo monoclonal anti-p53 pela técnica da estreptavidina-biotina-peroxidase. A expressão tecidual da proteína p53 foi relacionada às variáveis: gênero, idade, grau histológico, tipo histológico, tamanho do tumor, estadiamento TNM, profundidade de invasão da parede intestinal, comprometimento linfonodal, invasão angiolinfática, localização do tumor no intestino grosso em relação à flexura esplênica. Na avaliação estatística da relação entre expressão da proteína p53 e as variáveis consideradas empregou-se o teste qui-quadrado, estabelecendo-se nível de significância de 5% (p<0,05). RESULTADOS: A proteína p53 foi positiva em 77% dos casos. Com relação as diferentes variáveis consideradas verificou-se maior tendência de expressão da proteína mutante quando se considerava a idade (p=0,001), grau histológico (p=0,001), tipo histológico (p=0,001), estádios tardios da classificação TNM (p=0,001), maior profundidade de invasão na parede cólica (p=0,001), comprometimento linfonodal (p=0,001), invasão angiolinfática (p=0,02), localização após a flexura esplênica (p=0,001), não se encontrando relação com gênero (p=0,49) e tamanho do tumor (p=0,08). CONCLUSÃO: Os resultados do presente estudo permitem concluir que a expressão da proteína p53 mutante ocorre com maior freqüência nos tumores localizados a partir da flexura esplênica.