Dissertations / Theses on the topic 'Chronic myeloid leukemia gene therapy'

Orientadores: Carmino Antonio de Souza, Katia Borgia Barbosa Pagnano
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: O desenvolvimento da Leucemia Mielóide Crônica (LMC) tem como característica a formação do cromossomo Philadelphia que envolve a quebra do gene BCR gerando um rearranjo molecular denominado BCR-ABL, cujo produto final é uma proteína de fusão citoplasmática que determina a patogenia da doença. Esta proteína é uma tirosina quinase (TK) que possui capacidade de auto-ativação e para a inativação desta proteína, foram desenvolvidos os inibidores da tirosina quinase (ITK), que tem a capacidade de se ligar no mesmo sítio de ligação da molécula de ATP. Esta ligação impede a transferência dos grupos fosfatos aos substratos subseqüentes, bloqueando a cascata de transdução de sinais e prevenindo a ativação das vias mitogênica dependente da quinase Bcr-Abl e anti-apoptóticas levando à morte do fenótipo BCR-ABL.Um dos principais mecanismos de resistência ao tratamento com ITK são as mutações pontuais, sendo a T315I foco de estudos mais detalhados por tornar a proteína mutante altamente insensível a todas as drogas inibidoras da proteína TK disponíveis atualmente Foi utilizado neste trabalho a técnica de D-HPLC para fazer screening de mutações nos pacientes com LMC com resposta sub ótima ou falha de tratamento de acordo com os critérios da Leukemia Net. Para o screening do éxon 6 foram selecionados 93 pacientes com LMC: 5 eram intolerantes, 67 resistentes e 21 com resposta subótima. Como controle negativo foi usado o sangue periférico doadores de sangue do Hemocentro da UNICAMP. Para o screening de mutações de todo o gene BCR-ABL foram estudados 37 pacientes com LMC e como controle negativo, usamos a linhagem celular HL60 que não possui a translocação BCR-ABL. No screening do éxon 6, 23 amostras (25%) mostraram um perfil de eluição no D-HPLC anormal em relação ao controle, o que sugeriu a presença de mutação. A sobrevida global (OS) para todo grupo foi de 80% em uma mediana de tempo de observação de 30 meses. OS para pacientes sem mutações foi de 87% e para os pacientes com mutações foi de 56% em uma mediana de tempo de observação 37 e 10 meses, respectivamente (p <0,0001, RR = 68). No screening de todo o gene BCR-ABL 17 (46%) tiveram perfil cromatográfico diferente do controle Como estávamos estabelecendo a padronização do método, procedemos com o seqüenciamento de todas as amostras e os resultados obtidos foram comparados com a seqüência depositada no banco de dados GenBank (U07563). Das 17 amostras com alteração do perfil cromatográfico, observamos a presença de mutação em 13 amostras. Acreditamos que isso se deva a sensibilidade do método de D-HPLC que é capaz de identificar tanto polimorfismos quanto mutações com maior eficiência que o seqüenciamento. Em resumo, o D-HPLC demonstrou ser um método sensível e prático para o acompanhamento do aparecimento de mutações no domínio da quinase na rotina clínica. Mutações nessa região estudada são clinicamente relevantes e podem conferir um pior prognóstico. A detecção precoce pode ser uma ferramenta importante para otimizar a terapêutica na LMC.
Abstract: The development of chronic myeloid leukemia (CML) is the formation of the characteristic Philadelphia chromosome involving breach of the BCR gene generating a molecular rearrangement called BCR-ABL, whose final product is a cytoplasmic fusion protein that determines the pathogenesis of the disease. This is a protein tyrosine kinase (TK) that has self-ativaçãoe to inactivate this protein have developed the inhibitors of tyrosine kinase (ITK), which has ability to connect on the same site of binding of molecule of ATP. This connection prevents the transfer of phosphate groups to substrates subsequent, blocking the cascade of signal transduction and preventing the activation of mitogenic pathways dependent kinase BCR-ABL and anti leading to apoptotic death phenotype of BCR-ABL.One major mechanisms of resistance to treatment with ITK are mutations off, and the T315I focus of more detailed studies by making mutant protein highly insensitive to all drugs Inhibit TK protein currently available was used in this work to D-HPLC technique to screening for mutations in patients with CML with sub-optimal response or failure of treatment according to the criteria Leukemia Net For the screening of exon 6 were selected 93 CML patients: 5 were intolerant, 67 resistant and 21 with answer sub-optimal. The negative control we used the peripheral blood donors Blood from the blood of UNICAMP. For the screening of mutations throughout the BCR-ABL gene were studied 37 patients with CML and control negative, we used the HL60 cell line that does not have the translocation BCR-ABL. In the screening of exon 6, 23 samples (25%) showed a profile of the D-HPLC elution abnormal in the control, which suggested the presence of mutation. The overall survival (OS) for whole group was 80% in a median time of observation of 30 months. OS for patients with mutations was 87% and for patients with mutations was 56% in the median observation time of 37 and 10 months respectively (p <0.0001, RR = 68). In screening the entire gene BCR-ABL 17 (46%) had chromatographic profile different from the control we were setting the standardization of methods, procedures with the sequencing of all samples and the results were compared with the sequence deposited in the GenBank database (U07563). Of the 17 samples with change the chromatographic profile, we observed the presence of mutation in 13 samples. We believe that this is due to sensitivity of the method of D-HPLC is able to identify the mutations both polymorphisms with greater efficiency to the sequencing. In summary, the D-HPLC has proved a sensitive and practical method for monitoring the appearance of mutations in the kinase domain in the clinical routine. Mutations studied in this region are clinically relevant and may confer worse prognosis. Early detection can be a tool important to optimize therapy in CML.
Mestrado
Ciencias Basicas
Mestre em Clinica Medica

The aims of the studies described in the thesis were to investigate different treatment strategies in chronic myeloid leukemia (CML) patients. Furthermore, activity of imatinib was investigated by in vitro cytotoxicity assay, and the gene expression pattern in interferon treated patients.

In a randomized prospective national study, we examined the influence of busulphan (n=89) versus hydroxyurea (n=90) treatment on time to blast crisis, and survival. There was no significant difference in survival between hydroxyurea and busulphan treated patients; median survival was 3.5 and 3.2 years, respectively. The 26 patients who underwent allogeneic stem cell transplantation had a significantly longer median survival (4.7 years) than those who were not transplanted.

We investigated the feasibility of mobilizing Philadelphia chromosome negative blood stem cells with intensive chemotherapy and lenograstim in CML patients. Twenty-three patients (62%) were successfully mobilized. Twenty-one of these patients underwent autologous stem cell transplantation later on, with a 5-year overall survival at 68%.

Fluorometric Microculture Cytotoxicity Assay was used to analyze 32 tumor cell samples from CML patients, (26 chronic phase and 6 blast crisis). Imatinib showed a higher in vitro activity and more positive drug interactions in cells from blast crisis than from chronic phase. Interferon, daunorubicin and arsenic trioxide had the greatest benefit from a combination with imatinib.

Microarray-based gene expression analyses were performed on diagnostic CML samples prior to interferon treatment. We identified six genes that were differentially expressed in responders and non-responders to interferon. It might prove possible to use gene expression analysis to predict future response to interferon.

Orientadores: Carmino Antonio de Souza, Fernando Ferreira Costa
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: A elucidação dos mecanismos moleculares envolvidos na fisiopatologia e tratamento das doenças hematológicas, bem como no entendimento do perfil de expressão gênica das linhagens celulares leucêmicas, tem sido objeto de numerosas investigações. Com o uso da técnica SSH (Subtractive Supression Hybridization ou Biblioteca Subtrativa Supressiva) foi possível identificar importantes genes que se encontram diferencialmente expressos em granulócitos de pacientes com Leucemia Mielóide Crônica e indivíduos controle. Foram encontrados 39 genes superexpressos e 173 com expressão diminuída em células de LMC. Ao relacionar esses genes com vias metabólicas que estão reguladas positiva (expressão aumentada) ou negativamente (expressão diminuída) nessa doença, verificou-se que a maioria dos genes estavam relacionados com a regulação de NF-kB, AKT, o Interferon e a IL-4 em células de controle. Entre os genes superexpressos encontrados na LMC, foi observado o SEPT5, RUNX1, MIER1, KPNA6 e FLT3, enquanto PAN3, TOB1 e ITCH estavam com expressão diminuída nessa doença em comparação com indivíduos controle. O TOB1 se mostrou promissor, uma vez que é um gene supressor tumoral, pode estar envolvido na proliferação de células leucêmicas e interage com vários outros genes encontrados neste estudo. Assim, devido à grande heterogeneidade de funções relacionadas com a expressão desse gene, foi investigada a relação entre a expressão de mRNA e as respostas aos ITK's na LMC. A avaliação foi realizada por PCR em tempo real em doentes com CCgR, PCgR, MINCgR e NOCgR após tratamento com TKI's e os resultados foram comparados com a expressão em granulócitos de indivíduos controle, observando que os pacientes NOCgR têm uma expressão de TOB1 significativamente inferior em comparação com doadores saudáveis e pacientes que alcançaram RCgC. Ao comparar pacientes não resistentes e resistentes a diferença foi significativa. Esses resultados sugerem que a expressão diminuída de TOB1 em pacientes NOCgR pode ser indicativo de desregulação da apoptose e de vias de sinalização importantes nessa doença incluindo a via da AKT, conduzindo assim a resistência a ITK's nesses pacientes. Outro objetivo deste trabalho foi caracterizar a função dos genes TOB1 e SEPT5 nos processos celulares e vias de sinalização de apoptose, proliferação, migração e ciclo celular em linhagens celulares leucêmicas. Ao realizar o silenciamento desses genes (utilizando partículas lentivirais) notou-se que o silenciamento de TOB1, como já descrito na literatura em outras doenças, interfere na proliferação celular, clonogenicidade, apoptose, ciclo celular e expressão de proteínas importantes da cascata de sinalização, o que salienta sua importância em células BCR-ABL positivas. Já o gene SEPT5 ao ser silenciado leva a algumas alterações como a apoptose e ciclo celular. Nesse contexto, o silenciamento destes genes chama atenção para as possibilidades de controle da proliferação celular, apoptose, ciclo celular e clonogenicidade em células BCR-ABL positivas. Foi realizada a avaliação da expressão desses genes em células de sangue periférico e medula óssea de pacientes com LMC e indivíduos controles, linhagens celulares de câncer humano e linhagens de murino. Os resultados mostraram um aumento significativo na expressão do gene SEPT5 em todos os tipos celulares analisados em pacientes com LMC. O mesmo padrão foi observado em células de murino que possuem a mutação T315I e em células humanas que possuem a translocação t(9;22) e estão relacionadas com a fase blástica da doença [K562, KU812, NALM]. Quando avaliada a expressão do gene TOB1 nota-se diminuição em todos os tipos celulares analisados em pacientes com LMC e em células BaF3T315I. Também foi observada uma baixa expressão em células com a t(9;22) e estão relacionadas com a fase blástica da doença[K562, KU812, NALM] quando comparadas a expressão em medula óssea controle. Outro resultado interessante foi obtido a partir da análise de adesão celular em granulócitos de pacientes com LMC e controles, evidenciando a diminuição da adesão em granulócitos de pacientes com LMC em relação aos de controles, levando a hipótese de que essa alteração nas propriedades adesivas dos granulócitos em pacientes com LMC pode estar diretamente ligada à liberação de células jovens pela matriz da medula óssea. A criação de estratégias que levam ao melhor entendimento da fisiopatologia da doença e avanço no tratamento da LMC deve ser focada em vários genes alvos e não apenas no BCR-ABL, pois no desenvolvimento da LMC há a ativação e desativação de várias vias de sinalização celular. Os resultados deste estudo podem ajudar na melhor compreensão dessas vias e também para identificar outros genes e vias úteis para a melhora no manejo terapêutico e criação de novas drogas para o tratamento dessa doença
Abstract: The elucidation of the molecular mechanisms involved in the pathophysiology and treatment of blood disorders, as well as the understanding of genes expression profiling of leukemia cell lines has been the focus of numerous investigations. The use of the SSH (Suppression Subtractive Hybridization Library or Suppression Subtractive) technique made available the identification of important genes which are differentially expressed in granulocytes from patients with chronic myeloid leukemia (CML) and healthy controls. 39 genes overexpressed were found, and 173 with decreased expression in CML cells. When correlating these genes with metabolic pathways that are regulated positively (increased expression) or negatively (decreased expression) in this disease, it was found that most of the genes were related to the regulation of NF-kB, AKT, Interferon and IL-4 in control cells. The following genes were found overexpressed in CML: SEPT5, RUNX1, MIER1, KPNA6 and FLT3, while PAN3, TOB1 and ITCH were found with decreased expression in this disease compared with controls. The TOB1 gene showed promising since it is a tumor suppressor, may be involved in the proliferation of leukaemic cells and interacts with several others genes found in this study. Thus, due to the great heterogeneity of functions related to this gene, was investigated the relationship between mRNA expression and TKI's responses. The evaluation was performed by real time PCR in patients with CCgR, PCgR, MINCgR and NOCgR after treatment with TKI and healthy controls. Was observed that patients that have NOCgR, the TOB1 expression is significantly lower compared with healthy donors and patients who achieved CCgR. When comparing non-resistant and resistant patients the difference also was significant. These results suggest that reduced expression of TOB1 in NOCgR patients may indicate apoptosis deregulation and changes in important signaling pathways of CML including the Akt pathway, thereby leading to TKI's resistance of these patients. Another aim of this work was to characterize the function of TOB1 and SEPT5 in cellular processes and signaling pathways of apoptosis, proliferation, migration and cell cycle in leukemic cell lines. After the silencing of these genes (using lentiviral particles), was noted that the silencing TOB1 - as described in the literature for other diseases - interferes in cell proliferation, clonogenicity, apoptosis, cell cycle and in expression of important proteins at signaling cascade, which emphasizes its importance in BCR-ABL positive cells. The SEPT5 silencing leads to some changes such as apoptosis and cell cycle. In this context, the silencing of these genes leads to attention of possibilities of control of cell proliferation, apoptosis, cell cycle and cell clonogenicity in BCR-ABL positive cells. Was assessed the expression of these genes in cells from peripheral blood and bone marrow of CML patients and controls, as well in human and murine cell lines. Results showed a significant increase in SEPT5 gene expression in patients with CML in all cell types evaluated. The same profile was observed in murine cells BAF3T315I and in human cells having the translocation t (9; 22) been related to blast crisis [K562, KU812, NALM]. When measuring expression of TOB1, was noted decrease in all cell types studied in CML patients and cells BaF3T315I. Another interesting result was obtained from the analysis of cell adhesion at granulocytes in CML patients and controls which showed decreased adhesion of granulocytes in CML patients compared to controls, leading to the hypothesis that the change in adhesive properties at CML can be directly linked to the release of young cells by bone marrow. The creation of strategies that lead to better understanding of the pathophysiology of the disease and advance in the treatment of CML should be focused on several target genes and not only in BCR-ABL, since in the development of CML there is an activation and deactivation of multiple signaling pathways . The results of this study may help to better understand these pathways and also to identify other genes and pathways useful for improving the management and development of new therapeutic drugs to treat this disease
Doutorado
Clinica Medica
Doutora em Clínica Médica

Bcr-abl expression being associated with anti-apoptotic signaling and expression of DNA repair enzymes, we surmised that single molecules capable of blocking abl tyrosine kinase (TK) function and damaging DNA should lead to compounds with potency superior to that of GleevecRTM. To this end, we designed novel agents termed "combi-molecules" programmed to not only behave as bcr-abl inhibitors on their own, but also to further degrade to another inhibitor and a DNA damaging species. The released inhibitor was designed to sustain bcr-abl inhibition following degradation of the combi-molecule and the DNA damaging species to activate pathways leading to apoptosis. To model this strategy termed "combi-targeting", we synthesized ZRCM5 (a monoalkyltriazene) that showed antiproliferative activity superior to that of the classical DNA damaging agent TemodalRTM, but not to that of Gleevec RTM. This result was imputed to the rather weak bcr-abl inhibitory activity of ZRCM5 and its strong DNA damaging property. Another prototype designed to contain an aniline mustard moiety (AK04) was a strong bcr-abl inhibitor but a poor DNA alkylating agent. Its cytotoxic activity was again stronger than that of the clinical alkylating agent chlorambucil but inferior to that of GleevecRTM. Further chemical studies directed at structural modification of the benzamide moiety led to the synthesis of ZRF1 with strong potency against bcr-abl TK and strong DNA damaging property. This novel optimized combi-molecule showed a 1.6-3-fold greater potency than GleevecRTM against bcr-abl expressing cells. Further investigation with ZRF1, showed that its cytotoxic potency was dependent on the p53 wild-type status of the cells. In cells expressing wild-type p53, p21 transactivation was associated with cell cycle arrest and that of Bax with apoptosis. In addition to, the pro-apoptotic effect of bcr-abl inhibition, these multiple mechanisms of action may synergistically enhance the cytotoxic potency of ZRF1 in p53 wild-type cells. The study conclusively demonstrated that p53 is a major determinant for the cytotoxic advantage of the novel combi-molecular approach in chronic myelogenous leukemia (CML), a disease in which 70-85% of all cases express wild-type p53.

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

A introdução do Mesilato de Imatinibe (MI) como primeiro inibidor específico de BCR-ABL1 na prática clínica revolucionou o tratamento da Leucemia Mieloide Crônica (LMC), tornando-se a terapia padrão para o tratamento desta doença. Porém, cerca de 30% dos pacientes com LMC não respondem à terapia com MI e um número substancial destes casos de resistência não tem causa conhecida. O MI interage com transportadores de membrana ABCG2 e SLCO1A2. Este estudo teve como objetivo investigar a relação da expressão gênica de ABCG2 e de SLCO1A2 com marcadores de resposta ao tratamento com MI, em indivíduos com LMC e avaliar a influência dos polimorfismos ABCG2 c.421C>A e ABCG2 c.-19-99G>A na resposta ao MI. Foram incluídos 118 pacientes com LMC os quais foram classificados em dois grupos: Grupo Respondedor, constituído por 70 pacientes com resposta citogenética completa com a dose padrão de MI (400 mg/dia) por até 18 meses e, Grupo não Respondedor constituído por 48 pacientes sem resposta citogenética completa à dose inicial de 400 mg/dia de MI ou que perderam esta resposta ao longo do tratamento e foram reescalonados para doses de 600 ou 800 mg/dia. A resposta ao tratamento foi avaliada segundo os critérios da European LeukemiaNet. Foram excluídos pacientes com alterações citogenéticas diferentes do cromossomo Ph e mutações no gene BCR-ABL1. Amostras de sangue periférico foram utilizadas para: extração do RNA total para quantificação dos transcritos BCR-ABL1 e expressão gênica de ABCG2 e SLCO1A2; extração de DNA e análise citogenética de banda G. A expressão do gene ABCG2 e SLCO1A2 e as análises dos polimorfismos foram feitas por PCR em tempo real. A expressão de ABCG2 foi maior no grupo de não respondedores ao MI (P=0,028). Este resultado foi influenciado pelos pacientes com resistência primária (N= 34 P=0,029), mas não pelos que apresentaram resistência secundária (N=14 P=0,249) quando comparado com respondedores (N=70). A elevada expressão do gene ABCG2 foi também associada àqueles pacientes que não tiveram resposta molecular maior (número de transcritos BCR-ABL1 ≤ 0,1%) (P=0,027) quando todos os pacientes foram analisados. O gene estudado não foi associado com a resposta molecular completa (número de transcritos BCR-ABL1 ≤ 0,032%). Com relação ao gene SLCO1A2 não foi possível determinar sua expressão devido à baixa concentração do RNA obtido. Os polimorfismos c.421C>A e c.-19-99G>A não foram associados com a expressão do gene ABCG2 e a resposta ao MI. A RMC (no grupo de respondedores) foi associada com o genótipo 421CC e houve tendência a maior frequencia de portadores do genótipo -19-99GG neste mesmo grupo. Portadores do genótipo -19-99AA apresentaram tendência ao risco de ter LMC. Os resultados deste estudo nos permitem concluir que a maior expressão de ABCG2 está associada com a resistência primária ao MI podendo então ser um mediador da resistência ao MI. Os polimorfismos do gene ABCG2 não influenciaram na expressão gênica de ABCG2, mas impactaram na RMC no grupo respondedor ao MI.
The introduction of imatinib mesylate (IM) as the first specific inhibitor of BCR-ABL1 in clinical practice has revolutionized the treatment of chronic myeloid leukemia (CML), becoming the standard therapy for this disease. However, about 20% of CML patients do not respond to therapy with IM and a substantial number of these cases of resistance have no known cause. The MI interacts with membrane transporters ABCG2 and SLCO1A2. The aim of this study was to investigate the relationship of ABCG2 and SLCO1A2 gene expression with markers of response to MI in individuals with CML and evaluate the influence of polymorphisms ABCG2 c.421C> A and c. ABCG2-19-99G> A in response to the MI. One hundred and eighteen patients in chronic phase of CML were studied and classified in two groups: Responder Group comprised 70 patients who had a complete cytogenetic response within 18 months of treatment. The non-responder group comprised 48 patients who did not have a complete cytogenetic response with the initial dose (400 mg/day) of IM or who relapsed during treatment and were submitted to higher doses of 600 or 800 mg/day. Criteria of failed response to treatment were established by European LeukemiaNet. Patients with cytogenetic patterns other than the Philadelphia chromosome and patients with mutations in the BCR-ABL1 gene were excluded from this study. Blood samples were obtained for: total RNA extraction for quantification of BCR-ABL1 and gene expression of ABCG2 and SLCO1A2; genomic DNA extraction and band G cytogenetic analysis. The gene expression and the analysis of the polymorphisms were performed by real time PCR. Expression of ABCG2 in non-responder group was higher than in responder group (P=0.028). This result was influenced by patients with primary resistance (n= 34 P=0.029) but not secondary resistance (n=14 P=0.249) when compared with responders (n=70). The higher expression of ABCG2 gene was also associated with those patients who had major molecular response (number of BCR-ABL1 . 0.1%) (P=0.027) when all patients were analyzed. The studied gene was not associated with the complete molecular response (number of BCR-ABL1 .0.0032). Regarding to the gene SLCO1A2 was not possible to determine its expression due to low concentration of RNA obtained. The c.421C>A e c.-19-99G>A were not associated neither with the ABCG2 gene expression and MI response. CMR in responders group was associated with the 421CC genotype ant there was a trend for higher frequency of carriers of genotype -19-99GG in the same group. Carriers of 19-99AA genotype tended to the risk of having CML. The results of this study allow us to conclude that the higher expression of ABCG2 is associated with primary resistance to IM and may be a mediator of resistance to IM. The ABCG2 polymorphisms did not influence the gene expression of ABCG2 but impacted in CMR of the responders to IM.

A leucemia mieloide crônica (LMC) é uma expansão clonal da célula progenitora hematopoiética, traduzindo-se por hiperplasia mielóide, leucocitose, neutrofilia, basofilia e esplenomegalia. O cromossomo Filadélfia é característico da doença, sendo produto da translocação t(9;22) (q34;q11), resultando na fusão dos genes ABL e BCR. Esta fusão gera um gene híbrido que produz uma proteína com elevada atividade tirosinoquinase que tem um papel central da patogenia da LMC. O mesilato de imatinibe (MI) é um derivado da fenilaminopirimidina que inibe a proteína-tirosina quinase ABL in vitro e in vivo. O MI interage com transportadores de membrana de efluxo, como o ATP binding cassette B1 (ABCB1). Polimorfismos no gene ABCB1 têm sido associados com alteração na sua funcionalidade e podem estar envolvidos na resposta ao tratamento farmacológico. Este estudo tem por objetivo investigar a relação dos polimorfismos C1236T, C3435T e G2677T/A no gene ABCB1 com marcadores de resposta ao tratamento com MI, em indivíduos com LMC, e determinar os fatores de predisposição de resposta ao MI. Foram incluídos 118 pacientes portadores de LMC. Foram constituídos dois grupos: Grupo 1 com 70 pacientes com resposta citogenética completa com a dose padrão de MI (400 mg/dia de MI) por até 18 meses e, Grupo 2 com 48 pacientes sem resposta citogenética completa com a dose inicial de 400 mg/dia de MI ou que perderam esta resposta ao longo do tratamento . Amostras de sangue foram obtidas para: quantificação de BCR-ABL1, extração de DNA genômico e análise citogenética de banda G. As análises dos polimorfismos foram realizadas por PCR-RFLP. A resposta ao tratamento foi avaliada segundo os critérios da European LeukemiaNet. A distribuição da frequência dos genótipos dos polimorfismos C1236T, C3435T e G2677T/A foi similar nos dois gêneros e entre brancos e não brancos. Não houve influência dos polimorfismos estudados no risco de desenvolvimento da LMC e na resposta ao MI. O haplótipo ABCB1 1236CT/2677GT/3435CT (para os polimorfismos C1236T/G2677T/C3435T no gene ABCB1) foi encontrado em 51,7% dos pacientes com resposta molecular maior (P=0,010). Houve tendência a maior frequência de pacientes portadores de genótipos 1236 CT e TT no grupo de respondedores (86,7%) quando foi analisada a resposta molecular completa (p=0,069). O mesmo aconteceu no grupo de não respondedores quando foi considerado o polimorfismo C1236T. Houve tendência a maior frequência de resposta molecular completa em portadores de genótipo 2677 GT+TT+TA nos dois grupos (respondedores P=0,074 e não respondedores P=0,076). Em conclusão, os genótipos e haplótipos para os polimorfismos ABCB1 C1236T, C3435T e G2677T/A estão associados com a resposta molecular em portadores de LMC respondedores ao tratamento com MI.
The chronic myeloid leukemia (CML) is a clonal expansion of the hematopoietic progenitor cell, representing myeloid hyperplasia, leukocytosis, neutrophilia, basophilia and splenomegaly. The Philadelphia chromosome is peculiar on the disease, being the result of the translocation t(9; 22) (q34; q11), leading on the fusion of the ABL and BCR genes. This merger creates a hybrid gene that produces a protein with high activity of tyrosine kinase that is the main pathogenesis of CML. The Imatinib mesylate (IM) is a fenilaminopirimidine derivative which inhibits the ABL protein-tyrosine kinase in vitro and in vivo. The MI interacts with membrane efflux transporters, such as ATP binding cassette B1 (ABCB1). Polymorphisms in the ABCB1 gene have been associated with changes in its functionality and may be involved on the response to drug treatment. This study aims to investigate the relationship of C1236T, C3435T and G2677T / A polymorphisms in ABCB1 gene with response markers for MI treatment in individuals with CML, and to determine the predisposing factors of response to MI. 118 patients with CML were included and divided in two groups. Group 1: 70 patients with complete cytogenetic response and a standard dose of IM (400 mg / day IM) for up to 18 months. Group 2: 48 patients without a complete cytogenetic response and initial dose of 400 mg / day IM or whith response lost throughout the treatment. Blood samples were obtained for: quantification of BCR-ABL1, genomic DNA extraction and band G cytogenetic analysis. The analysis of the polymorphisms were performed by PCR-RFLP. The treatment response was evaluated according to European LeukemiaNet criteria. The frequency distribution of genotypes of C1236T, C3435T and G2677T / A polymorphisms were similar in both sexes and between whites and nonwhites. The polymorphisms studied had no influence on the CML development or MI response. The haplotype ABCB1 1236CT/2677GT/3435CT (for C1236T/G2677T/C3435T polymorphisms in the ABCB1) was found in 51.7% patients with major molecular response (P = 0.010). There was a tendency for higher frequency of patients with 1236 CT and TT genotypes in the responders group (86.7%) when the molecular response was analyzed (p = 0.069). The same happened in the nonresponders group when the C1236T polymorphism was considered. There was a tendency for a higher frequency of complete molecular response in patients with 2677 GT + TT + TA genotype in both groups (responders P = 0.074 and nonresponders P = 0.076). In conclusion, genotypes and haplotypes for ABCB1 C1236T, C3435T and G2677T / A polymorphisms are associated with molecular response in patients with CML that respond to MI treatment.

Orientador: Katia Borgia Barbosa Pagnano
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: A Leucemia Mielóide Crônica (LMC) é uma neoplasia mieloproliferativa crônica caracterizada pela presença do cromossomo Filadélfia (Ph) e produção da fusão proteica BCR-ABL que possui atividade tirosina quinase. O tratamento da LMC é realizado com inibidores de tirosina quinase (TKIs) e apesar das altas taxas de respostas obtidas com imatinibe, alguns pacientes são resistentes ou intolerantes ao tratamento, sendo necessário a troca para um TKI de segunda geração (nilotinibe ou dasatinibe). O monitoramento das respostas obtidas ao longo do tratamento permite identificar os pacientes que estão em um "estado seguro" (resposta ótima) e os que podem falhar ao tratamento. Os mecanismos de resistência ao tratamento são multifatoriais e a identificação desses mecanismos pode contribuir para o desenvolvimento de novas estratégias para o tratamento dos casos resistentes. Em um trabalho anterior do nosso grupo foram identificados diversos genes e RNAs longos não codificantes diferencialmente expressos em pacientes responsivos e não responsivos ao dasatinibe, entre eles os genes ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP e ncSLC44A2. O objetivo desse trabalho foi avaliar a resposta molecular em pacientes com LMC em uso de inibidores de tirosina quinase de segunda geração (dasatinibe ou nilotinibe) após falha ou intolerância a um ou dois TKIs e avaliar a expressão dos genes ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP e ncSLC44A2 em pacientes responsivos e resistentes ao dasatinibe. A metodologia utilizada para avaliação dos níveis de trancritos BCR-ABL e da expressão gênica foi o PCR quantitativo em tempo real. A pesquisa de mutações no domínio quinase do BCR-ABL foi realizada nos casos resistentes, através da técnica de sequenciamento direto. Setenta e um pacientes tratados com dasatinibe ou nilotinibe após falha ou intolerância ao imatinibe foram avaliados quanto à resposta molecular. Sessenta e sete porcento, 43% e 33% dos pacientes em fase crônica (FC), acelerada (FA) e crise blástica (CB) obtiveram resposta molecular maior (RMM), respectivamente, ao longo do tratamento. Os pacientes com respostas moleculares precoces (transcritos BCR-ABL <10% aos 3 meses e <1% aos 6 meses) apresentaram maiores SLP e SLE do que os casos que não alcançaram esses níveis de transcritos BCR-ABL aos 3 e/ou aos 6 meses. A avaliação molecular aos 3 meses e aos 6 meses permitiu a melhor identificação dos pacientes com pior prognóstico. Foram também avaliados 25 pacientes tratados com dasatinibe/nilotinibe após falha ou intolerância a dois TKIs. RMM foi obtida em somente 24% dos casos (em FC, um paciente em FA). As taxas de SG e SLP em 5 anos para pacientes em FC foram de 94% e 94%, respectivamente. Poucos pacientes alcançam respostas e essas respostas não são duráveis. Embora seja uma opção para pacientes não elegíveis ao TMO, é necessário o desenvolvimento de um tratamento mais eficaz para esses pacientes. Para avaliação da expressão dos genes ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP e ncSLC44A2 foram utilizadas amostras de 9 pacientes ao diagnóstico (sem tratamento prévio), 39 pacientes tratados com dasatinibe (25 responsivos com RCC e 14 resistentes) e 13 doadores saudáves. Não houve diferença de expressão do gene ncSLC44A2 entre os grupos avaliados. Os genes ALOX15B e ncMYLIP estavam hipoexpressos em pacientes com LMC ao diagnóstico em relação aos pacientes com LMC tratados com dasatinibe e ao grupo controle. O gene ncFOXO3A apresentou expressão diminuída em pacientes com LMC ao diagnóstico em relação aos pacientes tratados com dasatinibe. O genes ABCF2 e PAWR estavam hipoexpressos em pacientes ao diagnóstico e nos pacientes tratados com dasatinibe em relação ao grupo controle. Além disso, o gene PAWR estava pouco expresso em pacientes resistentes ao dasatinibe em relação aos pacientes responsivos. Portanto, os genes ABCF2, ALOX15B, PAWR, ncMYLIP e ncFOXO3A foram encontrados com expressão alterada nos grupos estudados e podem estar associados a mecanismos importantes relacionados ao desenvolvimento e resistência da LMC, o que deve ser elucidado em estudos prospectivos
Abstract: Chronic myeloid leukemia (CML) is a chronic myeloproliferative neoplasm characterized by the presence of Philadelphia chromosome (Ph) and production of BCR-ABL fusion protein that has tyrosine kinase activity. Currently, the treatment of CML is accomplished with tyrosine kinase inhibitors (TKIs). Despite the high rates of responses obtained with imatinib, some patients are resistant or intolerant to treatment and need to switch to second generation TKIs (dasatinib or nilotinib). Monitoring responses during treatment allows the identification of patients who are in a "safe haven" (optimal response) and patients who may fail to treatment. Mechanisms of resistance to treatment are multifactorial and identification of these mechanisms may contribute to the development of new strategies for treatment of resistant cases. In a previous report of our group were identified several genes and long non-coding RNAs differentially expressed in CML patients responders and non-responders to dasatinib, including ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP and ncSLC44A2 genes. The aim of this study was to evaluate molecular responses in CML patients treated with second generation TKIs (dasatinib or nilotinib) after failure or intolerance to one or two TKIs and to evaluate the expression of ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP and ncSLC44A2 genes in patients responsive and resistant to dasatinib. The methodology used to evaluate BCR-ABL transcript leves and the gene expression was quantitative real time PCR. BCR-ABL kinase domain mutations analysis was performed in resistant cases by direct sequencing. Seventy-one patients treated with dasatinib/nilotinib after failure or intolerance with imatinib were evaluated according to molecular responses. Sixty-seven percent, 43% and 37% of chronic phase (CP), accelerated phase (AP) and blast crisis (BC) CML patients achieved major molecular response (MMR), respectively, during treatment. Patients with early molecular responses (BCR-ABL1<10% at 3 months and <1% at 6 months) had superior PFS and EFS than patients that not achieved these landmarks. The evaluation at 3 and 6 months allows better identication of patients with worse prognosis. We analyzed molecular responses in 25 patients treated with dasatinib/nilotinib after failure or intolerance with two TKIs. MMR was achieved in 24% of cases (all in CP, one in AP). Five-year OS and PFS rates for CP-CML patients were 94% and 94%, respectively. Few patients achieved responses and these responses are not durable. Although, dasatinib/nilotinib had been options for patients not elegible for bone morrow transplantation, its necessary the development of a treatment more effective to these patients. To evaluate the expression of ABCF2, ALOX15B, PAWR, ncFOXO3A, ncMYLIP e ncSLC44A2 genes was used samples of 9 patients newly diagnosed (without treatment), 39 patients treated with dasatinib (25 responsives with CCyR and 14 resistant) and 13 healthy donors. There¿s no difference of ncSLC44A2 gene expression between the groups analized. ALOX15B and ncMYLIP genes were down-regulated in CML patients newly diagnosed in comparison with CML patients treated with dasatinib and control group. ncFOXO3A gene presented decreased expression in CML patients at diagnosis in comparison with patients treated with dasatinib. ABCF2 and PAWR genes were down-regulated in CMl patients newly diagnosed and in CML patients treated with dasatinib in comparison with control group. Moreover, PAWR gene was down-regulated in CML patient¿s resistants to dasatinib in comparison with responsives. ABCF2, ALOX15B, PAWR, ncMYLIP and ncFOXO3A were found with altered expression between the groups evaluated and may be associated with mechanisms related to the development and resistance of CML, which should be elucidated in prospective studies
Mestrado
Clinica Medica
Mestra em Ciências

O STI (imatinib, Glivec) é um inibidor da tirosina quinase BCR-ABL, responsável pela patogênese da leucemia mielóide crônica (LMC). Um total de 110 pacientes com LMC na fase crônica (FC) que falharam ou foram intolerantes ao tratamento com interferon, fase acelerada (FA) e crise blástica (CB) foram tratados com imatinibe entre dezembro de 2000 e setembro de 2003. Resposta hematológica completa e resposta citogenética maior foram observadas em 95,9% e 69,4% respectivamente em pacientes em FC e 93,2% e 36,4% em FA. Apenas 2 pacientes na CB estão vivos. O imatinib foi bem tolerado com altas taxas de resposta.
STI571 (Imatinib, Glevec) is an inhibitor of the Bcr-Abl tyrosine kinase that is central to the pathogenesis of chronic myelogenous leukemia (CML). A total of 110 patients with CML chronic phase (CP) who failed or were intolerant to interferon, accelerated phase (AP) and blastic crisis (BC) were treated with imatinib from December 2000 until September 2003. Complete hematologic response and major cytogenetic response were observed in 95,9% and 69,4% respectively of patients in CP and 93,2% and 36,4% in AP. Only 2 patients are alive in BC. Imatinib is well tolerated with high rates of response

A leucemia mielóide crônica (LMC) é uma doença mieloproliferativa, resultante da expansão clonal da célula-tronco hematopoética pluripotente. A fisiopatologia da LMC está associada a uma translocação entre os braços longos dos cromossomos 9 e 22, o que promove o aparecimento do neogene bcr-abl, cujo gene codifica uma proteína denominada Bcr-Abl. A oncoproteína Bcr-Abl possui atividade tirosina-quinase constitutiva que é a responsável pelo fenótipo maligno da célula, incluindo resistência à apoptose. O tratamento da LMC pode ser realizado com hidroxiuréia, IFN- associado à citarabina, inibidores de TK (mesilato de imatinibe e dasatinibe) e transplante de medula óssea. O tratamento de escolha para pacientes com LMC na fase crônica é o inibidor de tirosina-quinase mesilato de imatinibe e para os refratários utiliza-se o dasatinibe. Apesar do conhecimento acerca do mecanismo de ação dos inibidores de TK, pouco se sabe sobre seu efeito na maquinaria apoptótica. Sendo assim, no presente trabalho foi detectada a expressão dos genes e proteínas anti- (A1, Bcl-2, Bcl-Xl, Bcl-W, C-Flip, Ciap-1, Ciap-2 e Mcl-1) e pró-apoptóticos (Bad, Bak, Bax, Bcl-Xs, Bid, Bik, Bimel, Bmf, Bok, Fas, Fasl, Noxa e Puma) em células mononucleares de 32 indivíduos saudáveis e 26 pacientes com LMC antes e após 12 meses da terapia com mesilato de imatinibe e dasatinibe. Dentre os 26 pacientes avaliados, 13 eram do sexo feminino e 13 do sexo masculino, três eram negros, um amarelo e 22 brancos, com idade média de 48 anos (faixa etária de 25 a 77 anos). O grupo controle foi composto por 32 indivíduos, 16 do sexo feminino e 16 do sexo masculino, 26 eram brancos, quatro negros e dois amarelos, com idade média de 45 anos (idade de 23 a 77 anos). O isolamento das células mononucleares foi realizado pelo método de Ficoll-Hypaque, a determinação da expressão gênica por PCR em tempo real e a protéica por western-blot. Os resultados foram expressos em unidade relativa de expressão (U.R.E.), comparados entre os diferentes grupos (controle e pacientes pré- e pós-tratamento), associados à resposta aos medicamentos e correlacionados ao índice de prognóstico de SOKAL. Na comparação dos dados de expressão gênica entre pacientes e controles, verificou-se que os pacientes apresentaram maior expressão dos genes bcl-xL, c-flip, mcl-1 e fas e níveis reduzidos de bik. O mesilato de imatinibe modulou significativamente a transcrição dos genes bcl-xL, bok, mcl-1 e noxa, enquanto que o dasatinibe agiu sobre a expressão dos genes a1, bmf, c-flip, ciap-1, ciap-2 e mcl-1. Os pacientes refratários ao mesilato de imatinibe apresentaram níveis elevados de expressão de a1 e c-flip e reduzida expressão de bcl-2, ciap-2, bak, bax, bid e fasl em relação aos pacientes em remissão. A expressão protéica refletiu os dados da quantificação do RNAm dos genes. Os dados da presente investigação indicam que as células mononucleares dos pacientes com LMC apresentam desregulação do processo de apoptose celular. Essa alteração pode ser parcialmente associada ao fenótipo de resistência das células leucêmicas Bcr-Abl+ à apoptose e ausência de resposta aos inibidores de TK. Os dados revelam ainda que os inibidores de tirosina-quinase interferem na transcrição e tradução das moléculas envolvidas na regulação do processo de apoptose.
Chronic myeloid leukemia (CML) is a myeloproliferative disease resultant of a clonal expansion of pluripotent hematopoietic stem cells. The CML physiopathology is associated with a translocation between chromosomes 9 and 22 long arms, promoting the formation of a bcr-abl neogene, which codifies the Bcr-Abl protein. The Bcr-Abl oncoprotein presents tyrosine-kinase activity that is responsible for the malign phenotype which includes apoptosis resistance. CML treatment may be performed with hydroxyurea, IFN- plus cytarabine, tyrosine-kinase inhibitors (imatinib mesylate and dasatinib) and bone marrow transplantation. The standard treatment for CML patients in chronic phase is the tyrosine-kinase inhibitor imatinib mesylate (IM) and for IM-refractory patients dasatinibe is employed. Despite of the knowledge related to the mechanism of action of tyrosine-kinase inhibitors, little is known about its effects on the apoptosis machinery. In this work we characterized both the mRNA and protein patterns of expression of the anti- (A1, Bcl-2, Bcl-Xl, Bcl-W, C-Flip, Ciap-1, Ciap-2 e Mcl-1) and pro-apoptotic (Bad, Bak, Bax, Bcl-Xs, Bid, Bik, Bimel, Bmf, Bok, Fas, Fasl, Noxa e Puma) regulators in peripheral blood mononuclear cells (PBMC) from 32 healthy individual and 26 CML patients before and after 12 months of imatinib mesylate and dasatinibe therapy. Thirteen patients were female and thirteen were male, three were black, one was japanese and 22 were white, the mean age was 48 years (varying from 25 to 77 years). The control group was composed of 32 individuals, 16 were female and 16 were male, 26 were white, four black and two japanese, the mean age was 45 years (varying from 23 to 77 years). PBMC isolation was performed by Ficoll-Hypaque, gene expression was assessed by real time PCR and protein expression was carried out by western-blot methodology. Results were given by the relative expression, after comparison between the different groups (control and patients before and after treatment), associated with drug response and related to Sokal index. The comparison of gene expression profiles between patients and controls showed that CML patients present increased levels of bcl-xL, c-flip, mcl-1 and fas expression and reduced levels of bik gene expression. The imatinib mesylate significantly modulated the transcription of bcl-xL, bok, mcl-1 and noxa, whereas dasatinib affected the expression of a1, bmf, c-flip, ciap-1, ciap-2 and mcl-1. MI-refractory patients present higher levels of a1 and c-flip and lower levels of bcl-2, ciap-2, bak, bax, bid and fasl when compared to patients who achieved complete cytogenetic response. Overall, the patterns of protein expression agree with the profiles of mRNA expression. Taken together, the results described in this investigation indicate that PBMC from CML patients present deregulation in cell death pathways. These alterations could partly account for the apoptosis resistance phenotype observed in Bcr-Abl+ leukemic cells and for lack of response to tyrosine kinase inhibitors. Furthermore, our data also reveal that tyrosine kinase inhibitors interfere in the transcription and translation of molecules that regulate the apoptosis process.

Unter Verwendung eines mathematischen Hämatopoese-Modells werden verschiedene Fragen adressiert, die im Zusammenhang mit einer möglichen Optimierung der gegenwärtigen Therapie chronischer myeloischer Leukämie (CML) stehen. Es handelt sich um ein agentenbasiertes Modell, das heißt, jede Zelle wird als einzelnes Objekt repräsentiert und gemäß festgelegter Regeln im Computer simuliert. Es werden proliferative von ruhenden Stammzellen unterschieden, wobei sich der Proliferationszustand reversibel ändern kann. Das Modell basiert auf der Annahme, dass sich normale und maligne Stammzellen in einem Wettbewerb um gemeinsame Ressourcen befinden, wobei der CML-Klon einen kompetitiven Vorteil besitzt. Es ist ungeklärt, ob Tyrosinkinaseinhibitoren wie Imatinib (IM) in der Lage sind, die Erkrankung zu heilen. Es gibt Evidenz, dass residuale leukämische Stammzellen im Knochenmark persistieren, welche in einem Ruhezustand (G0-Phase des Zellzyklus) von IM nicht eradiziert werden können. Proliferativ aktive Zellen sind der IM-Wirkung hingegen ausgesetzt. Das Modell sagt voraus, unter welchen Bedingungen eine Kombinationsstrategie von IM mit stammzellaktivierenden Substanzen Synergieeffekte hervorbringen könnte. Ein verwandtes Problem ist die Frage, in welchen Fällen nach Reduktion der Tumorlast auf ein mittels hochsensitiver Messmethoden undetektierbares Niveau ein Therapieabbruch gerechtfertigt ist. Basierend auf dem dynamischen Modell wird in dieser Arbeit ein Prädiktor vorgeschlagen, der vorhersagt, ob ein Patient nach Abbruch der Therapie einen molekularen Rückfall zu erwarten hat. Zusätzlich wird approximativ ein modellunabhängiger Prädiktor angegeben, der die Vorhersage nur auf Basis klinisch messbarer Größen gestattet.

Orientador: Fernando Ferreira Costa
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: Câncer é o resultado de anomalias no genoma acumuladas ao longo do tempo e corresponde a doença genética mais freqüente na população humana. Os últimos anos têm presenciado enormes avanços tecnológicos que facilitaram o desenvolvimento de técnicas para análise em larga escala do conjunto dos genes expressos nos diferentes tecidos, sendo responsável pela explosão do conhecimento em medicina molecular. No presente trabalho avaliamos o transcriptoma da leucemia mielóide crônica através da técnica de ORESTES (Open Reading Frame Expressed Sequence Tags). As seqüências geradas foram agrupadas de acordo com sua homologia através do pacote de bioinformática Phrap. Essa estratégia aumentou o grau de cobertura genômica, já que as seqüências originais apresentavam tamanho máximo de 500 a 700 bases. Após a retirada dos contaminantes, obtivemos 2933 agrupamentos de seqüências (contigs) e 11568 seqüências isoladas. Cada contig representa um gene em potencial e o seu conjunto foi submetido a comparação com o banco de dados público nr para possibilitar a anotação e classificação funcional. Os agrupamentos ORESTES foram classificados em comunicação celular (19%); crescimento, desenvolvimento e manutenção celular (9%); metabolismo celular (30%); estrutura, motilidade e transporte celular (15%); função desconhecida (28%). Adicionalmente, estabelecemos o mapeamento cromossômico dos contigs obtidos, observando distribuição relativamente homogênea e proporcional representada em todos os cromossomos humanos. O mapeamento dos contigs gerados por ORESTES apresentou-se com padrão de distribuição semelhante ao observado por Venter e colaborasores, 2001. Comparamos o padrão de expressão obtido com o transcriptoma de medula óssea de paciente portador de anemia hemolítica hereditária (doença hematológica não neoplásica) gerado por SAGE (Serial Analysis of Gene Expression). Os genes encontrados foram ordenados de acordo com sua representatividade ou nível de expressão. Não houve correlação entre os padrões de expressão observados pos SAGE e por ORESTES. Do conjunto dos 100 genes mais representados nos ORESTES, dez foram selecionados para validação da expressão por PCR quantitativo em tempo real, utilizando o agente fluorescente SybrGreen I. Identificamos e confirmamos o aumento da expressão em nove genes na LMC. Destes, sete tinham aumento superior a 10 vezes o controle (CAMP, ABR, DEFA3, CSF3R, MLL2, S100A8 e MS4A3), com dois deles (DEFA3 e ABR) com aumento de cerca de 50 vezes ou mais. A análise funcional particularizada para cada um deste genes em LMC tem o potencial de identicar possíveis alvos para novas intervenções terapeuticas. O método mostrou-se poderoso para evidenciar e validar as diferenças de expressão gênica observadas pelas técnicas de seqüenciamento utilizadas anteriormente. Os dados deste trabalho constituem a primeira descrição do transcriptoma da leucemia mielóide crônica
Abstract: The complete collection of transcripts generated from the human genome cannot be predicted from the genome sequence, but should be directly determined for each tissue, due to variations of gene expression in different tissues and disease states, and because genes can encode multiple transcripts derived from alternate splicing and polyadenylation sites. As part of larger project that produced up to 1.2 million ORESTES (open reading frames expressed sequence tags) from different cancer tissues, we constructed a set of cDNAs obtained from bone marrow cells of patients with CML, that represented partial expressed gene sequences that are biased toward the central coding regions of the resulting transcripts (Dias-Neto E et al, Proc Nat Acad Sci USA 97:3491, 2000). The 27,361 ESTs were assembled into contigs using the Phrap package producing 2933 clusters containing 2 to 210 ESTs (leaving 11568 isolated sequences). Functional categories were attributed to the contigs on the basis of the annotation of the matched sequences in nr, into 5 major functional categories and 22 subcategories (cell communication (19%); cell growth, development and m contigs formed by the larger number of EST in bone marrow cells was co mpared with a control bone marrow sample obtained from a non-neoplastic hematologic condition (hereditary hemolytic anemia) and evaluated with SAGE (serial analysis of gene expression). Ten out of 100 most representative contigs had their expression data evaluated further by realtime quantitative PCR with Sybr Green I reagent, confirming the ORESTES data. Seven out of the 10 genes were more than 10-fold upregulated (CAMP, ABR, DEFA3, CSF3R, MLL2, S100A8 e MS4A3) and two additional genes were 50-fold or higher upregulated in CML (DEFA3 e ABR). The wealthy of information provided by this approach demonstrates its usefulness for the analysis of gene expression in specific hematopoietic tissues and diseases
Doutorado
Clinica Medica
Doutor em Clínica Médica

Sabe-se que TRAIL é capaz de matar células tumorais de forma seletiva e que TRAIL tem sua expressão reduzida em diversos tumores, porém pouco se sabe sobre os mecanismos responsáveis pela sua inibição. Tendo em vista que a expressão de TRAIL pode ser regulada pelo Ácido Retinóico; que PRAME é capaz de inibir a via do ácido retinóico através da proteína EZH2 e que nós observamos anteriormente que a expressão de TRAIL esta diminuída em pacientes com LMC, nós decidimos investigar a associação entre PRAME, EZH2 e TRAIL na LMC. Nós demonstramos que PRAME, mas não EZH2, tem sua expressão aumentada em células BCR-ABL+ e sua expressão está associada com a progressão da LMC. Alem disto, existe uma correlação positiva entre PRAME e BCR-ABL e negativa entre PRAME e TRAIL nestes pacientes. A inibição da expressão de PRAME ou EZH2 por RNAi induziu um aumento da expressão de TRAIL. Estes dados revelam um novo mecanismo de regulação responsável por diminuir a expressão de TRAIL, e geram novos possíveis alvos para a terapia da LMC e, possivelmente, também para outros tumores.
TRAIL was shown to selectively kill tumor cells. Not surprisingly, TRAIL is down-regulated in a variety of tumor cells, but the mechanism responsible for TRAIL inhibition remains elusive. Because TRAIL can be regulate by retinoic acid; PRAME was shown to inhibit transcription of retinoic acid receptor target genes through the polycomb protein EZH2; and we have found that TRAIL is inversely correlated with BCR-ABL in CML patients, we decided to investigate the association of PRAME, EZH2 and TRAIL in BCR-ABL-positive leukemia. Here, we demonstrate that PRAME, but not EZH2, is up-regulated in BCR-ABL cells and is associated with the progression of disease in CML patients. In addition, PRAME expression is positively correlated with BCR-ABL and negatively with TRAIL in these patients. Importantly, knocking down of PRAME or EZH2 by RNA interference restores TRAIL expression. Our data reveal a novel regulatory mechanism responsible for lowering TRAIL expression and provide the basis of alternative targets for combined therapeutic strategies for CML.

Nous avons produit des CART-cells et des LT-mock ont été produits ex-vivo. L'efficacité de transduction est mesuré par l'expression CD3+/CD19+ (82% en moyenne, n=S), en cytométrie en flux. L'expression protéique de CAR a été vérifiée par western blot et en cytométrie en flux attestant de son expression membranaire. Nous avons testé la fonctionnalité de la cassette suicide iCaspase9/ AP1903 sur CART-cells après 48h de traitement à I' AP1903. Nous avons montré que plus de 90% des CART-cells entrent en apoptose (Marquage 7-AAD en cytométrie en flux). Nous avons ensuite réalisé des tests fonctionnels in-vitro des CART-cells contre des lignées LMC exprimant naturellement IL-lRAP ou contre des lignées transfectées pour exprimer la forme membranaire d'IL-lRAP. Après co­culture des CART-cells en présence des cellules cibles IL-lRAP+ nous avons montré qu'ils prolifèrent (test CFSE), qu'ils sécrètent de l'interféron y et des cytokines inflammatoires. Enfin, par marquage 7-AAD, nous avons démontré la cytotoxicité des CART-cells contre les cellules ILl-RAP+. Finalement, nous avons montré l'efficacité des CART-cells in vivo, dans un modèle de xénogreffe tumorales dans des souris immunodéficiences NSG greffées par la lignée K562-IL1RAP+ / Luciférase +. On constate une diminution de la masse tumorale 4 jours après injection des CART-cells, jusqu'à disparition totale. Cette preuve de concept laisse entrevoir des perspectives thérapeutiques alternatives dans le traitement de la LMC ou LAM, qui devront être optimiser dans des modèles murins (séquence et nombres d'injection, nombres de cellules, associations avec ITKS ou autres chimiothérapies) afin de conduire un essai clinique de phase I, pour démontrer la faisabilité et la sécurité de l'approche pour envisager une démonstration d'efficacité chez l'homme. La sécurisation par la cassette suicide permet d'envisager l'utilisation des CART-cells en situation autologue ou allogénique (Donor Lymphocytes infusion, DU)
Chronic myeloid leukemia (CML) is a myeloproliferative disorder and is characterized by the presence of a Philadelphia chromosome (Phl) encoding the BCR-ABL fusion protein with constitutive tyrosine kinase activity. The treatment by Tyrosine Kinase lnhibitors (ITK) is not curative. The problem today is ta target leukemic stem cells (HSCs) to prevent relapse of patients after stopping treatment with TKI and permanently eradicate the disease. Studies have identified the interleukin-1 accessory protein receptor (IL-lRAP) as a potential target for killing CSL (BCR-ABL1 positive) in CML or in acute myeloid leukemia (AML). We therefore propose to develop a cell therapy approach targeting IL-lRAP, using T cells (LT) redirected by a CAR (Chimeric Antigen Receptor) in the treatment of CML and AML. We produced a specific anti-lL-1RAP murine monoclonal antibody (mAb) called # A3C3. We tested the specificity of the antibody # A3C3 in flow cytometry, in Western blot, by immunohistochemistry or confocal microcopy, on positive human cell lines IL-1RAP (KU812) or IL-1RAP negative (Raji). Moreover, by using this antibody, we have demonstrated by immunohistochemistry, on 20 different normal tissues that our antibody does not recognize or very few non-specific (off-target) targets. Finally, we demonstrated that this antibody is able to detect positive IL-1RAP CSLs in primary bone marrow or peripheral blood samples of LMC patients at diagnosis or after ITK treatment. By molecular biology, we have sequenced and identified rearrangements of the heavy (lgH) and light {lgL) chains coding region for hypervariable regions of# A3C3. The coding sequence for the "single chain variable fragment" (scFv), lin king the 2 lgH and lgl chains, was cloned into a 3rd generation lentiviral skeleton securised by a suicide gene, inducible caspase 9 (iCASP9). We produced CART-cells and LT-mock ex-vivo. The transduction efficiency is measured by CD3 + / CD19 + expression (82% on average, n = 5), in flow cytometry. The functionality of the suicide cassette iCaspase9/AP1903 on CART-cells after 48h treatment with AP1903 was tested. We have shown the death of more than 90% of CART-cells (7-AAD labeling in flow cytometry). We then performed in-vitro functional tests of CART-cells against LMC lines naturally expressing IL-1RAP or against transfected lines to express the membrane form of IL-1RAP. After co-culture of CART-cells in the presence of IL-1RAP + target cells, we have shown that they proliferate (CFSE test), that they secrete interferon y and inflammatory cytokines (intracellular labeling and Cytokines Bead Array assay). They are able to degranulate (CD107a & b labeling). Finally, by 7 AAD labeling, we demonstrated the cytotoxicity of CART-cells against IL1-RAP + cells. Finally, we showed the effectiveness of CART-cells in vivo, in a tumor xenograft model in NSG immunodeficiency mice engrafted by the K562-IL1RAP+/Luciferase+ line. There is a decrease in the tumor load 4 days after injection of CART-cells, until complete disappearance.This proof of concept suggests alternative therapeutic perspectives in the treatment of CML or AML, which should be optimized in murine models (sequence and injection numbers, cell numbers, associations with ITKS or other chemotherapies) in order to Phase I clinical trial, to demonstrate the feasibility and safety of the approach to consider a demonstration of efficacy in human. Securing by the suicide cassette makes it possible to consider the use of CART-cells in an autologous or allogeneic situation (Donor Lymphocytes infusion, DU)

Foram analisados os resultados retrospectivos do transplante de medula óssea alogênico em 100 pacientes portadores de leucemia mielóide crônica, divididos em dois grupos: Grupo I, de 49 pacientes que recebeu alta hospitalar após a pega medular, e grupo II, de 51 pacientes, que recebeu alta precocemente, antes da pega medular, para acompanhamento ambulatorial. Foram comparados os dias de ocupação de leitos hospitalares, a morbidade e a mortalidade entre os grupos de alta até o dia 100 pós transplante. Verificou-se que, no grupo de alta precoce, houve, significativamente, menos dias de ocupação de leitos hospitalares, sem aumento da morbidade e da mortalidade
We analyzed the results of a retrospective study of 100 patients with chronic myelogenous leukemia submitted to allogeneic stem cell transplantation in one of two settings: Group I, with 49 patients, transplanted in the traditional inpatient and group II, with 51 patients, in partial outpatient. We compared the median number of days spent in hospital, morbidity and mortality within 100 after bone marrow transplantation. We concluded that there was a significant reduction in the median of hospital length of stay in the partial outpatient group, without increasing morbidity and mortality

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014
Drug delivery systems, such as Cell Penetrating Peptides (CPP), which are short peptides with transfection ability and some of viral origin, have been developed over the last years to increase genetic therapies efficiency. In this work, Dengue Virus Capsid Protein derived peptides (PepM and PepR) were studied for their ability to transfect a variety of cell lines with several cargos. They were also tested with a clinical model – Chronic Myeloid Leukemia (CML) which having a single oncogenic mutation (which originates BCR-ABL gene), was a perfect target for siRNA therapy. It was demonstrated that both peptides have CPP abilities, and were efficient as delivery agents for the siRNA against BCR- ABL gene, thus proving it as a potential therapy for this pathology. Therefore, these peptides are of great value for other genetic therapies, but also CML therapy observed a breakthrough no longer being dependent on tyrosine kinase inhibitors, and future work on gene editing may lead to a curative therapy.
Os sistemas de Drug Delivery, como os Cell Penetrating Peptides (CPP), que consistem em pequenos péptidos com capacidade de transfecção e alguns de origem viral, têm vindo a ser desenvolvidos ao longo dos últimos anos para aumentar a eficácia das terapias genéticas. Neste trabalho, os péptidos derivados da proteína da Cápside do Vírus da Dengue (Pep M e Pep R) foram estudados para averiguar a sua capacidade de transfectar uma variedade de linhagens celulares, com vários tipos de cargas. Foram também testados com um modelo clínico – Leucemia Mielóide Crónica (LMC), que tendo uma única mutação oncogénica (que origina o gene BCR-ABL), é um alvo perfeito para terapia com siRNA. Demonstrou-se que ambos os péptidos têm capacidade de CPP, tendo sido eficientes agentes de transfecção do siRNA contra o BCR-ABL, que por sua vez se revelou uma potencial terapia para a LMC. Deste modo, estes péptidos têm grande valor para outras terapias genéticas, mas também a terapia desenvolvida para a LMC representa uma alternativa aos inibidores de tirosina cinase, sendo que investigação futura em edição genica pode conduzir a uma terapia curativa.

Understanding the factors that regulate the growth and differentiation of haemopoietic stem cells (HSC) remains a major challenge. In this study, the proliferation and differentiation of CD34+ cells from normal donors and chronic myeloid leukaemia (CML) patients was compared. The proliferation and entry of CML cells into the cell cycle was decreased relative to cells from normal donors, and greater heterogeneity in the phenotype of CML cells at the initiation of culture was observed. Analysis of phenotype concomitant with cell division also demonstrated that the differentiation of normal CD34+ cells was consistent between donors, while marked variability was observed in the differentiation of CD34+ cells from CML patients. This included expression of CD13, CD33, CD38 and HLA-DR, which were linked to cell division in normal but not CML cells. The tyrosine kinase inhibitor, imatinib, is a novel drug displaying promising results in the treatment of CML by specifically inhibiting the growth of leukaemic cells. To examine whether myelosuppression observed in patients treated with imatinib may arise from inhibition of normal haemopoiesis, imatinib was added to colony assays established using cells from normal bone marrow. Suppression of monocyte/macrophage growth, but not that of eosinophils or neutrophils, was observed at therapeutic concentrations of imatinib. Inhibition of monocytic differentiation to macrophages was also observed and was associated with decreased functional capacity such as altered antigen uptake, production of proinflammatory cytokines and stimulation of responder cells. The specific suppression of monocyte/macrophage differentiation and function was not due to blockade of tyrosine kinases known to be inhibited by imatinib and was consistent with an inhibition of the M-CSF/c-fms signalling pathway. This hypothesis was tested using a cell line that was dependent on M-CSF for growth and survival. Cell proliferation and phosphorylation of c-fms were inhibited at an IC50 of 1.9μM and 1.4μM imatinib respectively and this was not attributable to decreased c-fms expression. These important findings therefore identify c-fms as a further target of imatinib, and suggest that imatinib should be considered for treatment of diseases where c-fms is implicated. This includes breast and ovarian cancer and inflammatory conditions such as rheumatoid arthritis. Potential side effects resulting from imatinib treatment must also be considered.
Thesis (Ph.D.)--School of Medicine, 2004.

Understanding the factors that regulate the growth and differentiation of haemopoietic stem cells (HSC) remains a major challenge. In this study, the proliferation and differentiation of CD34+ cells from normal donors and chronic myeloid leukaemia (CML) patients was compared. The proliferation and entry of CML cells into the cell cycle was decreased relative to cells from normal donors, and greater heterogeneity in the phenotype of CML cells at the initiation of culture was observed. Analysis of phenotype concomitant with cell division also demonstrated that the differentiation of normal CD34+ cells was consistent between donors, while marked variability was observed in the differentiation of CD34+ cells from CML patients. This included expression of CD13, CD33, CD38 and HLA-DR, which were linked to cell division in normal but not CML cells. The tyrosine kinase inhibitor, imatinib, is a novel drug displaying promising results in the treatment of CML by specifically inhibiting the growth of leukaemic cells. To examine whether myelosuppression observed in patients treated with imatinib may arise from inhibition of normal haemopoiesis, imatinib was added to colony assays established using cells from normal bone marrow. Suppression of monocyte/macrophage growth, but not that of eosinophils or neutrophils, was observed at therapeutic concentrations of imatinib. Inhibition of monocytic differentiation to macrophages was also observed and was associated with decreased functional capacity such as altered antigen uptake, production of proinflammatory cytokines and stimulation of responder cells. The specific suppression of monocyte/macrophage differentiation and function was not due to blockade of tyrosine kinases known to be inhibited by imatinib and was consistent with an inhibition of the M-CSF/c-fms signalling pathway. This hypothesis was tested using a cell line that was dependent on M-CSF for growth and survival. Cell proliferation and phosphorylation of c-fms were inhibited at an IC50 of 1.9μM and 1.4μM imatinib respectively and this was not attributable to decreased c-fms expression. These important findings therefore identify c-fms as a further target of imatinib, and suggest that imatinib should be considered for treatment of diseases where c-fms is implicated. This includes breast and ovarian cancer and inflammatory conditions such as rheumatoid arthritis. Potential side effects resulting from imatinib treatment must also be considered.
Thesis (Ph.D.)--School of Medicine, 2004.

The aim of this study was to test whether GM-CSF could modulate the response of chronic myeloid leukemia progenitors to imatinib. In addition it was aimed to examine CML cell production of GM-CSF. Findings suggest that non-CD34+ cells may be a source of GM-CSF.
Thesis (Ph.D.) - University of Adelaide, School of Medicine, 2006

Dissertação de Mestrado em Bioquímica apresentada à Faculdade de Ciências e Tecnologia
A leucemia mieloide crónica (LMC) é uma doença mieloproliferativa maligna que se desenvolve quando as células estaminais hematopoiéticas adquirem o cromossoma Philadelphia, sendo que este resulta da translocação entre os cromossomas 9 e 22. O resultado molecular desta translocação é uma proteína de fusão BCR-ABL,que se encontra constitutivamente ativada com ação de tirosina cinase . O uso de inibidores de tirosina cinase (TKIs) representam a terapia de referência em LMC, no entanto o único tratamento curativo é o transplante alogénico de células estaminais hematopoiéticas. O sistema imunitário, em particular as células Natural Killer e as CD8+ T, têm vindo a demonstrar ter um papel importante no controlo da LMC. No entanto as células tumorais desenvolvem diferentes mecanismos imunosupressores para escapar ao controlo do sistema imune. Um destes mecanismos é o aumento da expressão de immune checkpoints nas células imunes. O mais destacado nos últimos tempos é o recetor de morte programada-1 (PD-1); os anticorpos monoclonais para este recetor e para os seus ligandos tem vindo a ser descritos como uma arma promissora na imunoterapia. O objetivo principal deste trabalho foi estudar o papel do PD-1 nas células NK na LMC. Em primeiro lugar, a expressão do PD-1 e dos seus ligandos foi analisada por citometria de fluxo em 37 doentes com diferentes características clínicas. Os doentes em diagnóstico tiveram a expressão mais elevada de PD-1, demonstrando que a terapia tem a capacidade de modular o papel do PD-1. Além disso, quando os resultados foram analisados de acordo com a resposta molecular, a terapêutica também demonstrou a sua capacidade de diminuir a expressão do PD-1. A partir do momento em que os doentes atingiram uma pre resposta molecular major verificou-se uma tendência para a percentagem de células que expressam PD-1 diminuir com uma resposta molecular mais profunda . Foi medida uma maior concentração do PD-L1 solúvel comparativamente com o PD-1 solúvel, e para além disto o sPD-L1 teve a tendência para aumentar com uma resposta molecular mais profunda. Desta forma, 4 doentes em tratamento com uma resposta molecular 5.0 logs (MR5.0) foram selecionados para proceder as experiências com os anticorpos bloqueadores. O efeito destes anticorpos foi avaliado pela medição das funções citotóxicas e citolíticas das células NK. Desta forma, a desgranulação e a produção de IFN- e Granzima B foram medidos por citometria de fluxo. Adicionalmente, também se mediu a citotoxicidade direta mediada pelas células NK através do ensaio NK-TVA. Os resultados desta experiência com doentes de LMC, demonstraram que os anticorpos bloqueadores não aumentaram o potencial citotóxico das células NK, excluindo a possibilidade dos doentes com estas características clínicas poderem vir a beneficiar de imunoterapia com anticorpos bloqueadores.
Chronic myeloid leukemia (CML) is a malignant myeloproliferative disease developed when hematopoietic stem cells (HSCs) acquire the Philadelphia (Ph) chromosome, which is caused by the translocation between chromosomes 9 and 22. The molecular result of this translocation is a fusion protein BCR-ABL, which is a constitutively active tyrosine kinase. Tyrosine kinase inhibitors (TKIs) targeting the BCR-ABL kinase represent the standard care in CML, however the only curative treatment is the allogeneic HSCs transplantation. The immune system, in particular Natural Killer cells and CD8+ T cells, have been demonstrate to have an important role in CML control. Still, different immunosuppressive mechanisms are developed by tumour cells in order to escape immune surveillance. One of the immunosuppressive mechanisms is the expression of checkpoint inhibitors by the immune cells. Programmed death receptor 1 (PD-1) is the most remarkable of recent times, likewise monoclonal antibodies against this receptor and its ligands have been described as the new weapon of immunotherapy. The main goal of this work was to understand the role of PD-1 on NK cells in CML disease. In the first place, the expression of PD-1 and its ligands were analysed by flow cytometry in 37 CML patients with different clinical characteristics. Naïve patients showed the highest expression of PD-1, demonstrating that TKIs have the capacity to modulate PD-1 role. From the moment that CML patients achieved a pre major molecular response (Pre-MMR), the percentage of cells expressing PD-1 tends to increase with a deep molecular response. Higher concentrations of sPD-L1 were measured compared to sPD-1 and it was also shown a tendency to increase the sPD-L1 with a deepness MR. In this way, 4 patients undergoing Imatinib with a molecular response of 5.0logs (MR5.0) were chosen to proceed blocking experiences. The effect of blockade was assessed by the measurement of NK cytotoxicity functions and cytokine production. For this purpose, degranulation, IFN- and the Granzyme B production were measured by flow cytometry. Additionally, a NK-TVA assay was also done to measure the direct NK-mediated cytotoxicity. The results of blocking experiences in CML patients did not show the improvement of NK cells functions, excluding the possibility that CML patients, with these clinical characteristics, could benefit with the blocking antibodies to improve NK cells functions.
Outro - Funded by the FEDER Funds through COMPETE 2020 and by FCT within the framework of the Strategic Project with reference assigned by COMPETE: POCI-01-0145-FEDER-007440.

Thesis (Ph.D.)--University of Adelaide, Dept. of Medicine; and, Institute of Medical and Veterinary Science, Division of Haematology, 2005.
Title from title page of source document; viewed 19 July 2005. Bibliography: p. 157-184 of source document. Also available in print.

碩士
高雄醫學大學
醫學研究所
91
Imatinib mesylate, a potent inhibitor of the Bcr-Abl tyrosine kinase that is central to the pathogenesis of CML, has demonstrated remarkable hematologic and cytogenetic response especially in chronic phase. This was well documented in various studies including phase III study. JunB is a component of the Jun family genes of the activating protein-1 transcription factors that are important in the control of cell growth, differentiation and neoplastic transformation. It was demonstrated that transgenic mice lacking JunB expression developed myeloproliferative disease and eventually progressing to blast crisis that resembles human CML. Recently, it was demonstrated that down-regulated JunB expression in CML was due to the inactivation of JunB gene by methylation in the promoter area, and the differential expression was correlated to the ratio of cells being methylated. Here we used real-time quantitative RT-PCR to monitor the serial changes of both JunB and Bcr-Abl expression in peripheral blood in our patients receiving imatinib. Total 22 patients were treated with imatinib, and in 19 of the 22 patients (9 male and 10 female, median age 37 years-old) who received regular follow-up, 14 patients were in chronic phase and 5 patients were in accelerating phase. All of the 14 chronic phase patients achieved complete hematologic response (100%), and major cytogenetic response was found in 10 of 14 (71.4%) patients and complete cytogenetic response in 9 of 14 (64.3%) patients, with median time 16 and 18 weeks respectively. Molecular response was also noted in 8 of 14 (57.1%) patients with median time 21 weeks. Among the 5 patients in accelerating phase, one of them (20%) achieved complete cytogenetic response and molecular response, two of them (40%) remained in accelerating phase and two of them (40%) with disease progression to blast crisis with clonal evolution. Grade III to IV leukopenia and thrombocytopenia caused by imatinib was found in 8 of 19 (36.4%) and 6 of 19 (27.3%) patients, and other side effects were not so obvious compared with other studies. Gradual increase in JunB expression with decrease or undetectable Bcr-Abl expression during imatinib treatment was found in 5 patients, all of them achieved complete cytogenetic response (100%) and even molecular response (100%). Gradual decrease to even very low level of JunB expression with variable Bcr-Abl expression was found in two patients who possessed disease progression to blast crisis with clonal evolution and leaded to mortality. Variable JunB expression with undetectable Bcr-Abl expression was found in 3 patients, all of them achieved complete cytogenetic response. Variable JunB expression with gradual decrease Bcr-Abl expression was found in other 3 patients, 2 of them achieved complete cytogenetic response and one of them achieved major cytogenetic response. No significance existed on the median time to complete cytogenetic response and median time to initiation of imatinib between these two groups. The other 6 patients (4 in chronic phase and 2 in accelerating phase) with variable JunB and Bcr-Abl expression revealed no cytogenetic response and remained in stable disease. Significance existed between increased JunB expression and good clinical response such as complete cytogenetic response or molecular response. Conclusively, similar clinical response rate including major and complete cytogenetic response during chronic and accelerating phase was found in our results compared with previous studies, indicated the clinical efficacy of imatinib in the treatment of CML. It seemed that more grades III to IV leukopenia and thrombocytopenia were found during treatment in our study. The correlation between those who possessed gradual increase in JunB expression and good clinical response implied that the increase in JunB expression during imatinib treatment might be used as a predictor for good clinical response and a basis for developing new treatment tragedy. The fact that variable JunB expression could be found in those who possessed complete cytogenetic response indicated that there were still other mechanisms responsible for regulation of JunB expression. The possible mechanism accounting for increasing JunB expression is caused by more demethylation in promoter area of JunB gene or by other mechanism needs to be further investigated. Furthermore, the changes in specific genes expression other than JunB that is down-streamed to Bcr-Abl protein during imatinib treatment, the possible mechanisms for those who revealed drug resistance, and the long-term effects of imatinib, still needed to be further investigated.

Dissertação de mestrado em Biotecnologia Farmacêutica, apresentada à Faculdade de Farmácia da Universidade de Coimbra
A Leucemia Mieloide Crónica (LMC) é uma doença clonal mieloproliferativa caracterizada pela existência da translocação t(9:22), da qual resulta o cromossoma Filadélfia. Esta translocação dá origem ao gene de fusão BCR-ABL, que codifica a oncoproteina BCRABL com atividade de tirosina cinase aumentada. O Imatinib é um inibidor de tirosina cinase (TKI) que veio alterar a estratégia terapêutica habitualmente utilizada em doentes de LMC, o interferão alfa, e é atualmente o tratamento de primeira linha na doença. O Imatinib bloqueia especificamente a atividade da oncoproteina BCR-ABL e promove uma boa resposta por parte dos doentes. No entanto são conhecidos casos de resistência, sendo a razão mais comum o aparecimento de mutações no domínio BCR-ABL que impedem que o Imatinib se ligue com sucesso e exerça a sua função. Para além disto, existem outros mecanismos moleculares envolvidos na resistência a este fármaco, como a alteração da expressão dos transportadores de influxo e efluxo e das enzimas envolvidas na metabolização do fármaco, entre outros. Recentemente têm surgido várias terapias que atuam em vias de sinalização celular que se têm revelado cada vez com mais de interesse no tratamento da LMC. O Bortezomib, um inibidor do proteassoma, o Parthenolide, inibidor do NF-κB, e o Everolimos, inibidor do mTOR, são apenas alguns exemplos de novos fármacos que, devido ao seu mecanismo de ação podem revelar-se importantes no tratamento de doentes que apresentam resistência ao Imatinib. Os microRNAs são pequenas moléculas de ARN não codificante, que regulam a expressão génica ao nível pós-transcripcional. Cada vez mais se tem verificado que a alteração da expressão dos microRNAs está envolvida em várias patologias, nomeadamente no cancro. Alguns microRNAs, como o miR-21, o miR-125b e o miR-155, têm sido relacionados com a aquisição de resistência a determinadas terapias em vários tipos de neoplasias. Os objetivos deste trabalho foram avaliar a influência dos níveis de expressão dos microRNAs, miR-21, miR-125b e miR-155 na sensibilidade e resistência ao Imatinib em linhas celulares de LMC, bem como no potencial efeito terapêutico de novos fármacos xii anticancerígenos dirigidos a alvos moleculares, em particular o Bortezomib, Parthenolide e Everolimus. Para atingir estes objetivos utilizámos uma linha celular modelo de LMC sensível ao Imatinib, as células K562, e uma linha celular resistente a este TKI obtida a partir da linha celular anterior, as células K562 RC. Para avaliar o efeito dos diversos fármacos na viabilidade celular recorreu-se ao ensaio metabólico da rezasurina. A morte celular foi avaliada por citometria de fluxo com a dupla marcação anexina V e iodeto de protídeo, e por microscopia óptica através da coloração May-Grünwald-Giemsa. Alguns dos mecanismos envolvidos foram analisados através dos níveis de expressão de BAX e BCL-2, dos níveis intracelulares de NF-κB, de conjugados de ubiquitina e de p53 por citometria de fluxo recorrendo à marcação com anticorpos monoclonais. Avaliou-se também por western blot os níveis de expressão e ativação da proteína AKT, na ausência e na presença dos três compostos em estudo de forma a perceber a influência destes compostos nesta via de sinalização, devido ao facto de esta via estar relacionada com os mecanismos de ação dos três microRNAs em estudo. A avaliação da expressão dos miRNAs efetuou-se por PCR em tempo real com recurso a kits comerciais. Os ensaios realizados com os fármacos em estudo revelaram que, o Bortezomib, o Parthenolide e o Everolimus, em monoterapia, induziram diminuição da viabilidade celular, de modo dependente da linha celular, da concentração, do tipo de fármaco e do tempo de incubação, induzindo morte celular preferencialmente por apoptose. Assim, nas células resistentes ao Imatinib (K562 RC) tratadas com Bortezomib e Parthenolide, observou-se um efeito citotóxico mais acentuado do que nas sensíveis, enquanto o Everolimus apresentou um efeito mais evidente nas células sensíveis K562 relativamente às células K562 RC. Por outro lado, verificamos aumento da expressão dos miR-21 e miR-125b nas células K562 RC em relação as K562. Pelo contrário, os níveis de miR-155 são inferiores nas células K562 RC em relação às K562. Estas alterações podem significar que estes miRNAs desempenham algum papel na aquisição de resistência ao Imatinib, podendo eventualmente constituir novos biomarcadores preditivos de resposta e/ou de monitorização da terapêutica com este TKI. Quando as células foram expostas a Bortezomib, Parthenolide e Everolimus, verificou-se alteração dos níveis de expressão dos microRNA nas células sensíveis e resistentes ao Imatinib. Nas células K562 verificou-se que o tratamento com os três compostos em estudo induziu um ligeiro aumento nos níveis de expressão dos miR-21 e xiii miR-155 em relação ao controlo, não se tendo observado nenhuma expressão do miR-125b. Por outro lado, nas células K562 RC, observou-se uma ligeira diminuição dos níveis de expressão do miR-21 e miR-125b, quando expostos aos três compostos em estudo. No entanto, os níveis de expressão do miR-155 apresentaram um ligeiro aumento com a exposição ao Bortezomib e ao Parthnolide e um decréscimo com a exposição ao Everolimus. Assim, o Bortezomib, Parthenolide e Everolimus poderão constituir uma nova abordagem terapêutica em doentes de LMC resistentes à terapêutica com Imatinib, podendo os níveis de expressão do miR-21, miR-125b e miR-155 ser indicadores e/ou influenciar a resposta à terapêutica.
Chronic Myeloid Leukemia (CML) is a clonal, myeloproliferative disorder characterized by the existence of the t(9:22) translocation which results in the Philadelphia Cromossome. This translocation results in the BCR-ABL fusion gene, which encodes the BCR-ABL oncoprotein with enhanced tyrosine-kinase activity. Imatinib is a tyrosine kinase inhibitor (TKI) that modified the therapeutic strategy usually used in patients with CML, the interferon alfa, and nowadays is the first line treatment in the disease. Imatinib specifically blocks the activity of the BCR-ABL oncoprotein and promotes good response by patients. However there are known cases of resistance, the most common reason being the onset of mutations in the BCR-ABL gene that prevent Imatinib to bind successfully and perform its function. Furthermore, there are other molecular mechanisms involved in resistance to this drug, as the altered expression of influx and efflux transporters and of the enzymes involved in the metabolism of the drug, among others. Recently several therapies that act in pathways that have become increasingly interesting in CML therapy, have emerged. Bortezomib, a proteasome inhibitor, Parthenolide an NF-κB inhibitor and Everolimus, an mTOR inhibitor are just a few examples of novel therapies that, due to its mechanism of action may prove to be important in the treatment of patients who present resistance to Imatinib. MicroRNAs are small noncoding RNA molecules that regulate gene expression at the post-trasncripcional level. Increasingly there has been observed that the altered expression of microRNAs is involved in several diseases, particularly in cancer. Some microRNAs, such as miR-21, miR-125b and miR-155, have been related to the acquisition of resistance to certain therapies in various types of malignancies. The aims of this study were to evaluate the influence of the expression levels of miR- 21, miR-125b and miR-155 in the response and resistance to Imatinib in CML cell lines, as well as the potencial therapeutic effect of new antineoplasic targeted drugs, particularly Bortezomib, Parthenolide and Everolimus. For this, we used a CML cell line sensitive to Imatinib, K562 cells, and a cell line resistant to this TKI, obtained from the previous, K562 RC cells. To evaluate the effect of xvi various drugs on cell viability we used the resazurin metabolic assay. Cell death was assessed by flow cytometry, with annexin V and propidium iodide double staining and by optical microscopy through staining with May-Grünwald-Giemsa. Some of the mechanisms involved were analyzed by flow cytometry, trough the expression levels of BAX and BCL-2 and the intracellular levels of NF-kB, conjugated ubiquitin and p53, using specific antibodies. AKT expression and activation levels were assessed by western blot, in the absence and presence of the three compounds in study, in order to understand the influence of these compounds in this signaling pathway, due to the fact that this pathway is related with the mechanisms of action of the three miRNAs in study. Evaluation of the expression of miRNAs was performed by real-time PCR using the commercially available kits. The assays performed with the drugs in study revealed that Bortezomib, Parthenolide and Everolimus, in monotherapy, induced decrease of cell viability, in time, dose, drug and cell line dependent manner, inducing death preferably by apoptosis. Therefore, cells resistant to Imatinib (K562 RC) treated with Bortezomib and Parthenolide presented a cytotoxic effect more pronounced than in sensitive cells, while Everolimus showed a less pronounced effect in K562 RC cells than in K562 cells. Additionally, we observed increased expression of miR-21 and miR-125b in K562 RC cells compared to K562 cells. By contrast, the levels of miR-155 decreased in K562 RC relative to K562. These changes might mean that these miRNAs play some role in the acquisition of resistance to Imatinib, and may eventually constitute new biomarkers predictive of response and / or monitoring of therapy with this TKI. Upon exposure to Bortezomib, Parthenolide and Everolimus it was observed an alteration in the expression levels of the microRNAs in Imatinib-sensitive and resistant cells. In K562 cells it was noted that treatment with the three compounds in study induced a slightly increase in the expression levels of miR-21 and miR-155, when compared to control, not having been noted any expression of miR-125b. Moreover, in K562 RC cells, it was observed a slightly decrease in the expression levels of miR-21 and miR-125b, when exposed to the three compounds in study. However, miR-155 expression levels presented a slightly increase upon exposure to Bortezomib and Parthenolide, and a decrease with Everolimus exposure. Thus, Bortezomib, Parthenolide and Everolimus may constitute a novel therapeutic approach to CML patients resistant to treatment with Imatinib, and the expression levels of miR-21, miR-125b and miR-155 may be indicators and/or influence the therapeutic response

abstract: The phycologist, M. R. Droop, studied vitamin B12 limitation in the flagellate Monochrysis lutheri and concluded that its specific growth rate depended on the concentration of the vitamin within the cell; i.e. the cell quota of the vitamin B12. The Droop model provides a mathematical expression to link growth rate to the intracellular concentration of a limiting nutrient. Although the Droop model has been an important modeling tool in ecology, it has only recently been applied to study cancer biology. Cancer cells live in an ecological setting, interacting and competing with normal and other cancerous cells for nutrients and space, and evolving and adapting to their environment. Here, the Droop equation is used to model three cancers. First, prostate cancer is modeled, where androgen is considered the limiting nutrient since most tumors depend on androgen for proliferation and survival. The model's accuracy for predicting the biomarker for patients on intermittent androgen deprivation therapy is tested by comparing the simulation results to clinical data as well as to an existing simpler model. The results suggest that a simpler model may be more beneficial for a predictive use, although further research is needed in this field prior to implementing mathematical models as a predictive method in a clinical setting. Next, two chronic myeloid leukemia models are compared that consider Imatinib treatment, a drug that inhibits the constitutively active tyrosine kinase BCR-ABL. Both models describe the competition of leukemic and normal cells, however the first model also describes intracellular dynamics by considering BCR-ABL as the limiting nutrient. Using clinical data, the differences in estimated parameters between the models and the capacity for each model to predict drug resistance are analyzed. Last, a simple model is presented that considers ovarian tumor growth and tumor induced angiogenesis, subject to on and off anti-angiogenesis treatment. In this environment, the cell quota represents the intracellular concentration of necessary nutrients provided through blood supply. Mathematical analysis of the model is presented and model simulation results are compared to pre-clinical data. This simple model is able to fit both on- and off-treatment data using the same biologically relevant parameters.
Dissertation/Thesis
Doctoral Dissertation Applied Mathematics 2015

La leucémie myéloïde chronique (LMC) est un modèle d’évolution tumorale dans les cancers humains. Le processus d’évolution de la LMC de la phase chronique (PC) à la phase blastique (PB) est caractérisé par un arrêt de différenciation et l’acquisition de la capacité d’autorenouvellement incontrôlé d’une cellule souche ou d’un progéniteur hématopoïétique. La LMC en PB est associée à la présence d’anomalies génétiques additionnelles à la fusion BCR-ABL1 qui résulte de la translocation chromosomique t(9;22). Contrairement aux patients en PC, les patients en PB de la LMC n’obtiennent pas une réponse moléculaire complète à long terme avec 1’Imatinib mesylate, un inhibiteur de la tyrosine kinase (ITK) BCR-ABL1. De plus, les ITKs de deuxième et troisième générations sont moins efficaces en PB de la LMC lorsque les cellules leucémiques ont acquis une résistance au traitement indépendante des mutations de BCR-ABL1. Les mécanismes moléculaires des voies de signalisation impliquées dans la progression de la LMC en PB ne sont pas entièrement élucidés. Le but de notre travail est de caractériser de nouvelles anomalies génétiques dans la PB de la LMC. Nous avons identifié en cytogénétique, quatre nouvelles translocations chromosomiques : t(1;21)(p36;q22), t(7;17)(p15;q22), t(8;17)(q11;q22) et t(2;12)(q31;p13) dans les cellules leucémiques de patients en PB de la LMC résistants au traitement. En utilisant des techniques d'hybridation in situ en fluorescence, de RT-PCR et de séquençage, nous avons délimité les régions à investiguer au niveau des points de cassure et identifié un réarrangement de plusieurs gènes codant pour des facteurs de transcription importants lors de l’hématopoïèse tels que RUNX1, ETV6, PRDM16 et HOXA. L’altération de ces gènes pourrait expliquer l’arrêt de différenciation et/ou l’acquisition de la capacité d’autorenouvellement caractéristiques de la LMC en PB. Nous avons identifié les fusions RUNX1-PRDM16, MSI2-HOXA, MSI2-SOX17 et ETV6-HOXD11, respectivement associées aux translocations chromosomiques t(1;21), t(7;17), t(8;17) et t(2;12). Ces fusions génèrent différents transcrits alternatifs qui maintiennent et altèrent le cadre ouvert de lecture. L’analyse des séquences des transcrits chimériques identifiés dans ce projet, incluant RUNX1-PRDM16, MSI2-HOXA9, MSI2-HOXA10, MSI2-HOXA11 et ETV6-HOXD11, nous a permis de prédire les domaines fonctionnels potentiellement présents au niveau des protéines chimériques prédites. Les transcrits de fusion qui respectent le cadre ouvert de lecture peuvent générer des domaines fonctionnels des deux partenaires. C’est le cas des deux transcrits identifiés pour la fusion RUNX1-PRDM16 où le domaine de liaison à l’ADN RHD (Runt homology domain) de RUNX1 est fusionné avec la quasi-totalité des domaines de PRDM16. Les transcrits de fusion qui ne respectent pas le cadre ouvert de lecture donnent des formes tronquées des transcrits RUNX1, MSI2 et ETV6. La juxtaposition des régions promotrices de ces derniers en 5’ de leurs partenaires entraîne l’activation de la forme courte oncogénique de PRDM16 dans la t(1;21) ou de différents gènes HOXA/D dans les t(7;17) et t(2;12), ainsi que l’expression aberrante d’un nouveau transcrit alternatif de SOX17 dans la t(8;17). Notre étude nous a permis d’identifier de nouveaux gènes de fusion et/ou une activation de gènes qui pourraient coopérer avec la fusion BCR-ABL1 dans la progression de la LMC et être impliqués dans la résistance au traitement de la LMC en phase avancée. La caractérisation des événements génétiques associés à la transformation blastique de la LMC est essentielle pour l’investigation des voies moléculaires impliquées dans cette phase de la maladie. Investiguer la résistance au traitement de ces patients pourrait aussi contribuer à identifier de nouvelles cibles thérapeutiques dans cette leucémie.
Chronic myeloid leukemia (CML) is a model of tumor evolution in human cancer. The evolution process of CML from the chronic phase (CP) to the blastic phase (BP) is characterized by a blockade of differentiation and acquisition of uncontrolled self-renewal capacity by hematopoietic stem or progenitor cells. CML-BP is associated with the presence of other genetic abnormalities in addition to the BCR-ABL1 fusion which results from chromosomal translocation t(9;22). Unlike patients in the CP, patients with CML-BP do not achieve a long-term complete molecular response to Imatinib mesylate, an inhibitor targeting the BCR-ABL1 tyrosine kinase (TK). Moreover, second and third generation TK inhibitors are less effective in CML-BP when leukemic cells have acquired a therapeutic resistance independent of BCR-ABL1 mutations. The molecular mechanisms of the signaling pathways responsible for CML progression from CP to BP are poorly understood. The aim of our project is to characterize novel genetic alterations in the BP of CML. We have identified by cytogenetics, four novel chromosomal translocations: t(1;21)(p36;q22), t(7;17)(p15;q22), t(8;17)(q11;q22) and t(2;12)(q31;p13) in leukemic cells of patients with CML-BP resistant to therapy. Using fluorescence in situ hybridization, RT-PCR and sequencing techniques, we have mapped chromosomal translocation breakpoints and identified rearranged genes encoding transcription factors which are key regulators of hematopoiesis, such as RUNX1, ETV6, PRDM16 and HOXA. The disruption of these genes could explain the differentiation blockade and/or uncontrolled self-renewal associated with the CML-BP. We identified RUNX1-PRDM16, MSI2-HOXA, MSI2-SOX17 and ETV6-HOXD11 fusions created by chromosomal translocations t(1;21), t(7;17), t(8;17) and t(2;12) respectively. These fusions generate different alternative transcripts that both maintain and alter the open reading frame. Sequence analysis of chimeric transcripts identified in this project, including RUNX1-PRDM16, MSI2-HOXA9, MSI2-HOXA10, MSI2-HOXA11 and ETV6-HOXD11, allowed us to predict potential functional domains present in putative chimeric proteins. In-frame fusion transcripts can generate functional domains from both fusion partners. For example, in two RUNX1-PRDM16 transcripts, the RUNX1 DNA binding domain RHD (Runt homology domain) is fused to the majority of PRDM16 domains. Out-of-frame fusion transcripts resulted in truncated forms of RUNX1, MSI2 and ETV6. The juxtaposition of promoter regions of these genes to the 5’ part of their partners resulted in the activation of the oncogenic short form of PRDM16 in the t(1;21) or of different HOXA/D genes in t(7;17) and t(2;12), and in the aberrant expression of a novel alternative SOX17 transcript in the t(8;17). Our study allowed us to identify novel fusion genes and/or activation of genes that potentially cooperate with BCR-ABL1 fusion in the progression of CML and contribute to treatment resistance of this disease. The characterization of genetic events related to the blastic transformation of CML is an important step in the investigation of molecular pathways involved in this stage of the disease. Understanding treatment resistance of these patients might help to identify new therapeutic targets in this leukemia.