Дисертації з теми "Locally advanced cervical cancer"

Background: External Beam Radiotherapy is essential in the management of locally advanced cervical cancer (LACC). Generally, VMAT is thought to achieve higher conformity to the Planned Target Volume (PTV) and better sparing of organs at risk (OAR) when compared to 3D-CRT. This study focused on these principles as it applied to treatment and potential toxicity in the management of LACC. Aim: To compare dosimetric parameters between VMAT and 3D-CRT in the management of LACC. Setting: The study analysed patients treated at Groote Schuur Hospital between May and December 2017. Method: A non-randomized comparative retrospective study. EBRT plans for 3D-CRT and VMAT were generated and data on treatment parameters for PTV D50%, Dmax, Dmean, Conformity Index (CI), Homogeneity Index, Treated Volume (TV), Irradiated Volume (IV) and OAR constraints; femoral heads, bladder, bowel bag, rectum and bone marrow were collected. Results: Of the 45 patients assessed, VMAT showed significantly lower treatment parameter values for CI (1.09 vs 1.49; p< .001) whereas, 3D-CRT showed lower Dmax (48.1Gy vs 49.2Gy; p< .001) and rectum (88.5% vs 96%). A reduced 3D-CRT dose was noted for bladder Dmax (47.4Gy vs 48.3Gy; p< .001). Conclusion: VMAT offered a superior dosimetric option, with better OAR dose sparing and optimal tumour dosimetry.

ABSTRACT MULTIDRUG RESISTANCE IN LOCALLY ADVANCED BREAST CANCER ATALAY, Mustafa Can Ph. D., Department of Biotechnology Supervisor: Prof. Dr. Ufuk GÜ
NDÜ
Z June 2004, 70 pages Breast cancer is the most frequently detected cancer among women. Early diagnosis leads to long term survival when the patients are treated with surgery, radiotherapy, chemotherapy, and hormone therapy. Unfortunately, advanced disease could still be encountered in some patients resulting in a poorer prognosis. The primary treatment modality is chemotherapy for this group of patients. Drug resistance is a serious problem resulting in the use of different drugs during chemotherapy and knowing the possibility of resistance before initiating first line chemotherapy may save time and money, and most importantly, may increase patient&rsquo
s survival. Therefore in this study, multidrug resistance is studied in locally advanced breast cancer patients. The breast tissues obtained from 25 patients both before and after chemotherapy were examined for drug resistance. Reverse transcriptase polymerase chain reaction was used for the detection of mdr1 and mrp1 gene expression. In addition, immunohistochemistry technique was used for P-glycoprotein and MRP1 detection. JSB-1 and QCRL-1 monoclonal antibodies were utilized to detect P-glycoprotein and MRP1, respectively. Five patients were unresponsive to chemotherapy. In four of these patients mdr1 gene expression was induced by chemotherapy where as the fifth patient initially had mdr1 gene expression. In addition, Pgp positivity was detected in 9 patients after chemotherapy. Both the induction of mdr1 gene expression (p<
0.001) and Pgp positivity (p<
0.001) during chemotherapy were significantly related with clinical response. On the other hand, mrp1 gene expression and MRP1 positivity were detected in 68% of the patients before the therapy. After chemotherapy, mrp1 expression increased to 84%. Although 80% of the clinically unresponsive patients had mrp1 gene expression, the relation between mrp1 expression and clinical drug response was not strong. Thus, it can be concluded that in locally advanced breast cancer mdr1 gene expression during chemotherapy contributed to clinical unresponsiveness. However, mrp1 gene expression did not correlate strongly with the clinical response. When RT-PCR and immunohistochemistry methods are compared in terms of detection of drug resistance, it seems that both methods gave similar and reliable results.

Guidelines report a wide range of options in locally advanced pancreatic cancer (LAPC): definitive chemotherapy or chemoradiotherapy or the emerging stereotactic body radiotherapy (SBRT) (+/- chemotherapy). On behalf of the AIRO (Italian Association of Radiation Oncology and Clinical Oncology) Gastrointestinal Study Group, we collected retrospective clinical data on 419 LAPC from 15 Italian centers. The study protocol (PAULA-1: Pooled Analysis in Unresectable Locally Advanced pancreatic cancer) was approved by institutional review board of S. Orsola-Malpighi Hospital (201/2015/O/OssN). From this large database we performed tree different studies. The first was a retrospective study about 56 LAPC treated with SBRT at a median biologically equivalent dose of 48 Gy +/- chemotherapy. We demonstrated a statistically significant impact of biologically equivalent dose based on an α/β ratio of 10Gy ≥ 48Gy for local control (LC) (p: 0.045) and overall survival (p: 0.042) in LAPC. The second was a retrospective matched-cohort case-control study comparing SBRT (40 patients) and chemoradiation (40 patients) in LAPC in terms of different endpoints. Our findings suggested an equivalence in terms of most outcomes among the two treatments and an advantage of SBRT in terms of LC (p: 0.017). The third study was a retrospective comparison of definitive chemotherapy, chemoradiotherapy and SBRT (+/- chemotherapy) in terms of different outcomes in LAPC. A predictive model for LC in LAPC was also developed reaching an AUC of 68% (CI 58,7%-77,4%). SBRT treatment emerged as a positive predictive factor for improved LC. Findings deriving from our three studies suggest that SBRT is comparable to standard of care (definitive chemotherapy and chemoradiotherapy) in terms of outcomes. SBRT seems to be an emerging therapeutic option in LAPC significantly improving local control. Furthermore, we have shown the potential of a predictive model for LC. Randomized trials are needed to compare these different therapeutic options in LAPC.

The treatment of clinically locally advanced prostate carcinoma (stage cT3) remains controversial. One of the main reasons for this controversy results from the substantial staging error attached to the clinical diagnosis cT3 with overstaged T2 tumors and understaged node-positive cases. Treatment options in this situation include radical prostatectomy, external beam radiotherapy, immediate or delayed androgen deprivation treatment and the so-called ‘watchful waiting’. Acceptable and often surprisingly good tumor-specific survival rates have been reported for radical prostatectomy in pT3 series – based on good clinical case selection – approaching those of pT2 series. In lymph node-positive pT3 cases, adjuvant hormone deprivation seems to prolong survival which it does not in lymph node-negative pT3 disease. A benefit of adjuvant external beam radiotherapy after radical prostatectomy for pT3 cases in prolonging overall survival has not been shown, despite the fact that it can prevent or delay biochemical and local recurrence. External beam radiotherapy as the only treatment for cT3 disease results in unfavorable tumor-specific survival rates, which can be significantly improved with adjuvant hormonal treatment with LHRH agonists. If, in case of advanced age and/or significant comorbidity, primary hormonal treatment is chosen, early hormonal deprivation therapy seems to offer marginal benefits in survival compared to delayed treatment
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

The treatment of clinically locally advanced prostate carcinoma (stage cT3) remains controversial. One of the main reasons for this controversy results from the substantial staging error attached to the clinical diagnosis cT3 with overstaged T2 tumors and understaged node-positive cases. Treatment options in this situation include radical prostatectomy, external beam radiotherapy, immediate or delayed androgen deprivation treatment and the so-called ‘watchful waiting’. Acceptable and often surprisingly good tumor-specific survival rates have been reported for radical prostatectomy in pT3 series – based on good clinical case selection – approaching those of pT2 series. In lymph node-positive pT3 cases, adjuvant hormone deprivation seems to prolong survival which it does not in lymph node-negative pT3 disease. A benefit of adjuvant external beam radiotherapy after radical prostatectomy for pT3 cases in prolonging overall survival has not been shown, despite the fact that it can prevent or delay biochemical and local recurrence. External beam radiotherapy as the only treatment for cT3 disease results in unfavorable tumor-specific survival rates, which can be significantly improved with adjuvant hormonal treatment with LHRH agonists. If, in case of advanced age and/or significant comorbidity, primary hormonal treatment is chosen, early hormonal deprivation therapy seems to offer marginal benefits in survival compared to delayed treatment.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Brystkreft er den hyppigste kreftsykdommen blant kvinner. Lokalavansert brystkreft utgjør omtrent 10% av alle brystkrefttilfeller og omfatter en heterogen pasientgruppe med ulike prognoser. Pasienter med lokalavansert brystkreft får ofte kjemoterapi før kirurgisk fjerning av tumor, såkalt neoadjuvant kjemoterapi, for å redusere størrelsen på tumoren. Det er stor variasjon i behandlingsrespons for denne pasientgruppen, og det er derfor behov for å utvikle målrettet og individualisert behandling, samt metoder for oppfølging av behandlingsrespons. Metabolomics er en systematisk analyse av småmolekylære forbindelser (metabolitter) i biologiske prøver. Den metabolske profilen til brystkreftvev er vist å korrelere med viktige kliniske parametere, for eksempel tumorgrad, hormonreseptorstatus og lymfeknutespredning. Magnetisk resonans (MR) spektroskopi er en metode som kan gi en detaljert beskrivelse av metabolittprofilen i vevet. En fordel med denne metoden er at vevsprøven er intakt etter analysen slik at den samme vevsprøven kan analyseres videre med andre metoder, for eksempel immunohistokjemi, genuttrykk- eller proteinanalyse. En sentral gruppe metabolitter innenfor brystkreftforskning er kolinforbindelser. Disse metabolittene er viktig for celledeling, signaloverføring, lipidmetabolisme og cellens membranstruktur. Laktat er en annen viktig metabolitt som inngår i energimetabolismen. I dette arbeidet ble vevsprøver fra pasienter med lokalavansert brystkreft analysert ved bruk av MR spektroskopi for prediksjon av behandlingsrespons og overlevelse. I tillegg undersøkte vi rollen til glycerophosphodiester phosphodiesterase (GDPD) i regulering av kolinforbindelser Alle pasienter hadde en effekt av behandlingen som ble gitt, og nesten alle fikk en reduksjon i tumorstørrelse etter behandling. Resultatene viste ingen metabolske forskjeller mellom pasienter med klinisk god eller dårlig behandlingsrespons. Resultatene viser derimot at de metabolske forandringene som skjer under neoadjuvant kjemoterapi er forskjellig i pasienter som overlever mer enn fem år og de som dør før fem år. Høyere nivå av laktat, glycine og kolinforbindelser etter behandling var forbundet med dårlig prognose. Analysene av GDPD5 tyder på at enzymet er involvert i reguleringen av kolinmetabolismen, men dets rolle for bruk i målrettet terapi er fortsatt uklart og nye studier må til for å undersøke dette. MR metabolomics kan brukes til å undersøke metabolske forandringer under neoadjuvant kjemoterapi behandling og kan identifisere viktige metabolitter for prediksjon av overlevelse hos pasienter med lokalavansert brystkreft.
Breast cancer is the most frequent cancer disease among women globally. Locally advanced breast cancer (LABC) constitutes a heterogeneous group of patients with variable prognosis. Today’s treatment decision is predominately based on clinical assessment, histopathological evaluation, and hormone receptor and lymph node status. So far, these data are not sufficient for designing a proper personalized treatment or accurately predicting treatment response and survival. Molecular characterization of tumors may help stratifying patients for individualized treatment, thereby achieving better prognosis. Magnetic resonance (MR) metabolomics analyses assess the downstream products of gene and protein expressions, i.e. the metabolites, and have shown to provide both predictive and prognostic information for several types of cancers. Proton high resolution magic angle spinning (1H HR MAS) MR spectroscopy is a non-destructive and high-throughput technique that provides highly resolved MR spectra from biological tissue. Recently, altered cell metabolism is suggested as a new emerging hallmark of cancer. Choline phospholipid metabolism is involved in cell signaling, lipid metabolism, and the structural integrity of the cell membrane. Several MRS studies have suggested the total choline-containing metabolite (tCho) level as an in vivo biomarker for diagnosis and treatment evaluation of breast cancer. Reprogramming of energy metabolism and activation of tumor hypoxic response are commonly observed in cancers, and can be characterized by high lactate production. In this thesis, multivariate data analyses and metabolite quantification of 1H HR MAS MRS data were performed to investigate the potential of metabolomics for prediction of clinical response and long-term survival in LABC patients receiving neoadjuvant chemotherapy (NAC). In addition, the role of glycerophosphodiester phosphodiesterase (GDPD) in choline phospholipid metabolism of human breast cancer was investigated. All patients had a metabolic response to NAC and almost all patients had a reduction in tumor size. Our results show no clear differences in metabolic responses to NAC between patients with partial response and stable disease and no significant multivariate models for prediction of clinical response by MR metabolomics data. In general, all patients experienced a decrease in tCho levels. It is possible that a cohort including also patients with progressive disease would reveal clearer differences in the metabolite profiles between the clinical response groups. This thesis demonstrates that MR metabolomics contain prognostic information that is associated with survival status of LABC patients. Increase in lactate levels as a response to NAC was associated with low survival rates (< 5 years), while decreased glycine and choline phospholipid metabolites were associated with long-term survival (≥ 5 years). The observed metabolite profiles consisting of higher levels of lactate, glycine, and tCho post-treatment were predictive of low breast cancer survival rates. GDPD5 gene expression was correlated with choline phospholipid metabolite levels and with CHKA and PLD1 gene expressions suggesting GDPD5 to have a role in regulation of choline phospholipid metabolism in human breast cancer. However, more studies are needed to investigate the relationship between GDPD5 and tumor malignancy, and also estrogen receptor status, for use as target in breast cancer treatment. In conclusion, monitoring metabolic responses to NAC by MR metabolomics may have the potential to assist the prediction of survival and help identify new targets for therapeutic treatment of breast cancer.

INTRODUCTION: Breast cancer is the most common cancer in women worldwide and metastatic dissemination is the principal factor related to death by this disease. Breast cancer stem cells (bCSC), defined in this work as the ALDH1high/LIN-/ESA+ population, are thought to be responsible for metastasis and chemoresistance. The objective of this work is to find gene master regulators, in particular transcription factors (TFs), which are controlling the bCSC phenotype. METHODS: We used in this work two groups of datasets with transcriptome data, the discovery dataset group contains one dataset obtained by ourselves containing three paired samples comparing the bCSC and the bulk of the tumor (My Data - bCSC/Bulk dataset), a dataset with eight paired samples comparing the bCSC and cancer cells (Wicha - bCSC/CC dataset) and a dataset with 115 samples of breast cancer tissue (clinical response dataset). The second group, validation datasets, contains the BRCA-TCGA dataset with information of 621 samples, 4142 breast cancer samples of the Kmplot tool, 17 primary samples of BasL subtype and their information of grafting in patient derived xenografts and analyzes of cell lines (MF10A and HMLE). For the analyzes we used the paired t-test in the Limma R package, the ARACNE algorithm for the inference of regulons in the clinical response dataset, MRA-FET to define the master regulators of the bCSC phenotype, and GSEA to identify the biological meaning of the findings in the different datasets. RESULTS: We identified 12 TFs as master regulators of the bCSC phenotype, with nine of them forming two highly interconnected networks, one positively related with the bCSC phenotype formed by SNAI2, TWIST, PRRX1, BNC2 and TBX5 with its regulons, defined here as the mesenchymal transcription network and one negative correlated to the phenotype formed by SCML4, ZNF831, SP140 and IKZF3, defined as the immune response transcription network, totally unknown in the context of breast cancer in the literature. Although still with weak evidence, ZEB1 seems to control the two networks and can be responsible for the expression of ALDH1 and of the three remaining TFs: ID4, HOXA5 and TEAD1. As their names portray, our data showed in the different datasets, and independently of the molecular subtype and of the platform used, that the mesenchymal transcription network seems to be responsible for the bCSC phenotype and the immune response transcription network to the adaptive immune response in the tumor and a better prognosis for the patients. We also defined 10 membrane proteins as new markers and/or therapeutic targets of the bCSC. CONCLUSION: We found and described two TF networks that seem to control the bCSC phenotype, one of them totally unknown until now and correlated to a good prognosis. Our findings have a clear potential for clinical use.
INTRODUÇÃO: O cancer de mama é no mundo o câncer mais comum em mulheres e a disseminação metastática é o principal fator relacionado com a morte pela doença. Acreditasse que as células tronco do câncer de mama - bCSC, na sigla em inglês e definida neste trabalho com a população ALDH1high/LIN-/ESA+ - é responsável pela metástase e pela quimioresistência. O objetivo deste trabalho é encontrar genes que são essenciais para o controle do fenótipo das bCSC, em particular fatores de transcrição. MATERIAIS E MÉTODOS: Nesse trabalho nós utlizamos dois grupos de datasets com dados do transcriptoma, o grupo de datasets de descoberta contém um dataset gerado por nós com 3 amostras pareadas comparando as bCSC com o tumor total (My Data - bCSC/Bulk dataset), um dataset com 8 amostras pareadas comparando as bCSC com as células cancerígenas (Wicha - bCSC/CC dataset) e um dataset com 115 amostras de tecido de câncer de mama (Clinical Response dataset). O segundo grupo, grupo de validação, contém o dataset BRCA-TCGA com 621 amostras, as 4142 amostras de câncer de mama da ferramenta Kmplot, as 17 amostras humanas primárias do subtipo BasL e sua informação sobre a geração, ou não, de tumores em camundongos imunosuprimidos e a análise de linhagens celulares (MF10A e HMLE). Para a análise dos dataset utilizamos o test-t pareado no pacote Limma da liguagem R, o algoritmo ARACNE para a inferência de regulons no dataset Clinical Response, a análise MRA-FET para definir os Reguladores Mestres para o fenótipo das bCSC e a análise GSEA para identificar o significado biológico de nosso achados nos diferentes datasets. RESULTADOS E DISCUSSÃO: Nós identificamos 12 TFs como reguladores mestres, com 9 deles formando duas redes altamente conectadas, uma positivamente relacionada ao fenótipo bCSC formada por SNAI2, TWIST, PRRX1, BNC2 e TBX5 com seus regulons, e definida aqui como a rede de transcrição mesenquimal, e uma rede correlacionada negativamente, formada por SCML4, ZNF831, SP140 e IKZF3, definida aqui como a rede de transcrição da resposta imune e totalmente desconhecida da literatura no contexto do câncer de mama. Embora ainda com fraca evidencia, ZEB1 para controlar as duas redes e ser responsável pela expressão de ALDH1 e dos 3 TFs restantes: ID4, HOXA5 e TEAD1. Como mostram seus nomes, e independente do dataset, do subtipo molecular ou da plataforma utilizada, a rede de transcrição mesenquimal, parece ser responsável pela manutenção do fenótipo de células tronco cancerígenas e a rede de transcrição da resposta imune pela resposta imune adaptativa ao tumor e a um bom prognóstico para as pacientes. CONCLUSÃO: Nós encontramos e descrevemos duas redes de fatores de transcrição que parecem controlar o fenótipo das bCSC, uma delas totalmente desconhecida até agora e relacionada a um bom prognóstico. Nosso achados possuem um claro potencial para uso clínico.

Advances in treatment and prolonged survival times mean that increasingly individuals are living with advanced cancer, yet services remain disease orientated. This thesis has documented the process of undertaking a longitudinal qualitative study to explore the everydayness of living with locally advanced rectal cancer. The study has identified how this can influence individual’s day to day lives when the focus of care moves away from cure, but prior to the transition to ‘end of life’ care. The aim was to obtain data in which to situate local service development based on those aspects which were accorded primacy by the participants. This interpretive study used a longitudinal qualitative approach which was informed by phenomenology. The philosophical works of Heidegger, Merleau Ponty and Van Manen were influential in this work which involved ten participants, with locally advanced rectal cancer. Successive interviews with ten individuals were undertaken over a two year period. The 38 interviews were analysed using a combination of frameworks offered by Miles and Huberman and Saldana. Individuals during much of this time concentrated on maintaining normality in their everyday lives. The drive for stasis and focus on day to day living allowed the individual to remain in the present and distance a future which was associated with illness and annihilation. Crucial to this was the ability to self-manage. This allowed space to create a self-definition of health. Uncertainty during this time was life affirming. Avoiding those who may challenge this, was desirable for as long as possible. As illness progressed there was an inverse relationship between the ‘boundness’ of the body and the ‘boundness’ of the individual. Insights from this study raise the need for further research and exploration of alternative models of supportive care whilst focusing on the wellness of individuals and self-management within their daily lives.

BACKGROUND:In this study the feasibility of intensity-modulated radiotherapy (IMRT) and tomotherapy-based image-guided radiotherapy (IGRT) for locally advanced esophageal cancer was assessed.METHODS:A retrospective study of ten patients with locally advanced esophageal cancer who underwent concurrent chemotherapy with IMRT (1) and IGRT (9) was conducted. The gross tumor volume was treated to a median dose of 70Gy (62.4-75Gy).RESULTS:At a median follow-up of 14months (1-39 months), three patients developed local failures, six patients developed distant metastases, and complications occurred in two patients (1 tracheoesophageal fistula, 1 esophageal stricture requiring repeated dilatations). No patients developed grade 3-4 pneumonitis or cardiac complications.CONCLUSIONS:IMRT and IGRT may be effective for the treatment of locally advanced esophageal cancer with acceptable complications.

Background: Non-response to neoadjuvant therapy is a significant challenge for clinicians managing solid cancers. This thesis aimed to determine whether Epithelial Mesenchymal Transition (EMT) was associated with non-response to neoadjuvant therapy in patients with locally advanced rectal cancer. Methods: Representative tissue specimens from the tumour invasive front of consecutive patients undergoing resection of rectal cancer from 2009-2011 were used. Patients with marked regression to neoadjuvant therapy were classified as responders with the remainder as non-responders. Markers of EMT included: reduced immunohistochemical expression of membranous E-cadherin, increased nuclear beta-catenin expression and tumour budding. In-situ-hybridisation was used to assess the expression of microRNA-200c (mir200c), an upstream master-regulator of EMT. Real-time polymerase chain reaction was used to quantitate expression of the gene for E-cadherin. Results: From 103 patients undergoing resection of rectal cancer, 69 received neoadjuvant chemoradiotherapy; 65% of these were non-responders. Reduced mir200c expression was significantly associated with higher T grade. Reduced membranous E-cadherin, increased nuclear beta-catenin and tumour budding individually predicted the presence of extra-mural vascular invasion. Reduced E-cadherin, nucleic beta-catenin, reduced mir200c and tumour budding were all significantly associated with non-response to neoadjuvant therapy (all p<0.001). Reduced E-cadherin and mir200c expression were both associated with reduced cancer specific survival (log-rank p-value 0.036 and 0.009 respectively). E-cadherin gene expression was not related to radiotherapy response or tumour budding. Conclusion: Targeted biomarkers of EMT were associated with non-response to neoadjuvant therapy and reduced survival in advanced rectal cancer. EMT may provide a practical clinical biomarker and novel therapeutic target, to improve the proportion of patients who respond to neoadjuvant therapy.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.
Approximately 25% of patients with locoregional esophageal adenocarcinoma (EC) are resistant (marked by minimal tumor regression; TRG 3) to preoperative chemoradiation, including 5FU‐based and CROSS regimens. Previously, an immunohistochemistry (IHC) test that accurately identifies patients as responders (TRG 0‐2) or non‐responders (TRG 3) to neoadjuvant CTRT was developed and validated. The current study was designed to identify gene expression profile (GEP) signatures able to predict response to preoperative treatment. Methods: Formalin‐fixed, paraffin‐embedded (FFPE) tumor tissue from 24 diagnostic biopsies (14 responders, 10 non‐responders) was collected. RNA was isolated, and RT‐PCR performed to assess the expression of 96 candidate genes chosen from in silicoanalysis. Genetic signatures incorporating genes with significant expression differences in pathologically determined responders versus non‐responders were identified, and linear and non‐linear predictive modeling methods were used to assess the accuracy of the signatures for predicting treatment response. Cross validation was performed to attain corrected accuracy values. Ten‐, 18‐, and 24‐gene signatures were identified with significantly different gene expression levels in responders compared to non‐responders (p < 0.05). Functional groups represented by the signatures included DNA damage repair, extracellular matrix remodeling, and 5FU metabolism. Partial Least Squares (PLS) prediction of treatment response was compared to pathologic TRG determined by blinded pathologic reading, and resulted in an area under the curve (AUC) of 0.99 and overall accuracy of 100% for the 24‐gene signature. Corrected AUC of 0.99 and accuracy of 95% resulted from five‐fold cross validation with 20 iterations. Heatmap analysis of the 24‐gene signature separated the EC cases into two distinct clusters, the first with 93% responders and the second with 90% non‐responders. The current study identifies novel gene signatures able to accurately predict EC patient response to preoperative treatment. The GEP may allow non‐responders to avoid unnecessary toxicities associated with chemoradiation therapy.

Includes bibliographical references.
The purpose of the thesis is to determine the incidence of late radiation proctitis in patients treated with radical radiotherapy in Pretoria Academic Hospital during a peroid when hypofractionated radiotherapy and external boosts were being utilised for the treatment of advances carcinoma of the cervix. Possible contributing factors were also examined in an attempt to identify areas where possible changes to our treatment policies would ensure effective palliation without severe late radiation proctitis.

BACKGROUND:The aim of the study is to assess the effectiveness of intensity-modulated radiotherapy (IMRT) or image-guided radiotherapy (IGRT) for the prevention of retropharyngeal nodal recurrences in locally advanced head and neck cancer.METHODS:A retrospective review of 76 patients with head and neck cancer undergoing concurrent chemoradiation or postoperative radiotherapy with IMRT or IGRT who were at risk for retropharyngeal nodal recurrences because of anatomic site (hypopharynx, nasopharynx, oropharynx) and/or the presence of nodal metastases was undertaken.The prevalence of retropharyngeal nodal recurrences was assessed on follow-up positron emission tomography (PET)-CT scans.RESULTS:At a median follow-up of 22months (4-53months), no patient developed retropharyngeal nodal recurrences.CONCLUSION:Prophylactic irradiation of retropharyngeal lymph nodes with IMRT or IGRT provides effective regional control for individuals at risk for recurrence in these nodes.

Background: Patients with locally advanced esophageal cancer who are treated with trimodality therapy have a high recurrence rate. Preclinical evidence suggests that inhibition of cyclooxygenase 2 (COX2) increases the effectiveness of chemoradiation, and observational studies in humans suggest that COX-2 inhibition may reduce esophageal cancer risk. This trial tested the safety and efficacy of combining a COX2 inhibitor, celecoxib, with neoadjuvant irinotecan/cisplatin chemoradiation. Methods: This single arm phase 2 trial combined irinotecan, cisplatin, and celecoxib with concurrent radiation therapy. Patients with stage IIA-IVA esophageal cancer received weekly cisplatin 30 mg/m(2) plus irinotecan 65 mg/m(2) on weeks 1, 2, 4, and 5 concurrently with 5040 cGy of radiation therapy. Celecoxib 400 mg was taken orally twice daily during chemoradiation, up to 1 week before surgery, and for 6 months following surgery. Results: Forty patients were enrolled with stage IIa (30 %), stage IIb (20 %), stage III (22.5 %), and stage IVA (27.5 %) esophageal or gastroesophageal junction cancer (AJCC, 5th Edition). During chemoradiation, grade 3-4 treatment-related toxicity included dysphagia (20 %), anorexia (17.5 %), dehydration (17.5 %), nausea (15 %), neutropenia (12.5 %), diarrhea (10 %), fatigue (7.5 %), and febrile neutropenia (7.5 %). The pathological complete response rate was 32.5 %. The median progression free survival was 15.7 months and the median overall survival was 34.7 months. 15 % (n = 6) of patients treated on this study developed brain metastases. Conclusions: The addition of celecoxib to neoadjuvant cisplatin-irinotecan chemoradiation was tolerable; however, overall survival appeared comparable to prior studies using neoadjuvant cisplatin-irinotecan chemoradiation alone. Further studies adding celecoxib to neoadjuvant chemoradiation in esophageal cancer are not warranted.

Le cancer du col de l'utérus, bien que rare, est une maladie grave touchant souvent des femmes jeunes, avec environ 3 000 nouveaux cas par an en France. La survie dépend du stade de la maladie au diagnostic : les formes avancées nécessitent une radiochimiothérapie concomitante, et l'atteinte ganglionnaire lombo-aortique est un facteur pronostique essentiel. Traditionnellement, la stadification chirurgicale était utilisée pour évaluer cette atteinte, mais la TEP/TDM au 18F-FDG est aujourd’hui préférée, bien qu’elle soit limitée dans la détection de métastases de petite taille.Notre travail explore le potentiel de la radiomique, qui analyse des caractéristiques quantitatives issues de l’imagerie pour prédire des résultats cliniques, dans ce contexte. Dans un premier chapitre, nous avons développé un « modèle TEP » simple pour prédire l’atteinte lombo-aortique, basé sur le nombre d’adénopathies iliaques et les technologies time-of-flight des machines TEP plus modernes. Le second chapitre se concentre sur une revue systématique des applications de la radiomique dans les cancers du col, en évaluant la qualité méthodologique des études via le Radiomics Quality Score. Enfin, le troisième chapitre propose un modèle prédictif intégrant des caractéristiques radiomiques et cliniques, afin de prédire l’atteinte lombo-aortique occulte.Cette recherche souligne la nécessité de modèles prédictifs robustes pour améliorer la prise en charge des cancers du col, avec un potentiel de personnalisation des traitements grâce à des biomarqueurs non invasifs
Cervical cancer, though rare, is a serious disease often affecting young women, with approximately 3,000 new cases per year in France. Survival depends on the disease stage at diagnosis: advanced stages require concomitant chemoradiotherapy, and para-aortic lymph node involvement is a critical prognostic factor. Traditionally, surgical staging was used to assess this involvement, but 18F-FDG PET/CT is now preferred, although it has limitations in detecting small metastases.Our work explores the potential of radiomics, which analyzes quantitative features extracted from imaging to predict clinical outcomes, in this context. In the first chapter, we developed a simple “PET model” to predict para-aortic lymph node involvement based on the number of iliac lymph nodes and the time-of-flight technology of modern PET machines. The second chapter focuses on a systematic review of radiomics applications in cervical cancer, evaluating the methodological quality of studies using the Radiomics Quality Score. Finally, the third chapter presents a predictive model combining radiomic and clinical features to predict occult para-aortic lymph node involvement.This research highlights the need for robust predictive models to improve the management of cervical cancer, with the potential to personalize treatments through non-invasive biomarkers

Purpose: In patients with advanced oesophageal carcinoma palliation of dysphagia is important to maintaining a reasonable quality of life. The primary aim of this study was to determine the dysphagia progression-free survival (DPFS) in patients with advanced oesophageal carcinoma treated with palliative radiotherapy (RT). Methods: The medical records of all patients with oesophageal carcinoma presenting to Groote Schuur Hospital, Cape Town between January 2015-December 2016 were reviewed and patients who were not candidates for curative treatment and received palliative RT were selected. For these patients, the dysphagia score (DS) was recorded prior to RT, 6 weeks after RT and at each follow-up visit. The DPFS was calculated as the time from completion of RT to worsening in DS by ≥1 point or until death. Other outcomes measured were objective change in DS and survival post RT. Results: The study population comprised 84 patients. Squamous cell cancer was the primary histological subtype (93%). The median duration of DPFS after RT was 73 days, with approximately two-thirds of patients remaining able to swallow at least liquids and soft diet until death. The difference in median duration of DPFS was not statistically significant in stented versus non-stented patients (54 days vs 83 days; p =0.224). The mean change in DS was 0.45 ± 0.89 points following RT and the post RT survival was significantly shorter in patients with stent insertion (81 days vs 123 days; p=0.042). Conclusion: Palliative RT can be used successfully to prolong DPFS in patients with locally advanced and metastatic squamous cell cancer of the oesophagus.

Rectal cancer is the eight most common cancer diagnosis in Sweden in both men and women, with almost 2000 new cases per year. Radiotherapy, which is an important treatment modality for rectal cancer, has evolved during the past decades. Diagnostic tools have also improved, allowing better staging and offering information used to make well-founded decisions in multidisciplinary team conferences. In a retrospective study (n=46) with locally advanced rectal cancer (LARC) patients, unfit for chemoradiotherapy, patients were treated with short-course radiotherapy. Delayed surgery was done when possible. Radical surgery was possible in 89% of the patients who underwent surgery (80%). Grade IV diarrhoea affected three elderly patients. Target radiation volume should be reduced in elderly or metastatic patients. In a prospective study (n=68) with LARC patients, magnetic resonance imaging (MRI) and 2-18F-fluoro-2-D-deoxyglucose (FDG) positron emission tomography (PET) were used to determine if FDG-PET could provide extra treatment information. Information from FDG-PET changed the stage of 10 patients. Delineation with FDG-PET generally resulted in smaller target volumes than MRI only. Seven of the most advanced LARC patients in the above cohort were used for a methodological study to determine if dose escalation to peripheral, non-resectable regions was feasible. Simultaneous integrated boost plans with photons and protons were evaluated. While toxicity was acceptable in five patients with both protons and photons, two patients with very large tumours had unacceptable risk for intestinal toxicity regardless of modality. In the interim analysis of the Stockholm III Trial (n=303, studying radiotherapy-fractionation and timing of surgery in relation to radiotherapy) compliance was acceptable and severe acute toxicity was infrequent, irrespective of fractionation. Short-course radiotherapy with immediate surgery tended to give more postoperative complications, but only if surgery was delayed more than 10 days after the start of radiotherapy. Quality-of-life in the Stockholm III Trial was studied before, during and shortly after treatment using the EORTC QLQ-C30 and CR38 questionnaires. Surgery accounted for more adverse effects than radiotherapy in all groups. Postoperatively, the poorest quality-of-life was seen in patients given short-course radiotherapy followed by immediate surgery. No postoperative differences were seen between the two groups with delayed surgery.

Background: Based primarily on studies concerning early-stage tumours (treated surgically), and locally advanced disease (treated with chemoradiation), the prognosis for women with adenocarcinoma (AC) or adenosquamous (AS) carcinoma has been reported to be poorer than those with squamous cell carcinoma (SCCA) of the cervix. It is unclear whether differences in prognosis also persist in the setting of recurrent or metastatic disease treated using chemotherapy doublets with or without bevacizumab. Methods: Cases were pooled from three Gynaecologic Oncology Group randomised phase III trials of chemotherapy doublets. Pearson's test was used to evaluate response rate (RR) of AC/AS vs SCCA, Kaplan-Meier method to estimate progression-free survival (PFS) and overall survival (OS), and Cox proportional hazards model to estimate the impact of histology on PFS and OS. Results: Of 781 evaluable patients, 77% (N = 599) had SCCA and 23% (N = 182) AC/AS. There were no significant differences in RRs between histologic subgroups. The adjusted hazard ratio (HR) for death for SCCA vs AC/AS was 1.13 (95% CI 0.93, 1.38 P = 0.23). When comparing SC/AS (N = 661, 85%) to AC alone (N = 120, 15%), the adjusted HR for death was 1.23 (95% CI 0.97, 1.57, P = 0.09). Conclusions: AC/AS and SCCA have similar survival in recurrent or metastatic cervical carcinoma when treated with chemotherapy doublets.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior
Inflammatory Breast Cancer (IBC) is the most aggressive form of locally advanced breast cancer. It is more common in young women and unfavorably, in most of the times, evolves quickly. Presents with typical signs of inflammation such as hyperemia and hyperthermia its pathogenesis and evolution has been associated with possible participation of inflammatory mediators such as cytokines (TNF-α e IL-1β), enzymes (cyclooxygenase-2 [COX-2] and nitric oxide synthase [iNOS]), as well as, transcription factors (Nuclear Factor kappa B [NF-kB]) able to inducing them. In this regard, the objective of this research was to determine the NF-kB and Interleukin-18 (IL-18) expression in tissue samples obtained from IBC and Noninflammatory Locally Advanced Breast Cancer (LABC). The Hypothesis is that IBC would presents an increased expression of these factors than LABC. Demographics data and tumor characteristics, including response to neoadjuvant chemotherapy and overall survival in both tumor populations were also used to assessment and comparison. Furthermore, in this study, we evaluated the expression of IL-18 and p50 nuclear fraction of NF-kB by immunohistochemistry in specimens from IBC and LABC (T4b). Data analysis showed that about a quarter of cases of CIM occur in women up to 40 years. The overall survival is less in the group of CIM compared to LABC (2.3 vs. 4.3 years, respectively). This difference was also evident in the subgroups RE+, C-erbB-, and triple negative (2.3 vs. 4.4 years to ER+; 2.1 vs. 4.4 years to C-erbB2-; 2.0 vs. 3.4 for triple negative, respectively). Furthermore, it was not possible to detect differences in expression of NF-kB or IL-18 in the CIM and LABC groups. In summary, a quarter of the IBC cases studied appear in younger women (up to 40 years). The IBC has worse prognosis associated with less survival compared to LABC, as evidenced also in subgroups RE+, C-erbB-, and triple negative. Furthermore, there was no correlation between the expression of NF-kB and IL-18 in the IBC and LABC groups.
O Carcinoma InflamatÃrio da Mama (CIM) à a mais agressiva forma de cÃncer de mama localmente avanÃado. à mais frequente em mulheres jovens e evolui desfavoravelmente de forma rÃpida em boa parte das vezes. Ao se apresentar com sinais tÃpicos de processos infamatÃrios como hiperemia e hipertermia sua patogÃnese e evoluÃÃo tem sido associado a possÃvel participaÃÃo de mediadores inflamatÃrios como citocinas (TNF-α e IL-1β) assim como fatores de transcriÃÃo (Fator Nuclear kappa B [NF-kB]) capazes de induzi-los bem como enzimas participes de sua gÃnese (ciclooxigenase-2 [COX-2] e a Ãxido nÃtrico sintase induzida [iNOS]). Neste sentido, objetivou-se na presente investigaÃÃo avaliar a imunoexpressÃo do NF-kB e da Interleucina-18 (IL-18) em amostras teciduais obtidas de CIM e de Carcinoma da Mama Localmente AvanÃado nÃo inflamatÃrio (CMLA). Hipotetizou-se que nos CIM haveria uma expressÃo aumentada diferencial em relaÃÃo CMLA. Dados demogrÃficos e caracterÃsticas tumorais incluindo a resposta a quimioterapia neoadjuvante e a sobrevida geral nas duas populaÃÃes tumorais foram tambÃm motivo de avaliÃÃo e de comparaÃÃo. AlÃm disso, no presente estudo, foi avaliada a expressÃo atravÃs de imunoistoquÃmica, da IL-18 e da fraÃÃo nuclear p50 do NF-kB em espÃcimes de CIM e de CMLA (T4b). A anÃlise dos dados mostrou que na populaÃÃo estudada aproximadamente um quarto dos casos de CIM ocorrem em mulheres com atà 40 anos. A sobrevida mÃdia à mais desfavorÃvel no grupo dos CIM quando comparado ao CMLA (2,3 vs. 4,3 anos, respectivamente). Esta diferenÃa tambÃm foi evidenciada nos subgrupos RE+, C-erbB-, e triplo negativo (2,3 vs. 4,4 anos para RE+; 2,1 vs. 4,4 anos para C-erbB2-; 2,0 vs. 3,4 para triplo negativos, respectivamente). AlÃm disso, nÃo foi possÃvel detectar diferenÃas na expressÃo de NF-kB ou IL-18 nos grupos CIM ou CMLA. Em suma, na populaÃÃo aqui estudada um quarto dos casos de CIM aparecem em mulheres mais jovens (atà 40 anos). O grupo CIM tem pior prognÃstico associado a menor sobrevida quando comparado ao CMLA, como evidenciado tambÃm nos subgrupos RE+, C-erbB-, e triplo negativo. AlÃm disso, nÃo foi observado correlaÃÃo entre a expressÃo de NF-kB e IL-18 nos grupos CIM e CMLA.

The management of advanced cervical and ovarian cancers remains a significant challenge as many women fail to respond to recommended therapy, resulting in disease progression and ultimately patient death. Because of tumour heterogeneity, it is rare for all cancers of a particular type to respond to a specific therapy. Many patients therefore receive treatment from which they derive little or no benefit, leading to increased morbidity and costs. A marker that could rapidly predict disease outcome would clearly be beneficial in allowing the administration of tailored therapy while reducing toxicity and cost. Novel functional imaging techniques have the ability to characterise biological tissues and non-invasively integrate physical and metabolic information. These include diffusion weighted MRI (DW-MRI), which is particularly sensitive to the microscopic motion of water molecules and changes in tissue cellularity, as well as dynamic contrast-enhanced MRI (DCE-MRI) which can assess tumour vascular characteristics during the passage of a paramagnetic contrast agent through tissues. Both imaging techniques have demonstrated potential as biomarkers of tumour response in various malignancies such as brain tumours, but have not been fully explored in gynaecological cancers.

Treating cancer safely and effectively using radiotherapy requires accurate targeting of the tumour. However, internal motion of the tumour due to physiological activity compromises the accuracy of radiotherapy treatment. Managing motion during radiotherapy is further complicated for patients with advanced cancer or oligometastases, where multiple targets can undergo large, independent motion. Prior to this thesis no solution existed to adapt to the motion of independent targets in real time. The aim of this thesis was to develop the first real-time multi-target tracking method. The first two studies in this thesis investigate the use of Kilovoltage Intrafraction Monitoring (KIM) for image guidance (Chapter 4), and multileaf collimator (MLC) tracking as a real-time adaptation method (Chapter 5) for single-target prostate cancer treatments in a clinical trial. KIM was found to be accurate for prostate motion monitoring and MLC tracking was found to be dosimetrically accurate. A multi-target MLC tracking algorithm was then developed and tested for simulated locally advanced prostate cancer treatments, described in Chapter 6. Multi-target MLC tracking was found to irradiate the two targets with a higher accuracy compared to previously implemented methods. Multi-target MLC tracking was then experimentally implemented in Chapter 7, demonstrating that the radiation beam could be adapted to multiple targets simultaneously using a clinical treatment system. Finally in Chapter 8 a multi-target MLC tracking method that adapts to dosimetric errors in real time was developed and evaluated. This method reduced errors compared to the fluence-based approach to allow for multi-target tracking with improved target coverage. Through this thesis, a novel real-time multi-target tracking system was developed, advancing the current state of radiotherapy by providing a world-first, accessible method that will improve the accuracy of treatments for patients with multiple cancer targets.

A common co-pathology of large lung tumors located near the central airways is collapse of portions of lung due to blockage of airflow by the tumor. Not only does the lung volume decrease as collapse occurs, but fluid from capillaries also fills the space no longer occupied by air, greatly altering tissue appearance. During radiotherapy, typically administered to the patient over multiple weeks, the tumor can dramatically shrink in response to the treatment, restoring airflow to the lung sections which were collapsed when therapy began. While return of normal lung function is a positive development, the change in anatomy presents problems for future radiation sessions since the treatment was planned on lung geometry which is no longer accurate. The treatment must be adapted to the new lung state so that the radiation continues to accurately target the tumor while safely avoiding healthy tissue. However, to account for the dose delivered previously, correspondences of anatomy between the former image when the lung was collapsed and the re-expanded lung in a current image must be obtained. This process, known as deformable image registration, is performed by registration software. Most registration algorithms assume that identical anatomy is contained in the images and that intensities of corresponding image elements are similar; both assumptions are untrue when collapsed lung re-expands. This work was to develop an algorithm which accurately registers images in the presence of lung expansion. The lung registration method matched CT images of patients aided by vessel enhancement and information of individual lobe boundaries. The algorithm was tested on eighteen patients with lung collapse using physician-specified correspondences to measure registration error. The image registration algorithm developed in this work which was designed for challenging lung patients resulted in accuracy comparable to that of other methods when large lung changes are absent.

Introduction: Despite there are already many studies on robotic surgery as minimally invasive approach for non-small cell lung cancer (NSCLC) patients, the use of this technique for stage III disease is still poorly described. These are the preliminary results of our prospective study on safety and effectiveness of robotic approach in patients with locally advanced NSCLC, in terms of postoperative complications and oncological outcome. Methods: Since 2016, we prospectively investigated, using standardized questionnaire and protocol, 21 consecutive patients with NSCLC stage IIIA-pN2 (diagnosed by EBUS-TBNA) who underwent lobectomy and radical lymph node dissection with robotic approach after induction treatment. Then, we performed a matched case-control study with 54 patients treated with open surgery during the same period of time, with similar age, clinical and pathological tumor stage. Results: The individual matched population was composed of 14 robot-assisted thoracic surgery and 14 patients who underwent open surgery. The median time range of resection was inferior in the open group compared to robotic lobectomy (148 vs 229 minutes; P=0.002). Lymph nodes resection and positivity were not statistically significantly different (p=0.66 and p=0.73 respectively). No difference was observed also for PFS (P=0.99) or OS (P=0.94). Conclusions: Our preliminary results demonstrated that the early outcomes and oncological results of N2-patients after robotic lobectomy were similar to open surgery. Considering the advantages of minimally invasive surgery, robotic assisted lobectomy should be a safe approach also to patients with local advanced disease.

Background: Response to chemotherapeutic agents is highly variable among patients both in terms of efficacy and tolerability; consequently personalization of drug therapy is one of the main objective in cancer treatment in order to reduce adverse drug reactions (ADRs), improve efficacy while decreasing the costs of treatments. Many factors account for inter-individual differences. Among them, patient’s genetic background has attracted interest for personalization of drug therapy (Pharmacogenetics). Breast cancer (BC) is the female most frequently diagnosed malignancy and the primary cause of cancer-related death among females with 1.380.000 new cases and 458.000 deaths worldwide registered in 2008. Estrogen receptors (ER) are over-expressed in around 80% of breast cancer cases and ER-positive (ER+) cancer cells depend on estrogens for their growth. In postmenopausal women estrogens can derive only from androgens through an aromatization reaction. Aromatase (CYP19A1) is a key enzyme in this process and, for this reason, is the target of many inhibitors drugs, including exemestane. Anti-aromatase treatments represent the current corner-stone of ER+ BC therapy in postmenopausal women. Exemestane is a steroidal irreversible third generation aromatase inhibitor (AI) which determines the inactivation of the enzyme, resulting in estrogen synthesis inhibition and deprivation. Exemestane is used in adjuvant setting for ER+ early stage invasive BC and for the treatment of advanced stage BC progressed to a previous anti-estrogen therapy. Several germ line variations (polymorphisms) have been described in genes involved either in estrogens activity and metabolism or in the pharmacokinetics of exemestane. Aims: this PhD thesis had a dual aim: * setting up a pharmacogenetic method to analyze estrogen and exemestane-related polymorphisms (Single Nucleotide Polymorphisms (SNPs) and Short Tandem Repeats (STRs)), * determining the predictive and prognostic value of these polymorphisms in postmenopausal metastatic or locally advanced ER+ BC patients (Response Rate (RR), Clinical Benefit (CB), Time To Progression (TTP) and Overall Survival (OS)). Fifteen polymorphisms in genes involved estrogens synthesis (CYP17A1 and CYP19A1), activity (ESR1, ESR2 and RIZ1) and metabolism (CYP1B1, UGT1A1 and COMT) as well as genes implicated in the metabolic pathway of exemestane (CYP3A4 and CYP3A5) were investigated. We considered the CYP19A1_Ex11_410A/C (rs4646) SNP in the 3’ untraslated region (3'UTR) of the aromatase gene, previously associated to a better disease-free survival (DFS) (Colomer et al., 2008) in patients treated with the AI, letrozole, and to a better OS in patients treated with another AI, anastrozole (Liu et al., 2013). However, the role of this polymorphism has not yet been clearly defined. Other CYP19A1 polymorphisms analyzed were: CYP19A1_47T/C (rs700519), CYP19A1_1558T/C (rs10046) and CYP19A1_(TTTA)n (rs60271534), along with a SNP on the CYP17A1 gene (CYP17A1_27A/G (rs743572)), coding for another enzyme responsible for estrogens synthesis. Additionally, we investigated: * polymorphisms on estrogens receptors: ESR1: ESR1_497T/C (rs2234693), and ESR1_256A/G (rs9340799); ESR2: ESR2_1082A/G (rs1256049), and ESR2_1730A/G (rs4986938); RIZ1: RIZ1_delP704 (rs2308040); * polymorphisms on estrogens metabolizing enzymes: CYP1B1: CYP1B1*3_4326G/C (rs1056836), UGT1A1: UGT1A1*28_ TA(6/7) (rs8175347) and COMT: COMT_12A/G (rs4680); * polymorphisms on enzymes involved in the oxidative metabolism of exemestane: CYP3A4: CYP3A4*1B_-392A/G (rs2740574) and CYP3A5: CYP3A5*3_6986A/G (rs776746). Methods: genetic analyses were conducted in a group of 275 ER+ metastatic or locally advanced BC patients treated with exemestane as first line hormone therapy. Patients were subjected to blood sampling before the beginning of therapy. DNA was extracted from whole blood, and then amplified by Polymerase Chain Reaction (PCR). Four methods for polymorphisms genotyping were set up and developed: Pyrosequencing, TaqMan® Allelic Discrimination Assay, Automated Fragment Analysis and Illumina GoldenGate Assay. Statistical associations between genetic determinants and clinical outcome were assessed by the two-sided Fisher’s Exact Test (associations between genotypes and clinical responses) and the Kaplan-Meier product-limit method with the log-rank test statistic (associations between polymorphisms and TTP/OS). Results: For each polymorphism the most appropriate technique, based on the best result obtained in the setting up process, was chosen. As a result: * three SNPs were investigated with Pyrosequencing: CYP19A1_47T/C (rs700519), CYP3A4*1B_-392A/G (rs2740574), and RIZ1_delP704 (rs2308040); * ten SNPs were genotyped with TaqMan® Allelic Discrimination Assay: CYP19A1_Ex11+410A/C (rs4646), CYP19A1_1558T/C (rs10046), CYP3A5*3_6986A/G (rs776746), COMT_12A/G (rs4680), ESR1_497T/C (rs2234693), ESR1_256A/G (rs9340799), ESR2_1082A/G (rs1256049), ESR2_1730A/G (rs4986938), CYP17A1_27A/G (rs743572) and CYP1B1*3_4326G/C (rs1056836); * two STR were analyzed with Automated Fragment Analysis: CYP19A1_(TTTA)n (rs60271534) and UGT1A1*28_ TA(6/7) (rs8175347) * twelve of the above mentioned polymorphisms were additionally analyzed by Illumina GoldenGate Assay as positive controls. The results obtained by this validation process was a 100% accordance within the genotypes obtained. Among the polymorphisms investigated, a statistically significant association was observed for CYP1B1, the gene encoding for the enzyme which catalyze the phase I estrogens oxidative metabolism. The variant (G) allele of CYP1B1*3_4326G/C (rs1056836) was significantly associated with clinical response to exemestane (RR, ORGG = 2.91, 95% CI = 5.88 – 1.25, p = 0.0039; according to the two-sided Fisher’s exact test). The same variant allele was also significantly associated with the TTP and OS (TTP, dominant model: HR CG+GG= 0.66, 95% CI = 0.50 – 0.87, p = 0.0037; OS, dominant model = HR CG+GG= 0.66, 95% CI = 0.46 – 0.95, p = 0.023, according to the log-rank test) meaning that patients carrying at least one variant allele (G) not only showed a better clinical response, but experienced also a later progression and a longer survival than wild type patients. Regarding the aromatase gene (CYP19A1 gene), the only association found, even if marginal, was between CYP19A1_1558T/C (rs10046) SNP and TTP (HRCC recessive model=1.4, 95%CI = 1.04 – 1.89, p = 0.028). Conversely, we did not find any significant association between CYP19A1_Ex11_410A/C (rs4646) SNP, (the main objective of the study) and RR, CB, TTP or OS, respectively. Concerning aromatase gene polymorphisms, we were able to describe a new genetic variant for the CYP19A1_(TTTA)n (rs60271534) STR in intron 4. Genetic databases and literature report that the number of repeats varies from 7 to 13, but we found a still not described 14 (TTTA) repeats allele. Conclusions: in conclusion, this thesis work allowed defining a new molecular marker, CYP1B1*3_4326G/C (rs1056836) SNP, with a predictive and prognostic value for the exemestane-based treatment of postmenopausal ER+ metastatic or locally advanced BC patients. This indicates that, once validated, this marker could potentially be employable in the daily clinical oncology practice as a tool which may allow the identification of patients more likely to be responsive to treatment by a simple genetic evaluation from peripheral blood, performed prior to therapy. In addition, we described a new genetic variant in the aromatase gene.
Introduzione: La risposta agli agenti chemioterapici è altamente variabile tra i pazienti sia per quanto riguarda l’efficacia che la tollerabilità, di conseguenza la personalizzazione della terapia è uno dei principali obiettivi della ricerca in campo oncologico con l’obiettivo di ridurre le reazioni avverse al farmaco, migliorarne l’efficacia e nel contempo contenerne i costi. I fattori responsabili della variabilità interindividuale sono molteplici. Tra questi, il background genetico dei pazienti ha attratto interesse per la personalizzazione della terapia (Farmacogenetica). Il carcinoma mammario (breast cancer - BC) rappresenta la neoplasia più frequentemente diagnosticata e la prima causa di morte collegata al cancro tra le donne. Nel 2008 sono stati registrati, a livello mondiale, 1.380.000 nuovi casi e 458.000 morti a causa del cancro della mammella. Il recettore degli estrogeni (estrogen receptor - ER) risulta iper-espresso in circa l’80% dei casi di BC e le cellule cancerose positive al ER (ER+) dipendono dagli estrogeni per la loro crescita. Nelle donne in menopausa, gli estrogeni derivano unicamente dagli androgeni attraverso una reazione di aromatizzazione. L’aromatasi (CYP19A1) è un enzima chiave in questo processo e, per questa ragione, è diventato il target di numerosi farmaci inibitori, compreso exemestane. Il trattamento anti-aromatasi rappresenta attualmente il cardine della terapia del ER+ BC nelle donne in menopausa. Exemestane è un inibitore irreversibile dell’aromatasi (AI) di terza generazione e di tipo steroideo che determina l’inattivazione dell’enzima, provocando quindi l’inibizione della sintesi estrogenica. Exemestane è un farmaco impiegato in assetto adiuvante per il ER+ BC invasivo allo stadio precoce ed in assetto avanzato se la malattia è progredita dopo una precedente terapia anti-estrogenica. Sono state descritte numerose variazioni genetiche germinali (polimorfismi) in geni coinvolti sia nell’attività e metabolismo degli estrogeni che nella farmacocinetica di exemestane. Obiettivi: questa tesi di dottorato ha avuto un duplice obiettivo: * mettere a punto un metodo di indagine farmacogenetica per analizzare polimorfismi correlati ad estrogeni ed exemestane (polimorfismi a singolo nucleotide – SNPs e microsatelliti (short tandem repeats) - STRs) * determinare il ruolo predittivo e prognostico di tali polimorfismi come biomarcatori di efficacia del trattamento a base di exemestane, in termini di Response Rate (RR), Clinical Benefit (CB), tempo alla progressione (TTP) e sopravvivenza globale (OS). Sono stati considerati quindici polimorfismi in geni coinvolti nella sintesi (CYP17A1 e CYP19A1), attività (ESR1, ESR2 e RIZ1) e metabolismo (CYP1B1, UGT1A1 e COMT) degli estrogeni insieme a geni implicati nel pathway metabolico di exemestane (CYP3A4 e CYP3A5). Come obiettivo primario dello studio clinico è stato considerato lo SNP CYP19A1_Ex11_410A/C (rs4646) della regione non 3’ tradotta (3’ untraslated region - 3’UTR) del gene dell’aromatasi, già in precedenza associato ad una migliore sopravvivenza libera da malattia (disease free servival – DFS) (Colomer et al., 2008) in pazienti trattate con l’AI letrozolo e con la miglior OS in pazienti trattate con un altro AI, l’anastrozolo (Liu et al., 2013). Ciononostante, il ruolo di questo polimorfismo non è stato ancora chiaramente definito. Sono stati analizzati anche altri polimorfismi del gene CYP19A1 (CYP19A1_47T/C (rs700519), CYP19A1_1558T/C (rs10046) e CYP19A1_(TTTA)n (rs60271534)) insieme ad uno SNP nel gene CYP17A1(CYP17A1_27A/G (rs743572)), codificante per un altro enzima responsabile della sintesi degli estrogeni. Inoltre, sono stati indagati polimorfismi dei geni codificanti per: * i recettori degli estrogeni: ESR1: ESR1_497T/C (rs2234693), e ESR1_256A/G (rs9340799); ESR2: ESR2_1082A/G (rs1256049), e ESR2_1730A/G (rs4986938); RIZ1: RIZ1_delP704 (rs2308040); * gli enzimi deputati al metabolismo degli estrogeni: CYP1B1: CYP1B1*3_4326G/C (rs1056836), UGT1A1: UGT1A1*28_ TA(6/7) (rs8175347) e COMT: COMT_12A/G (rs4680); * gli enzimi responsabili del metabolismo ossidativo di exemestane: CYP3A4: CYP3A4*1B_-392A/G (rs2740574) e CYP3A5: CYP3A5*3_6986A/G (rs776746). Metodi: le analisi genetiche sono state condotte in un gruppo di 275 pazienti affetti da ER+ BC metastatico o localmente avanzato trattate con exemestane come prima linea di trattamento ormonale. Ai pazienti è stato effettuato un prelievo ematico prima dell’inizio della terapia. Il DNA è stato poi estratto dal campione di sangue intero ed amplificato tramite la reazione a catena della polimerasi (PCR). Per le analisi genetiche sono state messe a punto quattro tecniche di genotipizzazione: Pyrosequencing, Saggio di Discriminazione Allelica mediante sonde TaqMan®, Analisi dei Frammenti Automatizzata ed il saggio GoldenGate di Illumina. Sono state valutate le associazioni statistiche tra i determinanti genetici e l’outcome clinico dei pazienti attraverso il Test Esatto di Fisher a due vie per l’associazione di polimorfismi e risposta clinica e attraverso lo stimatore del prodotto limite di Kaplan Meier e il test dei ranghi logaritmici per l’associazione tra polimorfismi e TTP/OS. Risultati: per ogni polimorfismo è stata scelta la tecnica di indagine molecolare più appropriata a seconda del miglior risultato ottenuto durante la fase di messa a punto delle metodologie. Di conseguenza: * tre SNPs sono stati analizzati con il Pyrosequencing: CYP19A1_47T/C (rs700519), CYP3A4*1B_-392A/G (rs2740574), e RIZ1_delP704 (rs2308040); * dieci SNPs sono stati genotipizzati con il saggio di Discriminazione Allelica mediante sonde TaqMan®: CYP19A1_Ex11+410A/C (rs4646), CYP19A1_1558T/C (rs10046), CYP3A5*3_6986A/G (rs776746), COMT_12A/G (rs4680), ESR1_497T/C (rs2234693), ESR1_256A/G (rs9340799), ESR2_1082A/G (rs1256049), ESR2_1730A/G (rs4986938), CYP17A1_27A/G (rs743572) e CYP1B1*3_4326G/C (rs1056836); * due STR sono stati esaminati attraverso l’Analisi dei Frammenti Automatizzata: CYP19A1_(TTTA)n (rs60271534) e UGT1A1*28_ TA(6/7) (rs8175347); * i campioni analizzati per dodici dei sopraccitati polimorfismi sono stati, inoltre, inclusi nel saggio Illumina GoldenGate come controlli positivi. Il risultato di questo processo di validazione è stata una concordanza del 100% tra i genotipi ottenuti con questa tecnica e quelli derivanti dalle precedenti indagini. Tra i polimorfismi analizzati, è stata osservata un’associazione statisticamente significativa per CYP1B1, gene codificante per l’enzima responsabile del metabolismo ossidativo di prima fase degli estrogeni. L’allele variante G del polimorfismo CYP1B1*3_4326G/C (rs1056836) è stato significativamente associato con la risposta clinica ad exemestane (RR, ORGG = 2.91, 95% CI = 5.88 – 1.25, p = 0.0039; secondo il Test Esatto di Fisher a due vie). Lo stesso allele variante è stato significativamente associato anche al TTP e alla OS (TTP, modello dominante: HR CG+GG= 0.66, 95% CI = 0.50 – 0.87, p = 0.0037; OS, modello dominante = HR CG+GG= 0.66, 95% CI = 0.46 – 0.95, p = 0.023, secondo il test dei ranghi logaritmici). Questo significa che pazienti portatori di almeno un allele G non solo hanno dimostrato una miglior risposta clinica al trattamento ma hanno anche avuto una progressione più tardiva ed una sopravvivenza più lunga dei pazienti wild type. Per quanto riguarda il gene dell’aromatasi, l’unica associazione riscontrata, anche se marginale, riguarda il polimorfismo CYP19A1_1558T/C (rs10046) il cui allele variante C che è stato associato ad un ridotto TTP (HRCC modello recessivo =1.4, 95%CI = 1.04 – 1.89, p = 0.028, secondo il Test Esatto di Fischer a due vie). Al contrario, non è stata riscontrata alcuna associazione significativa tra lo SNP CYP19A1_Ex11_410A/C (rs4646), obiettivo principale dello studio, e RR, CB, TTP o OS. Riguardo i polimorfismi del gene dell’aromatasi, siamo stati in grado di descrivere una nuova variante genetica per il polimorfismo STR CYP19A1_(TTTA)n (rs60271534) dell’introne 4. Le banche dati genetiche e la letteratura riportano che il numero di ripetizioni della quadripletta TTTA vari tra 7 e 13, ma nel nostro studio è stato individuato un allele, finora mai descritto, con 14 ripetizioni. Conclusioni: in conclusione, questo lavoro di tesi ha permesso di definire un nuovo biomarcatore molecolare, lo SNP CYP1B1*3_4326G/C (rs1056836), con un valore predittivo e prognostico per il trattamento a base di exemestane in pazienti affetti da ER+ BC, metastatico o localmente avanzato. Questo presuppone che, se validato, questo biomarcatore potrebbe potenzialmente essere impiegato nella pratica clinica oncologica quotidiana come strumento che potrebbe aiutare ad identificare i pazienti che hanno una maggiore probabilità di risposta all’exemestane tramite una semplice valutazione genetica da sangue periferico da effettuarsi prima della terapia. Inoltre, è stata descritta una nuova variante genetica del gene dell’aromatasi.

Background: Breast cancer is the second most common cancer in adults and the most frequent cancer diagnosed in women. In South Africa, breast cancer accounts for 38.5% of cancers diagnosed in women. Since the presence, extent and location of distant metastases is one important prognostic factor in locally advanced breast cancer (LABC), accurate staging at diagnosis is crucial to ensure patients receive the appropriate treatment. Increasing evidence shows that the use of 18F-FDG PET/CT for disease staging of LABC may improve diagnostic sensitivity. Aim: To prospectively assess the difference in diagnostic accuracy between whole-body PET/PET-CT and conventional imagine (CI) for staging LABC. Methods: A total of 42 participants with clinical stage III and a select few stage II breast cancer underwent both 18F-FDG PET/CT and CI. Results: 18F-FDG PET/CT found significantly more (p=0.0077) distant metastatic sites than CI (36% vs. 21%). 18F-FDG PET/CT upstaged 9 (21.4%) of patients from clinical stage IIIa to stage IIIc, and changed management of 54% of patients. Thirty-eight percent (38%) of the patients had their clinical stage unchanged. One of 5 suspected metastatic sites 18F FDG PET/CT was positive for malignancy on biopsy. Conclusion: The 18F-FDG PET/CT is useful for staging locally advanced non-inflammatory infiltrating ductal carcinoma of the breast. Use of 18F-FDG PET/CT was superior to conventional imaging in assessing metastatic mediastinal lymphadenopathy, but with a poor specificity. The use of 18F-FDG PET/CT in LABC is useful, with the biopsy of isolated suspicious lesions for metastasis increasing its accuracy.

Background Primary radiochemotherapy with photons is the standard treatment for locally advanced-stage non-small cell lung cancer (NSCLC) patients. Acute radiation-induced side effects such as oesophagitis and radiation pneumonitis limit patients’ quality of life, and the latter can be potentially life-threatening. Due to its distinct physical characteristics, proton therapy enables better sparing of normal tissues, which is supposed to translate into a reduction of radiation-induced side effects. Methods/design This is a single-centre, prospective, randomised controlled, phase II clinical trial to compare photon to proton radiotherapy up to 66 Gy (RBE) with concomitant standard chemotherapy in patients with locally advanced-stage NSCLC. Patients will be allocated in a 1:1 ratio to photon or proton therapy, and treatment will be delivered slightly accelerated with six fractions of 2 Gy (RBE) per week. Discussion The overall aim of the study is to show a decrease of early and intermediate radiation-induced toxicity using proton therapy. For the primary endpoint of the study we postulate a decrease of radiation-induced side effects (oesophagitis and pneumonitis grade II or higher) from 39 to 12%. Secondary endpoints are locoregional and distant failure, overall survival and late side effects. Trial registration Registered at ClinicalTrials.gov with Identifier NCT02731001 on 1 April 2016.

Background Primary radiochemotherapy with photons is the standard treatment for locally advanced-stage non-small cell lung cancer (NSCLC) patients. Acute radiation-induced side effects such as oesophagitis and radiation pneumonitis limit patients’ quality of life, and the latter can be potentially life-threatening. Due to its distinct physical characteristics, proton therapy enables better sparing of normal tissues, which is supposed to translate into a reduction of radiation-induced side effects. Methods/design This is a single-centre, prospective, randomised controlled, phase II clinical trial to compare photon to proton radiotherapy up to 66 Gy (RBE) with concomitant standard chemotherapy in patients with locally advanced-stage NSCLC. Patients will be allocated in a 1:1 ratio to photon or proton therapy, and treatment will be delivered slightly accelerated with six fractions of 2 Gy (RBE) per week. Discussion The overall aim of the study is to show a decrease of early and intermediate radiation-induced toxicity using proton therapy. For the primary endpoint of the study we postulate a decrease of radiation-induced side effects (oesophagitis and pneumonitis grade II or higher) from 39 to 12%. Secondary endpoints are locoregional and distant failure, overall survival and late side effects. Trial registration Registered at ClinicalTrials.gov with Identifier NCT02731001 on 1 April 2016.

Determinar o valor prognóstico e preditivo do VEGF (vascular endothelial growth factor) e do HIF-1? (Hypoxia-inducible factor-1) em relação à sobrevida livre de doença (SLD) e sobrevida global (SG) em pacientes com carcinoma de mama localmente avançado (CMLA) tratadas primariamente pela quimioterapia neoadjuvante. MATERIAIS E METODOS: VEGF e HIF foram quantificados consecutivamente em plasma de 36 pacientes com CMLA pelo método de ELISA (enzyme labeling immunoassay absorbant) para o VEGF165 e o HIF-1?. O tratamento neoadjuvante foi realizado em todas as pacientes com docetaxel e epirrubicina. O tempo médio de seguimento foi de 56 meses. RESULTADOS: Uma análise univariada demonstrou que o HIF-1? está significantemente relacionado à SLD (P =.0238) e à SG (P = .0121) com as pacientes HER-2 positivas. Não houve diferença significante para a SLD ou SG no que diz respeito aos receptores de hormônio, comprometimento axilar ou grau tumoral. Os valores de VEGF foram maiores no grupo de pacientes RE+ do que no grupo RE negativo (P =.01). Inversamente os valores de HIF-1? foram menores no grupo RE+ comparados ao grupo RE - (P =.02). Pacientes com recorrência óssea apresentaram uma tendência a apresentarem valores de VEGF menores (media, 175.7 pg/ml) do que aquelas com recorrência visceral (441 pg/ml). Uma análise multivariada demonstrou o comprometimento axilar (P =.0004), receptores de estrógeno (ER) (P < .0001), e tamanho do tumor (P = .0085) como fatores independentes de SLD. O HIF-1? foi tido como um fator independente preditivo de SG (P =.0180). Não houve diferença estatisticamente significante entre os valores plasmáticos de HIF-1? ou VEGF nos períodos pré e pós quimioterapia. CONCLUSÕES: Os resultados sugerem que o nível plasmático do HIF-1? é preditivo de SLD e SG nas pacientes com CMLA apresentando uma sobreposição as pacientes HER-2 positivas. As dosagens de VEGF podem ser preditivas de resposta e prognóstico no tratamento neoadjuvante, mas são necessários novos estudos prospectivos comparados ao HIF-1? para conclusões mais consistentes.
To determine the predictive and prognostic value of vascular endothelial growth factor (VEGF) and Hypoxia-inducible factor-1 (HIF-1?) for relapse-free survival (RFS) and overall survival (OS) in locally advanced breast cancer (LABC) primarily submitted to neoadjuvant chemotherapy. MATERIALS AND METHODS: VEGF and HIF were quantitatively measured in plasma sample from 36 consecutive patients with LABC using an enzyme immunoassay for human VEGF165 and HIF-1?. Neoadjuvant treatment was given to all patients as docetaxel and epirrubicin. The follow-up median time was 56 months. RESULTS: Univariate analysis showed that HIF-1? is a significant predictor of RFS ( P = .0238) and OS (P = 0121) in HER-2 positive patients. No significant difference was seen in RFS or OS related to hormonal receptor, axillary status or tumoral grade. The VEGF level was higher in the group of patients who ER was positive than ER negative (P = .01). On the other hand, the HIF-1? level is higher in ER negative patients than ER positive ( P=.02). Patients with bone recurrences tended to have lower VEGF plasma level (median, 175.7 pg/ml) than patients with visceral metastasis (441 pg/ml). Multivariate analysis showed nodal status (P = .0004), estrogen receptor (ER) status (P < .0001), and tumor size (P = .0085) to be independent predictors of RFS. HIF-1? was found to be an independent predictor of OS (P = .0180). No statistically differences were observed related to pre and post chemotherapy period in HIF-1? or VEGF measurements. CONCLUSION: The results suggest that high level of plasma HIF-1? is associated to HER-2 over expression and they are major predictive factors of RFS and OS in LABC. VEGF content might also predict outcome after neoadjuvant treatment, however further studies in a prospective setting with HIF-1? homologous treatments are required.

Même si la néphrourétérectomie totale représente le traitement de référence des tumeurs de la voie excrétrice urinaire supérieure (TVEUS), il existe un risque élevé de récidive post-opératoire qui peut survenir soit au niveau de la vessie soit dans la loge de résection et/ou sur le plan systémique. L’objectif de ce travail était de caractériser ces différents modes évolutifs. En ce qui concerne la récidive intra-vésicale, une revue systématique de la littérature avec méta-analyse a permis d’identifier les principaux facteurs de risque à la fois cliniques et anatomopathologiques. Par ailleurs, une seconde analyse de cohorte suggère que, sur le plan biologique, cet événement pourrait être en rapport avec une mutation du gène FGFR3 identifiable à partir de l’ADN urinaire. En ce qui concerne la récidive locorégionale et métastatique, une relecture centralisée de lames de TVEUS classées pT3 a permis de proposer une sous-classification pronostique sur la base de l’étendu de l’envahissement du parenchyme rénal et/ou de la graisse péripyélique (pT3a vs. pT3b) afin de mieux adapter la prise en charge post-opératoire. Cependant, l’analyse d’un registre américain a montré que l’utilisation d’une chimiothérapie adjuvante pour le traitement des tumeurs localement avancées pT3-T4 et/ou pN+ serait associée à un bénéfice en termes de survie globale pour l’ensemble de ces patients. Enfin, l’étude préliminaire d’une large cohorte nationale de cas de TVEUS a permis de valider la technique de TMA avec des coupes de 2 mm au seuil de 5% pour l’analyse pronostique de l’expression de PD-L1 sur les cellules tumorales avec l’anticorps 28.8, et de l’expression de PD-1 sur les TILs avec l’anticorps NAT105
Although radical nephroureterectomy remains currently considered as the standard of care for upper tract urothelial carcinoma (UTUC), there is a high risk of postoperative recurrence, which can occur either within the bladder or the surgical field and/or distant sites. The aim of our study was to investigate and better characterize these events. With regards to intra-vesical recurrence, a systematic review and meta-analysis was conducted to identify all significant clinical and pathological predictors. Moreover, an additional cohort study suggested that, from a biological perspective, such an event could be related to the presence of the FGFR3 mutation detected from urinary DNA. With regards to locoregional and/or distant recurrence, a central pathology review of UTUC patients with pT3 disease showed that there may be a prognostic interest in stratifying these individuals based on the extent of local invasion (pT3a vs. pT3b) to propose a risk-adapted strategy for postoperative management. Nonetheless, an US hospital-based registry study revealed that all patients with pT3-T4 and/or pN+ UTUC could derive an overall survival benefit from adjuvant chemotherapy. Finally, a preliminary analysis from a large French cohort of UTUC patients established that the 2 mm TMA technique can be used to assess the prognostic interest of determining PDL1 expression on tumor cells with 28.8 antibody and PD-1 expression on TILs with NAT105 antibody, both at the 5% threshold for positivity

Neo-adjuvant chemo-radio therapy (pCRT) has been accepted as a standard care in the treatment of patients with locally advanced rectal cancer. The multimodality treatment has been established to improve tumour downstaging, pathological complete response, and local disease control. However, the response of individual tumors to the treament is not uniform and ranges from complete response to complete resistance. The discovery of new molecular markers that predict the tumour response is surely of wide interest for personalizing the therapy and reducing time, costs and side effects in the patients with resistant tumours. Many potential biomarkers have been evaluated in order to predict the response to pCRT, and to implement targeted therapeutics. However, single-marker or multi-markers analyses, based on pre-treatment tissue biopsies, often obtained conflicting results demonstrating the heterogeneity of the individual tumour response. Moreover, the prediction of histopathological response to neo-adjuvant treatment is complicated by the interaction and the involvement of the microenvironment in modulating the sensitivity to pCRT. In this study, we developed blood-based methods of biomarker analysis in order to evaluate the histopathological response to treatment in a broad contest that can take into account not only the signalling pathway of tumour cells but also the microenvironment as a part of a unique system. Indeed, the non-invasive nature and the dynamism for which different molecules could be detected according with physiological and pathological states has given us the possibility to monitor the response along the administration of the treatment. In particular, we focused on two different kind of circulating molecules: the cell-free DNA (cfDNA) and the circulating low molecular weight (LMW) peptides. In particular, we investigated the presence, the quantity of cfDNA and its integrity (cfDNA integrity = non apototic cfDNA / total cfDNA) along the chemo-radio treatment. For this purpose we measured the cfDNA concentration and cfDNA integrity in a prospective study of locally advanced rectal cancer patients plasma collected before the pCRT, after two weeks from initiation of the pCRT and after the pCRT. We evaluated the association of these markers with the histological response to the chemo-radio therapy, demonstrating a different kinetic of cfDNA integrity in association with the tumour response. Then we studied the LMW peptidome circulating in plasma, in order to find evidences of possible differences in the peptide profile that could reflect the tumour response. To overcome the technical difficulties in harvesting LMW species, we have employed the mesoporous chip-based technology, developed by the Nanomedicine Department of The Methodist Hospital Research Institute in Houston, Texas. This mesoporous device, in combination with matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF MS), allows the isolation and the detection of small peptides from the large proteins. We analyzed plasma of rectal cancer patients, with positive or negative response to the therapy, at the same time points as the cfDNA: before, during, after the chemo-radio therapy. Multivariate analyses of the LMW peptide profile at different time points identified combinations of peptides that revealed high discriminating capacity of the different tumour responses. In particular, before the pCRT, a pattern of five ionic species showed a sensitivity and a specificity of 80% and after the pCRT, a pattern of other five specific ionic species showed a sensitivity of 80% and a specificity of 85% to cluster patients on the basis of histopathologic response to pCRT. Moreover the identification of the amino acids sequences of the response-specific ionic species revealed the presence of protein fragments that could be directly or indirectly valuable for further investigation on the resistance mechanisms of the rectal tumour to the neo-adjuvant chemo-radio therapy
La radiochemioterapia neoadiuvante (pCRT) è un protocollo standard accettato per il trattamento di pazienti con cancro rettale localmente avanzato. Il trattamento preoperatorio multimodale è stato introdotto per la riduzione dello stadio del tumore, per l’aumento della risposta completa patologica e per il controllo locale della malattia. Tuttavia la risposta patologica al trattamento non è uniforme e varia da una risposta completa alla resistenza totale. La scoperta di nuovi marcatori molecolari in grado di predire la risposta del tumore è sicuramente di grande interesse al fine di personalizzare la terapia, riducendo così i tempi, i costi e gli effetti collaterali nei pazienti con tumori resistenti. Molti potenziali biomarcatori sono stati valutati con l’obiettivo di prevedere la risposta alla pCRT, e di attuare terapie mirate. Finora molti studi su singolo o multi-marcatore sono stati eseguiti prevalentemente su biopsie di tessuto pre-trattamento. I risultati ottenuti, tuttavia, erano spesso contrastanti dimostrando l'eterogeneità individuale della risposta tumorale al trattamento. Inoltre, la predizione della risposta istopatologica alla pCRT è complicata dall’interazione e dal coinvolgimento del microambiente che può modulare la sensibilità del tumore al trattamento. In questo studio, abbiamo sviluppato metodi di analisi di biomarcatori su sangue, al fine di valutare la risposta del tumore al trattamento in un contesto più ampio, che rende conto non solo dell’ambiente strettamente tumorale, ma che prende in considerazione anche il microambiente come parte di un sistema unico. Infatti, la natura non invasiva del materiale biologico analizzato e il dinamismo per cui molecole differenti possono essere rilevate secondo lo stato fisiologico e patologico dell’organismo, ci hanno permesso di monitorare la risposta lungo il tempo di somministrazione del trattamento. In particolare, ci siamo concentrati su due diversi tipi di molecole circolanti: il DNA libero da cellule (cfDNA) e i peptidi a basso peso molecolare (Low Molecular Weight, LMW). In particolare, abbiamo studiato la presenza, la quantità e l’integrità del cfDNA durante il trattamento radio-chemioterapico. A questo scopo abbiamo misurato la concentrazione e l'integrità del cfDNA (cfDNA integrity=cfDNA apoptotico/cfDNA totale) in uno studio prospettico di plasma di pazienti con carcinoma rettale localmente avanzato, raccolto prima della pCRT, dopo due settimane dall'inizio del trattamento e dopo la pCRT. Abbiamo valutato l'associazione di questi marcatori con la risposta istologica alla chemio-radio terapia, dimostrando la presenza di diversa cinetica nell’integrità del cfDNA, in associazione con la risposta tumorale. Nel plasma, abbiamo quindi studiato il peptidoma circolante a basso peso molecolare, al fine di trovare potenziali differenze nel profilo peptidico che potessero riflettere la risposta tumorale. Per superare le difficoltà tecniche nella rilevazione dei peptidi circolanti a basso peso molecolare, abbiamo utilizzato una strategia basata sull’esclusione dimensionale di un chip di silice mesoporosa (MSC), sviluppato dal Dipartimento Nanomedicina del The Methodist Hospital Research Institute di Houston, Texas. Questo dispositivo mesoporoso, in combinazione con l’utilizzo dello spettrometro di massa MALDI-TOF MS (Matrix-Assisted Laser Desorption/Ionization-Time Of Flight Mass Spectrometry), consente l'efficiente rimozione di grandi proteine e l'isolamento del peptidoma circolante da campioni di fluidi corporei. Abbiamo analizzato il plasma di pazienti con cancro rettale, prelevato in diversi tempi (prima, durante, dopo la chemio-radio terapia) e stratificati secondo la risposta positiva o negativa alla pCRT. L'analisi multivariata del profilo peptidico nei diversi tempi di analisi ha identificato combinazioni di peptidi che evidenziavano un’elevata capacità discriminante della risposta tumorale. In particolare, il modello di regressione logistica ha evidenziato, prima della pCRT, una combinazione di cinque specie ioniche capace di identificare i pazienti che non rispondono al trattamento, con una sensibilità e una specificità del 80%; mentre la stessa analisi con i campioni raccolti dopo la pCRT, ha identificato un'altra combinazione di cinque specie ioniche che evidenziano una sensibilità del 80% e una specificità del 85%. Inoltre, l'identificazione delle sequenze amminoacidiche di alcune tra le specie ioniche discriminanti la risposta alla pCRT, hanno rivelato la presenza di frammenti proteici che possono essere direttamente o indirettamente utili per ulteriori indagini sui meccanismi di resistenza del tumore rettale alla radio-chemio terapia neo-adiuvante

Fundamentos: La radioterapia (RT) neoadyuvante previa a la cirugía, ya sea la radioterapia de duración corta (RTDC) como la radioterapia de duración larga combinada con quimioterapia (QT) basada en 5-FU (QRTLD), es usada de forma rutinaria en el manejo del cáncer de recto localmente avanzado, con beneficios consistentes en el riesgo de recidiva local. Desafortunadamente, no se han podido demostrar mejorías en la supervivencia, especialmente en los casos tratados con cirugía radical en forma de una escisión mesorectal total (EMT). El riesgo de sobretratar a algunos pacientes y los posibles efectos secundarios a largo plazo han provocado a su vez dudas sobre el manejo con RT neoadyuvante, especialmente con QRTLD, en todos los pacientes con cáncer de recto localmente avanzado independientemente de su riesgo basal de recidiva local. Material y métodos: Revisión retrospectiva de una base prospectiva de pacientes con cáncer de recto cT3-T4 y/o cN+, tratados entre 1999 y 2014 con QRTLD basada en fluoropirimidinas orales y (en un 65%) oxaliplatino, seguido de EMT y QT adyuvante basada en 5-FU. Evaluamos factores pronóstico clínicos, radiológicos y patológicos para un mayor riesgo de recidiva local y de metástasis a distancia y una menor supervivencia libre de progresión (SLP) y supervivencia global (SG). Resultados: 203 pacientes fueron analizados. El riesgo de progresión precoz fue bajo y la mayor parte de pacientes procedieron a cirugía; hubo una EMT satisfactoria en el 89.7%. La tasa de infraestadiaje fue del 70.4% y el porcentaje de respuestas completas patológicas fue del 14.9%. No hubo ningún beneficio con la adición de oxaliplatino a la QRTLD. La tasa de recidivas locales fue del 8.3%. Los factores de riesgo para la recidiva local y para las metástasis a distancia fueron, con un valor variable para las dos situaciones, una EMT no exitosa, la calidad insuficiente del mesorecto, una resección R2, afectación del margen circunferencial radial (MCR) y del margen distal, no infraestadiaje, tumores pobremente diferenciados, regresión tumoral moderada o mínima, invasión perineural, afectación patológica linfática y una gran carga tumoral linfática. Los factores pronóstico clásicos como el estadio ypT ó ypN tuvieron mayor importancia que la regresión tumoral patológica. En el análisis multivariante, la afectación del MCR y la invasión perineural mantuvieron la significación. La cumplimentación de la QT adyuvante fue pobre, especialmente en los pacientes ancianos; menos de la mitad recibieron la dosis completa prevista. La SLP y SG a 5 y 10 años fue del 71.4% y 54.9% y del 75.4% y 62.4%, respectivamente. Los pacientes ancianos tuvieron una peor SLP y SG; ello estaba ligado a un aumento de las toxicidades graves no previsibles y una menor cumplimentación de la QRTLD y de la QT adyuvante. Los tumores mucinosos mostraron una respuesta muy pobre a la QRTLD. Factores significativos en el análisis multivariante para SLP y SG fueron una mayor edad, afectación del MRC, una EMT no exitosa y una gran carga tumoral linfática. Conclusiones: El pronóstico de los pacientes con un cancer de recto está determinado por dos factores competitivos: el riesgo de recidiva local y el de las metástasis a distancia. La identificación de los pacientes con un riesgo muy bajo de recidiva local, en donde el beneficio de la RT sea escaso depende de una exquisita estadificación con RMN y de un equipo quirúrgico especializado en la EMT. Un MRC libre y una EMT exitosa son los factores más importantes; los tumores rectales bajos y la carga linfática son también importantes. La QRTLD debería ser usada en los pacientes con una fascia mesorectal afecta clínica. El papel de la QT adyuvante es controvertido, aunque la cumplimentación es pobre. La QT neoadyuvante es una opción atractiva, especialmente en los pacientes con un mayor riesgo de metástasis a distancia. Por el contrario, otras opciones menos agresivas y mejor toleradas, como la RTCD, deberían ser usadas en pacientes ancianos o frágiles.
Background: Neoadjuvant radiotherapy previous to radical surgery, both as short-course radiotherapy (SCRT) and as long-course radiotherapy combined with 5-FU-based chemotherapy (LCRCT), is routinely used in the management of locally advanced rectal cancer, with consistent benefits in the reduction of the local relapse risk. Unfortunately, survival benefits have been elusive to demonstrate with this approach, especially in the setting of radical surgery in the form of total mesorectal excision (TME). Concerns about over-treating early-stage patients and of the possible long-term side effects have also cast more doubts in a blanket approach of treating all patients with neoadjuvant radiotherapy, especially with LCRT. Material and methods: Retrospective review of a prospective base of patients with cT3-T4 and/or N+ rectal cancer treated at our Institution between 1999 and 2014 with LCRCT and oral fluoropyrimidines and (in 65% of patients) oxaliplatin, followed by TME and adjuvant 5-FU-based chemotherapy. We report clinical, radiological and pathological prognostic factors for local relapse, distant metastases and long-term survival endpoints (disease-free survival (DFS) and overall survival (OS)) Results: 203 patients were analysed. The risk of early progression was small and most proceeded to surgery; a TME was done in 89.7%. The downstaging rate was 70.4% and the pathological complete response rate was 14.9%. No benefit was seen with the addition of oxaliplatin to LCRCT. Local relapse rate was 8.3%. Risk factors for local relapse and distant metastases were, to a varying degree for each situation, an unsuccessful TME, the unsatisfactory quality of the mesorectum, an R2 resection, involvement of the circumferential (CRM) and distal margins, no downstaging, poorly differentiated tumours, moderate or minimal regression, perineural invasion, pathological lymph node invasion and heavy lymph node burden. Classical pathological data such as ypT and ypN stage were better prognostic factors than tumour regression grading. In the multivariate analysis, CRM and perineural invasion retained their prognostic value. Compliance to adjuvant chemotherapy was poor, especially in elderly patients; less than half of patients received the full intended dose. 5- and 10-year DFS and OS were 71.4% and 54.9% and 75.4% and 62.4%, respectively. Elderly patients had an overall worse survival compared to younger patients; this was linked to higher unexpected toxicity and a lower compliance with LCRCT and adjuvant chemotherapy. Mucinous tumours showed a very poor response to LCRCT. Significant factors in the multivariate analysis for OS and DFS were older age, CRM involvement, an unsuccessful TME and a heavy lymph node burden. Conclusions: The prognosis of patients with locally advanced rectal cancer is determined by two competing factors: the risk of local relapse and the risk of distant metastases. The identification of patients with an extremely low risk of local relapse where radiotherapy would presumably offer little benefit is based on the premise of an exquisite imaging staging with MRI, supplemented with EUS, and a surgical team specialized in the TME procedure. A free CRM and a successful TME procedure are the most important factors; lower rectal tumours and a heavy lymph node burden are also important. In patients with invasion of the mesorectal fascia in the MRI, LCRCT should be used in order to lower the risk of a positive CRM. The role of adjuvant chemotherapy remains surprisingly undefined, although the compliance rates are poor in all published trials. Neoadjuvant chemotherapy is a possible option, especially in patients with a higher risk of distant metastases. On the other hand, other, better tolerated, options such as SCRT should be used in elderly or frail patients.

L’utilisation de systèmes informatiques pour formaliser, organiser et planifier le traitement des patients a abouti à la création et à l’accumulation de quantité importante de données. Ces informations comprennent des caractéristiques démographiques, socio-économiques, cliniques, biologiques, d’imagerie, et, de plus en plus, génomiques. La médecine et sa pratique, fondées sur la sémiologie et la physiopathologie, vont être profondément transformées par ce phénomène. La complexité et la quantité des informations à intégrer pour prendre une décision médicale pourrait dépasser rapidement les capacités humaines. Les techniques d’intelligence artificielle pourraient assister le médecin et augmenter ses capacités prédictives et décisionnelles. La première partie de ce travail présente les types de données désormais accessibles en routine en oncologie radiothérapie. Elle détaille les données nécessaires à la création d’un modèle prédictif. Nous explorons comment exploiter les données spécifiques à la radiothérapie et présentons le travail d’homogénéisation et de conceptualisation qui a été réalisé sur ces données, notamment via la création d’une ontologie, dans le but de les intégrer à un entrepôt de données. La deuxième partie explore différentes méthodes de machine learning : k-NN, SVM, ANN et sa variante, le Deep Learning. Leurs avantages et inconvénients respectifs sont évalués avant de présenter les études ayant déjà utilisé ces méthodes dans le cadre de la radiothérapie. La troisième partie présente la création d’un modèle prédictif de la réponse complète à la radiochimiothérapie (RTCT) pré-opératoire dans le cancer du rectum localement avancé. Cette preuve de concept utilise des sources de données hétérogènes et un réseau neuronal profond dans le but d’identifier les patients en réponse complète après RTCT qui pourraient ne pas nécessiter de traitement chirurgical radical. Cet exemple, qui pourrait en pratique être intégré aux logiciels de radiothérapie déjà existant, utilise les données collectées en routine et illustre parfaitement le potentiel des approches de prédiction par IA pour la personnalisation des soins
The use of Electronic Health Records is generating vast amount of data. They include demographic, socio-economic, clinical, biological, imaging and genomic features. Medicine, which relied on semiotics and physiopathology, will be permanently disrupted by this phenomenon. The complexity and volume of data that need to be analyzed to guide treatment decision will soon overcome the human cognitive abilities. Artificial Intelligence methods could be used to assist the physicians and guide decision-making. The first part of this work presents the different types of data routinely generated in oncology, which should be considered for modelling a prediction. We also explore which specific data is created in radiation oncology and explain how it can be integrated in a clinical data warehouse through the use of an ontology we created. The second part reports on several types of machine learning methods: k-NN, SVM, ANN and Deep Learning. Their respective advantages and pitfalls are evaluated. The studies using these methods in the field of radiation oncology are also referenced. The third part details the creation of a model predicting pathologic complete response after neoadjuvant chemoradiation for locally-advanced rectal cancer. This proof-of-concept study uses heterogeneous sources of data and a Deep Neural Network in order to find out which patient could potentially avoid radical surgical treatment, in order to significantly reduce the overall adverse effects of the treatment. This example, which could easily be integrated within the existing treatment planning systems, uses routine health data and illustrates the potential of this kind of approach for treatment personalization

La chimiothérapie néoadjuvante (CNA) est utilisée dans les cancers du sein agressifs ou localement avancés (CS). Au delà des bénéfices cliniques, elle représente une opportunité pour monitorer in vivo la sensibilité d’une tumeur à un traitement.A partir de l’analyse de sets de données de patients traités par CNA, nous souhaitons identifier des mécanismes associes à la résistance ou sensibilité au traitement. Dans la première partie, nous avons évalué des paramètres, cliniques, anatomopathologiques et transcriptomiques. Nous avons démontré que des éléments non explorés comme la présence d’embols après CNA revêtaient une information pronostique importante. Dans une 2ème partie, nous avons analysé l’impact de l’infiltrat immunitaire dans le cancer du sein, et avons décrit les changements observés entre des échantillons avant et après CNA. Nous avons montré que l’impact pronostique des TILs était différent avant et après CNA, et était opposé dans les CS triple négatif ou HER2-positif. Finalement, nous avons analysé l’impact des comédications pendant la CNA. Nous avons trouvé des effets positifs – via l’augmentation de l’infiltrat immunitaire et la réponse au traitement – et des effets négatifs avec des effets délétères dans certains sous groupes de patients. En conclusion, la situation néoadjuvante représente une plateforme pour générer et potentiellement valider des hypothèses de recherche. La mise à disposition de jeux de données de patients traités par chimiothérapie néoadjuvante constituerait une ressource majeure pour accélérer la recherche contre le cancer du sein
Neoadjuvant chemotherapy (NAC i.e. chemotherapy before surgery) is increasingly being used for aggressive or locally advanced breast cancer (BCs). Beyond clinical benefits, it represents an opportunity to monitor in vivo sensitivity to treatment. Based on the analysis of datasets of BCs patients treated with NAC, we aimed at identifying mechanisms associated with resistance or sensitivity to treatment.In the first part, we evaluated biological, clinical, pathological and transcriptomic patterns. We demonstrated that unexplored pathological features such as post-NAC lymphovascular invasion may carried an important prognostic information.In a second part, we analyzed impact of imune infiltration in BC and we described extensively the changes of tumor infiltrating lymphocytes (TILs) between pre and post-NAC samples. We showed that the prognostic impact of TILs was different before and after NAC, and was opposite in TNBC and HER2-positive BCs. Finally, we investigated the impact of comedications use during NAC. We found both positive effects - while enhancing immune infiltration and response to treatment - and negative effects with deleterisous oncologic outcomes in specific patients subgroups. In conclusion, the neoadjuvant setting represents a platform to both generate and potentially validate research hypotheses aiming at increasing the efficacy of treatment. The public release of real-life datasets of BC patients treated with NAC would represent a major resource to accelerate BC research

La Radiofrequenza è un metodo ablativo locale basata sulla coagulazione termica e denaturazione proteica. E 'stato ampiamente applicato in molti tumori solidi metastatici non operabili come fegato, polmone, della prostata, del rene, osso, seno, ghiandola surrenale e la milza, ma la sua applicazione nel cancro del pancreas è stata finora molto limitata. Il nostro gruppo ha recentemente dimostrato la fattibilità e la sicurezza della procedura nel tumore pancreatico localmente avanzato, con un tasso di complicanze del 24% e un tasso di mortalità del 2%. Tuttavia, con il miglioramento della curva di apprendimento, il tasso di complicanze si è dimezzato e la mortalità annullata. Anche se non era l'obiettivo primario del nostro studio, i dati sulla sopravvivenza hanno mostrato un OS mediana e un DSS mediana di 20 e 23 mesi, rispettivamente. Abbiamo cercato di analizzare i parametri immunologici dopo RFA di cancro al pancreas localmente avanzato. Questa ricerca è focalizzata sulla scoperta impatto immunologico di ablazione che spiegherebbe i suoi benefici di sopravvivenza. Sono stati arruolati tutti i pazienti sottoposti a RFA come primo step del trattamento. I parametri immunologici sono stati identificati in due categorie: subet cellulari e citochine. Dieci pazienti sono stati sottoposti RFA nel corso dello studio. I nostri dati suggeriscono una reazione sistemica alla procedura. Questa reazione è ipoteticamente diversa dal normale stress chirurgico o infiammazione perché abbiamo osservato una tendenza generale verso una diminuzione delle chemochine e sottopopolazioni cellulari ad attività immunosoppressiva. Questa prova è supportata da una stabilità di DN (Double negative) T linfociti e monociti, tendenza alla diminuzione di Tregs (T Regulators) e pDC (plasmocytoid Dendritic cells) che, nel cancro, esercitano un'attività immunosoppressiva. La produzione di chemochine, attraverso una reazione infiammatoria importante (vedi IL-6), un trend negativo di TGF-β e un trend positivo di IFN-γ, mostra un importante effetto sistemico e una tendenza alla diminuzione dell'attività immunosoppressiva.Inoltre i Temra (terminal Effector Memory), l'ultima fase della maturazione dei CD8 + , mostrano una tendenza verso una prolungata attività dopo la procedura, lasciando aperta la possibilità di un possibile effetto immunitario differente dalla normale reazione infiammatoria.In conclusione, questi dati rappresentano una prima caratterizzazione della risposta immunitaria generata dopo ablazione termica di un carcinoma pancreatico.
Radiofrequency is a local ablative method based on thermal coagulation and protein denaturation. It has been widely applied in many unresectable and metastatic solid tumours such as liver, lung, prostate, kidney, bone, breast, adrenal gland and spleen, but its application in pancreatic cancer has been very limited so far. Our group has recently shown the feasibility and safety of radiofrequency ablation (RFA) of locally advanced PDAC, with a 24% complication rate and a 2% mortality rate; however, along with the improvement of the learning curve, complications rate halved and mortality annulled. Although it was not the primary aim of our study, data on survival showed a median OS and a median DSS of 20 and 23 months, respectively, representing a promising result. We sought to analyse immunological parameters after RFA of locally advanced pancreatic cancer. This research is focused on exploring immunologic impact of ablation that would explain its survival benefits. Patients undergoing RFA as first step of treatment were enrolled. Immunological parameters were identified in two categories: cells subsets and cytokines. Ten patients underwent RFA as first-step procedure to treat cytologically proven locally advanced pancreatic cancer. .Our data suggest a systemic reaction to the procedure. This reaction is hypothetically different from normal surgical stress or inflammation because we observed a general trend towards a decrease of immunosuppressive chemokines or cells subset. This evidence is supported by a stability of DN (Double negative) T Lymphocytes and Monocytes, trend towards a decrease of Tregs (T regulators) and pDC (plasmocytoid dendritic cells) that, in cancer, exert an immunosuppressive activity. Chemokine production, towards an important inflammatory reaction (see IL-6), through a negative trend of TGF-β and a positive trend of IFN-γ, shows an important systemic effect and a trend in decreasing immunosuppressive agents. Furthermore TEMRA (termina effector memory), the last stage of CD8+ maturation, shows a trend toward a prolonged immunity activity weeks after the procedure, leading to a possible immunity effect either than a normal inflammatory response.In conclusion, these data represent a first characterization of the immunity response generated by pancreatic RFA.

碩士
臺灣大學
流行病學研究所
98
Although the concept and method of treating cancer have substantial improvement in recent years, there is limited improvement in treatment of esophageal cancer. Radical esophagectomy is still the mainstay for the resectable esophageal cancer, which provided the chance for long-term survival and better local control rate. However, the five-year survival is still low for esophagectomy, which is only 0~10%. Current trend of treatment in locally advanced esophageal cancer is tri-modality treatment (neoadjuvant chemoradiotherapy and surgery). Over ten randomized controlled tries have been conducted to elucidate the following question:” Is tri-modality treatment better than surgery alone?” However, as the results of these trials are not consistent the clinical decision-makers are puzzled. More importantly, one of reasons accounting for the discrepancy of results is attributed to the cross-over phenomenon of neoadjuvant therapy. The current thesis aimed to investigate this issue. We first generated the data from randomized controlled trials by using the simulation approach. We assessed the proportional hazard assumption of these trials by checking the cross-over of survival with time-dependent Cox regression model. We also tried to conduct a meta-analysis to get the pooled estimates by three categories in the light of presence of cross-over phenomenon. It is found that relative risk of death between two groups changed by different follow-up times. Only Walsh and Tepper’s study fitted the proportional hazard assumption. After using time-dependent Cox regression model, we found that we could divide the nine trials into three groups: no cross-over, positive cross-over and negative cross-over. The time dependent variables were not statistically significant in individual trial. However, in pooled analysis, the time-dependent interaction term was statistically significant in pooled negative cross-over group (p=0.027) and marginally statistically significant (p=0.10) in positive cross-over group. All results show that the hazard ratio of treatment group varied with time. We conclude it is inappropriate to use log-rank test or the time-independent Cox-regression model before testing whether the cross-over survival exists.

碩士
逢甲大學
生醫資訊暨生醫工程碩士學位學程
98
Patients who present with late stage disease, which is frequently locally advanced (LABC), will be treated initially with neoadjuvant chemotherapy to down-stage the disease, followed by surgery and post-operative therapies. Monitoring a patient’s response to neoadjuvant chemotherapy is usually undertaken by clinical examination, mammography and ultrasound. Unfortunately, there is a poor correlation between the histological appearances of the tumor and measurements obtained by physical examination, mammography or ultrasound. Techniques for magnetic resonance (MR) imaging of the breast have been evolving over the past decade. Now, it has been suggested that breast MRI is more accurate in the diagnosis of breast tumor. Furthermore, dynamic contrast-enhanced MRI (DCE-MRI) permits evaluation of tumor neovasculature, thereby allowing an assessment of the pathophysiological response to chemotherapy therapy, which occurs prior to any volume changes. In this study, we would like to determine whether early changes of pharmacokinetic parameters during neoadjuvant treatment can predict final clinicopathologic response using dynamic contrast enhanced MR imaging.

碩士
國立陽明大學
醫務管理研究所
107
Background Lung cancer has ranked the top mortality of cancer for seven years in Taiwan. About 13,488 new cases of lung cancer were diagnosed in 2016 in Taiwan, of which 80%-85% were classified as non-small cell lung cancer (NSCLC). Clinical trials show that immune checkpoint inhibitors, such as Nivolumab, Pembrolizumab and Atezolizumab, are effective treatment options for NSCLC patients. The objective of this analysis was to assess the cost-effectiveness of Nivolumab, Pembrolizumab and Atezolizumab compared with Docetaxel as the second-line treatment for patients with locally advanced or metastatic NSCLC patients previously treated by chemotherapy. Methods We developed a three state Markov model to evaluate the cost-effectiveness of the three new innovative immunotherapies with the most popular chemotherapy in Taiwan. The analysis was from the perspective of Taiwan national healthcare system perspective. We reconstructed individual patient data (IPD) from published clinical trials for overall survival (OS) and progression free survival (PFS) using a validated algorithm. Costs were collected from Taiwan's National Health Insurance Research Databases and two medical centers. Published utility values associated with each of the health states were used. 3.5% discount rate was applied to all the costs. The values of health outcomes were summarized as discounted quality adjusted life years (QALYs) and incremental cost effectiveness ratios (ICER) were calculated. In using a willingness-to-pay threshold that is based on Taiwan’s per capita GDP in 2017, price that would achieve cost-effectiveness was NT$2,221,930 per QALYs gained. Both deterministic and probabilistic sensitivity analyses were undertaken. Results Base case results show that patients treated with immunotherapies were associated with higher costs and higher survival times. The mean costs of Docetaxel, Pembrolizumab, Nivolumab and Atezolizumab were NT$457,549, NT$1,080,514, NT$1,254,861 and NT$1,582,202 respectively. The mean effectiveness of Docetaxel, Pembrolizumab, Nivolumab and Atezolizumab were 2.774, 3.728, 3.213, and 3.425 respectively. In addition, compared with Docetaxel, the incremental cost-effectiveness ratios (ICERs) of Pembrolizumab, Nivolumab and Atezolizumab were NT$652,998 per QALY, NT$1,817,770 per QALY and NT$1,727,968 per QALY, respectively. Conclusions Compare with Docetaxel, Pembrolizumab, Nivolumab and Atezolizumab three immune checkpoint inhibitors are cost-effective per the WHO criteria of three times GDP per capita for the treatment of advanced NSCLC at the current prices in the Taiwan health care setting. Reduced drug price, dose, or treatment duration may improve cost-effectiveness compared with Docetaxel. The further understanding of the real-world outcomes of the immunotherapies are required in order to find the optimal treatment strategies for NSCLC patients.

碩士
高雄醫學大學
醫務管理學研究所碩士在職專班
99
Purpose 1. Comparison of androgen deprivation therapy to androgen deprivation therapy with radiation therapy at the patient characteristics and hospital characteristics of the different medical treatment. 2. Comparison of androgen deprivation therapy to androgen deprivation therapy with radiation therapy at the cost difference. 3. Comparison of combined androgen deprivation therapy and differences in the effect of radiation therapy. 4. Androgen deprivation therapy to androgen deprivation therapy with radiation therapy Comparison of cost-effectiveness analysis Methods This study was retrospective secondary data analysis, form January 1997 to December 2008 between the diagnosis of primary prostate cancer patient and outpatient basis, Select the " androgen deprivation therapy "and" androgen deprivation therapy "for the study sample. The sources of this study, Mainly from the National Institutes of Health released the National Health Insurance Research Database, Of January 1997 to December 2008 detailed file of outpatient prescription treatment (CD) and hospital expenses detailed file list (DD) and the basic data file medical institutions, The statistical software package SPSS for Windows 14.0 Chinese, For data processing and analysis, Based on the framework and assumptions descriptive and inferential statistics, Using two-tailed test (two-tailed) of its P value to 0.05. Using chi-square test, independent sample t test, one factor ANOVA and survival analysis for data analysis and verification of hypotheses. Results The results showed, Prostate cancer patients in Taiwan to perform a single androgen deprivation therapy and androgen deprivation therapy and radiation therapy at a total of 124, Infer the end of the age of prostate cancer patients are mainly distributed in more than75 years of age. Currently patients androgen deprivation therapy and radiation therapy to the main medical center, And androgen deprivation therapy with radiation therapy 50% of the Taipei branch of androgen deprivation therapy significantly higher than that of a single branch in Taipei do not, The androgen deprivation therapy is 30.1% higher than the area south of androgen deprivation therapy with radiation therapy, Furthermore, Part of cost analysis, Direct costs of two treatments for two years and five years in significant differences, And total direct costs are also significant differences. The other effect analysis, Impact indicators referred to the number of complications, Survival time, outpatient visits and hospital days did not differ. Finally, cost-effectiveness analysis, both treatments may, the cost of outpatient treatment results are significantly different. Conclusions and suggestions Overall, for patient characteristics, hospital characteristics, and not in terms of branches found, androgen deprivation therapy with radiation therapy at the Medical Center, Taipei Branch and the main, Estimate shows north-south area treatment patients choose physicians of their choice or the way patients are very different, This study compared the androgen deprivation therapy and radiation therapy and androgen deprivation therapy cost , effectiveness and cost effectiveness of different, Found that both the total cost of treatment difference of about 23 million, However, no difference in treatment, nd cost-effectiveness analysis found that the average level of outpatient visits, androgen deprivation therapy with radiation therapy more than androgen deprivation therapy, Statistics show no difference between treatment. Its better than androgen deprivation therapy and radiation treatment of drug, addition cost analysis also showed that treatment costs less than a androgen deprivation therapy and radiation therapy. Select the end of the basic treatment for prostate cancer patients based on their conditions and will, Coupled with the clinical diagnosis of clinical specialist, However, this study found that treatment with different patients may cause the number of out-patient treatment costs and cost-effectiveness of different, This conclusion provides medical services, prostate cancer patients and their families to discuss their behavior decision-making principles, and propose that the unit can use the data of this study as a reference for the future allocation of medical resources to provide for appropriate and realistic Demand for payment standards.

Introduction: Pre-treatment abnormal lateral lymph nodes (LLNs) are present in approximately 20% of patients with locally advanced rectal cancer. Western treatment of LLNs consists of neoadjuvant (chemo)radiotherapy (nCRT) followed by total mesorectal excision (TME), meaning these nodes are not removed surgically. There is, however, potential benefit in performing an additional lateral lymph node dissection (LLND) as enlarged LLNs have been shown to be predictive for local recurrence. Furthermore, the impact on oncological outcomes when enlarged LLNs harbour malignant features is currently unknown. Therefore, the aims of this thesis were to investigate if patients benefit from an additional LLND after nCRT and to determine oncological outcomes when malignant features are present in enlarged LLNs. Methods: A multi-centre cohort study was conducted at six tertiary referral centres in the US, the Netherlands and Australia. All patients had locally advanced rectal cancer with enlarged LLNs with a short-axis of ≥5mm. Malignant features were defined as nodes with internal heterogeneity and/or border irregularity. Firstly, patients who underwent nCRT followed by TME (LLND-) were compared to those who underwent a LLND in addition to nCRT and TME (LLND+). Next, a systematic review and meta-analysis was performed on studies comparing LLND- versus LLND+. Finally, patients with and without malignant features were compared. Outcomes of interest were local recurrence-free survival (LRFS), distant metastatic-free survival (DMFS), disease-free survival (DFS), and overall survival (OS). Results: LLND+ patients (n=44) were younger with higher ASA-classifications and ypN-stages compared to LLND- patients (n=115). LLND+ patients had larger median LLNs short-axes and received more adjuvant chemotherapy (100 vs. 30%; p<0.0001). Between groups, LRFS was 97% for LLND+ versus 89% for LLND- (p=0.13). DFS (p=0.94) and OS (p=0.42) were similar. LLND was an independent significant factor for local recurrences (p=0.01) in the multi-variate analysis. Sub-analysis of patients who underwent long-course nCRT and had adjuvant chemotherapy (LLND- n=30, LLND+ n=44) demonstrated a higher LRFS for LLND+ patients (97% versus 84% for LLND-; p=0.04). DFS (p=0.10) and OS (p=0.11) were similar between groups. Seven studies were included in the systematic review. Five-year LRFS after LLND+ was improved (range 85-95%) compared to LLND- (43-89%; statistically significant in three studies). DFS was increased after LLND+ (range 61-74%) compared to LLND- (54-79%; significant in three studies). No study reported five-year overall survival benefit after LLND+ (range 72-80%; 69-91% for LLND-). In the analysis of malignant features, median LLNs short-axis was 7mm (range 5-28) for the complete cohort, of whom 60 patients (52%) had malignant features. LLNs with malignant features showed no difference in LRFS (p=0.20) but had worse DMFS (p=0.004) and OS (p=0.006) compared to those without malignant features. Cox regression analysis confirmed malignant features as an independent factor for DMFS. Conclusions: This thesis suggests that a LLND in addition to nCRT in locally advanced rectal cancer improves LRFS and DFS, and that malignant features present in enlarged LLNs are predictive for a worse DMFS. More high-quality studies are required to further explore the value of LLND and the role of malignant features in LLNs.
Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 2022

碩士
高雄醫學大學
臨床醫學研究所
100
Topic 1 Background and Objectives: This study is to evaluate the safety and efficacy of preoperative radiotherapy (RT), combined with bolus infusional 5-fluorouracil (5-FU) or oral capecitabine, in patients with locally advanced rectal cancer (LARC). Materials and Methods: Seventy-four patients were retrospectively analyzed. Twenty-seven patients were treated with 5-FU (350 mg/m2 IV bolus) and leucovorin (20 mg/m2 IV bolus) for 5 days/week during week 1 and 5 of RT. Forty-seven patients were treated with capecitabine (850 mg/m2, twice daily for 5 days/week). Both groups received the same RT course (45-50.4 Gy/25 fractions, 5 days/week, for 5 weeks). Patients underwent surgery in 6 weeks after completion of the chemoradiotherapy. Data of the observational study were collected. Results: Grade 3 or 4 toxicities occurred in 40.7% (5-FU) and 19.1% (capecitabine) of the patients (P = 0.044). Six patients in the 5-FU group (22.2%) and six patients in the capecitabine group (14%) achieved complete response. Primary tumor (T) downstaging were achieved in 51.9% (5-FU) and 69.8% (capecitabine) of the patients. The pathological ypT0-2 stage was 40.7% (5-FU) and 67.4% (capecitabine) (P = 0.028). Conclusions: In consideration of the better ypT0-2 downstaging rate, less severe toxicities, and no need for indwelling intravenous device on oral capecitabine regimen, the administration of oral capecitabine with RT may be a more favorable option in the neoadjuvant treatment for LARC. Topic 2 Background and Objectives: The objective of this study was to identify the efficacy and safety profile of preoperative helical tomotherapy in combination with oral capecitabine in Taiwanese patients with locally advanced rectal cancer, with the additional analysis on low-lying tumors (tumor located ≦ 5cm from the anal verge). Materials and Methods: Twenty-nine patients receiving treatment were retrospectively analyzed. All patients were treated with oral capecitabine (850 mg/m2 twice daily for 5 days/week) received the helical tomotherapy with 45 Gy in daily fractions of 1.8 Gy was delivered to the presacral space, regional lymph nodes and areas at risk for harboring microscopic disease. The dose was increased by a simultaneous integrated boost to 50.4 Gy to the gross tumor. Patients underwent surgery in 6-8 weeks after completion of the chemoradiotherapy. Data of the observational study were collected and the results were compared with the previous literature. Results: Grade 3 or 4 acute toxicities occurred in 10.3% of the patients. Diarrhea was the most frequently encountered toxicity in the study (72.4%). Except one patient who declined the operation, 28 patients received surgery after chemoradiotherapy. Of the 22 patients who had distal rectal cancer (≦ 5cm from anal verge), 19 patients received sphincter-sparing operation (anal preserving rate = 86.4%). Pathological tissue regression grade 2-4 was noted in 23 patients (82.1%). Four patients (14.3%) achieved pathological complete response. Primary tumor (T) and node (N) down-staging were achieved in 67.9% and 53.6% of the patients. Eighteen patients (64.3%) achieved ypT0-2N0 stage. Grade 3 or 4 late morbidity occurred in 14.3% of the patients. Better function outcome of the intestine after restoring the bowel continuity was noted in the present study in comparison with the treatment results of preoperative capecitabine plus 2-dimentional radiotherapy in the same hospital. Conclusions: In consideration of the better ypT0-2N0 rate and a better functional outcome after restoring the bowel continuity, oral capecitabine in combination with helical tomotherapy provides an alternative option in LARC other than conventional chemoradiotherapy.

碩士
高雄醫學大學
醫學研究所
100
The incidence of colorectal cancer (CRC) in Taiwan has been rapidly increasing in the past few years, and CRC is the second most common cancer and also the third leading cause of cancer death in Taiwan. For locally advanced rectal cancer (T3-4 or N1-2), preoperative chemoradiotherapy (CCRT) has been demonstrated to achieve a lower local recurrence rate and good sphincter preservation rate. Several prospective and retrospective analyses suggest that pathological stage of disease after preoperative CCRT has a significant prognostic impact on disease-free and overall survival. In particular, the subgroup of patients who achieve a complete pathological response has a very low risk of local or distant recurrence. Traditionally, it is usually depends on TNM stage to determine whether patient receives preoperative CCRT or not. This proposal is aimed to discover clinical factors that can increase the power to predict the efficacy of preoperative CCRT.