Photobiomodulation for prevention of oral mucositis in patients submitted to hematopoietic stem cell transplantation : comparison of two clinical protocols

Orientador: Manoela Domingues MartinsDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: A mucosite oral (MO) é um dos efeitos adversos de maior impacto para o paciente submetido ao Transplante de Células Progenitoras Hematopoéticas (TCPH). A Fotobiomodulação (FBM) tem sido empregada para prevenção e tratamento de MO em pacientes submetidos ao TCPH, sendo que vários estudos indicam aplicações diárias de irradiação com laser diodo, de forma contínua, com um comprimento de onda em torno de 660 nm e densidade de energia entre 2 e 8 J/cm2. No entanto, um dos fatores limitantes associado com os protocolos atuais de FBM é a necessidade de aplicações diárias, o que envolve a disponibilidade de profissionais treinados, gerando um aumento significativo no custo-efetividade para serviços de saúde que oferecem essa terapia. Diante disso, o objetivo do presente estudo foi avaliar o efeito preventivo de dois protocolos de FBM que variavam no número de sessões (três vezes/semana ou diário) na ocorrência de MO e avaliar os fatores de risco relacionados à incidência e severidade de MO em pacientes submetidos ao TCPH. Noventa e nove pacientes submetidos ao TCPH foram divididos em dois grupos de acordo com o protocolo de FBM: Grupo 1 (FBM aplicada 3 vezes/semana usando um laser diodo de onda contínua com comprimento de 660 nm, diâmetro de ponto de 0.04cm2, irradiância de 1 W/cm2, potência de 100 mW, densidade de energia de 6 J/cm2, e tempo de exposição de2,4 segundos/ponto, resultando em um total de energia de 0,24 J/ponto) e Grupo 2 (FBM aplicada 7 vezes/semana usando um laser diodo de onda contínua com os mesmos parâmetros utilizados para o grupo 1, exceto pelo potência que foi de 40 mW e o tempo de exposição que foi de 6 segundos/ponto, resultando também em um total de energia de 0,24 J/ponto). Dados demográficos e clínicos (doença de base, tipo de transplante, tipo de condicionamento e tipo de profilaxia para prevenção da Doença do Enxerto Contra o Hospedeiro (DECH)), o grau de MO de acordo com a classificação da Organização Mundial da Saúde (OMS), contagens de leucócitos totais e plaquetas, níveis de marcadores de função hepática (transaminase glutâmico-oxalacética (TGO), transaminase glutâmico-pirúvica (TGP) e bilirrubina) e de marcadores de função renal (creatinina e ureia) foram coletados dos prontuários médicos. Nossos resultados mostraram que não houve diferença na média de MO entre os dois protocolos de FBM usados (p=0,34) e que o protocolo de 3 vezes/semana foi tão eficaz quanto o protocolo de 7 vezes/semana. Independentemente do protocolo de FBM usado, pacientes que foram submetidos a transplante alogênico, que receberam condicionamento prévio ao TCPH com regimes contendo irradiação corporal total (ICT) (12 Gy), bussulfano + ciclofosfamida (BuCi) e metotrexato (MTX) tiveram maior incidência e severidade de MO. Mielossupressão e função renal comprometida também foram consideradas fatores de risco para MO. Concluindo, nosso estudo indica que um protocolo de FBM de 3 vezes/semana é tão eficaz quanto um protocolo de 7 vezes/semana na prevenção de MO em pacientes submetidos a TCPHAbstract: Oral mucositis (OM) is one of the adverse effects of greater impact for the patient submitted to Hematopoietic Stem Cell Transplantation (HSCT). Photobiomodulation (PBM) has been used as one effective preventive protocol for OM in HSCT patients and several studies indicate daily applications of a continuous-wave diode laser with a wavelength around 660 nm and energy density between 2 and 8J/cm2. Nevertheless, one of the main limiting factors associated with the current protocols of PBM is the necessity of daily application of therapy, which involves the availability of trained professionals, generating a significant increase in cost-effectiveness for health services that offer this therapy. Thus, the aim of this study was to evaluate the preventive effect of two PBM protocols that varied in the number of sessions (three times/week or daily) in the occurrence of OM and evaluate the risk factors related to the incidence and severity of OM in patients undergoing HSCT. Ninety-nine patients submitted to HSCT were enrolled. The patients were divided in two groups according to the PBM protocol: Group I (Three PBM sessions weekly using a continuous-wave diode laser at a wavelength of 660 nm, spot size of 0.04 cm2, irradiance of 1 W/cm2, power output of 100 mW, energy density of 6 J/cm2, and exposure time of 2.4 seconds per point, resulting in 0.24 J total radiant energy per point) and Group II (Daily PBM sessions using the same continuous-wave diode laser at the same settings used for Group I except power output was 40 mW and exposure time was 6 seconds, resulting in 0.24 J total radiant energy per point). Demographic and clinical data (baseline disease, type of transplant, type of conditioning and type of prophylaxis against Graft Versus Host Disease (GVHD)), the degrees of OM according to the classification of the World Health Organization (WHO), absolute leukocytes and platelet count, levels of liver function markers (Glutamic-oxalacetic transaminase (GOT), Glutamic-pyruvic transaminase (GPT) and bilirubin) and renal function markers (creatinine and urea) were collected in the medical records. Our results revealed that there were no differences in the OM average between the two PBM protocols used, and that the three times/week protocol was as effective as the daily protocol. Independently of PBM protocol used, patients that received allogeneic transplant, conditioning previous HSCT with regimens containing total body irradiation (TBI) (12Gy), busulfan + cyclophosphamide (BuCy) and Methotrexate (MTX)-containing regimens have high incidence and severity of OM. Myelosuppression and impaired renal function were also considered risk factors for OM. In conclusion, our study indicates that a three times/week FBM protocol is as effective as a daily protocol for the prevention of OM in patients undergoing HSCTMestradoEstomatologiaMestra em EstomatopatologiaCAPE

TGF-β1 and its association with clinicopathological features, proliferative activity and prognosis in oral squamous cell carcinoma : an immunohistochemical study

Introduction: The prognostic value of transforming growth factor beta-1 (TGF-ß1) in oral cancer remains unclear. Therefore, the aim of this study was to evaluate TGF-β1 expression in oral squamous cell carcinoma (OSCC) samples and its association with clinicopathological data, tumor proliferative activity, and patients’ prognosis. Methods: A total of 68 patients with histopathological diagnosis of OSCC were included, as well as 9 cases of normal oral mucosa for comparison purposes. The OSCC sample was categorized according to patients’ outcomes in favorable prognosis (n=30) or unfavorable prognosis (n=38). Immunohistochemical staining for TGF-β1 and Ki-67 were performed. The slides were semi-quantitatively and quantitatively evaluated for TGF-β1 and Ki-67, respectively. Results: TGF-β1 was significantly increased in OSCC compared to normal oral mucosa (<0.01). An inverse correlation was found between TGF-β1 and Ki67 staining in OSCC (p=0.01). No association was found between TGF-β1 expression and OSCC clinicopathological features, prognosis or survival. Conclusions: TGF-β1 had no prognostic value and appears to maintain its suppressive role concerning cell proliferation

TGF-β1 and its association with clinicopathological features, proliferative activity and prognosis in oral squamous cell carcinoma: An immunohistochemical study

Introduction: The prognostic value of transforming growth factor beta-1 (TGF-ß1) in oral cancer remains unclear. Therefore, the aim of this study was to evaluate TGF-β1 expression in oral squamous cell carcinoma (OSCC) samples and its association with clinicopathological data, tumor proliferative activity and patients’ prognosis. Methods: Sixty-eight patients with histopathological diagnosis of OSCC were included, as 9 cases of normal oral mucosa for comparison purposes. OSCC sample was categorized according to patients’ outcomes in favorable prognosis (n=30) or unfavorable prognosis (n=38). Immunohistochemical staining for TGF-β1 and Ki-67 was performed. The slides were semi-quantitatively and quantitatively evaluated for TGF-β1 and Ki-67, respectively. Results: TGF-β1 was significantly increased in OSCC compared to normal oral mucosa (<0.01). An inverse correlation was found between TGF-β1 and Ki67 staining in OSCC (p=0.01). No association was found between TGF-β1 expression and OSCC clinicopathological features, prognosis or survival. Conclusion: TGF-β1 had no prognostic value and appears to maintain it’s suppressive role concerning cell proliferation.   Keywords: Head and neck neoplasms; prognosis; transforming growth factor

Correlação da imunomarcação de TGF-β1 com proliferação celular em carcinomas espinocelulares de boca com diferentes prognósticos

O carcinoma espinocelular (CEC) representa cerca de 95% dos casos de câncer de boca e, mesmo com os avanços nos últimos anos, ainda apresenta altas taxas de mortalidade. Muitos fatores de crescimento já foram relacionados com o aumento da capacidade de invasão e progressão em diversos sítios tumorais, dentre eles, o Fator Transformador de Crescimento Beta-1 (TGF-ß1). TGF-β1 é uma citocina que desempenha um duplo papel na carcinogênese. Parece atuar como inibidor da proliferação celular nas fases iniciais, mas, em estágios mais avançados, pode contribuir para o crescimento tumoral e invasão dos tecidos. O objetivo do presente estudo foi analisar a imunomarcação do TGF-β1 como marcador prognóstico de CEC de boca, além de correlacioná-la com aspectos clínicos, demográficos e com o perfil proliferativo do tumor, determinado pela expressão de KI-67. Foram selecionados os prontuários médicos de 74 pacientes com diagnóstico histopatológico de CEC diagnosticados no Serviço de Patologia do Hospital de Clínicas de Porto Alegre (HCPA), atendidos no período de janeiro 2001 a dezembro de 2009. Os prontuários foram avaliados manualmente e foram coletadas informações quanto aos dados demográficos, fatores de risco, características clínicas do tumor, tratamento e sobrevida. Os casos foram separados em 34 pacientes com prognóstico favorável (sobrevida maior que 5 anos) e 40 pacientes com prognóstico desfavorável (sobrevida menor que 5 anos). Além disso, foram incluídos 9 casos de mucosa bucal com aspecto de normalidade, provenientes de casos de mucocele, para fins de comparação. Foram realizadas a graduação histológica dos tumores e as reações imunoistoquímicas para TGF-ß1 e Ki-67. A existência de associação entre as variáveis independentes e os desfechos foi avaliada por meio dos testes qui-quadrado, Kruskal-Wallis e Anova. Foram construídas as curvas de sobrevida pelo método de Kaplan-Meyer. Em todos os testes foi utilizado o software SPSS 19 e o nível de significância estabelecido foi de 5%. De todos os CEC analisados, 43,2% dos casos apresentaram marcação positiva em mais de 50% das células para o TGF-β1. Não houve diferença estatística na marcação de TGF-β1 relacionada com prognóstico e com graduação histopatológica, porém foi observado um aumento do TGF-β1 em CEC quando comparado à mucosa bucal normal. O índice de marcação do Ki-67 em CEC com prognóstico favorável foi de 49,85 (± 16,34) e de 51,16 (± 19,91) com prognóstico desfavorável. Foi encontrada diferença entre os escores mais altos (1 e 2) de TGF- β1 e menor média de Ki-67 (p= 0,01), assim como entre o tipo de tratamento e maior tempo de sobrevida (p=0,01). Conclui-se que o TGF-β1 e o Ki-67 estão altamente expressos nos CEC de boca em comparação com a mucosa normal, contudo não podem ser relacionados com o prognóstico dessas lesões. No entanto, TGF-β1 está associado com uma diminuição da taxa de proliferação celular em CEC de boca.Oral squamous cell carcinoma (OSCC) represents about 95% of cases of oral cancer and even with advances in recent years still has high mortality rates. Many growth factors have been associated with increased of invasion ability and tumor progression in various places, among them, the Transforming Growth Factor beta-1 (TGF-ß1). TGF-β1 is a cytokine that plays a dual role in carcinogenesis. It seems to act as an inhibitor of cell proliferation in the early stages, but, at later stages, can contribute to tumor growth and invasion of tissue. The aim of this study was to evaluate the immunohistochemistry of TGF-β1 as a prognostic marker of OSCC, and to correlate with clinical, demographic and proliferative tumor profile, determined by the expression of KI-67. The medical records of 74 patients were selected with histopathological diagnosis of OSCC diagnosed in pathology service of Hospital de Clínicas de Porto Alegre (HCPA), treated between January 2001 to December 2009. The records were manually evaluated and information was collected regarding demographic data, risk factors, clinical features of the tumor, treatment and survival. The cases were separated in 34 patients with good prognosis (survival higher than 5 years) and 40 patients with poor prognosis (survival less than 5 years). In addition, it was included 9 cases of oral mucosa with normal aspect, from Mucoceles cases, for comparison purposes. Histologic grading of tumors and immunohistochemical reactions for TGF-ß1 and Ki-67 was performed. The presence of association between independent variables and the outcome was evaluated using the chisquare test, Kruskal-Wallis and ANOVA. The survival curves were made using the Kaplan- Meyer method. In all tests we used the SPSS 19 software and the level of significance was 5%. In all OSCC analyzed, 43.2% of the cases showed positive labeling of TGF-β1 in more than 50% of the cells. There was no statistical difference in TGF-β1 marking related to prognosis and histological grade, however there was an increase in the TGF-β1 labeling in OSCC compared to normal oral mucosa. The labeling index of Ki-67 in CEC with a favorable prognosis was 49.85 (± 16.34) and 51.16 (± 19.91) with poor prognosis. Difference was found between the highest scores (1 and 2) of TGF-β1 and lower average Ki-67 (p = 0.01), as well as between the type of treatment and longer survival time (p = 0.01). We conclude that TGF- β1 and Ki-67 are highly expressed in the OSCC compared to normal oral mucosa, but they may not be related to the prognosis of these lesions. However, TGF-β1 is associated with a decrease in cell proliferation rate in OSCC