【作者】 黄永明；

【导师】 刘金文；

【作者基本信息】 广州中医药大学 ， 中医骨伤科学， 2009， 博士

【摘要】 骨肉瘤是常见的恶性程度极高的骨源性肿瘤,其发生、发展与机体免疫系统密切相关。恶性骨肿瘤病人通常伴有免疫抑制或损害,机体的免疫状态对骨肿瘤的发展、转归具有重要作用。随着保肢技术、综合化疗方案的应用及化疗剂量的增大骨肉瘤疗效有了显著的提高,但是,手术和化疗后易发生复发和耐药性。同时,化疗药除杀死肿瘤细胞外,对机体的免疫功能有较强的打击作用,从而严重影响疗效,甚至危及生命,因而提高骨肿瘤患者机体的免疫功能对于骨肿瘤的治疗显得十分重要。中医药在增强肿瘤患者机体免疫功能方面具有独特的作用,扶正培本法是医治疗恶性肿瘤的重要法则之一,尤其对机体免疫功能调节方面作用明显。本研究拟通过扶正培本中药加味六味地黄汤对恶性骨肿瘤化疗期间多项免疫指标的变化,分析恶性肿瘤病人的免疫状态,并研究其联合细胞因子诱导杀伤细胞（cytokines-induced killer,CIK）抗骨肉瘤细胞的作用,为骨肉瘤免疫治疗的有效证据。目的:1.评估骨肉瘤化疗前后外周血淋巴细胞多项免疫指标的变化;2.观察加味六味地黄汤对骨肉瘤化疗前后免疫调节作用;3.观察不同来源的CIK细胞及其与DC共培养后的扩增及表型情况,4.测定不同来源CIK细胞抗骨肉瘤细胞及骨肉瘤耐药细胞的作用;5.明确六味地黄汤含药血清对CIK细胞的诱导、增殖作用;6.测定六味地黄汤含药血清诱导扩增CIK细胞体外抗骨肉瘤作用。方法:1.采用流式细胞术检测104例骨肉瘤化疗病人的外周血T淋巴细胞抗原（CD3、CD4、CD8）,B淋巴细胞抗原（CD19、CD20）,NK细胞（CD16+56）等免疫指标变化;2.将104例骨肉瘤化疗患者分为中药治疗组、空白组、免疫治疗对照组,采用流式细胞仪检测治疗前后免疫指标的变化,以明确化疗对骨肉瘤患者免疫功能的影响及扶正固本法下组方加味六味地黄汤对骨肉瘤化疗患者的免疫调节作用;3.通过扩增来源于骨肉瘤患者和正常献血者的CIK细胞,使用来源骨肉瘤患者的肿瘤裂解物,负载DCs,以和CIK细胞共培养,经流式细胞仪检测扩增的CIK细胞增殖情况,和经⁵¹Cr细胞毒性分析检测扩增的CIK细胞细胞毒性活性;4.观察六味地黄汤含药血清对CIK细胞的增殖、细胞表型的作用,MTT显色法测定中药含药血清扩增CIK细胞体外抗骨肉瘤的毒活性。结果:1.骨肉瘤患者化疗后CD₃⁺、CD₄⁺、CD₈⁺分子水平及CD₄⁺/CD⁸⁺之比显著低于化治疗前（P＜0.01）,化疗使患者的Γ细胞数量明显减少,抑制性T细胞亚群显著性增多,骨肉瘤患者的细胞免疫功能显著性下降。骨肉瘤患者化疗前后CD19、CD20的水平比较有明显下降（P＜0.05或P＜0.01）,经T10方案化疗后,骨肉瘤患者的体液免疫也会受到抑制。2.经加味六味地黄汤治疗后,骨肉瘤患者的CD₃⁺和CD₈⁺的分子水平有显著性升高（P＜0.01）,而CD₄⁺的分子水平及CD₄⁺/CD₈⁺之比有增高但不明显（P＞0.05）,中药能使骨肉瘤化疗患者T细胞及其亚群数量增多,但免疫的球蛋白的功能改善不明显,其有一定增强患者的免疫功能的作用。经中药干预后,患者的CD19、CD20的水平有了显著性升高（P＜0.05或P＜0.01）,说明中药不但可提高骨肉瘤患者的免疫细胞水平,还能提高患者体液免疫水平。3.患者化疗期间采用欣吉尔治疗后,CD₄⁺、CD₃⁺的分子水平有升高,但不明显（P＞0.05）,CD₄⁺/CD₈⁺的比值有显著性升高（P＜0.01）,说明欣粒生具有一定改善骨肉瘤患者免疫功能的作用。经欣吉尔干预后,患者的CD19、CD20的水平有一定升高,但前后比较无统计分意义（P＞0.05）,欣吉尔对患者体液免疫水平作用有限。4.患者和正常献血者均成功诱导出CIK细胞,正常献血者的CIK细胞增殖和细胞毒性都略高于骨肉瘤患者。随着效靶比增加,每组中CIK细胞的细胞毒性也逐渐增加,不管正常献血者还是患者,与肿瘤裂解物负载的DCs共培养的CIK细胞的增殖和细胞毒性明显高于单独培养的CIK细胞（P＜0.05）。全部细胞的CD3⁺CD56⁺共表达在整个培养过程均明显增加。而且CIK细胞对骨肉瘤耐药性细胞有着强大的细胞毒性。5.单纯含中药六味地黄汤血清难以诱导出CIK细胞;含中药六味地黄汤血清联合细胞因子培养的CIK增殖倍数明显要高于无药血清和无血清培养的（P＜0.05）,而含药血清中剂量的CIK增殖速度高于低和高剂量血清培养的;流式细胞仪检测各组培养的CIK细胞表型,发现含药血清低剂量（2%）对CIK细胞表达CD3⁺CD56⁺双阳性最好,明显高于其他各组培养的CIK细胞,其中单纯含药血清中剂量培养对CIK细胞表达CD3⁺CD56⁺无较大作用。含药血清低剂量（2%）联合细胞因子的CIK细胞对骨肉瘤细胞的抑瘤作用明显强于各组的CIK细胞（P＜0.05）。结论:1.化疗会引起骨肉瘤病人的免疫功能降低。2.加味六味地黄汤及欣吉尔（IL-2）可激活骨肉瘤患者T淋巴细胞,提高患者的免疫功能,加味六味地黄汤可提高骨肉瘤患者细胞及体液免疫功能,而欣吉尔主要提高骨肉瘤患者的细胞免疫功能,对体液免疫功能影响较小。3.CIK细胞的体外增殖力及对骨肉瘤细胞的杀伤活性与机体状态有关,CIK细胞对骨肉瘤细胞及骨肉瘤耐药细胞的杀伤活性存在量效及时效关系,CIK细胞与肿瘤裂解物负载的DCs共培养后,有着更强的细胞毒性活性。4.单纯的六味地黄汤无法诱导出正常的CIK细胞,中药六味地黄汤可促进CIK细胞增殖,尤以中剂量为佳,低剂量中药组联合细胞因子诱导的CIK细胞表型最为稳定,联合CIK细胞具有更强杀死骨肉瘤细胞的作用,CIK可有效应用于骨肉瘤临床的免疫治疗。更多还原

【Abstract】 Osteosarcoma is a common bone tumor which has very high malignant.The occurrence and development of osteosarcoma correlates closely with immune system of the body.Patients with malignant bone tumor frequently have immune inhibition or damage.Immune condition of body has improtant role to development and improvement of bone tumor.With remarkable improvement of surgery,application of synthesis chemotherapy schemes and increasing of chemotherapy drugs’ bid,effect of osteosarcoma has promoted evidently.However,Osteosarcoma succumbs to relapse and durg-resistance after surgery and chemotherapy.Meanwhile,chemotherapy drugs damage to immune ability greatly besides skilling tumor cells,so influence curious effect seriously and threat human life.Therefore,increasing immune functions of osteosarcoma patients is very improtant to therapy of osteosarcoma.Traditional Chinese Medicines have unique roles on enhanced immune functions of tumor patients.The principle of reinforcing the vital energy and consolidating the constitution is one of improtant rules of TCM curing malignant tumor,in particular,the body regulatory roles of immune functions significantly.This study undestood changes on immune indexs among chemotherapy of osteosarcoma patients by using Chinese herbs（Liuwei Dihuang （LW） Decoction）,and analyzed immune condition of patients.Here the paper studied cytokines-induced killer（CIK） against osteosarcoma cells in vitro,so as to obtain efftective evident of immunotherapy on osteosarcoma patients.Objects:1.Assessed change of many immune indexes from peripherial blood lymphocytes before and after chemotherapy of osteosarcoma patients;2.Observed immune regulatory roles of Liuwei Dihuang（LW） Decoction before and after chemotherapy of osteosarcoma patients;3.Observed amplification and phenotype of CIK cells from different sources and the CIK cells after co-culture with dendritic cells（DC）;4.Studied the cytotoxic activity against osteosarcoma cells and osteosarcoma durg-resistance cells by CIKs from different sources;5.Defined the induce and proliferation of CIK cells using Liuwei Dihuang（LW） Decoction;6.Studied the cytotoxic activity against osteosarcoma cells by CIKs in vitro that were induced by using drug serum of Liuwei Dihuang（LW） Decoction.Methods:1.The study detected T lymphocytes antigens（CD3,CD4,CD8）,B lymphocytes antigens（CD19,CD20） and NK cells（CD16+CD56） deriving from peripherial blood of 104 osteosarcoma patients by flow cytometry;2.104 osteosarcoma patients divided into TCM therapy group,blank group and immune therapy control.It detected changes of immune indexes before and after therapy by using flow cytometry,and defined influence of immune functions of osteosarcoma patients and immune regulatory roles of Chinese herbs（Liuwei Dihuang（LW） Decoction） to osteosarcoma patients;3.The study expanded CIK cells from osteosarcoma patients and normal donors,and pulsed dendritic cells（DCs） by using tumor lysis from osteosarcoma patients.CIK cells co-cultured with DCs.The proliferation of expanded CIK cells was detected by Flow Cytometry.The cytotoxic activity of expanded CIK cells was tested with ⁵¹Cr cytotoxic method;4.The study observed proliferation and cell phenotypes of CIK cells by using drug resum of Liuwei Dihuang（LW） Decoction.The cytotoxic activity of expanded CIK cells was tested with MTT method.Results:1.The level of CD₃⁺,CD₄⁺,CD₈⁺and CD₄⁺/CD₈⁺ after chemotherapy of osteosarcoma patients were evidently lower than before chemotherapy（P＜0.01）.The chemotherapy of patients made T cells reduce.The inhibitive T cells increased evidently.The cell immune functions of osteosarcoma patients reduced evidently.The level of CD19 and CD20 reduced evidently before and after chemotherapy of osteosarcoma patients（P＜0.05 or 0.01）.The humour immune also were inhibited in osteosarcoma patients by T10 chemotherapy scheme.2.The level of CD₃⁺ and CD₈⁺ of osteosarcoma patients increased evidently after therapy of Liuwei Dihuang（LW） Decoction（P＜0.01）.The level of CD₄⁺ and CD₄⁺/CD₈⁺ increased but didn’t evident（P＞0.05）.Chinese herbs can increase T cells and sub-population,but immune globins didn’t evidently improve,and promote immune functions of osteosarcoma patients.The level of CD19 and CD20 increased evidently by therapy of chinese herbs（P＜0.05 or 0.01）.It is showed that chinese herbs can not only improve the levelof immune cells of osteosarcoma patients,but also increase the level of humour immune.3.The level of CD₄⁺ and CD₃⁺ increased but didn’t evident（P＞0.05） by using IL-2 during the period of chemotherapy.The ratio of CD₄⁺/CD₈⁺ increased evidently（P＜0.01）.It is showed that IL-2 can improve immune functions of osteosarcoma patients.The level of CD19 and CD20 also increased by therapy of IL-2 and didn’t statistical significant（P＞0.05）.It is showed that IL-2 was limited to humour immune.4.Both groups were successfully induced to CIK cells.The proliferation rate and cytotoxicity of the normal donors-CIK （ND-CIK） were slightly stronger than the osteosarcoma patients-CIK（OS-CIK）. Cytotoxicity of CIK cells from each group increased progressively along with increasing of the effect target density ratio.The proliferation and cytotoxicity of CIK cells co-cultured with tumor lysate-puling DCs were evidently higher than CIK solely in two groups regardless of normal and patients（P＜0.05）.The CD3⁺CD56⁺ co-expression of all CIK cells increased greatly among total culture.Furthermore the cytotoxicity of CIK against osteosarcoma drug-resistance cell was very strong.5.Drug resum of Liuwei Dihuang（LW） Decoction didn’t induce CIK cells sololy.The proliferation folds of CIK cells by using drug resum of Liuwei Dihuang（LW） Decoction were higher evidently than by using non-drug resum and non resum（P＜0.05）.The proliferation rates of CIK cells by using drug resum at middle bid were higher than low bid and high bid.The CIK cells phenotype was the best of CD3⁺CD56⁺ co-expression in drug resum at low bid（2%） which evidently higher than CIK cells of other groups.CIK cells didn’t promote coexpression of CD3⁺CD56⁺ in drug resum at middle bid.The cytotoxicity of CIK against osteosarcoma cell line OS-732 in drug resum at low bid（2%） was stronger than other groups（P＜0.005）.Conclusion:1.Chemotherapy could reduce immune ability of osteosarcoma patients;2.Liuwei Dihuang（LW） Decoction and immune therapy（IL-2） can active T lymphocytes and increase immune function of patients.Liuwei Dihuang（LW） Decoction can improve the levelof immune cells of osteosarcoma patients and the level of humour immune.IL-2 can improve immune functions of osteosarcoma patients and be limited to humour immune 3.It indicated that the proliferation and cytotoxicity of CIK cells are related to organism condition in vitro.CIK should exist effectiveness in clinical therapy of osteosarcoma.4.Drug resum of Liuwei Dihuang（LW） Decoction didn’t induce normal CIK cells sololy.Liuwei Dihuang（LW） Decoction can promote proliferation of CIK cells,especifically drug resum at middle bid.The phenotype in drug resum at low bid were most steady.The cytotoxicity of CIK against osteosarcoma cell line in drug resum at low bid was the strongest.CIK cells could apply for clinical therapy of osteosarcoma effectively.更多还原