【作者】 王晓妍；

【导师】 曹志群；

【作者基本信息】 山东中医药大学 ， 中医内科学， 2013， 博士

【摘要】 目的：通过文献回顾及临床研究，提出中晚期胃癌的常见证型（脾胃虚损瘀毒内蕴证）及其辨证要点，并对其相应治法进行文献研究。通过观察以“健脾消瘀”法为基础组方的昆参颗粒对大鼠胃组织病理的影响，以及对胃癌大鼠P53蛋白、C-myc蛋白及NF-κB表达的影响，探讨昆参颗粒防治胃癌的作用机制。方法：1.证型及治法研究：本文分别对1979年1月～2011年11月间公开发表文献，以及506例中晚期胃癌患者临床资料进行统计学分析，总结出中晚期胃癌常见证型。进一步对脾胃虚损瘀毒内蕴证患者病例资料进行分析，得出此证型的辨证要点及其与临床客观指标的相关性。分别对健脾养胃法及活血解毒法治疗中晚期胃癌的文献进行Meta分析，研究其临床疗效。2.实验研究：将Wistar大鼠随机分为正常组、模型组、参莲胶囊组、昆参大剂量组和昆参小剂量组。除正常组外，其余各组采用“MNNG+乙醇+氯化钠”的综合方法复制胃癌大鼠模型，共61周。第50周各组随机抽取7只大鼠，观察造模进展情况，除正常组外，各组大鼠开始给予药物干预。药物干预完毕后，于第61周取所有大鼠胃，留取胃组织切片。观察各组大鼠胃粘膜病理形态的改变，采用免疫组化法检测各组大鼠胃癌组织P53蛋白、C-myc蛋白及NF-κBp65的表达。结果：1.文献回顾研究：中晚期胃癌常见中医证型为脾胃虚损型、瘀毒内阻型、气血两亏型、肝胃不和型、胃热伤阴型。临床研究：中晚期胃癌的常见证型为脾胃虚损瘀毒内蕴证、心脾气血两虚证、脾虚痰湿凝结证、肝胃不和证、胃热伤阴证。以上研究表明脾胃虚损瘀毒内蕴证是中晚期胃癌的最常见证型。脾胃虚损瘀毒内蕴证的辩证要点包括：①主症：神疲懒言、体倦乏力、食少纳呆、胃脘刺痛、脉络瘀血、舌紫暗或青紫、苔薄、脉沉弱；②次症：腹胀、面色萎黄、肌肤甲错、便溏、苔白或腻、脉细；③兼症：恶心呕吐、大便不畅、黑便、苔厚、脉滑。与客观指标的相关性研究表明，肿瘤病变部位、病程、Borrmann分型、组织分化程度、TNM分期、肿瘤浸润深度、肿瘤标志物（CA72-4、CA19-9、CEA）、Karnofsky评分、QLQ-C30生活质量评分等指标可作为脾胃虚损瘀毒内蕴证的客观评价指标。Meta分析表明健脾养胃法和活血解毒法是治疗中晚期胃癌的有效方法。3.实验研究结果：①胃粘膜病理改变：昆参大剂量组大鼠胃癌发生率明显低于模型组，存在统计学差异（P＜0.05）。昆参大剂量组大鼠胃粘膜萎缩和异型增生的发生率较低，与模型组比较存在显著统计学差异（P＜0.01）。昆参小剂量组大鼠胃粘膜萎缩发生率明显低于与模型组，存在统计学差异（P＜0.05）。②P53蛋白：正常组P53蛋白表达弱，模型组表达强烈，两者存在显著统计学差异（P＜0.01）。与模型组相比，昆参大、小剂量组及参莲胶囊组大鼠胃癌组织P53蛋白表达较弱，存在显著统计学差异（P＜0.01），且昆参大、小剂量组组间存在显著统计学差异（P＜0.01）。昆参大剂量组P53蛋白表达明显低于参莲胶囊组，存在显著统计学差异（P＜0.01）。③C-myc蛋白：正常组C-myc蛋白表达弱，模型组表达强烈，两者存在显著统计学差异（P＜0.01）；与模型组相比，昆参大、小剂量组及参莲胶囊组大鼠胃癌组织C-myc蛋白表达较弱，存在显著统计学差异（P＜0.01），且昆参颗粒大、小剂量组组间存在显著统计学差异（P＜0.01）。昆参颗粒大剂量组与参莲胶囊组比较无统计学差异（P＞0.05）。④NF-κB p65：正常组NF-κB p65表达弱，模型组表达强烈，两者存在显著统计学差异（P＜0.01）；与模型组相比，昆参大、小剂量组及参莲胶囊组大鼠胃癌组织NF-κB p65表达较弱，存在显著统计学差异（P＜0.01），昆参大、小剂量组组间存在显著统计学差异（P＜0.01）。昆参大剂量组大鼠胃癌组织NF-κB p65表达低于参莲胶囊组（P＜0.05）。结论：1.脾胃虚损瘀毒内蕴证为中晚期胃癌最常见的证型。脾胃虚损瘀毒内蕴证的辩证要点包括：①主症：神疲懒言、体倦乏力、食少纳呆、胃脘刺痛、脉络瘀血、舌紫暗或青紫、苔薄、脉沉弱；②次症：腹胀、面色萎黄、肌肤甲错、便溏、苔白或腻、脉细；③兼症：恶心呕吐、大便不畅、黑便、苔厚、脉滑。肿瘤病位、病程、分型、分期、浸润深度、肿瘤标志物、生活质量评分等指标可作为脾胃虚损瘀毒内蕴证的客观评价指标。2.以“健脾消瘀”为法组方的昆参颗粒能显著降低MNNG诱发的大鼠胃癌的发生发展，其作用机制可能是通过抑制P53蛋白、C-myc蛋白以及NF-κB异常表达，从而抑制肿瘤细胞增殖。更多还原

【Abstract】 Object: Through literature review and clinical research, to propose the commonsyndrome (spleen deficiency and toxin resistance type) and dialectical points of theadvanced gastric cancer, and to study its corresponding treatments. Kunshen Granule wasmade based on the treatment “invigorating the spleen and removing stasis”. Throughobserving the influence of Kunshen Granule on gastric tissue of rats with pathology,and theexpression of the P53、C-myc protein and nuclear transcription factor (NF-κB) of gastriccancer in rats, to study the mechanism of action of Kunshen Granule on prevention andtreatment of gastric cancer.Methods:1. Study on the syndrome and treatment: In this paper, retrievalling thepublished literature from2011.1to1979.9and506cases of advanced gastric cancer werestatistically analyzed to find the common syndromes of advanced gastric cancer. Furtheranalysis the case information of spleen deficiency and toxin resistance type to find out theclinical dialectical main points and the correlation with clinical indexes. Meta-analysis ofspleen and nourishing the stomach and activating blood detoxification method treatmentsfor advanced gastric cancer,to study its clinical curative effects.2. Experimental Study:Wistar rats were separated into five groups at random, normal group, model group,Shenlian capsule group, Kunshen high dose group and Kunshen low dose group.Except thenormal group,all groups used the comprehensive method “MNNG+ethanol+sodiumchloride” to replicate models of gastric cancer in rats, a total of61weeks.In the fiftiethweeks,7rats were randomly selected from all groups to observe the mold development.Except the normal group, rats in other groups were treated with drug. Drug intervention after sixty-first weeks, all rats specimens from gastric biopsy. Firstly, morphologicalobservation of gastric mucosa pathological changes of rats in each group, then detecte theexpression of P53protein, C-myc protein and nuclear factor-κB p65byimmunohistochemistry in rat gastric carcinoma.Result：1. Reviewing the Literature: Common syndrome types of advanced gastriccancer are Deficiency of the spleen and stomach type,Stasis toxin resistance type,Qi andblood deficiency type,Liver stomach disharmony and Stomach yin deficiency type.Clinical Study: Common syndrome types of advanced gastric cancer are Spleen deficiencyand Toxin resistance type,Qi and blood deficiency type,Spleen dampness condensationtype,Phlegm coagulation type and Stomach yin deficiency type. Strengthening the spleenand stomach and Huoxue Jiedu are effective methods in the treatment of advanced gastriccancer. These studies show that the most common syndrome type of advanced gastriccancer is Spleen deficiency and Toxin resistance type. The dialectical points of spleendeficiency and toxin resistance type include:①primary symptom: spiritlessness、feeble、anorexia、epigastric pain、blood stasis、purplish tongue、moss thin and forceless deep pulse;②secondary symptom: abdominal distension、sallow complexion、squamous and dry skin、loose stool、white and greasy fur、thready pulse;③accompanied symptom: nausea andvomiting、astriction、melena、coating thickness、slippery pulse. The objective evaluationindex are the position and course of disease、Borrmann type、the degree of histologicaldifferentiation、TNM stage、depth of tumor invasion、CA72-4、CA19-9、CEA、Karnofskyscore and QLQ-C30score of life quality. Meta-analysis of the literature shows thatnourishing the stomach and activating blood detoxification method are effective methodsin the treatment of advanced gastric cancer.3.Experimental Study:①Pathological changesin gastric mucosa: Gastric cancer incidence of Kunshen large dose group was significantlylower than that in the model group, there was significant difference(P<0.05). Gastricmucosa atrophy and dysplasia incidences of Kunshen large dose group were lower,compared with the model group, there were significant differences(P<0.01). Gastricmucosa atrophy incidence of Kunshen low dose group was lower than that of model group,there was significant difference(P<0.05).②P53protein: The expression of P53protein innormal group was weak, model group expressed strong, there was significant differencebetween the two groups(P<0.01). Compared with the model group, Kunshen large, lowdose group and Shenlian capsule group P53protein in gastric cancer were weakly expressed, there was significant difference(P<0.01),and there was significant differencebetween Kunshen large and low dose groups(P<0.01).The expression of P53protein ofKunshen large dose group was significantly lower than the Shenlian capsulegroup(P<0.01).③C-myc protein: The expression of C-myc protein in normal group wasweak, model group expressed strong, there was significant difference between the twogroups(P<0.01). Compared with the model group, Kunshen large, low dose group andShenlian capsule group C-myc protein in gastric cancer were weakly expressed, there wassignificant difference(P<0.01),and there was significant difference between Kunshen largeand low dose groups(P<0.01). there was no significant difference between Kunshen largedose group and Shenlian capsule group(P>0.05).④NF-κB p65:The expression of NF-κBp65in normal group was weak, model group expressed strong, there was significantdifference between the two groups(P<0.01). Compared with the model group, Kunshenlarge, low dose group and Shenlian capsule group NF-κB p65in gastric cancer wereweakly expressed, there was significant difference(P<0.01),and there was significantdifference between Kunshen large and low dose groups(P<0.01).The expression of NF-κBp65of Kunshen large dose group was significantly lower than the Shenlian capsule group(P<0.05).Conclusion：1. The most common syndrome type of advanced gastric cancer isSpleen deficiency and Toxin resistance type. The dialectical points of spleen deficiencyand toxin resistance type include:①primary symptom: spiritlessness、feeble、anorexia、epigastric pain、blood stasis、purplish tongue、moss thin and forceless deep pulse;②secondary symptom: abdominal distension、sallow complexion、squamous and dry skin、loose stool、white and greasy fur、thready pulse;③accompanied symptom: nausea andvomiting、astriction、melena、coating thickness、slippery pulse. The objective evaluationindex are the position and course of disease、type、stage、depth of tumor invasion、tumormarkers、score of life quality.2. Kunshen Granule can significantly reduce the incidence ofgastric cancer induced by MNNG in rats, its mechanism is possibly through inhibitingthe expression of abnormal P53protein, C-myc protein and nuclear transcription factorNF-κ B, thereby inhibiting the proliferation of tumor cells.更多还原