结直肠癌新辅助治疗的疗效评价及相关基因/蛋白的表达与意义

【作者】 邱兴；

【导师】 赵洪川；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2012， 硕士

【摘要】 研究背景结直肠癌是最常见的消化系统恶性肿瘤之一,有研究表明其发病率正在逐年上升。新辅助化疗作为综合性治疗最重要的组成部分收到越来越多的关注。虽然对结直肠癌有众多的评价方法,包括广泛采用的实体瘤评价方法RECIST标准,但对结直肠癌而言,却缺乏统一的、有针对性的、行之有效的评价体系及标准。而日益成熟的分子诊断技术为我们提供了一条崭新的道路。若能找到预测新辅助治疗疗效的特异性的分子标志物,将可能对新辅助化疗的疗效评价及治疗产生深远的影响。目的临床研究通过对结直肠癌新辅助治疗患者临床病理等资料的分析,探讨新辅助化疗患者的特点、疗效评价、预后及相关因素。实验研究应用免疫组织化学方法,通过单因素和多因素统计分析,探讨TGOLN2和ZNF84在结直肠癌组织的表达情况及其与患者临床病理资料的关系；探讨TGOLN2、ZNF84、MMP-9、MMP-14、VEGFC、CTHRC1、 IRS-1七个蛋白在结直肠癌新辅助化疗病人前后的表达情况及其与患者基线资料和新辅助治疗疗效的关系。对象与方法研究纳入2003年1月至2011年6月在中日友好医院住院并符合入选条件的全部结直肠癌患者共1791例。临床研究选取其中行新辅助化疗的患者92例,通过单因素分析、配对T检验、二元非条件Logistic回归分析、Kaplan-Meier法、Cox单因素及多因素回归,探讨新辅助治疗的疗效评价指标及其对患者预后的影响。实验研究第一部分选取其中生存期大于5年或生存期小于2年的患者136例,探讨TGOLN2和ZNF84的表达情况及其与患者临床资料的关系；实验研究第二部分选取可以获得新辅助治疗前后结直肠癌病理标本的患者18例,探讨七个蛋白的在新辅助化疗前后的表达及其与新辅助治疗疗效和患者临床资料的关系。结果临床研究的结果提示：行新辅助化疗的患者中,临床表现缓解的占63.0%,血CEA缓解的占13.1%,原发灶大小缓解的占33.6%,浸润深度缓解的占13.0%。综合评价,按照制定的疗效评价标准,在这92例新辅助治疗的患者中,最终结果为有效的患者有63例(占68.5%),无效的为29例(占31.5%)。通过对各项评价指标灵敏度、特异度、阳性预测值、阴性预测值、正确率、约登指数、kappa值的再评价,提示浸润深度(即T分期)是其中最好的评价指标。新辅助化疗会对患者的中性粒细胞计数、红细胞计数、血红蛋白、血小板计数、谷丙转氨酶、血清肌酐、白蛋白、甘油三酯、肿瘤最大径等指标发生影响。二元Logistic回归分析提示影响新辅助化疗有效的指标包括血钠值(OR1.252,95%CI1.042-1.505,P=0.016)；血糖值(OR0.730,95%CI0.540-0.986,P=0.040)和肿瘤发病部位的不同(OR5.490,95%CI1.574-19.149,P=0.008)。Cox多因素分析提示转移淋巴结个数(RR1.340,95%CI1.058-1.697,P=0.015)可能是新辅助治疗患者预后独立的危险因素。实验研究第一部分的结果提示：TGOLN2在结直肠癌组织中的表达高于癌旁(P<0.001),ZNF84无明显差异(P=0.825)；ZNF84的阳性表达与患者的性别(P=0.053),血压(P=0.022),血管癌栓(P=0.041)有关,Logistic回归结果提示高血压(OR5.699,95%CI1.428-22.744,P=0.014)可能为影响ZNF84表达的独立相关因素。将136例患者按照生存期大于5年或生存期小于2年分组后进行单因素分析发现,患者年龄(P=0.021)、癌组织的分化程度(P<0.001)、淋巴结转移(P<0.001)和远处转移(P<0.001)可能对预后有影响；多因素分析提示肿瘤分化程度(OR0.847、95%CI0008-0.847、P=0.036)和远处转移(OR0.033、95%C10.003-0.352、P=0.005)为影响预后的独立相关因素。实验研究第二部分的结果提示：IRS-1(P=0.023)、TGOLN2(P=0.028)在新辅助治疗前癌组织的表达大于新辅助治疗后,ZNF84(P=0.576)、MMP-14(P=0.710)、MMP-9(P=0.151)、VEGFC (P=0.779)、CTHRC1(P=0.626)蛋白的表达无明显差异。单因素分析的结果提示,TGOLN2可能与病程的长短(P=0.017)、呼吸次数(P=0.012)以及CA199(P=0.026)相关；MMP-14可能与呼吸次数(P=0.001)、中性粒细胞计数(P=0.008)相关;CTHRC1在与红细胞计数(P=0.003)、血红蛋白(P=0.048)、血小板计数(P=0.045)、总胆红素(P=0.004)和血糖(P=0.018)相关；MMP-9可能与血钠(P=0.036)相关。结论：92例行新辅助治疗的患者中,评价有效的患者为69例(占75.0%),浸润深度(即T分期)可能是评价新辅助化疗疗效较好的的指标；血钠、血糖和肿瘤发病部位可能是影响新辅助化疗疗效的三个独立相关因素;TGOLN2在结直肠癌组织中的表达高于癌旁(P<0.001),ZNF84无明显差异(P=0.825)；是否合并高血压可能为影响ZNF84阳性表达的独立相关因素；IRS-1和TGOLN2在新辅助化疗前的表达高于新辅助治疗后,可能作为判断新辅助化疗疗效的参考指标。更多还原

【Abstract】 BackgroundColorectal cancer is the most malignant tumors in digestive system. Neoadjuvant chemotherapy has received more and more attention, as a comprehensive treatment of tumors. Although there are so many ways to evaluate colorectal cancer, including RECIST which has widely used, there is lack of evaluation system and standards of colorectal cancer which is unified, targeted, and effective. And the increasing sophisticated molecular diagnostic technique provides us with a new way. If specific molecular markers were found to predict the efficacies of neoadjuvant therapy, it will lead far-reaching effect on evaluation and treatment of neoadjuvant chemotherapy.PurposeClinical research:we analyzed the clinical and pathological data of neoadjuvant therapy patients with colorectal cancer to explore the characteristics, efficacy evaluation, prognosis and the related factors in neoadjuvant chemotherapy patient. Experimental study:We used immunohistochemistry method and statistical analysis to explore the expression of TGOLN2and ZNF84in colorectal cancer and the relationship of clinic pathological data and to explore the expression of TGOLN2, ZNF84, MMP-9, MMP-14, VEGFC, CTHRC1and IRS-1in colorectal cancer of neoadjuvant chemotherapy patients and the relationship between the patients’base data and the effect of neoadjuvant therapy.MethodsA total of1791colorectal cancer patients, hospitalized in China-Japan Friendship Hospital, in the period of January2003and June2011, were studied. And92patients who used the neoadjuvant chemotherapy were selected in clinical study. Univariate analysis, paired T-test, and binary non-conditional logistic regression analysis, the Kaplan-Meier method, Cox single factor and multivariate regression were used to explore the efficacy evaluation effect of neoadjuvant therapy and the impact on the prognosis of patients. On the first part of the experimental study, a total of136patients, more than the5-year survival of less than2-year old, were selected to explore the expression of TGOLN2and ZNF84and its relationship of the clinical data. The second part of the experimental study, a total of18colorectal cancer patients who can be obtained pathology specimens of before and after neoadjuvant therapy, were chosen to explore the expression of the seven relative proteins on before and after neoadjuvant chemotherapy, and the relationship of the neoadjuvant treatment efficacy and patient clinical data.ResultsClinical research:The new adjuvant chemotherapy in patients with clinical remission accounted for63%, blood CEA remission for13.1%, primary tumor size in remission for33.6%, the depth of invasion accounted for13%.Overall merit:According to the curative effect evaluation, in these92neoadjuvant therapy patients, effective for63cases (68.5%), invalid for29patients (31.5%). The evaluation sensitivity, specificity, positive predictive value, negative predictive value, the correct rate, youden index, the re-evaluation of the kappa value, suggesting that infiltration depth (T stage) is one of the best evaluation. The neoadjuvant treatment may impact neutrophil count, red blood cell count, hemoglobin, platelet count, alanine aminotransferase, serum creatinine, albumin, triglycerides and maximum tumor size. Serum sodium (OR1.252,95%CI1.042-1.505, P=0.016); blood glucose levels (OR0.730,95%CI0.540-0.986, P=0.040) and different parts of the tumor incidence (OR5.490,95%CI1.574-19.149, P=0.008) could impact the effective of neoadjuvant treatment by using binary logistic regression analysis. Cox multivariate analysis indicated that the metastatic lymph node number (RR1.340,95%CI1.058-1.697, P=0.015) may be independent prognostic risk factors of patients with neoadjuvant therapy.The first part of experimental study:Higher than that of expression of TGOLN2in colorectal cancer, Para neoplastic (P<0.001), the ZNF84no significant difference (P=0.825); of ZNF84the positive expression of the patient’s gender (P=0.053), blood pressure (P=0.022).vascular tumor thrombus (P=0.041), logistic regression results suggest that hypertension (OR5.699,95%CI1.428-22.744, P=0.014) may affect ZNF84expression was independently associated factors. Univariate analysis found136patients in accordance with the survival of greater than5year survival of less than2years grouping, patient age (P=0.021), the degree of differentiation of cancer tissue (P<0.001), lymph node metastasis (P <0.001) and distant metastasis (P<0.001) may affect the prognosis; Multivariate analysis showed that the degree of tumor differentiation (OR0.847,95%CI,0008-0.847, P=0.036) and distant metastasis (OR0.033,95%CI0.003-0.352, P=0.005) for prognostic factors independently associated.The second part of experimental study:IRS-1(P=0.023), TGOLN2(P=0.028) after neoadjuvant therapy in the neoadjuvant therapy before the cancer tissues than ZNF84(P=0.576) and MMP-14(P=0.710) and MMP-9(P=0.151), VEGFC (P=0.779), CTHRC1(P=0.626) protein expression was no significant difference. Univariate analysis, the results suggest that TGOLN2possible with the length of the course (P=0.017), respiratory rate (P=0.012) and CA199(P=0.026); MMP-14may be associated with respiratory rate (P=0.001), neutral granulocyte count (P=0.008); CTHRC1with the red blood cell count (P=0.003), hemoglobin (P=0.048), platelet count (P=0.045), total bilirubin (P=0.004) and glucose (P=0.018); MMP-9may be associated with serum sodium (P=0.036).ConclusionsIn92neoadjuvant therapy patients, the effective one with63cases (68.5%), infiltration depth (T stage) may be the better indicators to evaluate the efficacy of neoadjuvant chemotherapy. Sodium, glucose, and tumor diseased parts may be the three separate factors affecting the efficacy of neoadjuvant chemotherapy. The expression of TGOLN2in colorectal carcinoma was higher than that in adjacent (P<0.001), and the expression of ZNF84had no significant difference (P=0.825). Hypertension may be the independent factors on the positive expression of ZNF84expression. The expression of IRS-1, and TGOLN2before neoadjuvant chemotherapy was higher than that after neoadjuvant therapy, before neoadjuvant chemotherapy was higher than that of neoadjuvant therapy.And it may be used as a reference index to determine the efficacy of neoadjuvant chemotherapy更多还原