本文選題：骨髓增生異常綜合征 + 較低危��； 參考：《浙江大學》2017年碩士論文

【摘要】：目的研究基因突變對較低危骨髓增生異常綜合征(MDS)患者的臨床意義以及構建較低危MDS患者的分子預后模型。方法本研究回顧性分析浙江大學醫(yī)學院附屬第一醫(yī)院自2009年1月1日至2016年10月30日期間住院治療的較低危(低�；蛑形�-1)MDS患者的臨床資料,包括年齡、性別、血常規(guī)、骨髓原始細胞比例、骨髓增生程度、網(wǎng)狀纖維染色分級、染色體核型、WHO分型等。從骨髓單個核細胞提取的DNA通過Sanger和高通量測序 15 項 MDS 相關基因,包括 DNMT3A、SF3B1、SRSF2、IDH1、IDH2、ASXL1、EZH2、JAK2、TET2、CBL、ETV6、TP53、NRAS 和 RUNX1;比較各基因突變型、野生型的上述臨床資料特征,并統(tǒng)計分析各基因突變之間的相關性。單因素分析各基因突變型與野生型以及不同突變位點在總生存時間(OS)上有無統(tǒng)計學差異。對本隊列患者進行較低危MDS預后評分系統(tǒng)(LR-PSS)模型的驗證。多因素分析LR-PSS以及各基因突變的相對危險度。篩選出有統(tǒng)計學意義的基因突變,并嘗試整合LR-PSS模型和基因突變結果構建新的預后模型-LR-PSSM 模型。結果本研究共納入176例較低危MDS患者,中位隨訪時間和中位總生存時間分別為38.1、15.0個月,中位發(fā)病年齡為57歲,男女比例為1.29(99/77)。異常核型檢出率為19.3%(34/176),染色體聯(lián)合基因突變檢測的克隆證據(jù)檢出率為51.7%(91/176)。突變頻率較高的基因依次為 SF3B1(13.1%,21/160)、TET2(12.5%,7/56)、U2AF1(10.4%,17/163)、ASXL1(9.5%,7/74)、TP53(7.0%,5/71)、RUNX1(6.7%,4/60)、SRSF2(6.3%,11/174).比較基因突變型、野生型的各臨床資料特征發(fā)現(xiàn):累計基因突變個數(shù)與年齡分層有統(tǒng)計學差異(p=0.008);隨著年齡的增大,基因突變的個數(shù)也增多。ASXL1突變在年齡分層上有統(tǒng)計學差異(P=0.030),好發(fā)于老年患者。TET2、ASXL 突變型、野生型患者在性別上有統(tǒng)計學差異(P=0.041,P=0.017),TET2突變好發(fā)于女性患者,ASXL1突變則好發(fā)于男性患者。U2AF1、EZH2突變患者分別在骨髓增生程度、網(wǎng)狀纖維染色分級上有統(tǒng)計學差異(P=0.030,P=0.003);U2AF 突變傾向于骨髓增生活躍或異�；钴S,而EZH2突變則傾向于中重度網(wǎng)狀纖維染色。SF3B1突變型、野生型在WHO分型上有統(tǒng)計學差異(P0.001),SF3B1突變與RARS亞型有相關性(r=0.359,P0.001)。以下6組基因突變存在正相關性:IDH和NRAS(r=0.70,P0.001),ASXL1和RUNX1(r=0.40,P0.001),JAK2和SRSF2(r=0.57,P0.001),AAK2和EZH2(r=0.57,P0.001),IDH2和SRSF2(r=0.28,P0.001),ILH2和DNMT3A(r=0.44,P0.001)�？偵鏁r間的單因素分析發(fā)現(xiàn):SRSF2突變型患者預后較野生型差(P=0.032),中位 OS 分別為 19.8 個月、58.4 個月。U2AF1 P=0.055)、TP53(P=0.064)、TET2(P=0.069)突變型較野生型患者的OS有縮短的趨勢。U2AF1不同突變位點患者的OS有統(tǒng)計學差異(P=0.024),U2AF1-Q157突變預后最佳(中位OS:29.1個月),U2AF1野生型次之(中位OS:20.9個月),U2AF1-S34突變的患者預后最差(中位OS:17.5個月)。SF3B1-K700突變(中位OS:57.8個月)較SF3B1-非K700突變患者(中位OS:25.7個月)有預后更好的趨勢(P=0.066)。本隊列驗證了 LR-PSS模型:本隊列的5.7%(10/176)的患者為LR-PSS中相對應的第1組,中位OS為91.9個月;58.0%(102/176)的患者為第2組,中位OS為46.0個月;35.8%(63/176)的患者為第3組,中位OS為23.1個月;這三組間患者的OS有統(tǒng)計學差異(P=0.011);并在LR-PSS的基礎上加入SRSF2突變變量,構建了新預后模型LR-PSSM,將本隊列患者分為4組,中位生存時間依次為 105.3、46.0、23.1、12.0 個月。結論累計基因突變數(shù)目隨著年齡的增大而增多。ASXL1突變可能好發(fā)于老年、男性患者,而TET2突變則女性患者相對多見。U2AF1突變與骨髓增生活躍或異�；钴S有一定相關性,而EZH2突變患者則傾向于中重度網(wǎng)狀纖維染色。SF3B1突變與RARS亞型存在相關性。本研究單因素和多因素生存分析提示僅SRSF2突變?yōu)橛绊戄^低危MDS患者預后的獨立危險因素。U2AF1、TP53、TET2突變患者可能提示預后不良,待進一步驗證�；蛲蛔兊牟煌稽c也可能會影響預后。本隊列驗證了 LR-PSS模型,結果與文獻報道相仿�；贚R-PSS模型加入SRSF2突變因素構建了新預后模型LR-PSSM。LR-PSSM模型將有助于篩選出較低危MDS患者中的相對高�；颊�,使得這部分患者可以盡早接受相對積極治療;同時也有利于挑選出較低危MDS患者中的極低�；颊�,對其生存時間的預估更精確,但仍需大樣本以及其他中心的研究加以驗證。
[Abstract]:Objective to study the clinical significance of gene mutation in patients with low risk myelodysplastic syndrome (MDS) and to construct a molecular prognostic model for low risk MDS patients. Methods a retrospective analysis of the lower risk (low or medium risk -1) MD in the first hospital affiliated to the Zhejiang University Medical College from January 1, 2009 to October 2016 was reviewed. S patients' clinical data, including age, sex, blood routine, bone marrow primordial cell proportion, myelodysplastic degree, reticular fiber staining classification, chromosome karyotype, WHO typing, and so on. The DNA extracted from bone marrow mononuclear cells by Sanger and high throughput sequencing of 15 MDS related genes, including DNMT3A, SF3B1, SRSF2, IDH1, IDH2, ASXL1, EZH2, EZH2, CBL, ETV6, TP53, NRAS and RUNX1; compare the characteristics of various gene mutation and wild type, and analyze the correlation between the mutations of each gene. Single factor analysis has no statistical difference between the mutant and the wild type and the different mutation loci in the total survival time (OS). The prognosis of the low risk MDS in this cohort is the prognosis. Verification of the scoring system (LR-PSS) model. Multifactor analysis of LR-PSS and the relative risk of gene mutations. Screening out a statistically significant gene mutation, and trying to integrate the LR-PSS model and gene mutation to construct a new prognostic model -LR-PSSM model. Results this study included 176 patients with lower risk MDS, median follow-up time, and the results of this study. The median total survival time was 38.1,15.0 months, the median age was 57 years, the proportion of men and women was 1.29 (99/77). The abnormal karyotype detection rate was 19.3% (34/176), and the detection rate of cloned evidence for chromosome joint gene mutation detection was 51.7% (91/176). The higher mutation frequency was SF3B1 (13.1%, 21/160), TET2 (12.5%, 7/56), U2AF1 (10.4%, 1). 7/163), ASXL1 (9.5%, 7/74), TP53 (7%, 5/71), RUNX1 (6.7%, 4/60), SRSF2 (6.3%, 11/174). Compare the clinical data of gene mutation and wild type: the cumulative number of mutations is statistically different from the age stratification (p=0.008); as the age increases, the number of mutations is also increased in age stratification. The difference (P=0.030) is good for the elderly patients with.TET2, ASXL mutant, and wild type patients with statistical difference (P=0.041, P=0.017), TET2 mutation well in female patients, ASXL1 mutation in male patients.U2AF1, EZH2 mutation patients in the degree of myelodysplastic, reticular fiber staining classification has statistical difference (P=0.030, P=0.00) 3): U2AF mutation tended to be active or abnormally active in myelodysplastic, while EZH2 mutation tended to be a medium and severe reticular fiber staining of.SF3B1 mutagenesis, and there was a statistically significant difference between the wild type in WHO typing (P0.001), SF3B1 mutation and RARS subtype (r=0.359, P0.001). The following mutations were positive correlation: IDH and NRAS (r=0.70, etc.) L1 and RUNX1 (r=0.40, P0.001), JAK2 and SRSF2 (r=0.57, P0.001), AAK2 and EZH2 (r=0.57, P0.001), single factor analysis of the total survival time, found that the prognosis of the mutant patients is less than the wild type, and the median is 19.8 months and 58.4 months respectively. 4) the OS of TET2 (P=0.069) mutant was shorter than that of wild type patients. The OS of the patients with different mutations at.U2AF1 was statistically different (P=0.024), the prognosis of U2AF1-Q157 mutation was the best (median OS:29.1 months), U2AF1 wild type (median OS:20.9 month), and the worst (median OS:17.5 month) mutation (median OS:17.5 month) was the worst. Compared with SF3B1- non K700 mutations (median OS:25.7 months), there was a better prognosis (P=0.066). This cohort demonstrated the LR-PSS model: 5.7% (10/176) in this cohort were first groups in LR-PSS, median OS was 91.9 months; 58% (102/176) patients were second, median OS was 46 months; 35.8% (63/176) patients In the third group, the median OS was 23.1 months; the OS of the three groups was statistically different (P=0.011); and on the basis of LR-PSS, a new prognostic model was added to construct a new prognostic model, LR-PSSM, and the cohort was divided into 4 groups, and the median survival time was 105.3,46.0,23.1,12.0 months. A large number of.ASXL1 mutations may well occur in elderly, male patients, while TET2 mutations in women have a relative number of.U2AF1 mutations associated with active or abnormal activity of myelodysplastic, while EZH2 mutations tend to be associated with.SF3B1 mutations in moderate to severe reticular fiber staining and RARS subtypes. This study is a single factor and multiple factors. The survival analysis suggests that only SRSF2 mutation is an independent risk factor that affects the prognosis of lower risk MDS patients.U2AF1, TP53, TET2 mutation may indicate poor prognosis. The different loci of the gene mutation may also affect the prognosis. This cohort has verified the LR-PSS model, and the results are similar to that of the literature. Based on the LR-PSS model, the SRSF2 process is added. The variable factor construction of a new prognostic model LR-PSSM.LR-PSSM model will help to screen relatively high risk patients in patients with lower risk MDS, making this part of the patients receiving relatively active treatment as early as possible, and also for the selection of extremely low risk patients in lower risk MDS patients and more accurate estimates of their survival time, but still need large samples. And other centers of research to verify.

【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R551.3
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本文編號：1844885