【摘要】：背景及目的:賁門癌是起源于胃食管結(jié)合部的腺癌。雖然世界范圍內(nèi)非賁門癌發(fā)病有下降趨勢,但近年來包括中國在內(nèi)的一些地區(qū),尤其是西方國家,賁門癌發(fā)病率有增長趨勢。賁門癌具有與非賁門癌不同的一些特殊的病因和臨床病理特征。目前有關(guān)接受R0術(shù)后賁門癌患者預(yù)后因素研究很少,而且接受R0術(shù)后賁門癌患者與非賁門癌患者預(yù)后差異的研究也很少,且結(jié)論不一致。因此,R0術(shù)后賁門癌患者臨床病理特征及預(yù)后仍不完全清楚,尤其是相同分期賁門癌與非賁門癌預(yù)后有無差異目前研究極少,需要進一步明確。本研究旨在比較R0術(shù)后賁門癌與非賁門癌臨床病理特征及預(yù)后的差異。方法:連續(xù)收集自2009年12月至2011年12月在國內(nèi)4家醫(yī)院經(jīng)組織學(xué)確診為胃癌,且經(jīng)R0切除(即顯微鏡下無腫瘤細(xì)胞)的患者。分析患者臨床病理特征包括年齡、性別、民族、手術(shù)時間、解剖學(xué)位置、組織學(xué)類型、pTNM分期、手術(shù)方式、脈管及神經(jīng)侵犯、(新)輔助化療、(新)輔助放療和復(fù)發(fā)時間。分析生存數(shù)據(jù)包括術(shù)后無病生存期(Disease-freesurvival,DFS)和總生存期(Overallsurvival,OS)。將患者分為賁門癌和非賁門癌2組,分析2組患者臨床病理特征及長期生存的差異。結(jié)果:共有1633名患者納入研究,其中賁門癌組581例,非賁門癌組1052例。比較賁門癌及非賁癌臨床病理特征發(fā)現(xiàn):民族及神經(jīng)侵犯在兩組間分布相似,但賁門癌組患者確診時年齡更大(P0.001),男性比例更高(P0.001),pT3及pT4期病例更多(P0.001),淋巴結(jié)陽性比例更高(P = 0.003),病理分期Ⅱ-Ⅲ期更多(P0.001),病理學(xué)中分化更多(P0.001),脈管侵犯比例更高(P = 0.035)。治療方面,接受淋巴結(jié)清掃(P=0.088),新輔助化療(P=0.489),新輔助放療(P=1.000)或輔助化療(P = 0.068)比例在兩組間并無顯著差異,但是賁門癌患者較非賁門癌患者接受更多的輔助放化療(P = 0.006)。比較2組DFS,賁門癌患者5年DFS較非賁門癌患者低(50.84 vs.59.22%,P0.001)。但是根據(jù)每一個病理分期分析DFS時,除了Ⅰ期賁門癌患者5年DFS更低(77.88 vs.86.92%,P=0.038)外,病理分期為Ⅱ期及Ⅲ期患者5年DFS并無差異。對于總體pTNM分期而言,5年疾病相關(guān)生存率賁門癌組(55.57%)低于非賁門癌組(62.38%;P=0.005)。然而,當(dāng)根據(jù)每個pTNM分期分別分析OS時,賁門癌組和非賁門癌兩組間無顯著性差異(P均0.05)。根據(jù)每個pT分期或pN分期分別分析OS時,2組也沒有顯著差異性(P均0.05)。單因素生存分析顯示年齡、病理分期、腫瘤分級、脈管侵犯及神經(jīng)侵犯與賁門癌OS具有相關(guān)性。COX多因素回歸分析發(fā)現(xiàn)病理分期Ⅲ期是一個獨立的預(yù)后危險因素(P0.001),而病理分期Ⅱ期統(tǒng)計學(xué)分析處于具有顯著性差異的臨界值(P=0.054)。結(jié)論:與非賁門癌相比,賁門癌患者具有診斷時年齡更大,男性比例較多,明顯不同的臨床病理特征和術(shù)后pTNM病理分期較晚等特點。全部R0術(shù)后胃癌患者人群中,與非賁門癌患者相比,賁門癌患者5年DFS較低。然而,相同pTNM分期的賁門癌和非賁門癌中的總生存差異并沒有顯著性(至少在Ⅱ-Ⅲ期如此)。病理分期是影響賁門癌總生存的獨立預(yù)后因素。在這項研究中的中國賁門癌術(shù)后患者病理分期更晚。研究提示只要患者能夠及時進行檢查作出早期診斷并接受合適的治療,賁門癌患者可以獲得與非賁門癌患者相似的預(yù)后。背景及目的:環(huán)境原因中除了幽門螺旋桿菌(Helicobacter pylori,HP)這一主要因素外,地理因素也在胃癌的發(fā)生和預(yù)后中起著重要作用。GLOBOCAN2012數(shù)據(jù)顯示東亞是世界上胃癌發(fā)病率最高的地區(qū)。高原是一個特殊的低氧環(huán)境,也與胃癌發(fā)生存在相關(guān)性。雖然已有一些研究報道高原地區(qū)胃癌發(fā)病率和死亡率均較高,但目前仍然沒有關(guān)于高原地區(qū)和平原地區(qū)胃癌臨床病理特征及預(yù)后差異的研究。我們開展這項多中心研究比較了中國高原和平原地區(qū)R0術(shù)后胃癌臨床病理特征及預(yù)后的差異。方法:從2009年12月至2011年12月,收集四個中國高原地區(qū)和平原地區(qū)中心胃癌術(shù)后病例并進行回顧性分析。所有患者均在青海大學(xué)附屬醫(yī)院、青海省人民醫(yī)院、青海省紅十字醫(yī)院或中國醫(yī)學(xué)科學(xué)院腫瘤醫(yī)院經(jīng)組織學(xué)診斷為原發(fā)性胃癌并接受R0切除。所有患者均長期居住在高原或者平原地區(qū)。按居住海拔將患者分為2組,海拔大于2200m者為高原組,低于1000m者為平原組。采集臨床病理特征包括患者年齡、性別、民族、手術(shù)方式、腫瘤位置、組織學(xué)分級、pTNM分期、(新)輔助化療、(新)輔助放療和隨訪等參數(shù)。分析2組患者臨床病理特征及長期生存的差異。COX比例風(fēng)險模型評估高原因素對胃癌預(yù)后的影響。結(jié)果:共納入高原地區(qū)251例患者和1382例平原患者。分析2組間病理特征和預(yù)后差異,與平原地區(qū)患者比較,在高原地區(qū)患者患病年齡更小,而且這種年齡差異僅存在于非賁門胃癌,而不存在于賁門癌患者;少數(shù)民族更多;非賁門胃癌比例更高;病理學(xué)中-高分化比例更高而低-中分化比例較少;接受新輔助化療和輔助放療的患者更少。生存分析發(fā)現(xiàn),高原地區(qū)3年腫瘤相關(guān)生存率與平原地區(qū)差異無顯著性(70.35%,72.22%,P=0.172)。而且,按不同部位分析,高原地區(qū)賁門癌患者3年腫瘤相關(guān)生存率(72.09%)與平原地區(qū)(67.38%)差異也無顯著性(P = 0.987)。然而,非賁門患者3年腫瘤相關(guān)生存率(69.94%)低于平原地區(qū)(75.23%)(log-rank test:P = 0.033)。通過多變量Cox比例風(fēng)險模型分析,高原被確定為非賁門胃癌的重要預(yù)后因素(HR:高原地區(qū)vs平原地區(qū):1.50,95%CI:1.14-1.97,P= 0.004),且獨立于其它所有預(yù)后因素。結(jié)論:高原地區(qū)R0術(shù)后胃癌患者患病年齡較平原地區(qū)更小,而且這種年齡差異僅存在于非賁門癌;非賁門癌比例高;病理分期與性別無差異。高原地區(qū)非賁門術(shù)后患者預(yù)后較平原地區(qū)差。高原被確定為非賁門胃癌的重要預(yù)后因素,且獨立于其它所有預(yù)后因素。高原可能在非賁門癌發(fā)病及發(fā)展中起一定作用。需要重視和提高對高原地區(qū)胃癌患者的診治。背景及目的:由于腫瘤細(xì)胞快速增值、血管異常及貧血等原因,實體瘤內(nèi)低氧是其常見特征。研究表明低氧與實體瘤發(fā)生發(fā)展密切相關(guān)。實體瘤獨特的低氧微環(huán)境除了參與腫瘤代謝、血管生成和轉(zhuǎn)移等以外,目前普遍認(rèn)為其還與腫瘤細(xì)胞的放化療抵抗有關(guān)。通過調(diào)節(jié)低氧誘導(dǎo)因子家族成員EPAS-1/HIF-2(Endotheial PAS domain-containing protein 1,EPAS-1;Hypoxia-inducible factor-2,HIF-2)是低氧參與腫瘤發(fā)展的重要作用方式之一。近年有越來越多的研究表明EPAS-1也在實體瘤耐藥中起著重要作用。有諸多機制參與EPAS-1介導(dǎo)的耐藥,對同一個病例而言,還可能有多種機制同時參與EPAS-1調(diào)節(jié)的耐藥過程。而且,藥物耐藥網(wǎng)絡(luò)機制復(fù)雜,在不同腫瘤都會不同,甚至藥物耐藥會隨著腫瘤發(fā)展而發(fā)生變化。目前報道的EPAS-1參與腫瘤耐藥的機制包括調(diào)節(jié)細(xì)胞增殖、增加DNA修復(fù)能力、增強藥物外排、調(diào)控細(xì)胞代謝、調(diào)節(jié)干細(xì)胞以及影響信號傳導(dǎo)通路等。另外,胃癌仍然是威脅人類健康的常見腫瘤之一,化療藥物是晚期胃癌的重要治療手段之一。雖然研發(fā)了很多化療藥物,但晚期胃癌患者預(yù)后仍然很差,幾乎所有患者最后都出現(xiàn)耐藥,迫切需要進一步研究胃癌多藥耐藥機制。EPAS-1表達(dá)于包括胃癌在內(nèi)的多種腫瘤中。推測EPAS-1也參與胃癌耐藥,但其在胃癌中耐藥機制尚未見報道。而且,雖然目前已有許多研究表明EPAS-1可以促進腫瘤增值、遷移和侵襲等,但其具體機制仍然不完全明確。本研究旨在明確EPAS-1與胃癌的關(guān)系及其參與胃癌耐藥的機制。方法:通過免疫組化檢測胃癌配對組織中EPAS-1的表達(dá),明確其與胃癌病理特征及預(yù)后的關(guān)系;ELISA檢測EPAS-1在胃癌患者和健康對照組血清中的表達(dá),明確其與對照組表達(dá)差異;以免疫共沉淀(Co-immunoprecipitation)和GSTpulldown實驗確定EPAS-1和核受體Pregnane X Receptor(PXR)蛋白相互作用;以染色質(zhì)免疫沉淀(Chromatin immuno-precipitation,ChIP)明確 EPAS-1、PXR 及其靶基因 CYP 3A4 的關(guān)系;以亞細(xì)胞分離實驗(Subcellular fractionation assays)定位 PXR 和 EPAS-1;以軟瓊脂實驗觀察細(xì)胞增長;以流式細(xì)胞儀檢測細(xì)胞周期及凋亡;Trans-well實驗檢測細(xì)胞侵襲;裸鼠成瘤實驗檢測EPAS-1體內(nèi)成瘤能力;胃癌細(xì)胞系過表達(dá)EPAS-1或沉默EPAS-1表達(dá),檢測EPAS-1在胃癌增殖和對絲裂霉素(Mitomycin C,MMC)及紫杉醇(Paclitaxel,PTX)作用效果的影響。結(jié)果:EPAS-1在胃癌高表達(dá)并與胃癌預(yù)后不良相關(guān),胃癌患者血清EPAS-1升高。EPAS-1/可以促進BGC-823胃癌細(xì)胞生長,并且EPAS-1可以與PXR相互作用,后者可以調(diào)節(jié)多個參與多藥耐藥(Multi-drugs resistance,MDR)基因的轉(zhuǎn)錄。以免疫共沉淀和GST pull down實驗確定EPAS-1蛋白可以與PXR蛋白相互作用,EPAS-1募集PXR到它的反應(yīng)元件—CYP3 A4的啟動子/增強子,而后者是PXR的靶基因。過表達(dá)EPAS-1可以增加PXR反應(yīng)基因的表達(dá),促進BGC-823細(xì)胞增值,導(dǎo)致BGC-823細(xì)胞對MMC和PTX等細(xì)胞毒化療藥物耐藥;而通過siRNA下調(diào)EPAS-1表達(dá)則可以抑制BGC-823細(xì)胞增值,并增強BGC-823細(xì)胞對化療藥物MMC和PTX的敏感性。而且,EPAS-1促進胃癌細(xì)胞裸鼠體內(nèi)成瘤。結(jié)論:EPAS-1在胃癌增值、生存及預(yù)后和MDR方面均起著重要作用。EPAS-1與PXR可以共同作用,參與胃癌發(fā)展尤其是MDR過程。這些發(fā)現(xiàn)有可能為探索更加有效的胃癌靶向治療藥物提供新的方向。
[Abstract]:BACKGROUND AND OBJECTIVE: Cardiac cancer is an adenocarcinoma originating from the gastroesophageal junction. Although the incidence of non-cardiac cancer has been declining worldwide, the incidence of cardiac cancer has been increasing in some regions including China, especially in western countries in recent years. Cardiac cancer has some special etiology and Clinicopathology different from non-cardiac cancer. The prognostic factors of patients with cardiac cancer after R0 operation are seldom studied, and the prognostic differences between patients with cardiac cancer after R0 operation and those without cardiac cancer after R0 operation are few and inconsistent. The purpose of this study was to compare the clinicopathological characteristics and prognosis of cardiac cancer and non-cardiac cancer after R0 surgery. Methods: A series of patients with gastric cancer diagnosed histologically from December 2009 to December 2011 were collected from 4 hospitals in China, who underwent R0 resection (that is, no tumor cells under microscope). Patient. The clinicopathological features of the patients were analyzed, including age, sex, ethnicity, operative time, anatomical degree, histological type, pTNM stage, surgical procedure, vascular and nerve invasion, neoadjuvant chemotherapy, neoadjuvant radiotherapy, and recurrence time. Results: A total of 1633 patients were included in the study, including 581 patients with cardiac cancer and 1052 patients with non-cardiac cancer. Similarly, patients with cardiac cancer were older at diagnosis (P 0.001), more males (P 0.001), more pT3 and pT4 (P 0.001), more lymph node positive (P = 0.003), more pathological stages II-III (P 0.001), more differentiated (P 0.001), and more vascular invasion (P = 0.035). For treatment, patients received lymph node dissection (P = 0.035). 088, neoadjuvant chemotherapy (P = 0.489), neoadjuvant radiotherapy (P = 1.000) or adjuvant chemotherapy (P = 0.068) were not significantly different between the two groups, but patients with cardiac cancer received more adjuvant radiotherapy and chemotherapy than patients without cardiac cancer (P = 0.006). Compared with the two groups, patients with cardiac cancer had lower 5-year DFS (50.84 vs. 59.22%, P 0.001). The 5-year disease-related survival rate (55.57%) was lower in cardiac cancer group (62.38%) than in non-cardiac cancer group (62.38%; P = 0.005) according to the overall pTNM stage. There was no significant difference between the two groups in OS staging (P 0.05). There was no significant difference between the two groups in OS staging (P 0.05). Univariate survival analysis showed that age, pathological stage, tumor grade, vascular invasion and nerve invasion were associated with OS. Multivariate regression analysis showed that pathological stage III was an independent prognostic risk factor (P 0.001), while the statistical analysis of pathological stage II was at a critical value with significant difference (P = 0.054). Conclusion: Compared with non-cardiac cancer, patients with cardiac cancer had older age at diagnosis, more males and significantly different clinicopathological characteristics. Five-year DFS was lower in all patients with gastric cancer after R0 than in non-cardiac cancer. However, there was no significant difference in overall survival between cardiac cancer and non-cardiac cancer at the same pTNM stage (at least in stage II-III). Pathological stage was an independent factor affecting the overall survival of cardiac cancer. Prognostic factors. Pathological staging was later in this study in patients with cardiac cancer after surgery in China. The study suggests that patients with cardiac cancer can achieve similar prognosis as non-cardiac cancer patients if they are able to make early diagnosis and receive appropriate treatment promptly. Background and objective: Environmental causes other than Helicobacter pylori (Helicobacter pylori) Geographical factors also play an important role in the occurrence and prognosis of gastric cancer. GLOBOCAN 2012 data show that East Asia has the highest incidence of gastric cancer in the world. We conducted a multicenter study to compare the clinicopathological characteristics and prognosis of gastric cancer after R0 surgery in Plateau and plain areas in China. METHODS: From December 2009 to December 2011, four cases were collected. All patients were histologically diagnosed as primary gastric cancer and underwent R0 resection in the Affiliated Hospital of Qinghai University, Qinghai People's Hospital, Qinghai Red Cross Hospital or Cancer Hospital of the Chinese Academy of Medical Sciences. The patients were divided into two groups according to their living altitude, the plateau group was higher than 2200m, and the plain group was lower than 1000m. Results: A total of 251 patients in plateau area and 1382 patients in plain area were included. Pathological characteristics and prognosis differences between the two groups were analyzed. Patients in plateau area were younger and worse than those in plain area. Differentiation exists only in non-cardiac gastric cancer, not in cardiac cancer patients; more ethnic minorities; a higher proportion of non-cardiac gastric cancer; a higher and lower-to-moderate pathological differentiation rate; fewer patients received neoadjuvant chemotherapy and adjuvant radiotherapy. Survival analysis found that the 3-year tumor-related survival rate in plateau areas was worse than in plain areas. There was no significant difference (70.35%, 72.22%, P = 0.172). Moreover, there was no significant difference in 3-year tumor-related survival rate (72.09%) between Plateau and plain areas (67.38%) according to the location analysis. However, the 3-year tumor-related survival rate (69.94%) in non-cardiac patients was lower than that in plain areas (75.23%) (log-rank test: P = 0.033). Multivariate Cox proportional hazard model analysis showed that plateau was identified as an important prognostic factor for non-cardiac gastric cancer (HR: plateau vs plain area: 1.50, 95% CI: 1.14-1.97, P = 0.004), independent of all other prognostic factors. Conclusion: Patients with gastric cancer after R0 operation in plateau area were younger than those in plain area, and this age difference existed only in Plateau area. The prognosis of non-cardiac cancer patients in plateau area was worse than that in plain area. Plateau was identified as an important prognostic factor of non-cardiac cancer and independent of all other prognostic factors. Plateau may play a role in the pathogenesis and development of non-cardiac cancer. BACKGROUND AND OBJECTIVE: Hypoxia in solid tumors is a common feature of gastric cancer at high altitude due to rapid proliferation of tumor cells, vascular abnormalities and anemia. Studies have shown that hypoxia is closely related to the occurrence and development of solid tumors. Hypoxia-inducible factor-2 (HIF-2), a member of the hypoxia-inducible factor family EPAS-1/HIF-2 (Endothelial PAS domain-containing protein-1, EPAS-1), is one of the most important mechanisms of hypoxia-inducible factor-2 (HIF-2) in tumor development. There are many mechanisms involved in EPAS-1-mediated drug resistance. In the same case, there may be many mechanisms involved in the regulation of EPAS-1 at the same time. Moreover, drug resistance network mechanism is complex, different tumors will be different, and even drug resistance will change with the development of tumors. The reported mechanisms of EPAS-1 involved in tumor resistance include regulating cell proliferation, increasing DNA repair capacity, enhancing drug efflux, regulating cell metabolism, regulating stem cells, and affecting signal transduction pathways. Many chemotherapeutic drugs have been developed, but the prognosis of advanced gastric cancer patients is still poor. Almost all patients eventually develop drug resistance. Further study on the mechanism of multidrug resistance of gastric cancer is urgently needed. EPAS-1 is expressed in a variety of tumors including gastric cancer. Although many studies have shown that EPAS-1 can promote tumor proliferation, migration and invasion, the specific mechanism is still not clear. The purpose of this study is to clarify the relationship between EPAS-1 and gastric cancer and its mechanism involved in drug resistance in gastric cancer. The expression of EPAS-1 in serum of gastric cancer patients and healthy control group was detected by ELISA, and the difference between EPAS-1 and control group was clarified. The relationship between EPAS-1, PXR and its target gene CYP 3A4 was clarified by precipitation, subcellular fractionation assays were used to localize PXR and EPAS-1, soft agar assay was used to observe cell growth, flow cytometry was used to detect cell cycle and apoptosis, trans-well assay was used to detect cell invasion, and nude mice tumorigenesis assay was used to detect EPAS-1. The proliferation of gastric cancer and the effect of mitomycin C (MMC) and paclitaxel (PTX) on the proliferation of gastric cancer were detected by overexpression of EPAS-1 or silence of EPAS-1 expression in gastric cancer cell lines. 823 gastric cancer cells grew, and EPAS-1 could interact with PXR, which could regulate the transcription of multiple genes involved in multidrug resistance (MDR). Overexpression of EPAS-1 can increase the expression of PXR-responsive gene and promote the proliferation of BGC-823 cells, resulting in resistance of BGC-823 cells to cytotoxic chemotherapeutics such as MMC and PTX. Downregulation of EPAS-1 expression by siRNA can inhibit the proliferation of BGC-823 cells and enhance the sensitivity of BGC-823 cells to MMC and PTX. Conclusion: EPAS-1 plays an important role in the proliferation, survival, prognosis and MDR of gastric cancer. EPAS-1 and PXR can play a joint role in the development of gastric cancer, especially in the MDR process.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R735.2

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1 趙久達(dá);不同部位和海拔胃癌預(yù)后分析及EPAS-1參與胃癌耐藥研究[D];北京協(xié)和醫(yī)學(xué)院;2017年

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本文編號：2224463