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TGFBR2基因多态性与晚期NSCLC铂类化疗
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摘要
背景:绝大多数非小细胞肺癌(non-small cell lung cancer,NSCLC)患者确诊时已属晚期(III或者IV期,约占肺癌总发病率的80%),铂类联合化疗是其标准的一线治疗方案。然而,NSCLC五年存活率低于15%。近年的研究表明,基因标志物可预测肿瘤化疗的预后,如,药物转运、代谢、DNA修复和凋亡相关基因的多态性可预测药物的细胞毒性及药物疗效。迄今的研究表明,转化生长因子受体II (transforming growth factor beta type II receptor, TGFBR2)在细胞增殖和凋亡中起重要作用,推测极有可能影响到铂类药物的预后。
     一、TGFBR2基因多态性和NSCLC铂类化疗疗效及毒性反应关联分析
     目的: TGFBR2基因多态性与NSCLC铂类化疗疗效和毒副反应的关联及预测分析。
     方法:
     (一)研究对象:回顾性研究,收集2005年3月至2010年1月收住于上海长海医院、胸科医院和中山医院的初治为铂类化疗的III-IV期NSCLC汉人患者。
     (二)疗效、毒性与体力状态评判:患者在接受两个疗程治疗后,按照RECIST标准进行疗效评价,计算疾病控制率(疾病控制和疾病未控制),疾病控制包括完全缓解(CR)、部分缓解(PR)和稳定(SD)患者,疾病未控制为进展(PD);化疗药物的血液和胃肠道毒副反应每周两次进行评估,毒副反应程度按美国国家癌症研究所不良反应分级标准3.0,轻度毒性反应包括0、1和2级毒性反应,严重毒性反应包括3和4级毒性反应。评估由经治医师完成并记录,专人再收集,对经治医师采用双盲方法。
     (三)SNP位点选择:采用Haploview软件选择标签TGFBR2 SNP,选点原则为MAF大于0.05,r2大于0.8。
     (四)基因分型:用Infinium HD Assay分型技术进行基因分型。
     (五)统计分析:SNP多态性与毒性、疗效的关联用非条件逻辑回归(Unconditional logistic regression)进行分析,经性别、年龄、体力状况及治疗方案校正。单点分析:以每个多态性位点(SNP)的突变型纯合子基因型(BB AA)或突变型杂合子基因型(AB),与野生型纯合子基因型(AA )相比较(BB VS AA,或AB VS AA),计算OR值、95%可信区间及p值。多点分析:用PHASE II和Haploview软件对TGFBR2基因SNP进行单倍域(Haplotype block)分析,计算OR值、95%可信区间及p值。校正方法采用Bonfferoni法。
     结果:
     (一)研究对象的临床特征:
     1、病人基本特征:共收集1004例经病理确诊的IIIA-IV期非小细胞肺癌患者,年龄为26-82岁。中位年龄58岁,≤58岁514例,>58岁486例;化疗前PS评分0-1为904例,PS评分2为86例;男性706例,女性297例;IIIA 81例,IIIB 293例,IV 625例;铂-长春瑞滨316例,铂-吉西他滨239例,铂-紫杉醇313例,铂-其它136例。
     2、疗效和毒副反应:疾病控制率为81.7%。各种毒性反应:严重贫血3.1%,严重血小板毒性反应3.6%,严重白细胞毒性反应15.2%,严重粒细胞毒性反应12.3%,严重血液总毒性发生率为23.9%,严重胃肠道毒性发生率为8.3%。
     (二) SNP选择和分型结果:共选择34个TGFBR2标签SNP位点,rs9844092未能进行分型(MAF = 0),其余位点分型准确率大于99%,重复样本分型一致性为100%。因此,最后进行关联分析的为33个SNP位点。
     (三)关联分析结果:
     (1)单点分析: TGFBR2基因多态性显著增加重度总毒性反应的风险:女性人群rs2276768 CT VS CC,OR = 3.026,95% CI = 1.741-5.258,p = 0.00008575;TGFBR2基因多态性显著增加重度血液毒性反应风险:女性人群rs2276768 CT VS CC, OR = 4.031,95% CI =
     2.171 - 7.482,p = 0.00001004。经Bonfferoni方法校正后,女性人群中rs2276768杂合子CT显著增加总毒性及重度血液毒性反应风险。
     (2)单体型分析:根据1004例研究对象的基因型,将TGFBR2的33个SNP分为九个单倍域(Block1-9)。分析显示Block 9 (rs2276768,rs3773663,rs304839和rs2276767)的单体型CGTC相对于TGAC,与疾病控制率负显著相关,OR值0.672,95% CI为0.514-0.879,p=0.004。
     二、TGBFBR2 rs2276768单核苷酸多态功能初探
     检测104例经铂类治疗的肺癌患者,携带rs2276768变异等位基因CT的个体,其TGFBR2 mRNA相对表达量的平均值相对于野生纯合子CC个体,增加约30.3%,与增加血液毒性风险的预期相一致。
     目的:研究TGBBR2基因多态性是否通过影响该基因mRNA表达,影响血液毒性反应。
     方法:
     (一)研究对象:1004例入组病人中长海医院病人104例。
     (二)全血RNA抽提。
     (三)定量RT-PCR分析:RNA抽提、定量PCR检测和分析。
     结果:
     携带rs2276768变异等位基因CT的个体,其TGFBR2 mRNA相对表达量的平均值相对于野生纯合子CC个体,增加约30.3%,与增加疾病控制率和重度血液毒性风险的预期相一致。
     小结:
     一、单点分析和多点分析结果提示,女性人群中rs2276768杂合子CT显著增加总毒性及重度血液毒性反应的风险,单体型CGTC相对于单体型TGAC(block顺序:rs2276768,rs3773663,rs304839和rs2276767),显著增加疾病未控制率风险。
     二、rs2276768杂合子可能通过增加TGFBR2 mRNA表达量,增加血液毒性反应风险。
     结论:本次实验首次发现TGFBR2基因多态性和晚期NSCLC铂类化疗疗效和毒性反应显著关联,其中rs2276768杂合子CT显著增加女性严重总毒性和血液毒性反应风险;rs2276768可能通过改变mRNA水平,降低血液毒性风险。上述关联分析结果尚需进行深入的功能验证。
Non-small cell lung cancer (NSCLC) accounts for approximately 80% of such deaths. Most NSCLC patients are diagnosed in the advanced (stage III or IV) stages. Five-year survival rates for NSCLC remain less than 15%. Standard treatment for NSCLC involves chemotherapy with a platinum agent and another cytotoxic agent. Recent clinical studies suggest a large potential for genomic findings in treatment outcome predictions. It is widely recognized that genetic polymorphisms in genes for drug transport, drug metabolizing, DNA repair and apoptosis often play important roles in the variability of cytotoxic chemotherapy toxicity outcomes. In this study, we focused on transforming growth factor, beta receptor II (TGFBR2), being important in cell proliferation and apoptosis.
     Purpose: to investigate the association between TGFBR2 polymorphisms and the incidence of adverse events in advanced non-small cell lung cancer (NSCLC) patients receiving first-line platinum-based chemotherapy through mRNA expression.
     Patients and Methods: A retrospective pharmacogenetic association study was performed in 1004 Chinese patients with advanced NSCLC receiving platinum-based regimens (including 221 treated with cisplain-navelbine, 195 with cisplatin-gemcitabine, 190 with carboplatin-paclitaxel, and 108 with cisplatin-paclitaxel). Information about grade 3 or 4 overall toxicity, gastrointestinal toxicity (nausea/vomiting) and hematologic toxicity (neutropenia, anemia, thrombocytopenia) was available. 34 tag single nucleotide polymorphisms (SNPs) of TGFBR2 were assessed.
     PATIENTS AND METHODS:Study design and patients recruitment. All patients enrolled in the study were Chinese, and had histologically diagnosed stage IIIA-IV NSCLC at Shanghai Chest, Shanghai Zhongshan and Shanghai Changhai Hospitals between March 2005 and January 2010. Patient responses to the treatment were evsluated after first two courses by the Response Evaluation Criteria in Solid Tumors(RECIST) guideline, which classify Patient responses to the treatment were evaluated after first two courses, which classify the responses into four categories: complete response (CR),partial response (PR), stable disease88 (SD), and progressive disease (PD). For the data analysis, CR and PR were combined as responders, and SD and PD were grouped as non-responders. Chemotherapy toxicity was assessed twice weekly and graded according to the National Cancer Institute Common Toxicity Criteria version 3.0. Toxicities included neutropenia, anemia, thrombocytopenia, nausea, and vomiting. Severe hematologic toxicity included grade 3 or 4 neutropenia, anemia, or thrombocytopenia. Severe gastrointestinal toxicity included grade 3 or 4 nausea or vomiting. Severe overall toxicity included grade 3 or 4 hematologic or gastrointestinal toxicity. The complete medical record (including progress notes of the treating oncologist and nurses) was available and reviewed. Investigators were blinded to the genotype status of the patients. Chemotherapy regimens: all patients enrolled in this study were considered to be inoperable, so received first-line platinum-based chemotherapy (Patients receiving definitive chemoradiotherapy were excluded): cisplatin, or carboplatin, both administered, in combination with navelbine, or gemcitabine, or paclitaxel, or docetaxel. Few patients were given other platinum-based treatment. All chemotherapeutic drugs were administered intravenously, and all included patients were treated for two to six cycles. TGFBR2 SNP selection and genotyping: the genotype data of TGFBR2 gene regionfrom the CHB population were downloaded from phase II HapMap SNP database, and tag-SNPs were selected by the Haploview Software, using a minor allele frequency (MAF) cut-off of 0.05 and r threshold of 0.8. Blood samples were obtained in EDTA tubes from patients at the time of re-cruitment. Genomic DNA was extracted using the QIAamp DNA Maxi Kit. All SNPs selected were genotyped using iSelect HD BeadChip (illumina), with quality control criteria as follows: genotyping call rate of SNP>0.95; MAF>0.05; GenCall score>0.2. Therefore, a polymerase chain reaction (PCR)-SNaPshot method was used to supplement Statistical Analysis. The analyses were specified to investigate the relation-ships between TGFBR2 polymorphisms and severe toxicity occurrence, overall and by treatment arm, respectively. Toxicity outcomes were dichotomized by the presence or absence of (i) any grade 3 or 4 overall toxicity, (ii) any grade 3 or 4 hematologic toxicity (including neutropenia, anemia, and thrombocytopenia), and (iii) any grade 3 or 4 gastrointestinal toxicity (nausea/vomiting). We then investigated whether these polymorphisms were associated with severe hematological toxicity, gastrointestinal toxicity, or disease controlled rate among 1004 platinum-based chemotherapy treated advanced NSCLC patients. Single gene polymorphisms correlation analysis has been done. OR, 95% confidence interval and p value were calculated respectively. Each polymorphic loci (SNP) of the mutant homozygous genotype (BB ) or mutant heterozygous mutant genotype (AB), compared with wild homozygous genotype(AA),is represented by BB VS AA or AB VS AA.Adjusting covariates were the
     genotyping data of polymorphisms (gender, age at diagnosis, performance status and type of treatment regimen. Statistical analyses used SPSS. Pairwise linkage disequilibrium defined by the four-gamete rule in the Haploview Software. Individual haplotype frequencies were estimated based on the Bayesian algorithm, using the PHASE 2.0 program. Haplotype-toxicity association was evaluated for each block, using SPSS.
     Outcome:In this study, 33 tag single nucleotide polymorphisms in TGFBR2 gene were selected except rs9844092 (MAF =0). 1004 patients enrolled in the study. Among the 1004 NSCLC patients. The median age of patients was 58 years (range, 18–82), and there were 706 patients (male) and 297 (female). The majority of patients (62.6%) had stage IV disease. Disease controlled rate was 81.7%, while severe toxicity incidenceincidences were 3.1% (anemia), 3.6% ( thrombocytopenia), 15.2% (leukocytopenia), 12.3 %( agranulocytosis), 23.9% (any grade 3 or 4 hematologic toxicity), and 8.3% (any grade 3 or 4 gastrointestinal toxicity). An association between the variant genotypes of and the risk of severe overall toxicity was aslo observered (rs2228048, CT VS CC, OR= 1.638, 95% CI =1.131 - 2.372, p = 0.00894, among male group; rs2276768, CT VS CC, OR = 3.026, 95%CI = 1.741-5.258, p=0.00008575, among female patient groups.An increased risk was assciated between the variatn genotypes (rs9310940, TT VS GG,OR = 4.85,95%CI=1.503-15.65,p=0.00825, among adenocarcinoma Patient groups.
     Conclusion: this study showed TGFBR2 gene polymorphism played a predictive role on clinic outcome in advanced NSCLC patients receiving first-line platinum-based chemotherapy, especially among female patient groups. Furthermore, was associated with hematological toxicity through mRNA expression.
引文
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