肿瘤防治的新挑战肿瘤异质性分子分型及个体化冶疗

肿瘤防治的新挑战 (肿瘤异质性, 分子分型, 及个体化冶疗),中国医学科学院 北京协和医学院 肿瘤研究所 肿瘤医院 程书钧,我国恶性肿瘤发病及死亡情况的回顾与预测,预计在2020年，全球新发病例将达1500万(我国占1/5)，死亡1000万(我国占1/4)，现患病例3000万。,肿瘤防治模式,高危个体 癌前病变 占位病变 预防 予警、发现 手术、放疗、化疗 生物，初级阶段,Wood,LD,et.al(Science,2007,Nov.16,Vol.318:1108) isolated DNA from 11 breast and 11 colorectal tumors and determined the sequences based on exons representing 20,857 transcript from 18,191gene. Any gene that was mutated in the tumor but not in normal tissue from the same patients was analyzed in 24 additional tumors. Pathway rather than individual genes appear to govern the course of tumorigenesis. Disruption of a pathway by mutation in any one of its genetic components would presumably lead to similar changes in growth. The 15 driver mutation in an individual tumor likely reflect alterations in a similar number of pathways.,A few gene mountains are mutated in a large proportion of tumors; most genes are mutated in 5% of tumors represented as hills两个肿瘤突变基因重复的很少， (Science 2007,318: 1108),Greenman,C et al(Nature, 2007,446:153-)reported 1,000 somatic mutations found in the coding exons of 518 protein kinase genes in 210 diverse human cancers. There was substantial variation in the number and pattern of mutations in individual cancer. Most somatic mutations are likely to be passengers that do not contribute to oncogenesis. However, there was evidence for driver mutation contributing to the development of the cancer studied in approximately 120 genes.,Thomas,RK et al.(Nature genetics,2007,39:347-)determined 238 known oncogen mutation across 1,000 human tumor samples of 17 cancer types. Of 17 oncogens analyzed, they found 14 to be mutated at least once, and 298(30%) samples carried at least one mutation,1). Wood,LD,et.al determined the 乳腺癌和结直肠癌 DNA sequences based on exons of 20,857 transcript from 18,191gene. (Science,2007,Nov.16,Vol.318:1108) 2). Thomas RK,et al 分析17类肿瘤 238个oncogenes 的突变(Nature genetics, 2007: 39; 153-) 3). Greenman,C;et al. 分析210个不同人的肿瘤的 518 protein kinase gene exons 的突变 ( Nature, 2007, 446: 153-) 两个肿瘤之间突变基因重复的很少 Pathway rather than individual genes appear to govern the course of tumorigenesis. Disruption of a pathway by mutation in any one of its genetic components would presumably lead to similar changes in growth. The differences are likely to be the basis for the wide variation in tumor behavior and responsiveness to therapy,The epigenetic progenitor model of cancer Stem/progenitor cells表观遗传学(epigenetic)改变; Gatekeeper mutation; Genetic and epigenetic instability Feinberg,AP et al.( Nature Review Genetics,2006,7: 21-33),我们还不清楚一个肿瘤包含有多少个基因的改变，以及相互的作用机理？ 但研究已揭示与癌变有关的基因参与的复杂性，造戌了肿瘤病人的个体反应不同，这是肿瘤分子分型和个体化冶疗的基础,肿瘤异质性, 分子型, 及个体化冶疗 Systems biology,基因突变谱 (SNP) （Array CGH） 基因组甲基化谱 基因表达谱 MicroRNAs谱(Oncomirs) 蛋白标志谱 染色体异常 细胞组织,Diffuse large B-cell(DLBCL)(the most common subtype of non-Hodgkins lymphoma) Germinal centre B-like DLBCL, to express genes characteristic of germinal centre B cell, had a significant better survival.(LMO2, BCL6,FN1, expression related to longer survival) Activated B-like DLBCL, to express genes normally induced during in vitro activation of peripheral blood B cells. (CCND2, SCYA3, BCL2. expression related to shorter survival) ( N. Engl. J. Med. 2004, 300: 1828-1837),Breast cancer patients with the same stage can have markedly different treatment responses. The clinical behaviour (such as lymph node status and histological grade) fail to classify accurately outcome. Chemotherapy or hormonal therapy reduces distant metastases by one-third, however 70-80% of these patients would not developed distant metastases without the adjuvant treatment, these patients may not benefit from the treatment, and may potentially suffer from the side effects. (Nature, 2002,VOl.415, 530),FDA News FOR IMMEDIATE RELEASE P07-13 February 6, 2007 Media Inquiries: . The MammaPrint test uses the latest in molecular technology to predict whether existing cancer will metastasize (spread to other parts of a patients body). 70 genes activity confers information about the likelihood of tumor recurrence.,MicroRNA(miRNAs 300-1000) are an abundant class of negative gene regulators that have been shown to control a wide range of biological functions such as cellular proliferation, differentiation and apoptosis. About half of the annotated human miRNAs map within fragile region of chromosomes, which are areas of the genome that are associated with various human cancers. miRNA mutations or mis-expression correlate with various human cancers and can function as tumor suppressors and oncogenes. A single miRNA might bind as many as 200 gege targets and so, miRNAs potentially control the expression of about one-third of human mRNAs . Nature Reviews/ Cancer 2006, 6;259-269,Lu et al.( Nature,2005 435:834-),约25%临床诊断为肺癌Ia期患者，单纯接受手术治疗后会复发。因此有必要识别此亚型的患者，以便给予更有效的治疗。 Potti等（ N Engl J Med 2006, 355:570- ）用89例早期NSCLC病例构建了一个“肺癌转移模型”表达谱芯片(准确率93%, ，高于目前应用的基于临床病理特征的预测方法 64%) ，并可鉴别出需要术后化疗的Ia期患者。 该研究已被美国临床肿瘤学会（ASCO）评为2006年临床肿瘤研究主要进展之一。,N ENGL J MED 2006,355:570-,N ENGL J MED 2006,355:570-,Methylation of the promotor regions of P16 and CDH13 in both tumor and mediastinal lymph nodes in stage 1 NSCLC patients was associated with an odds ratio of recurrent cancer of 15.5. 有甲基化病人无复发存活时间明显低于无甲基化(N.ENGL.J.MED.2008,358:1118-),42个基因可区分肺癌淋巴结转移,(50%),分子标志谱在判断乳腺癌治疗敏感性中的应用 (北京市科委重大专项),通过分析新辅助化疗有效(完全缓解+部分缓解)与无效(肿瘤进展)患者治疗前后的肿瘤组织标本以及血标本, 发现与乳腺癌化疗敏感性相关的分子标志谱。 根据NCCN Clinical Practice Guidelines in Oncology (Breast Cancer, Version 1.2005) 选取临床IIA（T2, N0, M0）、IIB（T2, N1, M0；T3, N0, M0）、IIIA（T3, N1, M0）期患者、其他符合保乳手术治疗的患者（除外肿瘤大小因素）以及局部进展期乳腺癌患者(IIIA: T0-3, N2, M0; IIIB: T4, N0-2, M0; Any T, N3, M0)入组。在接受治疗前，对入组患者进行空心针穿刺活检（core needle biopsy）取得病理诊断；随后给予4周期EC方案（表阿霉素+环磷酰胺，14天/周期）；评价疗效 运用基因芯片技术，对治疗前后标本的mRNA表达情况进行检测、分析。比较治疗反应阳性组与治疗反应阴性组患者的上述检测指标之间的差异，寻找与新辅助化疗疗效相关的分子标志谱，建立预测化疗疗效的临床生物学模型。,Is cancer metastasis predetermined and predictable?,利用此153个有显著差异的基因，在国际上首次建立了一个肝癌转移的预测模型。 这一模型预测待检标本的准确率达90%以上。(Ye QH, et al. Nat Med, 2003, 9; 416-423),NSCLC有淋巴结转移与无淋巴结转移病人比较, 前者 有1q25-32, 12q23-24.3, 17q12-22 区域DNA拷贝增加，而且这种差别在原位癌阶段即已形成, 提示在原位癌阶段即可能巳经有与转移相关的driver genes 在不断推 动以后的肺癌 转移 (J ,Ma. et al. J Pathl 2006, 210: 205-213),癌前病变与癌,癌变的多阶段发生模式,从正常细胞发展到危及生命的恶性肿瘤，大多经历“癌前病变”阶段。而从“癌前病变”发展成侵袭性癌一般需要10年或更长的时间，“癌前病变”的一个重要特征是具有可逆性。,1570%宫颈原位癌在10年后会发展成浸润癌；大约在3.54.5年中，16%的宫颈轻度不典型增生发展成重度不典型增生及原位癌。,胃粘膜多阶段癌变过程,异型增生发生癌变的危险度增加41倍多；,控制癌前病变,1950年以来，巴氏涂片检测宫颈癌前病变加上外科切除，使宫颈癌发生率和死亡率分别下降78和79，而未实施这项措施的国家,宫颈癌仍然是妇女肿瘤的主要死亡原因。,20mg/day (6682人) 对照(6706人) 69个月后 22/1000 43.4/1000 49岁下降44%; 50-59组降51%; 60组降55% 原位癌组降56%;不典型增生组降86% Estrogen受体阳性组降69% Estrogen受体阴性肿瘤无明显影响 子宫内膜癌危险性上升 Stage1,Tamoxifen,为什么有些癌前病变会发展成为浸袭性癌？而大部分不会？ Molecular lesions that occur in early stage of cancer or in precursor lesions are more likely to have a direct influence (Drivers) on cancer occurrence and progression than those that accumulate at the later stage of cancer development. Among the latter, many alterations may be considered as passengers 早期癌变预警标志,肿瘤早期发现和诊断是肿瘤治疗的关键,肺癌 Stage 1病人5年生存率70%左右 Stage IV病人5年生存率5%左右,Low-dose CT筛查 31,567 无症状人群 (1993-2005)发现的 412 Stage 1肺癌病人10年生存率 88%, 302例病人在诊断后一个月做手术,10年生存率92%, 8例病人Stage 1,诊断后未接受治疗5年之内去世。 (N.Engl. J.Med. 2006, 355: 1763-),未来肿瘤早诊研究趋势：,分子影像学 体液中肿瘤分子标志谱,技术路线 (Molecular & Cellular Proteomics 2005, 4: 1480),收集条件培养基,浓缩、冻干,1-D SDS-PAGE电泳,质谱鉴定,临床组织标本验证,检测到肺癌相关游离（分泌）蛋白已有1000多种。通过对肺癌患者血浆的检测分析，已鉴定出11种蛋白，8种明显差异（增高或降低，如MMP1、Fascin、 CD98、 SC、 14-3-3-eta、-sigma、-beta、LAMC2)，其中有7种未见在人血浆中被检出的报道。 这也是目前国际上同类研究中最大的一个肿瘤相关分泌释放蛋白数据库 (Molecular & Cellular Proteomics 2005, 4: 1480),人类控制肿瘤的关键,预防 与病毒相关的宫颈癌、肝癌将首先被控制 控制癌前病变 不断减少晚期肿瘤发生 早期诊治 晚期肿瘤的多靶点综合治疗(个体化冶疗),内在遗传因素: 在北欧瑞典、丹麦、芬兰研究了44,788对双胞胎，其中10,803(9,512对)人发生肿瘤，表明有遗传因素影响的肿瘤是：,前列腺癌 42% 大肠、直肠癌 35% 乳腺癌 27% (N.Eng.J.Med. 2000,342:78-85),与病毒相关的宫颈癌、肝癌将首先被控制 1). HPV病毒疫苗 2). 2006年6月9日美国FDA批准Gardasil (加德西)上市。5年随访发现 该疫苗有 效预防了HPV16和HPV18型有关的宫颈、外阴和阴道癌前病变发生。 预防HPV6 和 HPV11型相关的生殖器疣发生。,American Botanical Council (Austin, Texas, Nov 9, 2006),”非赢利的美国植物学会创建者和执行主任马克布鲁蒙萨尔说：“一种复杂的草本制剂得以作为处方药进入美国市场，这是近半个世纪以来的第一次。” “这种新药, 其安全和功效已经得到了充分的临床证明，并且跟所有化学或生物药物一样获得了FDA的批准。这一批准实际上为一个新药行业的建立铺平了道路。”,What we dont know 一种基因能治好晚期肿瘤？ 一种药物能否治好晚期肿瘤？ 单一生物标志能否淮确 预测肿瘤予后？ 晚期病人带瘤生存治疗？ 多靶点综合治疗(个体化冶疗) 实现个体化治疗，避免过度治疗，是改善目前肿瘤治愈率低和死亡率高的有效途径。,路 在 何 方 针对临床实际问题进行临床与实验室密切结合的研究(未来十年内中国医学科学研究自主创新的主战场一旦取得突破，成果就有可能转化为新的技术, 应用于临床。 Herceptin (trastuzumab)针对HER2-positive breast cancer ( tumor regression 11-26% for unselected乳腺癌病人 34% for HER2-positive乳腺癌病人) (10%-40% 服 Herceptin乳腺癌病人 无明确的 positive test, 20%乳腺癌病人 HER2检测不准确) Pathway-targeted drug Molecular typing-personalized therapy 希 望 和 挑 战 (个体化治疗战略前移) Tar