BRAF基因突变在甲状腺乳头状癌中应用

1、BRAF基因突变在甲状腺乳头状癌中应用*目录 CONTENTS相关文献回顾相关文献回顾BRAF基因基因BRAF与与PTC展望展望* 相关相关文献回顾文献回顾1* BRAF文献回顾BRAF Mutations in Hairy-Cell Leukemia The BRAF V600E mutation was present in all patients with HCL who were evaluated Implications for the pathogenesis, diagnosis, and targeted therapyN Engl J Med June 16 2011;3

2、64:2305-15.；毛细胞白血病毛细胞白血病所有毛细胞白血病BRAF V600E发生了变异可以用来研究发病机理、诊断、靶向治疗* BRAF文献回顾Cetuximab and Chemotherapy as Initial Treatment for Metastatic Colorectal CancerCetuximab plus FOLFIRI compared with FOLFIRI alone reduced the risk of progression of metastatic colorectal cancerN Engl J Med april 2,2009;360:1

3、408-17.转移性结直肠癌西妥昔单抗合并 FOLFIRI 降低对KRAS突变转移性结直肠癌患者的疾病进展风险2011版NCCN提出：具有BRAF突变的患者预后差，一线治疗后疾病进展的，利用西妥昔单抗治疗是无效的* BRAF文献回顾Improved Survival With Vemurafenib In Melanoma With BRAF V600E MutationAberrant activation of the BRAF kinase occurs in 60% of melanomas, and although BRAF inhibitors have shown signif

4、icant early clinical successN Engl J Med 2011;364:2507-16.黑色素瘤在黑色素瘤中有60%患者发生BRAF V600E突变发生BRAF V600E突变的患者经vemurafenib（威罗菲尼）治疗，患者的总生存率和无进展生存率分别提高（37%&26%）。但易产生耐药。* BRAF基因介绍基因介绍2* PTC中中BRAF基因突变的分布基因突变的分布The worldwide prevalence of BRAF mutations in PTCEndocrine-Related Cancer (2006) 13 455464 文献结论

5、 B-RAFV600E mutation was found in 99 out of 260 PTCs (38%) The B-RAFV600E mutation was present in 48.3% of cases of classic PTC (85 out of 176), in 17.6% (nine out of 51) of follicular variants of PTC, in 21.7% (five out of 23) of other PTC variants and in none of the ten poorly differentiated tumor

6、s.The B-RAFV600E was correlated with an older age at diagnosis (P =0.01) Endocrine-Related Cancer (2006) 13 455464 BRAF基因突变的致病机理基因突变的致病机理The model illustrates the two major signaling pathways, the PI3K/Akt and the MAP kinase pathways。The increasing color intensity of the circle represents the increa

7、sing progression and aggressiveness ofthe tumor. MAPK pathway, the RasRafMEKMAPERK pathway.Clin Cancer Res 2007;13:1161-1170.Peng Hou, Dingxie Liu, Yuan Shan, et al. BRAF信号通路信号通路Expert Rev. Mol. Diagn. Future Science Group (2012)BRAF蛋白与KRAS蛋白同为 RAS-RAF-MEK-ERK信号通 路中上游调节因子，在 MAPK/ERK信号通路中起着 举足轻重的作用；通

8、过这些途径，将胞外信号转化为胞内信号，从而有效 应对外界的信号刺激，调节细胞的生长、增殖、分化， 抑制细胞的凋亡。Ad PRASBRAFMEKERKERKNucleusNuclear gene regulationFigure 1. Molecular signaling of the MAP kinase pathway. RTK dimerizes uponligand (growth factor, cytokine and hormone) binding and acquires ikinasedomain,leading to activation of RAS via a ser

9、ies of Ad Ps. Through cascadephosphorylation events, the activated RAS recruits BRAF to the cell membrane andactivates it. BRAF then activates downstream MEK, which in turn activates ERK. Theactivated ERK translocates from cytosol into nucleus to regulate gene expression.Ad P: Adaptor protein; RTK:

10、Receptor tyrosine kinase.Ad P MAPK通路通路Activation of MAPK signaling pathway by RAS, RET/PTC and BRAFV600E mutations.J Chin Med Assoc March 2010 Vol 73 No 3 MAPK通路负反馈通路负反馈J Chin Med Assoc March 2010 Vol 73 No 3Proposed model of feedback inhibition in tumor cells with RET/PTC or RTKs and with BRAFV600E

11、* BRAF与与PTC3* BRAF基因突变的临床应用协助诊断协助诊断判断预后判断预后指导治疗指导治疗PTCBRAF突变突变*BRAF基因突变在FNAB中的应用文献文献 The role of BRAFV600E mutation and ultrasonography for the surgical management of a thyroid nodule suspicious for papillary thyroid carcinoma on cytology Moon HJ, Yonsei University College of Medicine, Seoul, South

12、Korea.Ann Surg Oncol. 2009 Nov;16(11):3125-31术前诊断术前诊断91例通过FNAB怀疑PTC，42例发生BRAFV600E变异，术后组织病理全部是PTC，准确率100%。BRAFV600E阴性，术前诊断依赖于B超，术后：组织病理BRAF基因突变与临床病理特征分析32个研究6372个患者2个前瞻性2个常规行CND淋巴结转移临床分期甲状腺外侵犯肿瘤大小性别年龄多发病灶有无包膜亚型血管侵犯年龄与血管侵犯无统计学意义 BRAF基因突变预测DFSBRAF基因突变阳性患者更可能（ OR，3.06; 95CI，1.10-8.47， P=.032）产生PTC的持久性/

13、复发。通过细针穿刺细胞学标本检测BRAF 突变状态，对PTC的持久性/复发的 评估具有重要的预后价值。Xing M. et al.J Clin Oncol JUNE 20 200927:2977-2982.对FNA不能确诊的患者的治疗策略对于细胞学诊断不确定的细针穿刺样本进行BRAF分析BRAF V600E呈阴性（如果该患者没有其他风险因素）BRAF V600E呈阳性患者6-12月后再次接受穿刺检查全甲状腺切除+中央淋巴清扫术Yale University：Adebowale J,et al. Reflex BRAF Testing in Thyroid Fine-Needle Aspirat

14、ionBiopsy with Equivocal and Positive Interpretation:A Prospective Study.Thyroid .2011.7(21):717-723*BRAF基因突变在CND中的应用文献文献 Impact of lymph node metastases identified on central neck dissection (CND) on the recurrence of papillary thyroid cancer: potential role of BRAFV600E mutation in defining CND.Al

15、zahrani AS, Xing M Johns Hopkins University School of MedicineEndocr Relat Cancer. 2013 Jan 21;20(1):13-22指导指导CND379例甲状腺全切除，243例行CND,136未行CND。CND从无、有限、正常。复发风险率从4.7%、15.7%、40.5%（p0.0001)。CND从有限到正常，颈部淋巴结转移率从18%到77.3%（p0.0001)。BRAFV600E变异有一致的结果。* 文文 献献 解解 读读4* JAMA 解 读Association Between BRAFV600E Muta

16、tion and Mortality in Patients With Papillary Thyroid Cancer Objective：To investigate the relationship between BRAF V600E mutation and PTCrelated mortalityMingzhao Xing, MD, PhD， Division of Endocrinology and Metabolism, JohnsHopkins University Schoolof MedicineJAMA, April 10, 2013Vol 309, No. 14背景背

17、景回顾性研究 多中心1849例患者（男性 438，女性 1411）7个国家，13个中心 ，时间跨度（1978-2011）中位年龄46岁 （34-58）中位随访时间 33月 （13-67月）* 研 究 概 况 入入 组组 标标 准准所有病例为PTC，甲状腺全切除治疗性NLD按标准适应症病理诊断符合WHO标准术后按治疗标准行I131治疗随访起点：第一次手术后死亡标准：死于PTC，排除其他死因结 果总死亡率：5.3%(45/845） vs 1.1% (11/1004）(P .001)千人年死亡率：12.87 vs 2.52千人年死亡率（传统PTC）： 11.80vs 2.25 风险率（HR)：2.6

18、6 不同研究中心死亡相关分析BRAF总突变45.7%总死亡：56人 占3%其中 45人BRAF基因突变 占80.4%总死亡：BRAF（+）5.3%BRAF（-）1.1% 不同病理类型死亡相关分析All types ： 56/1849 (3.0) 45/845 (5.3) 11/1004 (1.1) .001Conventional ： 39/1233 (3.2) 33/659 (5.0) 6/574 (1.0) .001Follicular variant： 6/411 (1.5) 4/82 (4.9) 2/329 (0.6) .02 年龄及临床特征死亡相关分析有明显统计学意义:年龄大于45岁

19、尤其大于60岁无明显统计学意义：无淋巴结转移无远处转移甲状腺外侵犯StageI、II、III肿瘤大小 Kaplan-Meier 生存曲线生存曲线Kaplan-Meier 生存曲线分层生存曲线分层Kaplan-Meier 生存曲线生存曲线 年龄年龄 结结 论论 BRAFV600E基因突变与PTC总死亡率明显相关（80.4%） BRAFV600E基因突变不是PTC死亡率预测的独立因子，但给研究其分子机理及其他基因提供了依据（VEGF、c-MET等），更有利于分层研究 为PTC的预后判断及治疗提供了一定的依据 鉴于PTC总体生存期长，随访时间短,其死亡率相关性的原因尚不清楚，有待进一步研究* NEJM 解 读Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology Objective： A novel diagnostic test improve the preoperative risk assessment for Patients with cytologically indeterminate n