临床免疫学-肿瘤免疫与实验诊断

1、 肿瘤免疫与实验诊断肿瘤免疫与实验诊断 TUMOR IMMUNOLOGY AND IMMUNE DIAGNOSIS 主 要 内 容1. 简要肿瘤生物学简要肿瘤生物学2. 肿瘤免疫学简介肿瘤免疫学简介3.目前肿瘤诊疗现状与前景目前肿瘤诊疗现状与前景 免疫系统与肿瘤免疫系统与肿瘤u 强大的免疫功能强大的免疫功能- 人类自然人类自然 生存的前提生存的前提u 免疫监督是免疫功能之一免疫监督是免疫功能之一肿瘤现状肿瘤现状l肿瘤是一种生物现象肿瘤是一种生物现象 突变是自然的突变是自然的、必然的进化形式、必然的进化形式l成瘤也是一种适应性进化成瘤也是一种适应性进化l四千多年的历史，治疗无能为力四千多年的历史

2、，治疗无能为力 19世纪至世纪至20世纪初的手术世纪初的手术 20世纪初的放疗世纪初的放疗 1947年后的化疗年后的化疗Concepts of tumor biologyTumor: A cell-clone malignant disease Diseases continuous changing their nature Kinds of specific genetic diseases Cell cycle G 0 M G 1 S G 2 Cell alteration processes: cell benign prolif. being malig. Tumor 1 2 10

3、6 10 9 10 12 Tumor Cell Biology 20771mm, 1mg 1cm, 1g1kgMonths to yearsmonthsdays 肿瘤发生学的主要学说肿瘤发生学的主要学说 Main hypothesis in tumorigenesisuSomatic mutation and gene mutation（突变）（突变）uChromosome abnormalityuEvolution theory（进化）（进化）uMicro-environment hypothesis （微环境）（微环境）uChronic InflammationuStem cells et

4、c.Anti-tumor immunity Yes or no? Yes !lLigation test (肿瘤结扎实验肿瘤结扎实验), more than 100 yearslSyngeneic mice (等基因鼠等基因鼠)lClinical dataEvidence for immune surveillance in humanslIncreased incidence of EBV+ B cell lymphomas in transplant patients treated with immunosuppressive drugslIncreased incidence of K

5、aposis sarcoma & EBV+ B cell lymphomas in AIDS patientslGastric cancer associated with H. pylori infectionlCervical cancer caused by HPVlLiver cancer caused by hepatitis B & C No !l HIV infectionl Nudo mice (裸鼠裸鼠)l TSA, TAAImmunological SurveillanceEhrlich, Burnet & ThomasPaul Ehrlich (1

6、909) First to conceive of the concept of Cancer Immunosurveillance. Predicted that cancer would occur at “incredible frequency” if host defenses did not prevent the outgrowth of continuously arising cancer cells.Lewis Thomas (1957) “primary function of cellular immunity.is to protect from neoplastic

7、 disease”Macfarland Burnet (1957) “It is by no means inconceivable that small accumulations of tumour cells may develop and because of their possession of new antigenic potentialities provide an effective immunological reaction with regression of this tumor and no clinical hint of its existence” Ess

8、ences:Tumor is autologous or heterologousOr does exist specific tumor antigen ? Essences: Can tumor stimulate immune system to provoke effective response ? Essences:lHow can tumor escape from the surveillance of immune system (免疫监督免疫监督)lWhat can we do in dealing with tumor Immune System A well devel

9、oped defense systeml Non specific and specific defense mechanisms(特异与非特异免疫特异与非特异免疫)l Initave immunityl Acquired immunity Humoral, CellularTumor antigensKey molecules between tumor and human bodyu Classificationu Tumor markers and tumor antigensTumor antigen discoveringl TSTA TSA: a long road to look

10、ing forl Three stages: Original McAb TAA T cell clone TSAIs Tumor Antigen Provoke Immune Response(免疫激发免疫激发) long time controversial Yes ! Show special features: weak differential antigen embryonic antigen oncoviral antigen mutation genesWhy ? Tumor escaping the Immune System(免疫逃逸免疫逃逸) in many ways 1

11、Low antigenicity (抗原性抗原性): MHC expressing defect TPA Co-stimulating molecules Adhering molecules etc. Pathway of Antigen Presentation by Antigen-Presenting Cells(抗原递呈)Structures of Class I and Class II Major Histocompatability Complex (MHC) MoleculesRole of Co-stimulation in T-Cell ActivationDendrit

12、ic Cells, the Surface Changes Occurring With MaturationWhy ? Tumor escaping the Immune System in many ways 2n Introcyto-moleculesn antigenic modulationn inhibition factors:n TGF FasL Tsn blocking factors Anti-Tumor Immunology 选择免疫治疗是无奈之举选择免疫治疗是无奈之举u 一百多年前的肿瘤结扎试验一百多年前的肿瘤结扎试验u Coleys toxinu 临床的提示临床的提示

13、 免疫的进展放大了人们的预期免疫的进展放大了人们的预期l 单克隆抗体的出现单克隆抗体的出现l 人源性抗体的问世人源性抗体的问世l 人类基因组计划的完成人类基因组计划的完成l 免疫监测点功能的发现免疫监测点功能的发现l CAT 细胞的应用细胞的应用肿瘤免疫与与生物治疗的关联肿瘤免疫与与生物治疗的关联 细胞因子治疗细胞因子治疗 免疫细胞治疗免疫细胞治疗 基因治疗基因治疗 分子靶向治疗分子靶向治疗 抗体治疗抗体治疗肿瘤免疫治疗肿瘤免疫治疗目前，全球癌症免疫治疗主要包括以下三个方面：目前，全球癌症免疫治疗主要包括以下三个方面：1. 针对新抗原的特异性针对新抗原的特异性T细胞治疗细胞治疗;2. 以基因修

14、饰为核心的以基因修饰为核心的ACT: CAR-T、TCR-T免疫细胞治疗；免疫细胞治疗；3. 肿瘤相关靶点抗体与肿瘤相关靶点抗体与免疫检查点抗体。免疫检查点抗体。 重新审视免疫平衡理论重新审视免疫平衡理论l 关于免疫激发关于免疫激发l 对肿瘤发生学的影响对肿瘤发生学的影响l 已展现一定的临床效果已展现一定的临床效果免疫检验点抗体免疫检验点抗体 （immunol checkpoint） CAT 肿瘤治疗肿瘤治疗 (chimeric antigen receptor，CAR)目前受世人关注，这项技术最目前受世人关注，这项技术最早见于早见于1993年以色列科学家年以色列科学家Eshhar Z的报导。

15、将抗体序列表达在抗肿瘤的报导。将抗体序列表达在抗肿瘤免疫细胞表面免疫细胞表面。CAT 的技术路线的技术路线（1）靶点，这方面专利多数己过期）靶点，这方面专利多数己过期（2）与靶点结合的单链抗体与靶点结合的单链抗体（3）跨膜区与胞内区，所有）跨膜区与胞内区，所有CAR-T的差别不大，的差别不大，这些都是美国的专利这些都是美国的专利（4）刹车及安全开关刹车及安全开关（5）转染技术，国际上常用的慢病毒载体系统）转染技术，国际上常用的慢病毒载体系统肿瘤治疗的耐药肿瘤治疗的耐药 耐药产生的基本原理耐药产生的基本原理-生物变异与适应生物变异与适应 耐药发生的必然性耐药发生的必然性 抗体耐药发生的特点抗体耐

16、药发生的特点 Immune response -two stagesl Immune excitation recognition, antigen presentationl Immune response non-specific, specific-humoral and cellular The Anti-tumor Immune ResponseAmount Attack to the Tumoru Tumor antigenicity enhancingu Manipulate the immune system i.e tumor vaccinesu Adopted specif

17、ic therapies cellular humoralCellular Tumor killing mechanism:l NK and K (MHC inhibit receptor)l CTLl macrophagesl Ab and humoral moleculesEffector Mechanisms of Tumor Cell Killing by Cytotoxic T Cells (CTLs)ABThe effect models of antibodyl Epitope binding:l Neutralizationl ADCC effectl Induced comp

18、liment functionl Signal transductionl Prevention is not practical by now (with the except of lung cancer)l Early diagnosis is the only effective measurelPathological that is too latelImaging techniques show limited roles because of molecular features in tumor cell lSerological a valuable field to de

19、lving lGenetic method a hopeful field血液血液(体液体液)肿瘤相关分子检测肿瘤相关分子检测1. 1. 多肽与蛋白类多肽与蛋白类2. 2. 核酸类核酸类( (基因基因) ) （1 1）内源基因的变异：）内源基因的变异： 基因结构突变基因结构突变 基因表达异常基因表达异常 （2 2）外源基因的入侵）外源基因的入侵3. 3. 复合形式复合形式 脂蛋白，糖蛋白脂蛋白，糖蛋白, AFP, AFP异质体，异质体，CACA抗抗原类等原类等4. 4. 各种修饰形式各种修饰形式 ( (甲级化、磷酸化、甲级化、磷酸化、 组氨酸、组氨酸、 乙乙酰化、酰化、 泛素化、糖化等泛素化、

20、糖化等) )l Bens Jones protein AFP, CEA Several dozens l Become more significantl Show hopeful futureHistorical Background 1846 Bence Jones protein 1940 Acid phosphatase 1960 Immunoassay 1963 AFP 1965 CEA 1975 McAb 1980 PSA CA serial 1970-1980 Oncogenes 1990-Characteristics of the “Ideal” Tumor Marker M

21、easured easily sensitivity and specificity. Quantitative level Multiple usagesTypes of Tumor Markers Hormone: hCG calcitonin gastrin prolactin growing hormones Enzymes: acid phosphatase alkaline phosphatase Proteins and Glycoproteins: PSA CA Oncofetal antigens: Receptors: PR ER EGFR Oncogen products

22、: RAS myc bcl Tumor suppressor genes: p53 RbTechniques of Tumor Marker Detection Physic-chemical methods Primary immune methods Amplified immune methods Amplified immune methodsRIA, ELISA, Immune fluorescence, Luminex, Micro-particles etc.Significance and limitations the application of tumor markers

23、 Screening Diagnosis and differencial diagnosis Staging and prognosis Therapy assessments Monitoring RecurrenceLimited value, but:lAFP in ChinalPSA in USA in male more than 50 lCA-125 for ovary tumor Early detectable Tissue specific Significant in Risk populations Marker utilitiesTumor Marker Screening Prog. Monitoring Recurrence Colon CEA n y y yHepto AFP y com n y yOvary CA125 p com n y yOvary CEA n n y yBrea CA153 n n y yPanc CA199 p com y yGastro CA724 p com y yProst PSA p com y y y Non-Hodgk