胃癌的個體化治療(鼓樓醫(yī)院)

—南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院腫瘤中心—住院病區(qū)日間化療放射治療生物治療微創(chuàng)治療溫?zé)嶂委熤兴幹委熌暇┐髮W(xué)臨床腫瘤所細(xì)胞室藥分室病理室標(biāo)本室分子室動物室學(xué)科簡介現(xiàn)在是1頁\一共有65頁\編輯于星期日學(xué)科簡介江蘇省醫(yī)學(xué)重點(diǎn)學(xué)科江蘇省臨床重點(diǎn)?？平K省青年文明號江蘇省醫(yī)學(xué)分子技術(shù)重點(diǎn)實(shí)驗(yàn)室南京大學(xué)臨床腫瘤研究所現(xiàn)在是2頁\一共有65頁\編輯于星期日

目錄個體化療——簡介腫瘤組織——為檢查對象的個體化治療外周血漿——為檢查對象的個體化治療現(xiàn)在是3頁\一共有65頁\編輯于星期日

目錄個體化療——簡介腫瘤組織——為檢查對象的個體化治療外周血漿——為檢查對象的個體化治療現(xiàn)在是4頁\一共有65頁\編輯于星期日“標(biāo)準(zhǔn)化療”的成就與無奈：當(dāng)今腫瘤的化療：

胃癌：FAMFAMtxEAPFPECFFOLFOXTFP

RR:28%-46%

均<50%

肺癌：RR30％-40%腫瘤“異質(zhì)性”：有效率~毒副作用------個體差異……很大現(xiàn)在是5頁\一共有65頁\編輯于星期日個體化療：

細(xì)胞水平－藥物敏感實(shí)驗(yàn)

基因水平－DNA水平（突變、甲基化）

－RNA水平（mRNA、miRNA）2004年ASCO預(yù)測：

未來5-10年將是由當(dāng)今標(biāo)準(zhǔn)化療向個體化療的過渡期2005年ASCO預(yù)測：

藥物基因指導(dǎo)下“個體化療”是腫瘤化療的一場革命2006年ASCO描述：

腫瘤的化療已經(jīng)邁入“個體化療”的新時代2009年ASCO描述：

個體化醫(yī)療成為大會主題2010年以后態(tài)勢：大樣本的論文相繼發(fā)表“藥物相關(guān)基因指導(dǎo)下個體化療”現(xiàn)在是6頁\一共有65頁\編輯于星期日個體化療藥物遺傳學(xué)（pharmacogenetics)藥物基因組學(xué)（pharmacognomics）藥物遺傳學(xué)：研究與藥物反應(yīng)性/毒性相關(guān)的個體間DNA序列/基因多態(tài)性/甲基化的差異。藥物基因組學(xué)：將全基因組技術(shù)（即基因表達(dá)數(shù)據(jù)）用于預(yù)測一個患病個體對一個/一組藥物的敏感性或抵抗性?，F(xiàn)在是7頁\一共有65頁\編輯于星期日現(xiàn)在是8頁\一共有65頁\編輯于星期日DPD:

二氫嘧啶脫氫酶

TS:

胸腺嘧啶核苷酸合成酶

OPRT:乳清酸磷酸核糖基轉(zhuǎn)移酶

TP:胸(腺嘧啶脫氧核)苷磷酸化酶氟脲密啶

(5-FU)現(xiàn)在是9頁\一共有65頁\編輯于星期日足葉乙甙（VP－16)-------------------------MDM2現(xiàn)在是10頁\一共有65頁\編輯于星期日現(xiàn)在是11頁\一共有65頁\編輯于星期日開普拓（CPT11)----------------------------WRN現(xiàn)在是12頁\一共有65頁\編輯于星期日Colorectalcancerstreatedwithirinotecan現(xiàn)在是13頁\一共有65頁\編輯于星期日開普拓（CPT11)TopoI現(xiàn)在是14頁\一共有65頁\編輯于星期日甲氨蝶呤（MTX)------------------------DHFR現(xiàn)在是15頁\一共有65頁\編輯于星期日中國人群STAT3rs4796793位點(diǎn)多態(tài)性分布：

CC40.0%（IFNa敏感性較高）

CG46.7%GG13.3%干擾素（IFNa）------------------------STAT3現(xiàn)在是16頁\一共有65頁\編輯于星期日吉西他濱（GEM）-------------------hENT1、hCNT3現(xiàn)在是17頁\一共有65頁\編輯于星期日紫杉類

(paclitaxel，docetaxel)

1.Cytoskeletonandpaclitaxelsensitivityinbreastcancer:Theroleofβ–tubulinIntJCancer.2007;120,2078–20852.ClinicalsignificanceofclassIIIbeta-tubulinexpressionanditspredictivevalueforresistancetodocetaxel-basedchemotherapyingastriccancerIntJOncol.2006Feb;28(2):375-81

.Microtubule-AssociatedProtein-tauisaBifunctionalPredictorofEndocrineSensitivityandChemotherapyResistanceinEstrogenReceptorPositiveBreastCancerClinCancerRes2007;13(7):2061-7現(xiàn)在是18頁\一共有65頁\編輯于星期日甲氨蝶呤（MTX)DHFR現(xiàn)在是19頁\一共有65頁\編輯于星期日ERCC1(excisionrepaircross-Complementing1)ERCC1mRNA水平與鉑類的敏感性密切相關(guān)，可以當(dāng)成鉑類化療效果的獨(dú)立預(yù)測指標(biāo)。BRCA1(breastcancer1)參與DNA修復(fù)，與鉑類藥物及作用于微管蛋白藥物敏感性密切相關(guān)XRCC1

(X-rayrepaircross-complementinggroup1)XRCC1基因第399位密碼子由CGGCAG的變異可以導(dǎo)致編碼的氨基酸由ArgGln。變異型的DNA修復(fù)能力提高，對鉑類敏感性下降。XPD(xerodermapigmentosumpomplementarygroupD)XPD基因第751位密碼子由AAGCAG的變異導(dǎo)致氨基酸由LysGln。變異型的表型導(dǎo)致DNA修復(fù)能力的提高，鉑類敏感性下降。GSTP1(Glutathione-S-transferaseP1)GSTP1基因密碼子105位纈氨酸(Val)

轉(zhuǎn)變?yōu)楫惲涟被?Ile)

，這一氨基酸的替換導(dǎo)致酶活性升高,鉑類敏感性下降。鉑類藥物療效相關(guān)基因(總結(jié)）現(xiàn)在是20頁\一共有65頁\編輯于星期日

目錄個體化療——簡介腫瘤組織——為檢查對象的個體化治療外周血漿——為檢查對象的個體化治療現(xiàn)在是21頁\一共有65頁\編輯于星期日

1、方法學(xué)建立——胃癌石蠟包埋組織檢查微量的mRNA水平

2、開展胃癌化療與療效預(yù)后的隨訪

3、系統(tǒng)檢查了如下基因狀況

ERCC1mRNA&proteinexpressionTsmRNA&proteinexpressionOPRTmRNA&proteinexpression篩選提高化療效果的

XRCC1Arg399GlnSNP基因標(biāo)志

GSTP1Ile105ValSNPXPDLls751GlnSNP4、統(tǒng)計學(xué)分析：與療效及生存時間的關(guān)系胃癌

——

生物標(biāo)志篩選+臨床研究

從1760例胃癌中篩選出完整隨訪信息的病人現(xiàn)在是22頁\一共有65頁\編輯于星期日IF：4.0

他引次數(shù)：22胃癌

——

生物標(biāo)志篩選+臨床研究

5、發(fā)現(xiàn)：ERCC1mRNA與含鉑方案療效與預(yù)后有關(guān)

發(fā)現(xiàn)：XRCC1Arg399GlnSNP與含鉑方案療效與預(yù)后有關(guān)

發(fā)現(xiàn)：GSTP1Ile105ValSNP和XPDLls751GlnSNP無統(tǒng)計意義這一發(fā)現(xiàn)與西方人群有明顯差異

IF：4.51

他引次數(shù)：19現(xiàn)在是23頁\一共有65頁\編輯于星期日6、進(jìn)一步檢查了如下基因mRNA水平

BRCA1mRNARAP80mRNASUMO調(diào)控途徑核心基因PIAS1和PIAS4mRNA

發(fā)現(xiàn)：BRCA1水平高者含Doc化療生存時間是低表達(dá)者的

2-3倍IF：14.6胃癌

——

生物標(biāo)志篩選+臨床研究

國科金現(xiàn)在是24頁\一共有65頁\編輯于星期日7、癌性腹水開展了系列性基因標(biāo)志的檢查

ERCC1mRNA

BRCA1mRNAβ-tubulin

Ⅲ

mRNATs

mRNA、

OPRTmRNAcellfreemiR-152cellfreemiR-21cellfreemiR-146a…..胃癌

——

生物標(biāo)志篩選+臨床研究

23種miRNAs現(xiàn)在是25頁\一共有65頁\編輯于星期日胃癌

——

生物標(biāo)志篩選+臨床研究

再次證實(shí)：BRCA1與紫衫療效顯著相關(guān)

ERCC1與鉑類療效顯著相關(guān)

發(fā)現(xiàn)：miR-152

與紫衫療效具有相關(guān)性

現(xiàn)在是26頁\一共有65頁\編輯于星期日胃癌個體化治療BREC-CHINA

——前瞻性臨床研究BREC-AGC

胃癌“生物標(biāo)志指導(dǎo)下個體化療”的隨機(jī)對照前瞻性研究現(xiàn)在是27頁\一共有65頁\編輯于星期日倫理批文CRF報告表T2-T3RAP80(T1-T2BRCA1)T2-T3RAP80(T3BRCA1)Gem/CisDocetaxelDocetaxel/CisT1RAP80(T1-T3BRCA1)CONTROLDocetaxel/CisAdvancedNSCLC1:1EXPERIMENTAL肺癌治療啟動肺癌個體化化療BREC-CHINA前瞻性多中心臨床研究現(xiàn)在是28頁\一共有65頁\編輯于星期日

目錄個體化療——簡介腫瘤組織——為檢查對象的個體化治療外周血漿——為檢查對象的個體化治療現(xiàn)在是29頁\一共有65頁\編輯于星期日新一代血清生物標(biāo)志

------在腫瘤個體化藥物治療中的應(yīng)用前景

劉寶瑞

Ph.DMD南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院腫瘤中心南京大學(xué)臨床腫瘤研究所現(xiàn)在是30頁\一共有65頁\編輯于星期日目錄

一、血清中含有大量腫瘤生物信息二、血清中分子靶向藥物生物標(biāo)志

三、血清中化療藥物療效生物標(biāo)志四、南京大學(xué)附屬鼓樓醫(yī)院的探索現(xiàn)在是31頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息傳統(tǒng)意義上的生物標(biāo)志

目的：腫瘤診斷和隨訪回顧性預(yù)測治療效果內(nèi)容：血清蛋白標(biāo)志CEAAFPCA125CA199CY211

CA242CA724PSAfPSA

現(xiàn)在是32頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息2.新一類血清生物標(biāo)志——藥物療效標(biāo)志及預(yù)后標(biāo)志

目的：前瞻性預(yù)測藥物治療效果及腫瘤患者的預(yù)后

predictivemarkerprognosticmarker

內(nèi)容：外周血循環(huán)腫瘤細(xì)胞外周血循環(huán)特定的DNA

外周血循環(huán)特定的RNA

外周血循環(huán)特定的miRNA現(xiàn)在是33頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息文獻(xiàn)綜述——循環(huán)腫瘤細(xì)胞及游離DNA現(xiàn)在是34頁\一共有65頁\編輯于星期日Circulatingnucleicacidsasapotentialsourceforcancerbiomarkers.Russia.CurrMolMed.2010Mar;10(2):142-65.SincetheassociationofcirculatingDNAlevelchangeswithtumorgrowthwasdiscoveredmanyattemptshavebeenmadetodevelopthesensitiveandrobustblood-basedtestsforearlytumordiagnostics.BothgenomicaswellasmitochondrialDNAquantificationinthecirculationhavebeenextensivelyevaluatedasadiagnosticandprognostictooltomonitorcancertherapy.Cell-freeDNA

bearingthesamegeneticandepigeneticchangesasthetumortissueswereshowntobedetectableinplasma/serumofcancerpatientsindicatingtheprincipalpossibilitytocreatetheminimallyinvasivediagnostictestsbasedontumor-specificDNAmarkers.ApartfromcirculatingDNA,tumor-derivedRNA

inplasma/serumwasfoundtobeapromisingapproachforthedevelopmentofcancermarkers.Resultsofthelasttwoyearsestablishthequantificationofthe

tumor-derivedmicroRNAs

inplasma/serumasanextremelypromisingapproachforcancerdiagnostics.一、血清中含有大量腫瘤生物信息文獻(xiàn)綜述——循環(huán)DNA~RNA~miRNA現(xiàn)在是35頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息文獻(xiàn)——血漿RNA與mRNA現(xiàn)在是36頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息Chemosensitivityprofileassayofcirculatingcancercells:prognosticandpredictivevalueinepithelialtumors.Roma,Italy.IntJCancer2010;126(10):2437-47..Theprognosticvalueassociatedwiththedetectionofcirculatingtumorcells(CTCs)inmetastaticbreastcancerbytheCellSearchtechnologyraiseadditionalissuesregardingthebiologicalvalueofthisinformation.Wepostulatedthatadrug-resistanceprofileofCTCsmaypredictresponsetochemotherapyincancerpatientsandthereforecouldbeusedforpatientselection.Onehundred5patientswithdiagnosisofcarcinomawereenrolledinaprospectivetrial.CTCswereisolatedfromperipheralblood,andpositivesampleswereevaluatedforthe

expressionofapanelofgenesinvolvedinanticancerdrugsresistance.Sensitivityofthetest:abletopredicttreatmentresponsein98%ofpatients.Specificityofthetest:100%;nosamplefromhealthysubjectwaspositiveforthepresenceofCTCs.Weidentifiedadrug-resistanceprofileofCTCs,whichispredictiveofresponsetochemotherapy,independentoftumortypeandstageofdisease.Thisapproachmayrepresentafirststeptowardtheindividualizationofchemotherapyincancerpatients.文獻(xiàn)——循環(huán)腫瘤細(xì)胞的個體化療標(biāo)志現(xiàn)在是37頁\一共有65頁\編輯于星期日一、血清中含有大量腫瘤生物信息現(xiàn)在是38頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

1.外周血EGFR突變

2.胸水EGFR突變

3.外周血Kras突變

4.外周血Her2mRNA水平

現(xiàn)在是39頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

1.外周血EGFR突變（廣州）

Detectionofepidermalgrowthfactorreceptormutationsinplasmabymutant-enrichedPCRassayforpredictionoftheresponsetogefitinibinpatientswithnon-small-celllungcancer.HeC,LiuM,ZhouC,GuangzhouChina.IntJCancer.2009；125(10):2393-9.SpecimensourceandmethodsforEGFRmutationanalysisarelimitedbytissueavailabilityandtechnicalfeasibilityinclinicalapplication.Therefore,thecurrentstudyisdesignedtoestablishablood-basedapproachfortheassessmentofEGFRmutationsinNSCLCpatients,inparticulartheadvancedstage,andtotestitsclinicalapplication.Plasmasampleswereobtainedfromtheenrolled134NSCLCpatients.ThedetectionrateoftheEGFRexon19deletionsandexon21L858Rwas49.3%(66/134)bytheblood-based,mutant-enrichedpolymerasechainreaction.Inthepairedtumorandplasmasamples,thedetectedmutanttypesofeachpairrespectivelybydirectsequencingandmutant-enrichedpolymerasechainreactionwereconcordantin17of18(94.4%).Inthepatientstreatedwithgefitinibasasecond-linetherapy,thosewithplasmaEGFRmutationhaveaprolongedmedianprogression-freesurvivalcomparedwiththosewithEGFRwildtype(7.609vs.2.877months,p=0.002).Oncomparingtheefficacyofgefitinibwiththatofdocetaxel,itwasfoundthatthemedianprogression-freesurvivalwassignificantlylongerforpatientstreatedwithgefitinibthanthosewithdocetaxelinthoseharboringplasmaEGFRmutation(7.609vs.3.192months,p=0.006).Theseresultssuggestthattheblood-basedEGFRmutationstesthastheabilitytoprovideareliableguidanceforclinicaldecisionmakingforthetreatmentoftheadvancedNSCLCpatients.現(xiàn)在是40頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

1.外周血EGFR突變（北京）

EpidermalgrowthfactorreceptormutationsinplasmaDNAsamplespredicttumorresponseinChinesepatientswithstagesIIIBtoIVnon-small-celllungcancer.

BaiH,MaoL,WangHS,BeijingCancerHospitalJClinOncol.2009Jun1;27(16):2653-9PlasmaDNAsamplesandmatchedtumorsfrom230patientswithstagesIIIBtoIVNSCLCwereanalyzedforEGFRmutationsinexons19and21byusingdenaturinghigh-performanceliquidchromatography.WecomparedthemutationsintheplasmasamplesandthematchedtumorsanddeterminedanassociationbetweenEGFRmutationstatusandthepatients'clinicaloutcomesprospectively.In230patients,wedetected81EGFRmutationsin79(34.3%)ofthepatients'plasmasamples.Wedetectedthesamemutationsin63(79.7%)ofthematchedtumors.Sixteenplasma(7.0%)andfourteentumor(6.1%)samplesshoweduniquemutations.Inthe102patientswhofailedplatinum-basedtreatmentandwhoweretreatedwithgefitinib,22(59.5%)ofthe37withEGFRmutationsintheplasmasamples,whereasonly15(23.1%)ofthe65withoutEGFRmutations,achievedanobjectiveresponse(P=.002).PatientswithEGFRmutationshadasignificantlylongerprogression-freesurvivaltimethanthosewithoutmutations(P=.044)inplasma.EGFRmutationscanbereliablydetectedinplasmaDNAofpatientswithstagesIIIBtoIVNSCLCandcanbeusedasabiomarkertopredicttumorresponsetoTKIs.現(xiàn)在是41頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

1.胸水EGFR突變（日本）

EGFRmutationstatusintumour-derivedDNAfrompleuraleffusionfluidisapracticalbasisforpredictingtheresponsetogefitinib.KimuraH,Japan.BrJCancer.2006；95(10):1390-5.Weobtained43samples,whichwasthecell-freesupernatantofpleuralfluid,fromJapaneseNSCLCpatients,andexaminedthemforEGFRmutations.Theepidermalgrowthfactorreceptormutationstatuswasdeterminedbyadirectsequencingmethod(exons18-21inEGFR).EGFRmutationsweredetectedin11cases(E746_A750delinsevencases,E746_T751delinsAinonecase,L747_T751delinonecase,andL858Rintwocases).AcomparisonbetweentheEGFRmutantstatusandtheresponsetogefitinibinthe27patientswhoreceivedgefitinibrevealedthatallsevenpatientswithpartialresponseandoneofthesevenpatientswithstablediseasehadanEGFRmutation.NoEGFRmutationsweredetectedinthepatientswithprogressivedisease.TheresultssuggestthatDNAinpleuraleffusionfluidcanbeusedtodetectEGFRmutationsandthattheEGFRmutationstatusmaybeusefulasapredictoroftheresponsetogefitinib.現(xiàn)在是42頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

1.外周血及胸水EGFR突變（上海）

Predictionofepidermalgrowthfactorreceptormutationsintheplasma/pleuraleffusiontoefficacyofgefitinibtreatmentinadvancednon-smallcelllungcancer.JianG,SongwenZ,CaicunZ.JCancerResClinOncol.2010；136(9):1341-7.ThefreeDNAwasisolatedfromtheplasmaof56casesandpleuraleffusionofanother32casesofadvancedNSCLC.FivecommontypesofEGFRmutationswereanalyzedbyLightCyclePCRwithTaqman-MGBprobes.EGFRgenemutationswerefoundin22ofallthe88(25%)NSCLCpatients(23.2%of56plasmasamples,28.1%ofanother32pleuraleffusionsamples).TheEGFRmutationsintheserumandthepleuraleffusionfromadvancedNSCLCpatientscanbedetectedwithLightCyclePCRusingTaqman-MGBprobes.ThemutationshighlypredicttheefficacyofgefitinibinadvancedNSCLC.現(xiàn)在是43頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志2.外周血HER2mRNA（意大利）現(xiàn)在是44頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志DetectionofoccultHER2mRNA-positivetumorcellsintheperipheralbloodofpatientswithoperablebreastcancer:evaluationoftheirprognosticrelevance.ApostolakiS……Greece.BreastCancerResTreat.2009；117(3):525-34.ToevaluatewhetherHER2mRNAcouldbeusedasamarkerofcirculatingtumorcells(CTCs).AnestedRT-PCRassaywasdevelopedandusedforthedetectionofHER2mRNA-positiveCTCs.Bloodfrom216womenwithearlybreastcancerobtainedbeforeadjuvanttreatmentwastestedforHER2mRNA-positivecellstoassesstheirprognosticvalue.NestedRT-PCRforHER2mRNAshowedhighsensitivitywhereasnoHER2mRNA-positivecellscouldbeidentifiedinthebloodofhealthydonors.HER2mRNA-positiveCTCsweredetectedin53(24.5%)of216patientsandHER2mRNAdetectionwasassociatedwithreduceddisease-freesurvival(DFS;P<0.0001)andoverallsurvival(OS;P=0.004).Inmultivariateanalysis,detectionofHER2mRNA-positiveCTCsemergedasindependentprognosticfactorforDFS(P=0.0001)andOS(P=0.003).HER2mRNAcouldbeavaluableprognosticmarkerforthedetectionofCTCsinearly

breastcancerpatients.2.外周血HER2mRNA（希臘）現(xiàn)在是45頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志

2.外周血HER2mRNA(美國）CirculatingtumorcellsinHER-2positivemetastaticbreastcancerpatientstreatedwithtrastuzumabandchemotherapy.NunesRA,LiX,KangSP,Dana-FarberCancerInstitute,USA.IntJBiolMarkers.2009;24(1):1-10.ThegoalofthispaperistopresentasensitiveandspecificmethodologyofdetectingCTCsinwomenwithHER-2positivemetastaticbreastcancer,andtoexamineitsroleasamarkerthattracksdiseaseresponseduringtreatmentwithtrastuzumab-containingregimens.ThestudyincludedpatientswithHER-2-positivemetastaticbreastcancerenrolledontwodifferentclinicalprotocolsusingatrastuzumab-containingregimen.OurstudysupportstheprognosticandpredictiveroleofthedetectionofCTCsintreatmentofHER-2-positivemetastaticbreastcancerpatients.現(xiàn)在是46頁\一共有65頁\編輯于星期日二、血清中分子靶向藥物療效標(biāo)志OriginandprognosticvalueofcirculatingKRASmutationsinlungcancerpatients.GautschiO,HuegliB,ZieglerA,USA.CancerLett.2007;254(2):265-73.BecauseofthecurrentcontroversyontheoriginandclinicalvalueofcirculatingKRAScodon12mutationsinlungcancer,wescreened180patientsusingacombinedrestrictionfragment-lengthpolymorphismandpolymerasechainreaction(RFLP-PCR)assay.WedetectedKRASmutationsin9%plasmasamplesand0%matchedlymphocytes.PlasmaKRASmutationscorrelatedsignificantlywithpoorprognosis.WevalidatedthepositiveresultsinasecondlaboratorybyDNAsequencingandfoundmatchingcodon12sequencesinbloodandtumorin78%evaluablecases.TheseresultssupportthenotionthatcirculatingKRASmutationsoriginatefromtumorsandareprognosticallyrelevantinlungcancer.3.外周血Kras突變（美國）

現(xiàn)在是47頁\一共有65頁\編輯于星期日Potentialclinicalsignificanceofaplasma-basedKRASmutationanalysisinpatientswithadvancednon-smallcelllungcancer.WangS,AnT,WangJ,BeijingCancerHospital&InstituteClinCancerRes.2010:1324-30.DNAextractedfromplasmaandmatchedtumortissueswereobtainedfrom273patientswithadvancedstageNSCLC.KRASmutationsincodon12and13weredetectedusingPCR-restrictionfragmentlengthpolymorphism.Mutationsinplasmaandmatchedtumorswerecompared.KRASmutationwasfoundin35(12.8%)plasmasamplesand30(11.0%)matchedtumortissues.TheconsistencyofKRASmutationsbetweenplasmaandtumorsis76.7%(23of30;kappa=0.668;P<0.001).Among120patientswhoreceivedEGFR-TKItreatment,theresponseratewasonly5.3%(1of19)forpatientswithplasmaKRASmutationcomparedwith29.7%forpatientswithnoKRASmutationinplasmaDNA(P=0.024).Themedianprogression-freesurvivaltimeofpatientswithplasmaKRASmutationwas2.5monthscomparedwith8.8monthsforpatientswithwild-typeKRAS(P<0.001).KRASmutationinplasmaDNAcorrelateswiththemutationstatusinthematchedtumortissuesofpatientswithNSCLC.PlasmaKRASmutationstatusisassociatedwithapoortumorresponsetoEGFR-TKIsinNSCLCandmaybeusedasapredictivemarkerinpatientsforsuchtreatment.二、血清中分子靶向藥物療效標(biāo)志3.外周血Kras突變（北京）

現(xiàn)在是48頁\一共有65頁\編輯于星期日K-rasmutationalstatuspredictspoorprognosisinunresectablepancreaticcancer.ChenH,TuH,MengZQFudanUniversity,Shanghai,China.EurJSurgOncol.2010；

36(7):657-62.Bloodsampleswerecollectedfrom91patientswithunresectablepancreaticcancerpriortotreatment.K-rasgenewasamplifiedfromthecirculatingplasmaDNA.Mutationsweredetectedbydirectsequencing.TherelationshipbetweenthetypesofK-rasgeneandprognosisofunresectablepancreaticcancerwasevaluated.K-Rascodon12mutationswerefoundin30of91(33%)plasmaDNAsamples,17mutationswerec.35G>A(p.G12D),11werec.35G>T(p.G12V)andonly2werec.34G>C(p.G12R)).K-rascodon12mutationscouldsignificantlyreflecttheclinicalparameters,includingTNMtumorstaging(P=0.033)andlivermetastasis(P=0.014).ThemediansurvivaltimeofpatientswithK-rasmutationswasshorterthanthatofpatientswithwild-typeK-rasgene(3.9monthsvs.10.2months,P<0.001).K-rascodon12mutationfromplasmaDNAwasanindependentnegativeprognosticfactorforsurvival(hazardratio,7.39;95%confidenceinterval,3.69-14.89).二、血清中分子靶向藥物療效標(biāo)志3.外周血Kras突變（上海）

現(xiàn)在是49頁\一共有65頁\編輯于星期日三、血清中化療藥物療效標(biāo)志1.常見化療藥物的療效標(biāo)志——舉例2.血清中化療藥物療效標(biāo)志——推測

現(xiàn)在是50頁\一共有65頁\編輯于星期日三、血清中化療藥物療效標(biāo)志1.常見化療藥物的療效標(biāo)志（腫瘤組織）鉑類————BRCA1、ERCC1、XRCC1

紫杉類————BRCA1、TublinIII、TublinII

吉西他濱————hENT1、RRM1

開普拓————TopoI5-FU類————Ts、Tp、OPRT

足葉乙甙————MDM2

替莫唑胺————MGMT

培美曲賽————Ts現(xiàn)在是51頁\一共有65頁\編輯于星期日三、血清中化療藥物療效標(biāo)志2.血清中化療藥物療效標(biāo)志舉例

（潛在價值）TsmRNA水平與培美曲賽療效相關(guān)現(xiàn)在是52頁\一共有65頁\編輯于星期日PolymorphismsofXRCC1andsurvivalingastriccancerpatientsTsmRNA水平可以在外周血中檢出，且已被證實(shí)為來源于腫瘤細(xì)胞提示：外周血TsmRNA水平是否可以反映培美曲賽的療效？三、血清中化療藥物療效標(biāo)志2.血清中化療藥物療效標(biāo)志舉例

（潛在價值）現(xiàn)在是53頁\一共有65頁\編輯于星期日三、血清中化療藥物療效標(biāo)志

鉑類————BRCA1、ERCC1、XRCC1

紫杉類————BRCA1、TublinIII、TublinII

吉西他濱————hENT1、RRM1

開普拓————TopoI5-FU類————Ts、Tp、OPRT

足葉乙甙————MDM2

替莫唑胺————MGMT

培美曲賽————Ts問題——血中ERCC1mRNA意義？血中BRCA1mRNA意義？血中hENT1mRNA意義？血中TopoImRNA意義？現(xiàn)在是54頁\一共有65頁\編輯于星期日三、血清中化療藥物療效標(biāo)志miR-21&coloncancerSchetter,etal.JAMA,2008最近證實(shí)——（1）miR表達(dá)與化療療效有關(guān)（2）血中存在循環(huán)miR問題提出——