大肠癌KRAS基因遗传变异的研究及靶向治疗预后评估
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摘要
背景：
大肠癌在世界上发病率第三，死亡率第二，每年增加一百二十万患者。在中国，大肠癌已经一跃成为第三位肿瘤导致死亡的疾病。大肠癌的治疗是以手术为主的综合治疗，选择手术可以切除病灶，解除肿瘤造成的梗阻症状。手术后化疗近年来发展迅速，辅以基因靶向治疗、免疫制剂治疗、中医中草药治疗，近年兴起的靶向治疗发展迅速。大肠癌的发生是细胞在多种复杂环境、多步骤、多种癌基因及抑癌基因共同作用的结果。全身化疗会提高晚期大肠癌的预后，但患者对化疗药物耐受的情况经常发生，转移性大肠癌如果出现对化疗药物耐药的不良事件后，预后生存期会明显缩短。在针对大肠癌发生阶段进行研究，行基因遗传变异的检测，找到适合转移性大肠癌个体化治疗方案将提高转移性大肠癌的预后、最大限度的减少耐药不良事件的发生，为晚期大肠癌的个体化治疗提供新方案。研究发现原癌基因KRAS是EGFR下游信号通路中重要的分子，KRAS基因2号外显子的突变可以诱导肿瘤细胞的无限制增殖，从而摆脱正常EGFR信号通路的调控。KRAS基因的突变会影响EGFR抑制剂的效果。目前NCCN指南已经推荐西妥昔单抗联合化疗用于晚期大肠癌KRAS基因野生型患者的一线治疗，同时也推荐KRAS基因突变型晚期大肠癌一线治疗应用贝伐单抗联合化疗。大肠癌KRAS基因遗传变异特点、靶向治疗药物西妥昔单抗及贝伐单抗治疗转移性大肠癌患者的安全性及疗效数据多来源于西方文献报道，国内研究甚少。
目的：
大肠癌患者行KRAS基因遗传突变检测，明确大肠癌KRAS基因遗传变异特点、KRAS基因遗传变异与大肠癌临床病理学因素之间的关系，KRAS基因遗传突变与大肠癌预后关系、不同突变亚型之间预后的关系。为转移性大肠癌的治疗提供理论依据。为了比较分析靶向药物西妥昔单抗、贝伐单抗两种药物联合化疗治疗转移性晚期大肠癌患者的安全性及疗效情况，排除KRAS基因突变型、野生型对患者预后生存分析的干扰，全部选取KRAS基因野生型患者进行靶向治疗。分别比较西妥昔单抗一线、非一线治疗的疗效；贝伐单抗一线、非一线治疗的疗效。比较西妥昔单抗、贝伐单抗治疗晚期大肠癌的疗效性及安全性。
材料与方法：
第一部分：78例大肠癌石蜡包埋标本，通过HE染色挑选癌组织丰富的蜡块，用PCR-SSCP方法对大肠癌标本进行KRAS基因2号外显子上的12、13号密码子遗传突变检测。应用SPSS19.0软件，确切概率法检验进行统计学分析，分析临床病理学因素与KRAS基因突变之间的关系，应用Kaplan-meier、Log-rank法分析KRAS基因遗传变异与预后的关系、KRAS基因不同突变亚型与预后之间的关系。应用Cox回归分析影响患者预后的因素。第二部分：回顾性分析本院72例KRAS基因野生型晚期大肠癌患者应用靶向药物西妥昔单抗、贝伐单抗联合化疗治疗情况。探讨两种药物各自用于一线治疗与非一线线治疗之间的疗效情况，同时比较西妥昔单抗、贝伐单抗药物近期疗效、远期疗效。应用SPSS19.0统计软件进行统计学分析，确切概率法检验比较组间差异。Kaplan–meier生存曲线是评价晚期大肠癌患者生存期之间的关系。显著性检验采用Log-rank检验分析，Cox回归模型进行多变量生存数据分析，研究各种因素对大肠癌预后影响。P<0.05定义为有统计学意义。
结果：
第一部分：78例结直肠癌患者中，KRAS基因2号外显子12、13密码子突变共有26例，突变率33.3%（26/78）。KRAS基因突变均为单个碱基的点突变，未检测出两个或两个以上的碱基突变或者其他形式的突变。G-A突变发生频率最高，共20例（20/26，76.9%）；G-T突变5例（5/26，19.2%）；G-C突变仅1例（1/26，3.9%）。KRAS基因12号密码子突变19例（73.1%，19/26），共有3种突变方式：GGT-GAT突变13例（13/26，50%），甘氨酸Gly替换为天冬氨酸Asp；GGT-GTT突变5例（5/26，19.2%），甘氨酸Gly替换为缬氨酸Val；GGT-GCT突变1例（1/26，13.9%），甘氨酸Gly替换为丙氨酸Ala。13号密码子突变7例（26.9%，7/26），均为GGC-GAC突变（7/26，26.9%），甘氨酸Gly替换为天冬氨酸Asp。在氨基酸替换中，Gly替换为Asp发生频率最高，占76.9%（20/26）；其次Gly替换为Val占19.2%（5/26）；Gly替换为Ala发生频率仅占3.8%（1/26）。KRAS基因突变与临床病理学因素之间的关系：KRAS基因突变与结直肠癌分化程度（低分化52.6%vs中分化27.1%，P<0.05）、肝转移（肝转移46.7%vs无肝转移25%，P<0.05）有关。78例患者追踪随访发现：KRAS基因野生型患者平均生存时间35.05月，KRAS基因突变型患者平均生存时间是25.72月，有统计学意义(P<0.05)。KRAS基因12号密码子突变患者平均生存时间是25.69月，13号密码子突变患者平均生存时间是20.67月，无统计学意义（P>0.05）。单变量分析显示KRAS基因遗传变异与大肠癌患者预后不良有关（P<0.05），多变量分析则显示KRAS基因突变、肝脏转移、肿瘤低分化是大肠癌预后的独立危险因素（P<0.05, P<0.05, P<0.05）。
第二部分：回顾性分析本院收治krs基因野生型晚期大肠癌患者72例。西妥昔单抗联合化疗治疗38例，总体有效率34.2%，疾病控制率63.2%。一线治疗的有效率50%，疾病控制率87.5%。非一线有效率为22.7%，疾病控制率45.5%。一线治疗疾病控制率优于二线治疗，有统计学意义（P<0.05）。一线治疗有效率虽高于二线治疗，无统计学意义（P>0.05）。贝伐单抗联合化疗治疗34例，总体有效率29.4%，总体疾病控制率64.7%。一线治疗有效率42.9%，疾病控制率92.8%。非一线治疗有效率为20%，疾病控制率45%。一线治疗疾病有效率优于二线，有统计学意义（P<0.05）。一线治疗疾病控制率虽高于二线治疗，无统计学意义（P>0.05）。两种靶向治疗药物在有效率及控制率上比较均无统计学意义（P>0.05, P>0.05）。西妥昔单抗组与贝伐单抗组在常见不良反应方面出现频率无明显区别。西妥昔单抗联合化疗一线治疗组的中位生存期是16月，非一线治疗的中位生存期是12月，有统计学意义（P<0.05）。贝伐单抗联合化疗一线治疗组的中位生存期是24月，非一线治疗的中位生存期是17.5月，有统计学意义（P<0.05）。西妥昔单抗联合化疗组中的中位生存期是14月，贝伐单抗联合化疗组中的中位生存期是18.5月，贝伐单抗联合化疗组的中位生存期略高于西妥昔单抗联合化疗组，但两种靶向药物治疗在预后生存时间比较无统计学意义（P>0.05）。单变量分析显示：晚期大肠癌患者肿瘤所在的部位与预后不良有关（P<0.05）。多变量分析显示晚期大肠癌患者肿瘤所在部位及是否在初诊时候一线接受靶向治疗是预后独立的危险因素（P<0.05，P<0.05）。
结论：
KRAS基因突变在结直肠癌患者中普遍发生，且突变频率符合目前国际报道，突变频率较高33.3%。KRAS基因突变与结直肠癌低分化、肝脏转移关系密切。多变量分析显示肝脏转移、KRAS基因突变、肿瘤低分化是预后的独立危险因素。KRAS基因遗传变异结直肠癌患者预后不良。
转移性大肠癌患者接受靶向治疗联合化疗，一线治疗的疾病控制率、有效率及生存期均优于非一线治疗。晚期大肠癌患者肿瘤所在部位与预后不良有关。多变量分析显示肿瘤部位及是否在初诊时候一线接受靶向治疗是预后独立危险因素。两种靶向治疗药物西妥昔单抗及贝伐单抗在疗效性、安全性对比无明显差异，应用晚期结直肠癌患者安全、有效。
Colorectal cancer is the third in the worldwide incidence of cancer, thesecond in the mortality rate, about yield1.2million new patients a year. InChina, the colorectal cancer has become the third in tumor diseases of the causeof death. The direction of development of the treatment of colorectal cancer inactive and comprehensive treatment of surgery, surgery resection of the primarytumor, relieve obstructive symptoms caused by the tumor. Chemotherapy aftersurgery in recent years, combined with immunotherapy, traditional Chinesemedicine, gene therapy, especially targeted therapy for more and more clinical.The incidence of colorectal cancer is a multi-stage, multi-step involved in thecomplex process of the formation of a variety of oncogenes and tumorsuppressor gene activation or deactivation. Chemotherapy will improve survivalof advanced colorectal cancer, but some patients will be the emergence ofresistance, not more than six months once the resistance reported survival ofadvanced colorectal cancer. Therefore colorectal cancer gene mutationsdetection, expect to find for colorectal cancer targeted therapy will greatlyimprove the prognosis of advanced colorectal cancer, reduce the incidence ofresistant to adverse events, and new program individualized treatment forcolorectal cancer. The proto-oncogene KRAS important molecules in the EGFRdownstream signaling pathway, the KRAS gene mutations in the2exonunrestricted proliferation of tumor cells can be induced to get rid of the normal EGFR signaling pathway. KRAS gene mutations will affect the effect of EGFRinhibitors. NCCN will recommend cetuximab combined with chemotherapy asfirst-line treatment of advanced colorectal cancer patients with wild-type KRASgene bevacizumab combined with chemotherapy is recommended as first-linetreatment of advanced colorectal cancer (KRAS mutations). KRAS genemutation detection and cetuximab and bevacizumab in patients with advancedcolorectal cancer, the safety and efficacy of most of the data sources formforeign reports, the KRAS gene mutation of Chinese human colorectal featuresand application cetuximab single little of anti bevacizumab reported data.
Objective:
KRAS genetic testing of patients with colorectal cancer to identify thecharacteristics of Chinese human colorectal KRAS gene mutations, the KRASgene mutation and the clinicopathological factors between the relationshipbetween different KRAS gene mutation subtypes and prognosis. Retrospectiveobservational analysis of cetuximab combined with chemotherapy, bevacizumabin combination with chemotherapy, targeted therapy of the safety and efficacy inpatients with advanced colorectal cancer. Provide a theoretical basis for targetedtherapy of colorectal cancer.
Method:
Part I:78patients with colorectal cancer paraffin specimen selected by HEstaining cancer tissue paraffin blocks, followed by the application of PCR-SSCPin78cases of colorectal cancer were12,13codon on the2exon of KRAS genemutation detection. Between the analysis of the KRAS gene mutations and theclinicopathological factors. Patients were followed up, follow-up data line survival analysis to analyze the relationship between the subtypes and theprognosis of the the KRAS gene mutant and wild type prognostic differences,different mutations. Part II: Retrospective analysis cetuximab combined withchemotherapy and bevacizumab combined with chemotherapy in the treatmentof patients with advanced colorectal cancer. Explore the efficacy and safety offirst-line treatment of non-first-line-line treatment.
Results:
Part I:78patients with colorectal cancer, KRAS gene mutations in a totalof26cases, the mutation rate of33.3%(26/78). KRAS gene mutations aresingle base point mutations, not detected in two or more nucleotide mutations orother forms of mutations. The GA mutation frequency of the highest of20cases(20/26,76.9%); followed by GT mutations in five cases (5/26,19.2%); GCmutation in only1patient (1/26,3.9%). KRAS gene on the12th codonmutations in19cases(73.1%,19/26), a total of three different mutations way:GGT-GAT mutations in13cases (13/26,50%), glycine Gly replaced by asparticacid Asp; GGT-GTT mutation of the five cases (5/26,19.2%), glycine Glyreplaced with valine Val; GGT-GCT mutation (1/26,13.9%), Glycine Glyreplaced with alanine Ala. The13th codon mutations in7cases (26.9%,7/26),are GGC-GAC mutation (7/26,26.9%), glycine Gly replace the aspartic acidAsp. Amino acid substitutions, Gly substitute the Asp highest frequency,accounting for76.9%(20/26); followed by Gly replaced by Val accounted for19.2%(5/26); Gly with Ala the lowest frequency of only3.8%(1/26).Relationship between KRAS gene mutation and the clinicopathological factors:the degree of differentiation of the KRAS gene mutations and colorectal cancer (differentiation in poorly differentiated52.6%vs27.1%, P <0.05), livermetastases (liver metastases46.7%vs no liver Transfer to25%, P <0.05) related.78patients followed up: the KRAS gene wild type patients the average survivaltime of35.05months, the KRAS gene mutations in patients with type averagesurvival time is25.72months, there is a statistically significant (P <0.05).KRAS gene codon mutation in the12th with an average survival time was25.69months, the13th codon mutations in patients with an average survival time is20.67months, no statistically significant. Univariate analysis showed that thethe KRAS gene mutations in colorectal cancer patients with poor prognosis areclosely related (P <0.05), multivariate analysis showed that liver metastasesKRAS gene mutations, tumor poorly differentiated independent prognosticfactors (P <0.05, P <0.05, P <0.05).
Part II: A retrospective analysis of72patients admitted to our hospital withadvanced colorectal cancer. Receiving cetuximab combined with chemotherapyin the treatment of38cases, the overall efficiency of34.2%, and the diseasecontrol rate was63.2%. First-line treatment efficiency of50%. The diseasecontrol rate was87.5%. Non-first-line response rate was22.7%, the diseasecontrol rate was45.5%. First-line treatment of the disease control rate was thesecond-line treatment, there is a statistically significant (P <0.05). The first-linetreatment efficiency was higher than the second-line treatment, no statisticallysignificant. Receive bevacizumab combined with chemotherapy in the treatmentof34cases, the overall efficiency of29.4%,64.7%of the overall disease controlrate. The first-line treatment efficiency of42.9%. The disease control rate was92.8%. The effective rate of20%non-first-line therapy, disease control rate of 45%. The first-line treatment of the disease control rate was higher than thesecond-line treatment, a significant (P<0.05). The first-line treatment of thedisease control rate was higher than the second-line treatment, but no significant(P>0.05). The cetuximab group bevacizumab group point of view no significantdifference between the frequency of occurrence of adverse reactions in thegastrointestinal tract and bone marrow suppression. Cetuximab combined withchemotherapy in first-line treatment group the median survival time was16months, non-first-line treatment, the median survival time was12months, astatistically significant (P<0.05). Bevacizumab combined with chemotherapy infirst-line treatment group, the median survival time is24months, and thefirst-line treatment median survival of17.5months, a significant (P<0.05).Cetuximab combined with chemotherapy group, the median survival time was14months, bevacizumab in combination with the chemotherapy group's mediansurvival of18.5months (P>0.05). No statistically significant. Univariateanalysis showed: the site of advanced colorectal cancer with a poor prognosisare closely related (P<0.05). Multivariate analysis revealed that tumor site inpatients with advanced colorectal cancer, and accept in newly diagnosed whenfirst-line targeted therapy is an independent prognostic risk factors (P <0.05, P<0.05).
Conclusion:
KRAS gene mutations in patients with colorectal cancer commonlyoccurring mutation frequency in line with the current international reports,higher mutation frequency of33.3%. KRAS gene mutation in poorlydifferentiated colorectal liver metastasis. Multivariate analysis revealed that liver metastases, the KRAS gene mutations, tumor poorly differentiated independentprognostic factors. KRAS gene mutation that prompts a poor prognosis inpatients with colorectal cancer.
Whether to accept patients with advanced colorectal cancer with cetuximabor bevacizumab treatment, select the first-line treatment of the disease controlrate and survival period were better than the non-first-line treatment. The site ofadvanced colorectal cancer with a poor prognosis. Multivariate analysis revealedthat tumor location and whether to accept the targeted therapy in newlydiagnosed, when first-line prognosis independent risk factor. Cetuximab andbevacizumab application of advanced colorectal cancer is safe and effective.
大肠癌在世界上发病率第三，死亡率第二，每年增加一百二十万患者。在中国，大肠癌已经一跃成为第三位肿瘤导致死亡的疾病。大肠癌的治疗是以手术为主的综合治疗，选择手术可以切除病灶，解除肿瘤造成的梗阻症状。手术后化疗近年来发展迅速，辅以基因靶向治疗、免疫制剂治疗、中医中草药治疗，近年兴起的靶向治疗发展迅速。大肠癌的发生是细胞在多种复杂环境、多步骤、多种癌基因及抑癌基因共同作用的结果。全身化疗会提高晚期大肠癌的预后，但患者对化疗药物耐受的情况经常发生，转移性大肠癌如果出现对化疗药物耐药的不良事件后，预后生存期会明显缩短。在针对大肠癌发生阶段进行研究，行基因遗传变异的检测，找到适合转移性大肠癌个体化治疗方案将提高转移性大肠癌的预后、最大限度的减少耐药不良事件的发生，为晚期大肠癌的个体化治疗提供新方案。研究发现原癌基因KRAS是EGFR下游信号通路中重要的分子，KRAS基因2号外显子的突变可以诱导肿瘤细胞的无限制增殖，从而摆脱正常EGFR信号通路的调控。KRAS基因的突变会影响EGFR抑制剂的效果。目前NCCN指南已经推荐西妥昔单抗联合化疗用于晚期大肠癌KRAS基因野生型患者的一线治疗，同时也推荐KRAS基因突变型晚期大肠癌一线治疗应用贝伐单抗联合化疗。大肠癌KRAS基因遗传变异特点、靶向治疗药物西妥昔单抗及贝伐单抗治疗转移性大肠癌患者的安全性及疗效数据多来源于西方文献报道，国内研究甚少。
目的：
大肠癌患者行KRAS基因遗传突变检测，明确大肠癌KRAS基因遗传变异特点、KRAS基因遗传变异与大肠癌临床病理学因素之间的关系，KRAS基因遗传突变与大肠癌预后关系、不同突变亚型之间预后的关系。为转移性大肠癌的治疗提供理论依据。为了比较分析靶向药物西妥昔单抗、贝伐单抗两种药物联合化疗治疗转移性晚期大肠癌患者的安全性及疗效情况，排除KRAS基因突变型、野生型对患者预后生存分析的干扰，全部选取KRAS基因野生型患者进行靶向治疗。分别比较西妥昔单抗一线、非一线治疗的疗效；贝伐单抗一线、非一线治疗的疗效。比较西妥昔单抗、贝伐单抗治疗晚期大肠癌的疗效性及安全性。
材料与方法：
第一部分：78例大肠癌石蜡包埋标本，通过HE染色挑选癌组织丰富的蜡块，用PCR-SSCP方法对大肠癌标本进行KRAS基因2号外显子上的12、13号密码子遗传突变检测。应用SPSS19.0软件，确切概率法检验进行统计学分析，分析临床病理学因素与KRAS基因突变之间的关系，应用Kaplan-meier、Log-rank法分析KRAS基因遗传变异与预后的关系、KRAS基因不同突变亚型与预后之间的关系。应用Cox回归分析影响患者预后的因素。第二部分：回顾性分析本院72例KRAS基因野生型晚期大肠癌患者应用靶向药物西妥昔单抗、贝伐单抗联合化疗治疗情况。探讨两种药物各自用于一线治疗与非一线线治疗之间的疗效情况，同时比较西妥昔单抗、贝伐单抗药物近期疗效、远期疗效。应用SPSS19.0统计软件进行统计学分析，确切概率法检验比较组间差异。Kaplan–meier生存曲线是评价晚期大肠癌患者生存期之间的关系。显著性检验采用Log-rank检验分析，Cox回归模型进行多变量生存数据分析，研究各种因素对大肠癌预后影响。P<0.05定义为有统计学意义。
结果：
第一部分：78例结直肠癌患者中，KRAS基因2号外显子12、13密码子突变共有26例，突变率33.3%（26/78）。KRAS基因突变均为单个碱基的点突变，未检测出两个或两个以上的碱基突变或者其他形式的突变。G-A突变发生频率最高，共20例（20/26，76.9%）；G-T突变5例（5/26，19.2%）；G-C突变仅1例（1/26，3.9%）。KRAS基因12号密码子突变19例（73.1%，19/26），共有3种突变方式：GGT-GAT突变13例（13/26，50%），甘氨酸Gly替换为天冬氨酸Asp；GGT-GTT突变5例（5/26，19.2%），甘氨酸Gly替换为缬氨酸Val；GGT-GCT突变1例（1/26，13.9%），甘氨酸Gly替换为丙氨酸Ala。13号密码子突变7例（26.9%，7/26），均为GGC-GAC突变（7/26，26.9%），甘氨酸Gly替换为天冬氨酸Asp。在氨基酸替换中，Gly替换为Asp发生频率最高，占76.9%（20/26）；其次Gly替换为Val占19.2%（5/26）；Gly替换为Ala发生频率仅占3.8%（1/26）。KRAS基因突变与临床病理学因素之间的关系：KRAS基因突变与结直肠癌分化程度（低分化52.6%vs中分化27.1%，P<0.05）、肝转移（肝转移46.7%vs无肝转移25%，P<0.05）有关。78例患者追踪随访发现：KRAS基因野生型患者平均生存时间35.05月，KRAS基因突变型患者平均生存时间是25.72月，有统计学意义(P<0.05)。KRAS基因12号密码子突变患者平均生存时间是25.69月，13号密码子突变患者平均生存时间是20.67月，无统计学意义（P>0.05）。单变量分析显示KRAS基因遗传变异与大肠癌患者预后不良有关（P<0.05），多变量分析则显示KRAS基因突变、肝脏转移、肿瘤低分化是大肠癌预后的独立危险因素（P<0.05, P<0.05, P<0.05）。
第二部分：回顾性分析本院收治krs基因野生型晚期大肠癌患者72例。西妥昔单抗联合化疗治疗38例，总体有效率34.2%，疾病控制率63.2%。一线治疗的有效率50%，疾病控制率87.5%。非一线有效率为22.7%，疾病控制率45.5%。一线治疗疾病控制率优于二线治疗，有统计学意义（P<0.05）。一线治疗有效率虽高于二线治疗，无统计学意义（P>0.05）。贝伐单抗联合化疗治疗34例，总体有效率29.4%，总体疾病控制率64.7%。一线治疗有效率42.9%，疾病控制率92.8%。非一线治疗有效率为20%，疾病控制率45%。一线治疗疾病有效率优于二线，有统计学意义（P<0.05）。一线治疗疾病控制率虽高于二线治疗，无统计学意义（P>0.05）。两种靶向治疗药物在有效率及控制率上比较均无统计学意义（P>0.05, P>0.05）。西妥昔单抗组与贝伐单抗组在常见不良反应方面出现频率无明显区别。西妥昔单抗联合化疗一线治疗组的中位生存期是16月，非一线治疗的中位生存期是12月，有统计学意义（P<0.05）。贝伐单抗联合化疗一线治疗组的中位生存期是24月，非一线治疗的中位生存期是17.5月，有统计学意义（P<0.05）。西妥昔单抗联合化疗组中的中位生存期是14月，贝伐单抗联合化疗组中的中位生存期是18.5月，贝伐单抗联合化疗组的中位生存期略高于西妥昔单抗联合化疗组，但两种靶向药物治疗在预后生存时间比较无统计学意义（P>0.05）。单变量分析显示：晚期大肠癌患者肿瘤所在的部位与预后不良有关（P<0.05）。多变量分析显示晚期大肠癌患者肿瘤所在部位及是否在初诊时候一线接受靶向治疗是预后独立的危险因素（P<0.05，P<0.05）。
结论：
KRAS基因突变在结直肠癌患者中普遍发生，且突变频率符合目前国际报道，突变频率较高33.3%。KRAS基因突变与结直肠癌低分化、肝脏转移关系密切。多变量分析显示肝脏转移、KRAS基因突变、肿瘤低分化是预后的独立危险因素。KRAS基因遗传变异结直肠癌患者预后不良。
转移性大肠癌患者接受靶向治疗联合化疗，一线治疗的疾病控制率、有效率及生存期均优于非一线治疗。晚期大肠癌患者肿瘤所在部位与预后不良有关。多变量分析显示肿瘤部位及是否在初诊时候一线接受靶向治疗是预后独立危险因素。两种靶向治疗药物西妥昔单抗及贝伐单抗在疗效性、安全性对比无明显差异，应用晚期结直肠癌患者安全、有效。
Colorectal cancer is the third in the worldwide incidence of cancer, thesecond in the mortality rate, about yield1.2million new patients a year. InChina, the colorectal cancer has become the third in tumor diseases of the causeof death. The direction of development of the treatment of colorectal cancer inactive and comprehensive treatment of surgery, surgery resection of the primarytumor, relieve obstructive symptoms caused by the tumor. Chemotherapy aftersurgery in recent years, combined with immunotherapy, traditional Chinesemedicine, gene therapy, especially targeted therapy for more and more clinical.The incidence of colorectal cancer is a multi-stage, multi-step involved in thecomplex process of the formation of a variety of oncogenes and tumorsuppressor gene activation or deactivation. Chemotherapy will improve survivalof advanced colorectal cancer, but some patients will be the emergence ofresistance, not more than six months once the resistance reported survival ofadvanced colorectal cancer. Therefore colorectal cancer gene mutationsdetection, expect to find for colorectal cancer targeted therapy will greatlyimprove the prognosis of advanced colorectal cancer, reduce the incidence ofresistant to adverse events, and new program individualized treatment forcolorectal cancer. The proto-oncogene KRAS important molecules in the EGFRdownstream signaling pathway, the KRAS gene mutations in the2exonunrestricted proliferation of tumor cells can be induced to get rid of the normal EGFR signaling pathway. KRAS gene mutations will affect the effect of EGFRinhibitors. NCCN will recommend cetuximab combined with chemotherapy asfirst-line treatment of advanced colorectal cancer patients with wild-type KRASgene bevacizumab combined with chemotherapy is recommended as first-linetreatment of advanced colorectal cancer (KRAS mutations). KRAS genemutation detection and cetuximab and bevacizumab in patients with advancedcolorectal cancer, the safety and efficacy of most of the data sources formforeign reports, the KRAS gene mutation of Chinese human colorectal featuresand application cetuximab single little of anti bevacizumab reported data.
Objective:
KRAS genetic testing of patients with colorectal cancer to identify thecharacteristics of Chinese human colorectal KRAS gene mutations, the KRASgene mutation and the clinicopathological factors between the relationshipbetween different KRAS gene mutation subtypes and prognosis. Retrospectiveobservational analysis of cetuximab combined with chemotherapy, bevacizumabin combination with chemotherapy, targeted therapy of the safety and efficacy inpatients with advanced colorectal cancer. Provide a theoretical basis for targetedtherapy of colorectal cancer.
Method:
Part I:78patients with colorectal cancer paraffin specimen selected by HEstaining cancer tissue paraffin blocks, followed by the application of PCR-SSCPin78cases of colorectal cancer were12,13codon on the2exon of KRAS genemutation detection. Between the analysis of the KRAS gene mutations and theclinicopathological factors. Patients were followed up, follow-up data line survival analysis to analyze the relationship between the subtypes and theprognosis of the the KRAS gene mutant and wild type prognostic differences,different mutations. Part II: Retrospective analysis cetuximab combined withchemotherapy and bevacizumab combined with chemotherapy in the treatmentof patients with advanced colorectal cancer. Explore the efficacy and safety offirst-line treatment of non-first-line-line treatment.
Results:
Part I:78patients with colorectal cancer, KRAS gene mutations in a totalof26cases, the mutation rate of33.3%(26/78). KRAS gene mutations aresingle base point mutations, not detected in two or more nucleotide mutations orother forms of mutations. The GA mutation frequency of the highest of20cases(20/26,76.9%); followed by GT mutations in five cases (5/26,19.2%); GCmutation in only1patient (1/26,3.9%). KRAS gene on the12th codonmutations in19cases(73.1%,19/26), a total of three different mutations way:GGT-GAT mutations in13cases (13/26,50%), glycine Gly replaced by asparticacid Asp; GGT-GTT mutation of the five cases (5/26,19.2%), glycine Glyreplaced with valine Val; GGT-GCT mutation (1/26,13.9%), Glycine Glyreplaced with alanine Ala. The13th codon mutations in7cases (26.9%,7/26),are GGC-GAC mutation (7/26,26.9%), glycine Gly replace the aspartic acidAsp. Amino acid substitutions, Gly substitute the Asp highest frequency,accounting for76.9%(20/26); followed by Gly replaced by Val accounted for19.2%(5/26); Gly with Ala the lowest frequency of only3.8%(1/26).Relationship between KRAS gene mutation and the clinicopathological factors:the degree of differentiation of the KRAS gene mutations and colorectal cancer (differentiation in poorly differentiated52.6%vs27.1%, P <0.05), livermetastases (liver metastases46.7%vs no liver Transfer to25%, P <0.05) related.78patients followed up: the KRAS gene wild type patients the average survivaltime of35.05months, the KRAS gene mutations in patients with type averagesurvival time is25.72months, there is a statistically significant (P <0.05).KRAS gene codon mutation in the12th with an average survival time was25.69months, the13th codon mutations in patients with an average survival time is20.67months, no statistically significant. Univariate analysis showed that thethe KRAS gene mutations in colorectal cancer patients with poor prognosis areclosely related (P <0.05), multivariate analysis showed that liver metastasesKRAS gene mutations, tumor poorly differentiated independent prognosticfactors (P <0.05, P <0.05, P <0.05).
Part II: A retrospective analysis of72patients admitted to our hospital withadvanced colorectal cancer. Receiving cetuximab combined with chemotherapyin the treatment of38cases, the overall efficiency of34.2%, and the diseasecontrol rate was63.2%. First-line treatment efficiency of50%. The diseasecontrol rate was87.5%. Non-first-line response rate was22.7%, the diseasecontrol rate was45.5%. First-line treatment of the disease control rate was thesecond-line treatment, there is a statistically significant (P <0.05). The first-linetreatment efficiency was higher than the second-line treatment, no statisticallysignificant. Receive bevacizumab combined with chemotherapy in the treatmentof34cases, the overall efficiency of29.4%,64.7%of the overall disease controlrate. The first-line treatment efficiency of42.9%. The disease control rate was92.8%. The effective rate of20%non-first-line therapy, disease control rate of 45%. The first-line treatment of the disease control rate was higher than thesecond-line treatment, a significant (P<0.05). The first-line treatment of thedisease control rate was higher than the second-line treatment, but no significant(P>0.05). The cetuximab group bevacizumab group point of view no significantdifference between the frequency of occurrence of adverse reactions in thegastrointestinal tract and bone marrow suppression. Cetuximab combined withchemotherapy in first-line treatment group the median survival time was16months, non-first-line treatment, the median survival time was12months, astatistically significant (P<0.05). Bevacizumab combined with chemotherapy infirst-line treatment group, the median survival time is24months, and thefirst-line treatment median survival of17.5months, a significant (P<0.05).Cetuximab combined with chemotherapy group, the median survival time was14months, bevacizumab in combination with the chemotherapy group's mediansurvival of18.5months (P>0.05). No statistically significant. Univariateanalysis showed: the site of advanced colorectal cancer with a poor prognosisare closely related (P<0.05). Multivariate analysis revealed that tumor site inpatients with advanced colorectal cancer, and accept in newly diagnosed whenfirst-line targeted therapy is an independent prognostic risk factors (P <0.05, P<0.05).
Conclusion:
KRAS gene mutations in patients with colorectal cancer commonlyoccurring mutation frequency in line with the current international reports,higher mutation frequency of33.3%. KRAS gene mutation in poorlydifferentiated colorectal liver metastasis. Multivariate analysis revealed that liver metastases, the KRAS gene mutations, tumor poorly differentiated independentprognostic factors. KRAS gene mutation that prompts a poor prognosis inpatients with colorectal cancer.
Whether to accept patients with advanced colorectal cancer with cetuximabor bevacizumab treatment, select the first-line treatment of the disease controlrate and survival period were better than the non-first-line treatment. The site ofadvanced colorectal cancer with a poor prognosis. Multivariate analysis revealedthat tumor location and whether to accept the targeted therapy in newlydiagnosed, when first-line prognosis independent risk factor. Cetuximab andbevacizumab application of advanced colorectal cancer is safe and effective.
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