基因突变对较低危骨髓增生异常综合征患者临床意义的研究

发布时间：2018-05-04 22:10

  本文选题：骨髓增生异常综合征 + 较低危　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的研究基因突变对较低危骨髓增生异常综合征(MDS)患者的临床意义以及构建较低危MDS患者的分子预后模型。方法本研究回顾性分析浙江大学医学院附属第一医院自2009年1月1日至2016年10月30日期间住院治疗的较低危(低危或中危-1)MDS患者的临床资料,包括年龄、性别、血常规、骨髓原始细胞比例、骨髓增生程度、网状纤维染色分级、染色体核型、WHO分型等。从骨髓单个核细胞提取的DNA通过Sanger和高通量测序 15 项 MDS 相关基因,包括 DNMT3A、SF3B1、SRSF2、IDH1、IDH2、ASXL1、EZH2、JAK2、TET2、CBL、ETV6、TP53、NRAS 和 RUNX1;比较各基因突变型、野生型的上述临床资料特征,并统计分析各基因突变之间的相关性。单因素分析各基因突变型与野生型以及不同突变位点在总生存时间(OS)上有无统计学差异。对本队列患者进行较低危MDS预后评分系统(LR-PSS)模型的验证。多因素分析LR-PSS以及各基因突变的相对危险度。筛选出有统计学意义的基因突变,并尝试整合LR-PSS模型和基因突变结果构建新的预后模型-LR-PSSM 模型。结果本研究共纳入176例较低危MDS患者,中位随访时间和中位总生存时间分别为38.1、15.0个月,中位发病年龄为57岁,男女比例为1.29(99/77)。异常核型检出率为19.3%(34/176),染色体联合基因突变检测的克隆证据检出率为51.7%(91/176)。突变频率较高的基因依次为 SF3B1(13.1%,21/160)、TET2(12.5%,7/56)、U2AF1(10.4%,17/163)、ASXL1(9.5%,7/74)、TP53(7.0%,5/71)、RUNX1(6.7%,4/60)、SRSF2(6.3%,11/174).比较基因突变型、野生型的各临床资料特征发现:累计基因突变个数与年龄分层有统计学差异(p=0.008);随着年龄的增大,基因突变的个数也增多。ASXL1突变在年龄分层上有统计学差异(P=0.030),好发于老年患者。TET2、ASXL 突变型、野生型患者在性别上有统计学差异(P=0.041,P=0.017),TET2突变好发于女性患者,ASXL1突变则好发于男性患者。U2AF1、EZH2突变患者分别在骨髓增生程度、网状纤维染色分级上有统计学差异(P=0.030,P=0.003);U2AF 突变倾向于骨髓增生活跃或异常活跃,而EZH2突变则倾向于中重度网状纤维染色。SF3B1突变型、野生型在WHO分型上有统计学差异(P0.001),SF3B1突变与RARS亚型有相关性(r=0.359,P0.001)。以下6组基因突变存在正相关性:IDH和NRAS(r=0.70,P0.001),ASXL1和RUNX1(r=0.40,P0.001),JAK2和SRSF2(r=0.57,P0.001),AAK2和EZH2(r=0.57,P0.001),IDH2和SRSF2(r=0.28,P0.001),ILH2和DNMT3A(r=0.44,P0.001)。总生存时间的单因素分析发现:SRSF2突变型患者预后较野生型差(P=0.032),中位 OS 分别为 19.8 个月、58.4 个月。U2AF1 P=0.055)、TP53(P=0.064)、TET2(P=0.069)突变型较野生型患者的OS有缩短的趋势。U2AF1不同突变位点患者的OS有统计学差异(P=0.024),U2AF1-Q157突变预后最佳(中位OS:29.1个月),U2AF1野生型次之(中位OS:20.9个月),U2AF1-S34突变的患者预后最差(中位OS:17.5个月)。SF3B1-K700突变(中位OS:57.8个月)较SF3B1-非K700突变患者(中位OS:25.7个月)有预后更好的趋势(P=0.066)。本队列验证了 LR-PSS模型:本队列的5.7%(10/176)的患者为LR-PSS中相对应的第1组,中位OS为91.9个月;58.0%(102/176)的患者为第2组,中位OS为46.0个月;35.8%(63/176)的患者为第3组,中位OS为23.1个月;这三组间患者的OS有统计学差异(P=0.011);并在LR-PSS的基础上加入SRSF2突变变量,构建了新预后模型LR-PSSM,将本队列患者分为4组,中位生存时间依次为 105.3、46.0、23.1、12.0 个月。结论累计基因突变数目随着年龄的增大而增多。ASXL1突变可能好发于老年、男性患者,而TET2突变则女性患者相对多见。U2AF1突变与骨髓增生活跃或异常活跃有一定相关性,而EZH2突变患者则倾向于中重度网状纤维染色。SF3B1突变与RARS亚型存在相关性。本研究单因素和多因素生存分析提示仅SRSF2突变为影响较低危MDS患者预后的独立危险因素。U2AF1、TP53、TET2突变患者可能提示预后不良,待进一步验证。基因突变的不同位点也可能会影响预后。本队列验证了 LR-PSS模型,结果与文献报道相仿。基于LR-PSS模型加入SRSF2突变因素构建了新预后模型LR-PSSM。LR-PSSM模型将有助于筛选出较低危MDS患者中的相对高危患者,使得这部分患者可以尽早接受相对积极治疗;同时也有利于挑选出较低危MDS患者中的极低危患者,对其生存时间的预估更精确,但仍需大样本以及其他中心的研究加以验证。
[Abstract]:Objective to study the clinical significance of gene mutation in patients with low risk myelodysplastic syndrome (MDS) and to construct a molecular prognostic model for low risk MDS patients. Methods a retrospective analysis of the lower risk (low or medium risk -1) MD in the first hospital affiliated to the Zhejiang University Medical College from January 1, 2009 to October 2016 was reviewed. S patients' clinical data, including age, sex, blood routine, bone marrow primordial cell proportion, myelodysplastic degree, reticular fiber staining classification, chromosome karyotype, WHO typing, and so on. The DNA extracted from bone marrow mononuclear cells by Sanger and high throughput sequencing of 15 MDS related genes, including DNMT3A, SF3B1, SRSF2, IDH1, IDH2, ASXL1, EZH2, EZH2, CBL, ETV6, TP53, NRAS and RUNX1; compare the characteristics of various gene mutation and wild type, and analyze the correlation between the mutations of each gene. Single factor analysis has no statistical difference between the mutant and the wild type and the different mutation loci in the total survival time (OS). The prognosis of the low risk MDS in this cohort is the prognosis. Verification of the scoring system (LR-PSS) model. Multifactor analysis of LR-PSS and the relative risk of gene mutations. Screening out a statistically significant gene mutation, and trying to integrate the LR-PSS model and gene mutation to construct a new prognostic model -LR-PSSM model. Results this study included 176 patients with lower risk MDS, median follow-up time, and the results of this study. The median total survival time was 38.1,15.0 months, the median age was 57 years, the proportion of men and women was 1.29 (99/77). The abnormal karyotype detection rate was 19.3% (34/176), and the detection rate of cloned evidence for chromosome joint gene mutation detection was 51.7% (91/176). The higher mutation frequency was SF3B1 (13.1%, 21/160), TET2 (12.5%, 7/56), U2AF1 (10.4%, 1). 7/163), ASXL1 (9.5%, 7/74), TP53 (7%, 5/71), RUNX1 (6.7%, 4/60), SRSF2 (6.3%, 11/174). Compare the clinical data of gene mutation and wild type: the cumulative number of mutations is statistically different from the age stratification (p=0.008); as the age increases, the number of mutations is also increased in age stratification. The difference (P=0.030) is good for the elderly patients with.TET2, ASXL mutant, and wild type patients with statistical difference (P=0.041, P=0.017), TET2 mutation well in female patients, ASXL1 mutation in male patients.U2AF1, EZH2 mutation patients in the degree of myelodysplastic, reticular fiber staining classification has statistical difference (P=0.030, P=0.00) 3): U2AF mutation tended to be active or abnormally active in myelodysplastic, while EZH2 mutation tended to be a medium and severe reticular fiber staining of.SF3B1 mutagenesis, and there was a statistically significant difference between the wild type in WHO typing (P0.001), SF3B1 mutation and RARS subtype (r=0.359, P0.001). The following mutations were positive correlation: IDH and NRAS (r=0.70, etc.) L1 and RUNX1 (r=0.40, P0.001), JAK2 and SRSF2 (r=0.57, P0.001), AAK2 and EZH2 (r=0.57, P0.001), single factor analysis of the total survival time, found that the prognosis of the mutant patients is less than the wild type, and the median is 19.8 months and 58.4 months respectively. 4) the OS of TET2 (P=0.069) mutant was shorter than that of wild type patients. The OS of the patients with different mutations at.U2AF1 was statistically different (P=0.024), the prognosis of U2AF1-Q157 mutation was the best (median OS:29.1 months), U2AF1 wild type (median OS:20.9 month), and the worst (median OS:17.5 month) mutation (median OS:17.5 month) was the worst. Compared with SF3B1- non K700 mutations (median OS:25.7 months), there was a better prognosis (P=0.066). This cohort demonstrated the LR-PSS model: 5.7% (10/176) in this cohort were first groups in LR-PSS, median OS was 91.9 months; 58% (102/176) patients were second, median OS was 46 months; 35.8% (63/176) patients In the third group, the median OS was 23.1 months; the OS of the three groups was statistically different (P=0.011); and on the basis of LR-PSS, a new prognostic model was added to construct a new prognostic model, LR-PSSM, and the cohort was divided into 4 groups, and the median survival time was 105.3,46.0,23.1,12.0 months. A large number of.ASXL1 mutations may well occur in elderly, male patients, while TET2 mutations in women have a relative number of.U2AF1 mutations associated with active or abnormal activity of myelodysplastic, while EZH2 mutations tend to be associated with.SF3B1 mutations in moderate to severe reticular fiber staining and RARS subtypes. This study is a single factor and multiple factors. The survival analysis suggests that only SRSF2 mutation is an independent risk factor that affects the prognosis of lower risk MDS patients.U2AF1, TP53, TET2 mutation may indicate poor prognosis. The different loci of the gene mutation may also affect the prognosis. This cohort has verified the LR-PSS model, and the results are similar to that of the literature. Based on the LR-PSS model, the SRSF2 process is added. The variable factor construction of a new prognostic model LR-PSSM.LR-PSSM model will help to screen relatively high risk patients in patients with lower risk MDS, making this part of the patients receiving relatively active treatment as early as possible, and also for the selection of extremely low risk patients in lower risk MDS patients and more accurate estimates of their survival time, but still need large samples. And other centers of research to verify.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R551.3
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本文编号：1844885