颅咽管瘤侵袭性的分子学及种植转移的临床研究

发布时间：2018-06-22 00:54

本文选题：颅咽管瘤 + 侵袭性　；参考：《首都医科大学》2014年博士论文

【摘要】：背景颅咽管瘤是蝶鞍区常见的先天性肿瘤，组织学上可分为造釉细胞和鳞状乳头两种亚型，二者在临床特征上存在不同。颅咽管瘤病理学分类为良性，按照WHO中枢神经系统肿瘤分类为Ⅰ级，但是表现出恶性的生物学行为，呈侵袭性生长，浸润粘连周围重要神经血管结构，手术全切困难，术后并发症多，致死致残率高，总体预后不良，即使手术完全切除后，也会有较高的肿瘤复发率，还有罕见的种植转移现象发生，这是困扰该肿瘤治疗的难题。目前认为侵袭性生长是颅咽管瘤不同于蝶鞍区其他良性肿瘤的最主要特征，也是影响其预后的重要因素。从分子水平对颅咽管瘤的侵袭性进行研究，明确这一恶性生物学行为的机制，有助于加深对颅咽管瘤这一难治性肿瘤的理解，对于探索有效的治疗方案，降低术后复发率，减少死亡率，提高远期生存质量具有重要意义。颅咽管瘤种植转移是术后极其罕见的现象，其发生的机制及危险因素目前尚不明确，现有的治疗手段不能有效防止其发生，需要全面的分析来增加对该现象的认识，并进一步提出可行的防治手段。第一部分：14-3-3Zeta与颅咽管瘤侵袭性的研究目的研究14-3-3Zeta蛋白在颅咽管瘤中的表达情况，并通过比较该蛋白的表达与颅咽管瘤临床病理特征、β-Catenin异常表达、肿瘤增殖性、p63过表达之间的关系，探索14-3-3Zeta蛋白对颅咽管瘤侵袭性的影响及作用机制，为进一步认识颅咽管瘤的侵袭机制提供新的线索，为治疗颅咽管瘤的新方法提供依据。方法根据纳入标准，由2012年2月至2013年8月间于我院神经外科行开颅手术切除并经术后病理学确诊的颅咽管瘤患者序列中随机选取62例进行研究，收集患者的临床资料。取入组62例颅咽管瘤组织石蜡块，切片行常规HE染色进一步明确肿瘤分型。采用免疫组织化学的方法，对62例肿瘤标本以及4例正常脑组织标本中14-3-3Zeta、β-Catenin、p63及Ki-67表达水平进行研究，分析相应指标水平与患者临床及病理特征的关系。对术中液氮快速冰冻并保存于-80℃超低温冰箱中的62例肿瘤标本和4例对照脑组织标本行免疫印迹检查，比较各组间14-3-3Zeta蛋白表达水平的差异。对20例液氮速冻肿瘤标本行定量PCR检查明确颅咽管瘤YWHAZ基因转录水平。结果 62例颅咽管瘤患者中，根据HE染色分为造釉细胞型46例，鳞状乳头型16例，其中侵袭性颅咽管瘤27例，均为造釉细胞亚型，非侵袭性造釉细胞型颅咽管瘤19例。14-3-3Zeta免疫组化显示：14-3-3Zeta在造釉细胞型及鳞状乳头型颅咽管瘤中表达水平差异不显著；侵袭性造釉细胞型颅咽管瘤中表达水平显著高于非侵袭性造釉细胞型肿瘤及鳞状乳头型颅咽管瘤；非侵袭性造釉细胞型肿瘤与鳞状乳头型颅咽管瘤表达水平差异不显著。β-Catenin免疫组化显示：β-Catenin异常表达率在造釉细胞型颅咽管瘤显著高于鳞状乳头型颅咽管瘤；在侵袭性造釉细胞型颅咽管瘤中β-Catenin异常表达率显著高于非侵袭性造釉细胞型肿瘤及鳞状乳头型颅咽管瘤；非侵袭性造釉细胞型肿瘤及鳞状乳头型颅咽管瘤异常表达率差异不显著。14-3-3Zeta强阳性表达细胞与β-Catenin异常表达细胞在肿瘤组织内相似地分布于漩涡状细胞簇中。p63免疫组化显示：p63阳性表达于颅咽管瘤的细胞核中，阳性细胞弥漫分布于组织内，侵袭性颅咽管瘤与非侵袭性颅咽管瘤p63过表达水平无统计学差异。Ki-67的免疫组化显示：在造釉细胞亚型Ki-67阳性细胞主要分布于栅栏状结构内，漩涡状细胞簇内少见阳性细胞。在鳞状乳头亚型肿瘤中Ki-67阳性细胞散在分布于肿瘤实质中。侵袭性颅咽管瘤与非侵袭性颅咽管瘤Ki-67标记指数无统计学差异。β-Catenin异常表达组与正常表达组14-3-3Zeta表达水平存在显著差异，而按照年龄、性别、初复发、肿瘤大小、p63过表达、Ki-67指数分组14-3-3Zeta表达水平差异无统计学意义。Western Blot结果显示：14-3-3Zeta在侵袭性造釉细胞型颅咽管瘤中相比对照脑组织表达显著增高，，而在非侵袭性造釉细胞型以及鳞状乳头型颅咽管瘤表达水平增高不显著，颅咽管瘤病理类型之间以及侵袭性与非侵袭性肿瘤之间表达水平差异不显著。RT-PCR显示：20例颅咽管瘤YWHAZ基因mRNA转录水平高于对照脑组织，但病理类型之间、侵袭性与非侵袭性肿瘤之间转录水平的差异无统计学意义。结论 14-3-3Zeta在侵袭性颅咽管瘤中存在过表达现象，其过表达与肿瘤细胞的侵袭性相关而与增殖活性无相关。14-3-3Zeta的过表达与Wnt信号通路核心蛋白β-Catenin的异常表达呈显著相关，在组织中的分布均主要位于造釉细胞型颅咽管瘤的漩涡状细胞簇中，提示14-3-3Zeta过表达可能通过调控Wnt通路而影响颅咽管瘤的侵袭性。肿瘤细胞的增殖活性以及p63表达水平与颅咽管瘤的侵袭性无相关。第二部分：颅咽管瘤种植转移的临床研究目的回顾性研究种植转移颅咽管瘤病例的临床和病理资料，回顾该罕见现象既往文献报告，分析其可能的危险因素，提出预防和治疗该并发症可行的方案。方法收集我科治疗的4例种植转移颅咽管瘤患者的临床、影像及病理资料，并结合文献回顾总结归纳该罕见现象的特征及可能的危险因素，探讨可行的防治方法。结果 4例种植转移颅咽管瘤患者均为成年男性，种植部位均为前次手术路径，本次住院均未发生原位复发。病理类型上3例患者为鳞状乳头亚型，1例为造釉细胞亚型，4例复发肿瘤标本Ki-67标记指数均不高于5%。结论颅咽管瘤种植转移十分罕见，其发生的具体机制目前尚不清楚，囊性肿瘤是该现象发生可能的危险因素，术中严格隔离肿瘤，防止肿瘤破裂及囊液播散可能减少种植转移的发生，颅咽管瘤术后需长期密切随访以早期发现和处理种植转移颅咽管瘤，术后常规应用放射治疗预防颅咽管瘤并非必要，手术切除种植转移病灶可取得良好的治疗效果。
[Abstract]:background
Craniopharyngioma is a common congenital tumor in the sella region. Histologically, it can be divided into two subtypes of enamel and squamous papilla. The two is different in clinical characteristics. The pathological classification of craniopharyngioma is benign. It is classified as grade I according to the WHO central nervous system tumor, but shows malignant biological behavior, invasive growth and infiltration. The important neurovascular structure around adhesion, the operation is difficult to cut, the postoperative complications are more, the death rate is high, the overall prognosis is bad. Even after the operation is completely excised, there will be a high recurrence rate of tumor and rare implant metastasis. This is a difficult problem for the treatment of the tumor. It is considered that invasive growth is not a craniopharyngioma at present. The most important features of other benign tumors in the sella region are also an important factor affecting the prognosis. The study of the invasiveness of craniopharyngioma at the molecular level and the clear mechanism of this malignant biological behavior will help to deepen the understanding of the intractable tumor of the craniopharyngioma, to explore the effective treatment and to reduce the postoperative recovery. The occurrence of craniopharyngioma implantation metastasis is an extremely rare phenomenon after operation. The mechanism and risk factors of the occurrence of craniopharyngioma are not clear, the existing treatment means can not effectively prevent it from happening. It needs comprehensive analysis to increase the understanding of this phenomenon and further put forward the feasibility. The means of prevention and control.
Part I: 14-3-3Zeta and craniopharyngioma invasiveness
objective
To investigate the expression of 14-3-3Zeta protein in craniopharyngioma, and compare the relationship between the expression of the protein and the clinicopathological features of craniopharyngioma, abnormal expression of beta -Catenin, tumor proliferation, and p63 overexpression, explore the influence and mechanism of 14-3-3Zeta protein on the invasiveness of craniopharyngioma, in order to further understand the invasion of craniopharyngioma. The mechanism provides new clues for providing new evidence for the treatment of craniopharyngioma.
Method
According to the inclusion criteria, 62 cases of craniopharyngioma in the Department of Neurosurgery of our hospital from February 2012 to August 2013 were selected randomly and 62 cases were selected randomly to collect the clinical data of the patients. 62 cases of craniopharyngioma tissue paraffin block were taken into the group, and the sections were stained by conventional HE staining to further clarify the tumor classification. The expression of 14-3-3Zeta, beta -Catenin, p63 and Ki-67 in 62 cases of tumor and 4 normal brain tissue were studied by immunohistochemistry. The relationship between the level of the corresponding index and the clinical and pathological features of the patients was analyzed. 62 cases of tumor specimens and 4 in the cryopreservation of cryopreservation at -80 C were frozen and 4 were frozen in the intraoperative liquid nitrogen. The difference in the expression of 14-3-3Zeta protein was compared between the specimens of the brain tissue and the difference of the expression level of 14-3-3Zeta protein in each group. The transcriptional level of the YWHAZ gene in the craniopharyngioma was determined by quantitative PCR examination.
Result
62 cases of craniopharyngioma were divided into 46 cases of enamel cell type, 16 cases of squamous papilla type, 27 cases of invasive craniopharyngioma, and 27 cases of invasive craniopharyngioma, all of which were the subtypes of enamel cells, and 19 cases of non aggressive actin craniopharyngioma in 19 cases of.14-3-3Zeta immunohistochemistry showed that the expression level of 14-3-3Zeta in the enamel fine cell type and the squamous papillary craniopharyngioma was poor. The expression level of the invasive enamel type craniopharyngioma was significantly higher than that of non invasive apioid tumor and squamous papillary craniopharyngioma, and the expression level of non invasive apioid tumor and squamous papillary craniopharyngioma was not significant. Beta -Catenin immunohistochemical staining showed that the abnormal expression rate of beta -Catenin was in the formation. The enamel type craniopharyngioma was significantly higher than that of the squamous papillary craniopharyngioma, and the abnormal expression rate of beta -Catenin in the invasive enamel type craniopharyngioma was significantly higher than that of non invasive enamel type tumor and squamous nipple type craniopharyngioma, and the abnormal expression rate of noninvasive apex type and squamous papillary craniopharyngioma was different. The abnormal expression of.14-3-3Zeta strong positive expression cells and beta -Catenin cells in the tumor tissues resemble in the swirling cell cluster in.P63 immunohistochemical staining: p63 positive expression in the nucleus of craniopharyngioma, positive cells diffuse in the tissue, invasive craniopharyngioma and non invasive craniopharyngioma p63 overexpression of water The immunological histochemistry of.Ki-67 without statistical difference showed that the Ki-67 positive cells in the apioma subtype were mainly distributed in the palisade structure, and the positive cells were rare in the vortex cell cluster. In the squamous papillary subtype tumor, Ki-67 positive cells were scattered in the tumor parenchyma. Invasive craniopharyngioma and non invasive craniopharyngioma Ki-67 standard There was no significant difference in the index of the expression of 14-3-3Zeta in the abnormal expression group of beta -Catenin and the normal expression group, while the age, sex, initial recurrence, tumor size, p63 overexpression, and the 14-3-3Zeta expression level of the Ki-67 index group were not statistically significant.Western Blot results showed that 14-3-3Zeta was in the invasive enamel cell type. The expression of the craniopharyngioma was significantly higher than that of the control brain tissue, but the expression level of the noninvasive enamel type and the squamous papillary craniopharyngioma was not significant. There was no significant difference in the expression level between the pathological types of craniopharyngioma and the invasive and non invasive tumor.RT-PCR: 20 cases of craniopharyngioma YWHAZ gene mRNA turn The level of transcription was higher than that of control brain tissue, but there was no significant difference in the transcriptional level between invasive and noninvasive tumors.
conclusion
The overexpression of 14-3-3Zeta in invasive craniopharyngioma is associated with the invasiveness of the tumor cells and the overexpression of.14-3-3Zeta, which is not related to the proliferation activity, is significantly related to the abnormal expression of the core protein beta -Catenin of the Wnt signaling pathway, and the distribution in the tissue is mainly located in the whirlpool of the enamel type craniopharyngioma. In the cell clusters, the overexpression of 14-3-3Zeta may affect the invasiveness of craniopharyngioma by regulating the Wnt pathway. The proliferation activity of the tumor cells and the level of p63 expression are not related to the invasiveness of the craniopharyngioma.
The second part: clinical study of craniopharyngioma implant metastasis.
objective
To review the clinical and pathological data of the cases of metastatic craniopharyngioma, review the previous literature report on the rare phenomenon, analyze the possible risk factors, and propose a feasible scheme to prevent and treat the complications.
Method
The clinical, imaging and pathological data of 4 patients with metastatic craniopharyngioma treated by our family were collected, and the characteristics and possible risk factors of the rare phenomenon were summarized and summarized in the literature review. The feasible methods of prevention and treatment were discussed.
Result
4 patients with metastatic craniopharyngioma were all adult male, and the implant site was the first operation route. There were no recurrence in this hospital. 3 cases were squamous papillary subtype, 1 cases were apioform subtype, and 4 cases of recurrent tumor specimens were not higher than 5%. Ki-67 markers.
conclusion
Craniopharyngioma implantation metastasis is very rare, and the specific mechanism of its occurrence is unclear. Cystic tumor is a possible risk factor for this phenomenon. Intraoperative strict isolation of tumor, prevention of tumor rupture and cystic fluid dissemination may reduce the occurrence of implant metastasis. Long term close follow-up after craniopharyngioma is needed to identify and deal with early metastasis. Craniopharyngioma is not necessary for routine postoperative radiotherapy to prevent craniopharyngioma. Surgical removal of the metastatic lesion can achieve good results.
【学位授予单位】：首都医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R739.41

【参考文献】