淋巴管肌瘤病（LAM）基因突变筛查及血浆游离DNA的检测和结节硬化症（TSC）的肺部表现总结及分析

发布时间：2018-04-25 11:06

本文选题：淋巴管肌瘤病 + 肿瘤驱动基因　；参考：《北京协和医学院》2016年博士论文

【摘要】：第一部分：淋巴管肌瘤病(lymphangioleiomyomatosis, LAM)患者基因突变筛查及血浆游离DNA的检测目的：探究肿瘤个性化突变筛查在LAM患者诊断中的作用,同时初步探讨基因检测在发现LAM治疗新靶点中的作用。探究循环肿瘤DNA (circulating tumor DNA, ctDNA)在LAM诊断中的应用前景。研究方法：纳入2015年10月至2016年5月就诊北京协和医院内科门诊的LAM患者10例,通过经支气管镜肺活检(transbronchial lung biopsy, TBLB)或肺活检获得肺脏标本,或获得患者既往的手术标本。收集患者的临床信息包括病史、胸腹部部影像学资料及血清血管内皮细胞生长因子-D (vascular endothelial growth factor-D, VEGF-D)水平。收集患者的病理诊断资料,包括形态学及免疫组化染色(SMA及HMB-45)。留取10mL血液用于分离白细胞及血浆DNA。通过二代测序方法对病理组织的突变进行初筛,找到突变位点后设计相应的引物在血浆中扩增,进行突变检测。结果：在10例受试者中,6例患者组织标本中发现了8个TSC2突变,组织标本中的突变频率在2.10%-47.60%,TSC2突变与临床诊断及病理诊断大致相符。在3例受试者中未发现TSC2突变,但有其他肿瘤驱动基因的突变(FGF23、KMT2C、FZR1、 NOTCH2)。在ctDNA中,突变频率一般在0.0005%-0.0164%。结论：对于LAM的分子诊断,对病理标本进行的基因筛查有一定作用,并且有可能发现潜在的治疗靶点。但ctDNA的突变频率较低,其对于LAM的诊断及治疗检测作用需要进一步数据以明确。第二部分：北京协和医院结节硬化症(tuberous sclerosis complex, TSC)病例22例的肺部表现总结及分析目的：探究结节硬化症患者的肺部受累临床表现,包括呼吸系统症状及胸部影像学检查表现。方法：收集2015年10月至2016年6月就诊北京协和医院呼吸内科门诊的拟诊为TSC的患者22例,分析其临床资料、影像学检查。重点关注淋巴管肌瘤病(LAM)及多发性小结节样肺细胞增生(multifocal micronodular pneumocyte hyperplasia, MMPH)。结果：22例患者中,肺部影响学表现符合LAM的患者9人(40.9%),其中男性1人,女性8人。表现为多发结节的患者13人(59.1%),其中男性7人,女性6人。病史中有呼吸系统症状的患者8人(36.4%),其中男性2人,女性6人。肺部多发结节与性别、症状无显著相关性,LAM与性别及呼吸系统症状有显著相关性。对3例有随访胸部影像学检查的患者分析发现在雷帕霉素治疗期间肺部结节均有好转。结论：胸部影像学检查对于TSC的肺部受累评估具有较大意义,雷帕霉素对TSC肺部多发结节可能具有一定疗效。
[Abstract]:Part I: gene mutation screening and plasma free DNA detection in lymphangioleiomyomatosisObjective: to explore the role of personalized mutation screening in the diagnosis of LAM. At the same time, the role of gene detection in the discovery of new targets for LAM therapy was discussed. To explore the application prospect of circulating tumor DNA circulating tumor DNA (ctDNA) in the diagnosis of LAM. Methods: from October 2015 to May 2016, 10 patients with LAM were enrolled in the outpatient clinic of Department of Internal Medicine of Peking Union Union Hospital. Lung specimens were obtained by transbronchial lung biopsys or lung biopsy, or previous surgical specimens were obtained. Clinical information including history, chest and abdomen imaging data and serum levels of vascular endothelial growth factor-D endothelial growth factor-D- (VEGF-D) were collected. The pathological diagnosis data, including morphological and immunohistochemical staining of SMA and HMB-45, were collected. 10mL blood was retained for the separation of white blood cells and plasma DNA. The mutation of pathological tissue was screened by the second generation sequencing method, and then the corresponding primers were designed to amplify the mutation in plasma and detect the mutation. Results: eight TSC2 mutations were found in 6 out of 10 patients. The mutation frequency of TSC2 in tissue samples was 2.10-47.60m, which was approximately consistent with clinical diagnosis and pathological diagnosis. No TSC2 mutation was found in 3 subjects, but there were other mutations in the tumor-driven gene, FGF23, KMT2CnFZR1, NOTCH2. In ctDNA, the mutation frequency is generally 0. 0005-0. 0164. Conclusion: for molecular diagnosis of LAM, gene screening of pathological specimens may be useful and potential therapeutic targets may be found. However, the mutation frequency of ctDNA is low, and further data are needed for the diagnosis and treatment of LAM. Part two: pulmonary manifestations of 22 cases of tuberous sclerosis complex in Peking Union Hospital objective: to investigate the clinical manifestations of pulmonary involvement in patients with tuberous sclerosis, including respiratory symptoms and chest imaging findings. Methods: from October 2015 to June 2016, 22 patients with TSC were selected from Department of Respiratory Medicine, Peking Union Hospital, and their clinical data and imaging examination were analyzed. The focus is on lymphangiomyomatosis (Lam) and multiple focal micronodular pneumocyte hyperplasia (MMPH). Results among the 22 patients, 9 patients with LAM were found to have lung effects, including 1 male and 8 female. There were 13 patients with multiple nodules, including 7 males and 6 females. There were 8 patients with respiratory symptoms, including 2 males and 6 females. There was no significant correlation between multiple pulmonary nodules and sex, and there was no significant correlation between the symptoms of Lam and the symptoms of gender and respiratory system. Analysis of 3 cases with chest imaging showed that pulmonary nodules improved during rapamycin treatment. Conclusion: chest imaging is of great significance in the assessment of lung involvement in TSC. Rapamycin may be effective in the treatment of multiple pulmonary nodules in TSC.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R733

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