【作者】 王威；

【导师】 李勇； 范立侨；

【作者基本信息】 河北医科大学 ， 外科学， 2007， 硕士

【摘要】 目的:我国胃癌死亡率居恶性肿瘤之首,胃癌淋巴结转移是影响预后的重要因素,根治术后仍有部分复发和死亡的病例,淋巴结转移是主要的原因之一。化疗作为肿瘤术后最有效的辅助治疗手段,在防治肿瘤的复发与转移方面有着举足轻重作用。虽然目前胃癌的化疗方案不断完善,但由于不同的肿瘤药物敏感性不同,不同的肿瘤患者即便为同一种病理类型对抗癌药物的敏感性也可有显著差异,甚至同一患者在不同阶段对抗癌药物的敏感性也不相同。故临床上很难针对不同患者选择相应的方案,这无疑是导致化疗失败的重要原因之一。因此个体化化疗逐渐成为肿瘤化疗研究的热点。目前国内外的有关肿瘤的体外药物敏感性实验研究大多只限于原发的肿瘤病灶、癌性胸腹水,其标本来源的相对单一性使得临床上一大部分失去手术机会的肿瘤患者、术后化疗耐药的患者、术前新辅助化疗的患者等无法获得肿瘤组织的患者不可能利用原发灶癌细胞进行化疗药敏试验,导致这部分患者的疗效无法得到改善。因此,寻找一种能有效替代原发灶癌细胞药物敏感试验的标本具有重要的实际意义。目前,对于肿瘤的转移灶的药敏试验的研究报道较少,尤其是对于临床治疗有着极大指导意义的淋巴结转移灶的药敏试验研究国内尚无相关报道。而且对于已切除原发病灶的肿瘤患者,化疗的重点应该是转移灶尤其是转移淋巴结,而并非原发灶,这样才更具科学性。本研究对胃癌原发灶(癌细胞)、转移灶(转移淋巴结癌细胞)和外周血淋巴细胞的体外化疗药物敏感性进行研究,并探讨其三者之间的相关性,旨在利用转移淋巴结癌细胞或外周血淋巴细胞替代原发灶癌细胞进行化疗药敏检测。方法:将取自河北医科大学第四医院外三科手术切除的36例胃癌患者癌组织、转移淋巴结(均经病理证实为转移淋巴结)和外周血标本,分别采用机械法从新鲜胃癌组织、转移淋巴结标本中获得癌细胞单细胞悬液,用淋巴细胞分离液从新鲜的外周血标本中获得外周血淋巴细胞,采用MTT法分别检测5-FU、CDDP、L-OHP、CPT-11、5-FU+ CDDP和5-FU+ L-OHP六种方案对胃癌细胞、转移淋巴结癌细胞和外周血淋巴细胞OD值(吸光度)并计算出CI值(抑制率)。结果:1不同胃癌患者的化疗药物敏感性存在明显的个体差异,胃癌原发灶癌细胞、转移淋巴结癌细胞和外周血淋巴细胞等三种不同来源细胞对每种药物及药物组合的平均抑制率极差均较大,原发灶癌细胞为(20.7~29.1)、转移淋巴结癌细胞为(22.7~57)、外周血淋巴细胞为(21.8~30.1)。2不同化疗药物及药物组合对于胃癌患者原发灶癌细胞、转移淋巴结癌细胞和外周血淋巴细胞的平均抑制率从高到低依次为:原发灶癌细胞5-FU+CDDP>5-FU+L-OHP> CDDP>L-OHP>CPT-11>5-Fu ;转移淋巴结癌细胞5-FU+L-OHP>5-FU+CDDP>L-OHP>CPT-11>5-Fu>CDDP;外周血淋巴细胞为:5-FU+L-OHP > 5-FU+CDDP> L-OHP> CDDP > CPT-11> 5-Fu。3胃癌原发灶癌细胞和转移淋巴结癌细胞对于5-FU、L-OHP、CPT-11、5-FU+ CDDP和5-FU+L-OHP 3种化疗药物及2种药物组合的敏感性差异无显著性(P>0.05),而仅对于CDDP敏感性差异有显著性(P<0.05)。相反外周血淋巴细胞与原发灶癌细胞及转移淋巴结癌细胞相比较,对于大部分化疗方案的敏感性差异有显著性(P<0.05)。外周血淋巴细胞的敏感性均低于原发灶癌细胞和转移淋巴结癌细胞。4胃癌原发灶癌细胞与转移淋巴结癌细胞对于5种化疗方案(5-FU、CDDP、L-OHP、CPT-11和5-FU+L-OHP)的化疗药物敏感结果均呈正相关(P <0.05),而转移淋巴结癌细胞与外周血淋巴细胞以及原发灶癌细胞与外周血淋巴细胞对于大部分化疗方案药敏结果均无相关性(P >0.05)。结论:1不同胃癌患者之间无论原发灶癌细胞、转移淋巴结癌细胞还是外周血淋巴细胞对相同化疗药物或药物组合化疗药物敏感性均不相同,存在明显的个体差异。2胃癌患者的原发灶癌细胞和转移淋巴结癌细胞对于相同的化疗药物敏感性无显著性差异;而转移淋巴结癌细胞与外周血淋巴细胞以及原发灶癌细胞与外周血淋巴细胞对于相同化疗药的化疗药物敏感性有显著性差异。外周血淋巴细胞的敏感性均低于原发灶癌细胞和转移淋巴结癌细胞。3胃癌患者的原发灶癌细胞和转移淋巴结癌细胞的化疗药物敏感性有相关关系,且呈正相关;而转移淋巴结癌细胞与外周血淋巴细胞以及原发灶癌细胞与外周血淋巴细胞之间的化疗药物敏感性无相关性。4目前尚不能以外周血淋巴细胞替代原发灶癌细胞或转移淋巴结癌细胞的来筛选敏感的化疗药物,但可根据其与其他两种组织的药敏结果选择对外周血淋巴细胞抑制率低而对原发灶及转移灶抑制率高的化疗药物,以减轻化疗过程中对患者外周血淋巴细胞的抑制作用。5对于胃癌术后病人,尤其对于临床上常见的无法性根治性手术的中晚期胃癌患者,有望通过转移淋巴结的体外药敏试验替代原发灶癌细胞的药敏试验筛选化疗用药,从而更有效的预防胃癌术后的复发、转移。6对于那些没有获得阳性转移淋巴结标本但极有可能存在微转移灶的患者,根据手术切除的原发灶癌细胞的体外药敏结果做为指导筛选化疗用药,以预防术后复发、转移亦可能获得相同效果。7对于失去手术机会的晚期胃癌患者,可尝试通过对经淋巴结活检证实呈阳性的远隔淋巴结细胞行体外肿瘤药敏试验来筛选化疗用药。更多还原

【Abstract】 Objective:The death rate of gastric cancer is the highest among all of the malignant tumors in our country. The absorbent gland matastasis is important in the prognosis, for the recur after the radical correction. The chemotherapy, the most efficient method after the operation,plays an important role in preventing and curing both palindromia and metastasis. However the chemotherapy is approving on and on, it is unable to choose chemotherapy individualized yet, partly because of the different sensitivity among drugs and patients. Undoubtedly this is one of the most important reasons to lead to chemotherapy fail,therefore individualized chemotherapy become the hot spot of chemotherapy study. At present, the researches on the sensitivity of chemodrug in vitroare limited to the primary lesion, and malignant abdominal dropsy and malignant pleural fluid. In this condition, some patients, who ether have lost the chance of operation, or have durg resisitant after operation ,or want to receive the neoadjuvant chemotherapy, don’t have the opportunity to have this examination, because of the simple resource of the biopsy. So we also couldn’t detect these patients’ drug sensitivity. It make that these patients’therapeutic effect couldn’t be improved. So it has actuality significance to find a kind of specimen to take place of the primary lesion with the drug sensitivity test. At present the study of drug sensitivity of metastasis is still not be reported. And the chemotherapy shoud be more scientific if it is aimed at metastasis instead of primary lesion,especially after operation. We investigated the correlation of drug sensitivity among tumor cells、metastatic lymph-node cells and peripheral blood lymphocyte (PBL) in vitro. To study the sensitivity of chemotherapeutic agents by use of peripheral blood lymphocyte instead of cancer cells of patients to instruct the individual therapyMethods:36 tumor tissues and metastatic lymph node (confirmed by patho)resected by surgical operation from the patients with gastric cancer were treated by mechanical dispersion method for single cell suspension respectively,and 36 peripheral blood specimens were treated by lymphocyte separating medium. The OD values were detected by MTT method and the CI values to 6 kinds of chemotherapy scheme, 5-FU、CDDP、L-OHP、CPT-11、5-FU+CDDP and 5-FU+L-OHP, were calculated according to the formula.Results:1 The chemotherapeutics sensitivity of different patient with gastric cancer has conspicuous individual difference. In tumor cell, the ranges of average inhibiting rates about different chemotherapy scheme were (20.7~29.1); in metastatic lymph node were (22.7~57); in PBL were (21.8~30.1).2 The average inhibiting rates of 5-FU、CDDP、L-OHP、CPT-11、5-FU+CDDP and 5-FU+L-OHP to tumor cell were arranged in order were 5-FU+CDDP>5-FU+L-OHP> CDDP>L-OHP>CPT-11>5-Fu; in metastatic lymph node were 5-FU+L-OHP>5-FU+CDDP>L-OHP>CPT-11>5-Fu> CDDP; in PBL were 5-FU+L-OHP > 5-FU+CDDP> L-OHP> CDDP > CPT-11> 5-Fu.3 For the 5 chemotherapy schema such as 5-FU、L-OHP、CPT-11、5-FU+CDDP and 5-FU+L-OHP ,the drug sensitivity discrepancy between metastatic lymph-node cells and tumor cells is not conspicuous (P>0.05). Only for the CDDP, the drug sensitivity discrepancy is conspicuous (P<0.05). Inversely, the drug sensitivity discrepancy between PBL and tumor cells or metastatic lymph-node cells is conspicuous (P>0.05) for subtotal chemotherapy schema. Moreover for all of chemotherapy schema, the drug sensitivity of PBL were lower than he drug sensitivity of tumor cells or metastatic lymph-node cells.4 There is a significant positive correlation in the drug sensitivities between metastatic lymph-node cells and tumor cells to the most of the chemotherapy schema such as 5-FU、CDDP、L-OHP、CPT-11 and 5-FU+L-OHP(P<0.05). And there is a significant positive correlation in the drug sensitivities between metastatic lymph-node cells and PBL as well as between tumor cells and PBL to the parts of chemotherapy schema(P>0.05).Conclusion:1 The tumor cells、metastatic lymph-node cells and PBL with gastric cancer in different individuals have different sensitivity to the same chemotherapy schema, have conspicuous individual variation.2 For the same chemotherapy schema, the drug sensitivity discrepancy between metastatic lymph-node cells and tumor cells is not conspicuous. And the drug sensitivity discrepancy between PBL and tumor cells or metastatic lymph-node cells is conspicuous for the same chemotherapy schema. The drug sensitivity of PBL were lower than he drug sensitivity of tumor cells or metastatic lymph-node cells.3 There is a significant positive correlation in the drug sensitivities between metastatic lymph-node cells and tumor cells. And there is a significant positive correlation in the drug sensitivities between metastatic lymph-node cells and PBL as well as between tumor cells and PBL.4 It is still unable to enforce individualized chemotherapy based on drug sensitivity effect of PBL instead of primary lesion and metastasis . But we can choose the chemotherapy schema base on the drug sensitivity of tumor cells and PBL. In order to lessen the inhibitory of anticancer drugs to the PBL in the chemotherapy.5 Metastatic lymph-node may take place of tumor tissue to select the sensitive drugs when tumoe tissue specimen couldn’t be gotten for the patients with advanced gastric cancer who have lost the chance of radical surgery. In order to efficaciously prevent the recidivation and aversion after the operation.6 For the patients who may have micrometastasis ,but we couldn’t get the metabasis , we can choose the sensitive drugs base on the sensitivity of primarily tumor tissue.7 For the patients with advanced gastric cancer, we can try to choose the sensitive drugs base on the sensitivity of metastatic lymph-node which have be confirm by the biopsy of far metastatic lymph-node.更多还原