【作者】 王丽娟；

【导师】 谭业辉；

【作者基本信息】 吉林大学 ， 临床医学硕士（内科学）（专业学位）， 2019， 硕士

【摘要】 目的:了解老年急性髓系白血病患者在不同年龄段基因突变的特点及不同染色体核型与基因突变的相关性。探索常见基因突变对患者临床特征、CR率、预后的影响。方法:回顾性分析2015年12月至2018年7月吉林大学第一医院血液科102例初治老年AML(≥60岁,非APL)患者的一般临床资料、细胞遗传学和分子生物学资料,计算不同年龄段基因突变的特点;结合染色体,探讨基因突变对预后分层的影响;探索不同基因突变患者WBC、HGB、PLT、外周血及骨髓原始细胞比例的差别,探讨基因突变对CR率、总生存期的影响。结果:1.102例患者中男55例(53.92%),女47例(46.08%),中位年龄65岁(62~68)。初诊时中位外周血白细胞计数12.77(2.31~52.42)×10~9/L,血红蛋白80.00(62.75~96.25)g/L,血小板54.00(25.75~95.00)×10~9/L,骨髓原始细胞比例66.75%,外周血原始细胞比例34.00%。2.102例患者中89例患者进行了染色体核型分析,其中81例患者找到了可供分析分裂相,成功检出率为90.01%,其中正常核型58例(71.60%),异常核型23例(28.40%);异常核型中t(8;21)(q22;q22)7例(30.43%),inv(16)(p13q22)1例(4.35%),复杂核型2例(8.70%),-7核型1例(4.35%),其他染色体异常12例(52.17%)。根据细胞遗传学进行分层,高危核型3例(复杂核型和-7)、中危核型70例(正常核型和其他核型)、低危核型8例(t(8;21)和inv(16)),中危核型所占比例最高(86.42%)。3.102例患者均进行了分子生物学检测,共检测出46种突变基因,突变率在10%以上的基因为DNMT3A(38.24%)、NPM1(29.41%)、FLT3-ITD(21.57%)、TET2(21.57%)、RUNX1(16.67%)、NRAS(15.69%)、IDH2(13.73%)、SRSF2(13.73%)、FLT3-TKD(12.75%)、CEBPA(11.76%,双突变5例、单突变7例)、BCOR(10.78%),且DNMT3A、TET2、FLT3-ITD突变率在60岁以上随年龄增长而增加,SRSF2在65岁以上随年龄增长而增加。联合分子生物学,按照中国成人急性髓系白血病中国诊疗指南(2017年版)标准分层,高危组55例(67.90%),中危组15例(18.52%),低危组11例(13.58%),高危组所占比例明显升高;根据年龄进行分组后,随年龄增长,高危组所占比例逐渐增加。4.在8例预后良好核型中有4例伴KIT突变;2例复杂核型均伴有TP53突变;正常核型患者58例,均检测到突变基因,以DNMT3A突变比例最高,占48.28%(28例)。5.DNMT3A、NPM1、FLT3-ITD分别与31、25、19种基因存在互联,且3者间相互联系最为常见;TET2互联的基因有25种,最常见的是DNMT3A、NPM1、FLT3-ITD、NRAS等。6.FLT3-ITD突变患者白细胞数、骨髓及外周血原始细胞比例较高,NPM1突变、TET2突变患者外周血白细胞计数较高,NRAS突变患者血红蛋白较低,IDH1/2突变患者白细胞数较低,FLT3-TKD突变患者骨髓原始细胞比例较高,且分别与无该相关突变患者的差异均有统计学意义(P<0.05)。7.102例患者中76例接受治疗,可评价患者63例,经1~2疗程诱导治疗达CR患者共37例,CR率为58.73%,RUNX1突变、BCOR/BCORL1突变患者2疗程诱导CR率较无该突变患者低,且差异均有统计学意义(P<0.05)。8.将可评价患者63例纳入生存分析,中位生存时间为8个月,单因素分析显示NPM1突变可能与较好预后有关,RUNX1突变可能与不良预后有关。结论:1.老年AML患者存在多种基因突变,各种基因突变的发生频率与年轻患者存在差别。本组人群中最常见的突变基因为DNMT3A,其次是NPM1、FLT3-ITD、TET2等,且DNMT3A、TET2、FLT3-ITD突变发生率在60岁以上随年龄增长而增加,SRSF2发生率在65岁以上随年龄增长而增加。2.联合基因突变和染色体可使预后分层更加精准,结合基因分层可使其高度异质性的中危核型的分层更加细化,在老年AML中高危预后分层患者比例随年龄增长而增加。3.不同基因突变对老年AML患者的临床特征、CR率、总生存期影响不同。在本组人群中,FLT3-ITD突变患者白细胞数、骨髓及外周血原始细胞比例较高,NPM1突变、TET2突变患者外周血白细胞计数较高,IDH1/2突变患者白细胞数较低,FLT3-TKD突变患者骨髓原始细胞比例较高;FLT3-ITD、DNMT3A、TET2突变对CR率和总生存期无明显影响,BCOR突变患者的CR率较低,NPM1突变可能与良好预后有关,RUNX1突变可能与低CR率与不良预后有关。更多还原

【Abstract】 Objective:To understand the characteristics of genetic mutations in different age groups of elderly patients with acute myeloid leukemia and the correlation between different karyotypes and gene mutations.Explore the effects of common gene mutations on clinical characteristics,CR rate,and prognosis.Methods:The clinical data,cytogenetics and molecular biology data of 102 patients with newly diagnosed AML(≥60 years old,non-APL)in the Department of Hematology,First Hospital of Jilin University from December 2015 to July 2018 were retrospectively analyzed.Calculate the characteristics of gene mutations in different age groups.Combine chromosomes to explore the effects of gene mutations on prognosis stratification.To explore the differences in the proportions of WBC,HGB,PLT,peripheral blood and bone marrow blasts in patients with different gene mutations.To explore the effect of gene mutation on CR rate and overall survival.Results:1.Among the 102 patients,55(53.92%)were male and 47(46.08%)were female,with a median age of 65(62-68).At the time of initial diagnosis,the median peripheral blood leukocyte count was 12.77(2.31~52.42)×10~9/L,hemoglobin 80.00(62.75~96.25)g/L,platelet 54.00(25.75~95.00)×10~9/L.The proportion of median bone marrow blast cells was 66.75%,and the proportion of peripheral blood blast cells was 34.00%.2.Among the 102 patients,89 patients underwent karyotype analysis,81 of whom were found to be able to analyze the segregation phase.The successful detection rate was 90.01%.There were 58 normal karyotypes(71.60%).Abnormal karyotype in 23 cases(28.40%),including t(8;21)(q22;q22)7 cases(30.43%),inv(16)(p13q22)1 case(4.35%),complex karyotype 2 cases(8.70)%),1 case of-7karyotype(4.35%),12 cases of other chromosomal abnormalities(52.17%).According to cytogenetics,there were 3 cases of high-risk karyotype(complex karyotype and-7),70 cases of moderate-risk karyotype(normal karyotype and other karyotypes),and 8 cases of low-risk karyotype(t(8;21)and inv(16)).The proportion of medium-risk karyotypes was the highest(86.42%).3.Molecular biological tests were performed in 102 patients,and 46 mutant genes were detected.The genes with mutation rate above 10%were DNMT3A(38.24%),NPM1(29.41%),FLT3-ITD(21.57%),and TET2(21.57%),RUNX1(16.67%),NRAS(15.69%),IDH2(13.73%),SRSF2(13.73%),FLT3-TKD(12.75%),CEBPA(11.76%,double mutation 5 cases,single mutation 7 cases)),BCOR(10.78%).Moreover,the mutation rate of DNMT3A,TET2 and FLT3-ITD increased with age over 60 years old,and SRSF2 increased with age over 65 years old.Combined molecular biology,according to the Chinese adult acute myeloid leukemia guidelines for Chinese diagnosis and treatment(2017 edition)standard stratification,55 patients(67.90%)in the high-risk group,15 patients(18.52%)in the intermediate-risk group,and 11 patients in the low-risk group(13.58%)).The proportion of high-risk groups has increased significantly.After grouping according to age,the proportion of high-risk groups gradually increased with age.4.Of the 8 well-preferred karyotypes,4 had KIT mutations.Two complex karyotypes were associated with TP53 mutations.In 58 normal karyotype patients,the mutant gene was detected,and the highest proportion of DNMT3A mutation was48.28%(28 cases).5.DNMT3A,NPM1,and FLT3-ITD are interconnected with 32,25,and 19genes,respectively,and the three are most commonly associated with each other.TET2 has 26 genes interconnected,the most common being DNMT3A,NPM1,FLT3-ITD,NRAS,etc.6.The number of white blood cells,the proportion of bone marrow blast cells and the percentage of peripheral blood blast cells in FLT3-ITD mutation patients were higher.The peripheral blood leukocyte counts of patients with NPM1 mutation and TET2 mutation were higher,the hemoglobin of patients with NRAS mutation was lower,and the number of white blood cells of patients with IDH1/2 mutation was lower.The FLT3-TKD mutation has a higher proportion of bone marrow blast cells.The differences were statistically significant(P<0.05).7.Of the 102 patients,76 were treated,and 63 patients were evaluated.37patients were treated with CR for 1 to 2 courses,and the CR rate was 58.73%.The CR rate of patients with RUNX1 mutation and BCOR/BCORL1 mutation was lower than that of patients without this mutation,and the difference was statistically significant(P<0.05).8.Sixty-three patients with evaluable patients were included in the survival analysis.The median survival time was 8 months.Univariate analysis showed that NPM1 mutation may be associated with better prognosis.RUNX1 mutation may be associated with poor prognosis.Conclusions:1.There are many gene mutations in elderly AML patients,and the frequency of various gene mutations is different from that of young patients.The most common mutation gene in this group is DNMT3A,followed by NPM1,FLT3-ITD,TET2 and so on.And the incidences of DNMT3A,TET2,FLT3-ITD mutations increase with age over 60 years old.The incidence of SRSF2 increases with age over 65 years old.2.Combining gene mutations and chromosomes can make prognosis stratification more precise.Combining gene stratification can make the stratification of highly heterogeneous medium-risk karyotypes more detailed.The proportion of patients with high-risk prognosis in elderly AML increases with age.3.Different gene mutations have different effects on clinical characteristics,CR rate and overall survival of elderly patients with AML.In this group of patients,FLT3-ITD mutation patients have a higher proportion of white blood cells,bone marrow and peripheral blood blast cells.Patients with NPM1 mutation and TET2mutation had higher white blood cell counts,and the number of white blood cells in patients with IDH1/2 mutation was lower.The proportion of bone marrow blast cells in FLT3-TKD mutation patients was higher.FLT3-ITD,DNMT3A,and TET2mutations had no significant effect on CR rate and overall survival.Patients with BCOR mutations had lower CR rates.NPM1 mutations may be associated with good prognosis.RUNX1 mutations may be associated with low CR rates and poor prognosis.更多还原