【作者】 王宁；

【导师】 李文瑜；

【作者基本信息】 华南理工大学 ， 临床医学， 2023， 硕士

【摘要】 第一部分 泽布替尼联合大剂量甲氨蝶呤治疗原发中枢神经系统淋巴瘤的回顾性分析目的:探究泽布替尼联合大剂量甲氨蝶呤治疗初治原发中枢神经系统淋巴瘤临床疗效和疾病基因突变谱。方法:收集广东省人民医院接受泽布替尼联合大剂量甲氨蝶呤方案治疗的初治原发中枢神经系统淋巴瘤患者,共19例。安全性和疗效根据CTCAE v5.0和RECIST v1.1进行评估,主要研究终点为客观缓解率(ORR),次要研究终点为无进展生存期(PFS)、生存率(OS)及安全性。结果:中位随访时间17.2个月(3.9-30),全组患者ORR为84.2%,2年PFS和OS分别为75.6%和94.1%。所有患者均完成诱导治疗,9例患者接受自体造血干细胞移植作为巩固治疗,ORR为88.9%(CR/PR-6/2)。10例患者接受泽布替尼作为维持治疗,ORR为80%。泽布替尼联合大剂量甲氨蝶呤方案药物安全性可。脑脊液和组织测序结果提示PIM1是原发中枢神经系统淋巴瘤最常见突变基因,ct DNA与疾病复发和缓解相关。结论:泽布替尼联合大剂量甲氨蝶呤治疗原发中枢神经系统淋巴瘤患者具有良好的临床疗效和药物耐受性。脑脊液监测是评估疗效和肿瘤负荷的可行性方法。第二部分 PI3K/HDAC双靶点抑制剂BEBT-908在原发中枢神经系统淋巴瘤中的疗效与机制研究目的:探究PI3K/HDAC双靶点抑制剂BEBT-908在原发中枢神经系统淋巴瘤中的疗效及作用机制。方法:采用细胞活力检测、流式细胞术检测经BEBT-908、甲氨蝶呤处理组淋巴瘤细胞IC50和细胞周期。构建小鼠脑淋巴瘤模型检测BEBT-908药物脑内代谢分布趋势,运用小动物活体成像仪监测BEBT-908给药和对照组小鼠脑淋巴瘤治疗疗效。此外,采用蛋白质印记法、免疫组织化学染色验证BEBT-908体内外抑制肿瘤周期及增殖的分子机制。结果:BEBT-908在B细胞淋巴瘤中的IC50为0.7-3.1n M,对比同组B淋巴瘤细胞在甲氨蝶呤中的IC50(40.4-344.6n M),提示了不错的抑制B细胞淋巴瘤增殖作用且抑制细胞周期在G0/G1期。小鼠体内实验正常脑组织最高药物浓度(Cmax)为520ng/g,脑肿瘤组织Cmax为497.4ng/g;正常脑组织和肿瘤组织的AUC0-t分别为879.89ng/g*h和6232.881ng/g*h,在肿瘤组织中药物聚焦度高。BEBT-908治疗组小鼠(8只)无死亡情况,6只小鼠疾病缓解;对照组小鼠均因疾病进展死亡。BEBT-908通过诱导细胞铁死亡杀伤肿瘤细胞,通过PI3K/AKT通路调节细胞周期和调节蛋白合成。结论:PI3K/HDAC双靶点抑制剂BEBT-908单药治疗原发中枢神经系统淋巴瘤可通过血脑屏障且诱导细胞铁死亡而达到不错的抑制肿瘤疗效,且药物耐受可。第三部分 继发中枢神经系统淋巴瘤的治疗疗效及预后不良因素分析目的:探究继发中枢神经系统淋巴瘤的诱导治疗疗效及预后不良因素。方法:回顾性收集广东省人民医院2010年至2021年间确诊为继发中枢神经系统淋巴瘤患者的生存资料、病理报告及标本测序结果等临床信息,采用回顾性队列研究对所有患者及分组患者进行疗效和预后的生存分析,多因素Logistic回归分析探究影响患者预后的不良因素。结果:在37例合并继发累及中枢的弥漫大B细胞淋巴瘤患者中,2年总生存率(OS)为46.01%,中位生存期为18.1个月;高剂量甲氨蝶呤(HD-MTX)治疗组与替莫唑胺(TMZ)治疗组比较,2年OS分别为34.4%和61%,中位生存期分别为8.7和38.3个月,中位无进展生存期(PFS)分别为8.1和47个月。多因素Logistic回归分析结果显示,患者生存与年龄、性别、IPI、Ann Arbor评分有关。CD79B、KMT2D、CXCR4、ERBB2、TBL1XRy1、BTG2、MYC、MYD88、PIM1基因突变患者的中位生存期为8.2个月,明显低于总体生存水平。结论:HD-MTX联合TMZ的一线治疗可改善患者预后,且早期应用基因检测有利于评估预后。更多还原

【Abstract】 Part 1 A retrospective analysis of Zanubrutinib/HD-MTX combination regimen in primary central nervous system lymphomaPurpose: To explore disease outcome and mutational profiles in newly diagnosed PCNSL patients who have been treated with Zanubrutinib/HD-MTX combination regimen,a retrospective analysis was performed.Methods:19 newly diagnosed PCNSL patients have been treated with Zanubrutinib/HD-MTX combination until disease progression,intolerable toxicities,or physician/patient withdrawal.Safety and efficacy were assessed by investigators per CTCAE v5.0 and RECIST v1.1,respectively.The primary endpoint was the objective response rate(ORR),and the secondary endpoints were PFS,OS,and safety.Results: The median follow-up duration was 17.2 months(range,3.9-30).The ORR for all patients was 84.2%,the 2-year PFS and OS were 75.6% and 94.1%,respectively.All patients completed the induction phase and 9 patients accepted autologous stem cell transplantation as consolidation therapy,demonstrating an ORR of 88.9%(CR/PR-6/2).Ten patients accepted Zanubrutinib as maintenance therapy and achieved an ORR of 80%.All patients showed an acceptable safety profile.Sequencing results of cerebrospinal fluid and tumor tissue showed that PIM1 mutations were the most frequent genetic alterations.ct DNA was correlated to disease relapse and response.Conclusions: Our real-world experience showed that the Zanubrutinib combined with HD-MTX brought great clinical response and tolerance in newly diagnosed PCNSL patients.CSF liquid biopsy profiling might be a feasible way to evaluate the treatment response and tumor burden.Part 2 Efficacy and mechanism of the dual PI3K/HDAC inhibitor BEBT-908 in primary central nervous system lymphomaPurpose: To explore the efficacy and mechanism of the dual PI3K/HDAC inhibitor BEBT-908 in primary central nervous system lymphoma.Methods: The IC50 and cell cycle of B-cell lymphoma treated with BEBT-908 or methotrexate were detected by cell viability assay and flow cytometry.A mouse CNS lymphoma model was established to detect the distribution of BEBT-908 drug metabolism,and Bioluminesence imaging was used to monitor the therapeutic effect.In addition,western blot and immunohistochemical staining were used to verify the molecular mechanism of BEBT-908 inhibiting tumor cycle and proliferation in vitro and in vivo.Results: The IC50 of BEBT-908 in B-cell lymphoma was 0.7-3.1n M,compared with the IC50(40.4-344.6n M)in methotrexate,suggesting a well inhibition of B cell lymphoma proliferation and cell cycle at G0/G1 phase.In vivo,the maximum drug concentration(Cmax)in brain tissue was 520ng/g,and the Cmax in brain tumor tissue was 497.4ng/g.AUC0-t of brain tissue and tumor tissue were 879.89ng/g*h and 6232.881ng/g*h,respectively.which showed high drug focus in tumor tissue.BEBT-908 treatment group(n=8)were no death,6mice disease remission;All mice died due to disease progression in control group.BEBT-908 inhibits tumor cells by inducing cell ferroptosis,regulates cell cycle and protein synthesis via PI3K/AKT pathway.Conclusions: The dual PI3K/HDAC inhibitor BEBT-908 monotherapy in primary central nervous system lymphoma can induce cell ferroptosis through the blood-brain barrier and achieve a good anti-tumor effect,and the drug is well tolerated.Part 3 Efficacy and poor prognostic factors of secondary central nervous system lymphomaPurpose: To explore the clinical efficacy and prognostic factors of secondary central nervous system lymphoma.Methods: Patients diagnosed with secondary CNS lymphoma(SCNSL)of DLBCL between January 2010 and March 2021 was collected from the pathology database and medical records of Guangdong Provincial People’s Hospital.A retrospective cohort study was performed on all and grouped patients to analyze the efficacy and survival.Multivariate logistic regression analysis was used to explore the prognostic factor.Results: 37 patients with SCNSL of DLBCL were included in the research.2-year OS was46.01% and median survival time was 18.1 months.Compared with HD-MTX-based treatment,TMZ-based treatment brought better 2-year OS,median survival time,and median PFS.Multivariate logistic regression analyses show that age,gender,IPI,Ann Arbor stage were correlated with survival.For patients with gene alterations of CD79 B,KMT2D,CXCR4,ERBB2,TBL1XR1,BTG2,MYC,MYD88,and PIM1,the median survival time was significantly lower than the overall level.Conclusion: HD-MTX combined with TMZ as the first-line strategy may improve the survival.And gene sequencing should be used as a prognostic factor in early time.更多还原