【作者】 李楠；

【导师】 张琨；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2023， 硕士

【摘要】 研究背景:作为育龄期女性常见的一种与雌激素代谢相关的疾病——子宫内膜异位症(Endometriosis,EMS),其患者常受腹痛和不孕等症状的困扰。EMS虽为良性疾病,但具有恶性发展(易复发、转移和侵袭等)及恶变的可能,且恶变多发于卵巢。卵巢EMS因病灶部位隐匿,不易早期发现,且与各种卵巢肿瘤难鉴别。EMS发病机制复杂,但血管生成始终是重要环节。子宫内膜组织逆流到腹腔或卵巢后,会经历增生、黏附、侵袭及新生血管形成等病理过程,最终形成异位病灶。剥脱的子宫内膜组织脱离血供,会经历一段缺氧状态,只有那些缺氧期游离到异位组织,并建立新的血供才完成异位定植。EMS动物模型及患者组织中许多促血管生成通路被证实具有重要意义。希佩尔-林道基因(Von Hippel–Lindau,VHL)是一种抑癌基因,其失活常导致缺氧诱导因子-1(Hypoxia Inducible Factor-1,HIF-1α)累积,从而激活下游靶基因导致癌症发生。卵巢癌和EMS病变组织中已观察到VHL低表达。HIF-1α/血管内皮生成因子(Vascular Endothelial Growth Factor,VEGF)是一条经典的血管生成通路,尚未见HIF-1α/VEGF通路与VHL联系起来在卵巢EMS血清中的研究。基于血管生成在EMS发生中的重要性,且EMS的无创诊断方法尚未明确,分析影响血管生成因素指标在外周血中的可能变化也许存在一定的临床意义。目的:本研究以VHL/HIF-1α/VEGF信号通路为切入点,以正常体检者、卵巢EMS患者、良性或恶性卵巢肿瘤患者为对象,采用酶联免疫吸附法(Enzyme-linked Immuno Sorbent Assay,ELISA),比较不同类型人群血清中HIF-1α/VEGF信号通路及上游调节因子VHL的表达水平,并分析卵巢EMS患者外周血中VHL/HIF-1α/VEGF与炎症细胞的关联情况,探讨VHL/HIF-1α/VEGF的检测在卵巢EMS诊疗中有否临床意义。方法:根据本研究设计的纳入和排除标准,收集2021年1月至2022年1月在我院首次住院经手术治疗的非绝经女性血清,包括117例卵巢EMS和47例卵巢良性肿瘤及同期38例卵巢癌患者和22例健康门诊体检者。采用ELISA方法检测各组血清VHL、HIF-1α和VEGF水平,比较其血管生成指标的水平差异,并对其在卵巢EMS中的鉴别效能进行分析。对117例卵巢EMS患者住院资料进行组内分析,初步探讨卵巢EMS血管生成指标与临床资料的可能关联。结果:1.一般情况分析:除卵巢癌组患者年龄略高于卵巢EMS组(P<0.05)外,其他各组年龄和BMI水平与卵巢EMS组比较均无显著性差异(P>0.05)。2.卵巢EMS组患者血清VHL水平高于卵巢癌组(P<0.05),与其余两组无显著差异(P>0.05);HIF-1α水平高于健康体检组(P<0.001),低于卵巢癌组(P<0.05),与卵巢良性肿瘤组对比无显著性差异(P>0.05);VEGF水平较健康体检组和卵巢良性肿瘤组高(P<0.05),较卵巢癌组低(P<0.05)。3.单独用血清HIF-1α和VEGF水平鉴别卵巢EMS患者和健康人群的ROC曲线下面积(AUC)分别为0.746、0.817;单独用血清血清HIF-1α和VEGF水平鉴别卵巢EMS患者与卵巢良性肿瘤患者的AUC分别为0.672、0.741;而VHL、HIF-1α和VEGF血清水平鉴别卵巢EMS患者与卵巢癌患者的AUC分别为0.679、0.692和0.777;HIF-1α和VEGF联合分析鉴别卵巢EMS与健康人AUC为0.862,鉴别卵巢EMS与卵巢良性肿瘤AUC为0.759;VHL联合HIF-1α和VEGF鉴别卵巢EMS与卵巢癌AUC为0.806。4.卵巢EMS患者外周血清HIF-1α水平与年龄相关,年龄越大,HIF-1α水平越高;VEGF水平不同其病灶播散状况和肿物大小不同(P<0.05),病灶分布越广泛、肿物越大,血清VEGF水平越高;血清VHL、HIF-1α和VEGF水平与卵巢EMS患者有无盆腔黏连、盆腔炎症、盆腔积液和痛经无关(P>0.05)。5.卵巢EMS患者外周血HIF-1α水平与白细胞和中性粒细胞数量均呈正相关,相关系数分别为0.322和0.336;VEGF水平与中性粒细胞数量呈正相关,相关系数为0.217。结论:1.卵巢EMS患者外周血清血管生成相关指标VHL、HIF-1α及VEGF具有与健康人、卵巢良性肿瘤或卵巢癌患者鉴别的潜在价值。2.卵巢EMS患者外周血清VEGF水平与其病灶大小和播散程度相关联,可参考作为判断疾病进展的血清学指标。3.卵巢EMS患者外周血HIF-1α、VEGF水平与炎症细胞数量相关,在卵巢EMS中血管生成及炎症反应过程存在相互影响。更多还原

【Abstract】 Research Background:Endometriosis(EMS)is a common disease associated with estrogen metabolism in women of childbearing age that is frequently accompanied by symptoms such as abdominal pain and infertility.Although EMS has a benign development,it has malignant characteristics(easy relapse,metastasis,and invasion,for example),there is the possibility of malignant transformation,and malignant transformation frequently occurs in the ovary.Because of the focus’ s hidden location,ovarian EMS cannot be detected early and is difficult to distinguish from other ovarian tumors.Angiogenesis is an important component of the pathogenesis of EMS.When endometrial tissue counterflows to the abdominal cavity or ovary,pathological processes such as hyperplasia,adhesion,invasion,and so on occur,resulting in neovascularization and,eventually,ectopic lesions.When exfoliated endometrial tissue is separated from the blood supply,it goes into hypoxia,and ectopic colonization can only be completed if those tissues are dissociated to ectopic tissue during the hypoxia period and a new blood supply is established.Several angiogenic pathways in EMS animal models and patient tissues have been shown to be extremely important.The Von Hippel-Lindau(VHL)gene functions as a tumor suppressor.This transcription factor’s inactivation frequently results in the accumulation of hypoxia-inducible factor-1(HIF-1α),which activates downstream target genes and leads to cancer.VHL expression has been found to be low in ovarian cancer and EMS lesions.The HIF-1α / VEGF pathway is a well-known angiogenic pathway,but there has been no research on the relationship between the HIF-1α / VEGF pathway and VHL in EMS serum.Given the importance of angiogenesis in the occurrence of EMS and the lack of a non-invasive diagnostic method for EMS,it may be clinically significant to investigate the possible changes of factors influencing angiogenesis in peripheral blood.Objective:The VHL/HIF-1α/VEGF signaling pathway was used as the breaking point in this study,with normal subjects,patients with ovarian EMS,and patients with benign or malignant ovarian tumors as the subjects.The expression levels of the HIF-1α/VEGF signaling pathway and upstream regulator VHL in different types of people’s serum were compared using an enzyme-linked immunosorbent assay,and the relationship between VHL/HIF-1α/VEGF and inflammatory cells in the peripheral blood of patients with ovarian EMS was investigated to see if VHL/HIF-1α/VEGF detection has clinical significance in the diagnosis and treatment of ovarian EMS.Methods:From January 2021 to January 2022,the sera of non-postmenopausal women treated for the first time in our hospital were collected using the inclusion and exclusion criteria designed in this study,including 117 cases of ovarian endometriosis,47 cases of benign ovarian tumors,38 cases of ovarian cancer,and 22 cases of healthy outpatients.The serum VHL,HIF-1α,and VEGF levels in each group were measured using an ELISA method,and the differences in angiogenesis indexes and their differential efficacy in ovarian EMS were compared.Within the group,the in-hospital data of 117 ovarian EMS patients were evaluated,and the probable link between angiogenic indices and ovarian EMS clinical data was originally investigated.Results:1.General analysis: With the exception of the age of patients in the ovarian cancer group,which was somewhat older than that in the ovarian EMS group(P<0.05),there were no significant variations in age and BMI levels in any of the other groups when compared to the ovarian EMS group(P>0.05).2.Serum VHL levels were significantly higher in the ovarian EMS group compared to the ovarian cancer group(P< 0.05),yet there was no notable change between the other two groups(P> 0.05).Serum HIF-1α levels in the ovarian EMS group were higher than in the healthy physical examination group(P< 0.001)and lower than in the ovarian cancer group(P < 0.05),with no notable difference when compared to the benign ovarian tumor group(P> 0.05);Patients in the ovarian EMS group had higher(P< 0.05)and lower(P< 0.05)serum VEGF levels than those in the healthy physical examination group and the ovarian benign tumor group,respectively.3.The ROC area under the curve(AUC)for ovarian EMS patients and healthy population identified by serum HIF-1α and VE GF levels alone was 0.746 and 0.817,respectively;The AUC of differentiating ovarian EMS patients from ovarian benign tumor patients by serum HIF-1α and VEGF levels were 0.672 and 0.741 respectively;while the AUCs of VHL,HIF-1α and VEGF serum levels to identify patients with ovarian EMS from those with ovarian cancer were 0.679,0.692 and 0.777,respectively;AUC of 0.862 for combined HIF-1α and VEGF analysis to identify ovarian EMS from healthy subjects and 0.759 for AUC to identify ovarian EMS from benign ovarian tumors;The AUC of VHL combined with HIF-1α and VEGF to discriminate ovarian EMS from ovarian cancer was 0.806.4.Peripheral serum HIF-1α levels in patients with ovarian EMS were found to be age-related,with the older the patient,the higher the HIF-1α level;VEGF levels differed with lesion dissemination status and mass size(P < 0.05),and the more extensive the lesion distribution and the larger the mass,the higher the serum VEGF level;serum VHL,HIF-1α,and VEGF levels were not correlated with the presence of pelvic adhesions,pelvic inflammation,Pelvic inflammation,effusion,and dysmenorrhea had no relationship(P>0.05).5.The correlation coefficients in the peripheral blood of patients with ovarian EMS were 0.322 and 0.336 for HIF-1α level and leukocyte and neutrophil counts,respectively,and 0.217 for VEGF level and neutrophil count.Conclusion:1.Indicators of peripheral serum angiogenesis In patients with ovarian EMS,VHL,HIF-1α,and VEGF have different potential values for distinguishing them from healthy subjects,benign ovarian tumors,and ovarian cancer cells,respectively.2.In patients with ovarian EMS,peripheral serum VEGF levels correlate with lesion size and degree of dissemination,and can be used as a reference as a serological indicator to determine disease progression.3.Peripheral blood HIF-1α and VEGF levels in patients with ovarian EMS correlate with the number of inflammatory cells,and there is an interaction between angiogenesis and inflammatory response processes in ovarian EMS.更多还原