腫瘤標(biāo)志物對(duì)胰腺癌診斷及預(yù)后評(píng)估作用的研究進(jìn)展

梁夏宜，孫娟 綜述 劉軍杰 審校

（1. 廣西醫(yī)科大學(xué)腫瘤醫(yī)學(xué)院，廣西 南寧 530021；2. 廣西醫(yī)科大學(xué)附屬腫瘤醫(yī)院 物理診斷中心，廣西 南寧 530021）

胰腺癌是世界上最常見(jiàn)的消化道惡性腫瘤之一[1]，大約有85%的胰腺癌屬于胰腺導(dǎo)管腺癌（pancreatic ductal adenocarcinoma cancer，PDAC）[2]，近年P(guān)DAC患者的5年生存率從4%～5%略改善到7%[3]。手術(shù)切除是唯一可能治愈PDAC的方法。在早期完全切除術(shù)中，淋巴結(jié)陰性患者的5年生存率為25%～30%，而淋巴結(jié)陽(yáng)性患者的5年生存率僅為10%[4]。大部分患者在確診時(shí)已處于胰腺癌晚期，僅有15%～20%的患者能夠得到及時(shí)有效的治療[2]。

胰腺癌的早期診斷對(duì)選擇最佳治療方案并提高PDAC患者的預(yù)后具有重要意義。許多腫瘤標(biāo)志物與胰腺癌有關(guān)聯(lián)，但CA19-9（carbohydrate antigen 19-9，CA19-9）是目前唯一被食品藥品監(jiān)督管理局（Food and Drug Administration，F(xiàn)DA）認(rèn)可的對(duì)PDAC有監(jiān)測(cè)效能的生物標(biāo)志物。盡管它普遍用于早期診斷、預(yù)后評(píng)估以及術(shù)后監(jiān)測(cè)復(fù)發(fā)和轉(zhuǎn)移，但仍具有局限性[5]，因此，急需尋求新的腫瘤標(biāo)志物對(duì)胰腺癌進(jìn)行早期診斷及預(yù)后評(píng)估。本文就腫瘤標(biāo)志物在評(píng)估PDAC患者術(shù)后復(fù)發(fā)、轉(zhuǎn)移、治療效能以及早期診斷PDAC的應(yīng)用等方面進(jìn)行綜述。

1 診斷標(biāo)志物

1.1 CA19-9、癌胚抗原（carcinoembryonic antigen，CEA）及其他碳水化合物

CA19-9是目前被最廣泛應(yīng)用于PDAC定位的一種單克隆抗體，也是FDA唯一認(rèn)可的能對(duì)胰腺癌預(yù)后有預(yù)測(cè)作用的標(biāo)志物[6]。CA19-9診斷PDAC的平均靈敏性與特異性分別為77.5%與77.6%[7]，對(duì)有明顯病癥的PDAC患者來(lái)說(shuō)陽(yáng)性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為72%和81%～96%[8]。但有研究顯示在急性膽管炎、胰腺炎、肝癌、膽管癌等患者的血清中可出現(xiàn)假陽(yáng)性[9]，容易受到血清膽紅素的影響而升高，且路易斯（Lewis）血型患者的血清中不表達(dá)CA19-9[10]，因此將CA19-9單獨(dú)作為診斷胰腺癌的指標(biāo)是不完全準(zhǔn)確的。

CEA是從人結(jié)腸癌組織中分離出來(lái)的一種可溶性蛋白。在胚胎時(shí)期生存于肝臟和胰腺，在出生后逐漸下降。當(dāng)正常細(xì)胞發(fā)生惡變時(shí)，血清CEA水平異常升高。在確定CA19-9的預(yù)測(cè)能力之前，CEA是唯一用于診斷PDAC的血清抗原[11]，但與CA19-9相比，CEA在診斷胰腺癌時(shí)更易出現(xiàn)誤診[12]。因此在臨床上，其常應(yīng)用于臨床療效觀察和術(shù)后隨訪的重要指標(biāo)，與其他腫瘤標(biāo)志物聯(lián)合診斷，提高診斷疾病的敏感性和特異性。

聯(lián)合CA19-9、CEA和其他標(biāo)志物能提高對(duì)胰腺癌患者的診斷。有研究顯示CA242（carbohydrate antigen 242，CA242）診斷胰腺癌的敏感性、特異性分別為67.8%、83.3%，CEA診斷的敏感度、特異性為39.5%、81.3%。但CA19-9與CA242聯(lián)合時(shí)，其診斷的靈敏度可高達(dá)89%（對(duì)特異性無(wú)影響）；CA19-9與CEA聯(lián)合診斷PDAC的靈敏度、特異性為89%、75%[7]。當(dāng)CA19-9、CEA、CA242三者聯(lián)合時(shí)，PDAC診斷的特異性高達(dá)95%，然而診斷的靈敏度出現(xiàn)降低。CA19-9、CEA、CA242與CA125聯(lián)合時(shí)，診斷的靈敏度達(dá)90.4%，特異性為93.8%[8]。因此，CA19-9、CEA和其他碳水化合物在臨床上對(duì)早期診斷PDAC具有重要的意義。

1.2 微小核糖核苷酸（microRNA，miRNA）和其他非編碼核糖核苷酸

miRNA影響胰腺發(fā)育、胰腺腫瘤的發(fā)生和進(jìn)展。識(shí)別胰腺癌中特異的miRNA，不僅可以區(qū)別胰腺的良惡性病變，還可以提高胰腺癌的早期診斷率[13]。研究[14-22]發(fā)現(xiàn)miR-21、miR-155、miR-196a和miR-210在PDAC患者的胰腺組織、血樣、糞便和胰液中表達(dá)水平上升，miR-216與miR-217在胰腺組織、糞便、胰液中呈持續(xù)下降的趨勢(shì)。尿中的miRNA濃度可對(duì)早期PDAC進(jìn)行診斷，有研究[6]證實(shí)miR-143、miR-22與miR-30e在胰腺癌患者的尿液中水平顯著升高。在聯(lián)合使用miR-143與miR-30e對(duì)胰腺癌患者進(jìn)行診斷時(shí)靈敏度為83.3%、特異性為96.2%。將miR-21、miR-155和miR-216聯(lián)合作為檢測(cè)PDAC患者時(shí)亦得類(lèi)似的結(jié)果（靈敏度與特異性達(dá)到83.3%）[23]。Caponi等[24]對(duì)miR-21、miR-155和miR-196a進(jìn)行了特殊標(biāo)記后，發(fā)現(xiàn)它們?cè)趯?dǎo)管內(nèi)乳頭狀粘液性惡性腫瘤（intraductal papillary mucinous neoplasm，IPMN）與胰腺上皮內(nèi)腫瘤（pancreatic intraepithelial neoplasia，PanIN）的組織標(biāo)本中高水平表達(dá)，這表明它們也是潛在的生物標(biāo)記物，特別是用于早期診斷惡性潛能的疾病。

1.3 巨噬細(xì)胞抑制細(xì)胞因子1（macrophage inhibitory cytokine 1，MIC-1）與四階脈沖幅度調(diào)制（4 level pulse amplitude modulation，PAM4）

MIC-1是轉(zhuǎn)化生長(zhǎng)因子家族的成員，在不同的腫瘤分期中高度表達(dá)[25]。有研究[26]顯示，與CA19-9相比，MIC-1能更好地從健康對(duì)照組中區(qū)分出胰腺癌患者，且其對(duì)胰腺癌的綜合診斷能力明顯優(yōu)于CA19-9，但對(duì)胰腺癌和慢性胰腺炎很難區(qū)分。Chen等[27]發(fā)現(xiàn)PDAC患者血清中檢測(cè)到MIC-1的靈敏度和特異性分別為79%、86%，且在聯(lián)合使用MIC-1與CA19-9診斷PDAC的研究中發(fā)現(xiàn)了類(lèi)似的結(jié)果。在CA19-9陰性的患者中，MIC-1的檢測(cè)靈敏度為63.1%[28]，在很大程度上能夠避免對(duì)CA19-9陰性的PDAC患者出現(xiàn)漏診。

PAM4是一種能在胰腺癌早期中表達(dá)并在疾病的進(jìn)展中保存下來(lái)的單克隆抗體[29]。Gold等[30]證實(shí)與胰腺良性病變相比，PAM4對(duì)PDAC的檢測(cè)總靈敏度為76%，特異性為85%，陽(yáng)性似然比（positive likelihood ratio，+LR）為4.93；與PAM4相比，CA19-9對(duì)PDAC的靈敏度為77%，特異性僅為68%，+LR為2.85（P=0.026）；聯(lián)合CA19-9與PAM4時(shí)，PDAC的檢測(cè)靈敏度為84%，特異性為82%，對(duì)胰腺癌的檢出率顯著提高。

1.4 鈣結(jié)合蛋白（calcyclin，Cacy，S100A6）

S100A6是一種鈣結(jié)合蛋白，在PDAC患者的血清水平中升高。有研究[31]發(fā)現(xiàn)胰液中S100A6水平的測(cè)定對(duì)于區(qū)分慢性胰腺炎、PDAC與IPMN具有重要的作用。雖然部分PDAC患者在超聲內(nèi)鏡引導(dǎo)下細(xì)針穿刺活檢（endoscopicultrasonographyfineneedleaspiration，EUS-FNA）的標(biāo)本中發(fā)現(xiàn)S100A6處于高水平狀態(tài)[32]，但目前為止未能證實(shí)循環(huán)中血清S100A6水平對(duì)胰腺癌具有診斷作用。

1.5 骨橋蛋白（osteopontin，OPN）

OPN是一種具有多功能的分泌蛋白，能在PDAC患者中表達(dá)升高，與侵襲性胰腺癌的癌細(xì)胞轉(zhuǎn)移生長(zhǎng)有關(guān)[33]。研究[13]顯示血清中高濃度OPN對(duì)PDAC患者的檢測(cè)靈敏度為80%，特異性為97%。OPN能區(qū)分出慢性胰腺炎和PDAC患者，同時(shí)能區(qū)分出早期PDAC患者。雖然OPN的診斷靈敏度低于CA19-9，但是在聯(lián)合使用OPN、CA19-9與金屬蛋白酶組織抑制劑1（tissue inhibitor of metalloproteases 1，TIMP-1）時(shí)，診斷靈敏度為87%，特異性為91%[34]，均優(yōu)于這三種生物標(biāo)志物單獨(dú)應(yīng)用。

1.6 鼠類(lèi)肉瘤病毒癌基因（kirsten rat sarcoma viral oncogene，KRAS）

KRAS基因是胰腺癌中最常見(jiàn)的突發(fā)型致癌基因。近期研究[35]顯示KARS突變分析與EUS-FNA樣本的細(xì)胞邏輯分析結(jié)合可使PDAC患者診斷的靈敏度由80.6提高到88.7%。KARS突變患者的總體生存率比無(wú)突變的患者小，這表明這KARS基因的檢測(cè)是用于診斷PDAC和預(yù)測(cè)生存率的新策略[36]。在細(xì)胞學(xué)不確定時(shí)可用KARS突變進(jìn)行輔助診斷PDAC患者，但Singh等[37]沒(méi)有發(fā)現(xiàn)血清中KARS突變的狀態(tài)與不同的臨床病理參數(shù)或生存率之間存在明顯的相關(guān)性。因此，仍需要研究來(lái)證實(shí)KARS突變可作為PDAC患者潛在的生物標(biāo)記物。

2 治療效果的預(yù)測(cè)指標(biāo)

2.1 吉西他濱標(biāo)記

對(duì)胰腺癌轉(zhuǎn)移以及在輔助性治療中發(fā)生轉(zhuǎn)移的PDAC患者來(lái)說(shuō)，吉西他濱可作為標(biāo)準(zhǔn)的化療藥物[38]，目前蛋白家族中平衡型核苷轉(zhuǎn)運(yùn)蛋白（equilibrative nucleoside transporters，ENTs）和集中型核苷轉(zhuǎn)運(yùn)蛋白（concentrative nucleoside transporters，CNTs）被認(rèn)為是吉西他濱治療的生物標(biāo)記[39]。

2.1.1 人平衡型核苷轉(zhuǎn)運(yùn)蛋白1（human ENT1，hENT1） 研究[40]發(fā)現(xiàn)hENT1升高能夠作為吉西他濱治療中的預(yù)測(cè)和評(píng)價(jià)預(yù)后效果的標(biāo)志物，使用免疫組織化學(xué)分析對(duì)用吉西他濱治療的晚期PDAC患者進(jìn)行活檢時(shí)發(fā)現(xiàn)hENT1高度表達(dá)，且在吉西他濱治療檢測(cè)中發(fā)現(xiàn)hENT1高度表達(dá)的患者總體生存率與無(wú)復(fù)發(fā)生存率更高。Yamada等[41]進(jìn)行了不同階段的PDAC患者治療前hENT1水平的測(cè)定，并將其與用吉西他濱治療后的切除標(biāo)本中的hENT1水平對(duì)比，發(fā)現(xiàn)hENT1是所有PDAC患者以及接受切除術(shù)的患者的獨(dú)立預(yù)后預(yù)測(cè)因子。

2.1.2 人集中型核苷轉(zhuǎn)運(yùn)蛋白（human CNT3，hCNT3） hCNTs是第二組吉西他濱的細(xì)胞膜轉(zhuǎn)運(yùn)體，能利用鈉梯度轉(zhuǎn)移吉西他濱通過(guò)質(zhì)膜[42]。Maréchal等[43]對(duì)45例以吉西他濱為基礎(chǔ)治療的患者分析發(fā)現(xiàn)hCNT3高表達(dá)患者的3年生存率與hCNT3低表達(dá)的患者相比顯著延長(zhǎng)（54.6% vs.26.1%，P=0.028）。hCNT3與 hENT1聯(lián)合應(yīng)用時(shí)，hCNT3與hENT1高表達(dá)的患者3年生存率為81.1%[43]。

2.1.3 脫氧胞苷激酶（deoxycytidine kinase，dCK） dCK是一種限速酶，它通過(guò)磷酸化將吉西他濱轉(zhuǎn)化為其活化的形式。研究[44]發(fā)現(xiàn)dCK信使RNA（mRNA）水平升高能顯著延長(zhǎng)應(yīng)用吉西他濱治療患者的生存期。但考慮到目前有限的數(shù)據(jù)，仍需要進(jìn)一步的臨床研究證實(shí)dCK與hCNT3能否作為評(píng)估吉西他濱治療的標(biāo)志物。

3 預(yù)后標(biāo)志物

3.1 CA19-9

術(shù)后CA19-9正?；蛐g(shù)前輕度升高（＜100 U/mL）預(yù)測(cè)預(yù)后良好，而CA19-9血清水平術(shù)前＞100 U/mL或術(shù)后＞37 U/mL與不良預(yù)后有關(guān)[8,24]。此外，胰腺切除術(shù)后正常CA19-9的下降趨勢(shì)亦與生存期延長(zhǎng)有關(guān)。術(shù)后持續(xù)升高的CA19-9水平則表明有病灶殘留并可能生存期更短。CA19-9術(shù)前改變率可以預(yù)測(cè)切除腫瘤包塊患者的生存率。術(shù)后的CA19-9水平正?；c提高患者術(shù)后生存率有很大的聯(lián)系，而術(shù)后CA19-9的非正?；c發(fā)生轉(zhuǎn)移性疾病或術(shù)后復(fù)發(fā)有很大的關(guān)聯(lián)[10]。研究路易斯陽(yáng)性血伴術(shù)后高CA19-9患者的預(yù)后情況，發(fā)現(xiàn)術(shù)后有54.5%的患者發(fā)生了局部復(fù)發(fā)和遠(yuǎn)處轉(zhuǎn)移，這些患者術(shù)后CA19-9再次上升發(fā)生在腫瘤復(fù)發(fā)2～9個(gè)月之前[45-46]，術(shù)后CA19-9持續(xù)性升高可比影像學(xué)檢測(cè)出復(fù)發(fā)早2周至5個(gè)月[11,47]。但也有研究顯示術(shù)后CA19-9水平正常化并不等同于良好的預(yù)后效果[12,47]。

3.2 富含半胱氨酸的分泌型酸性蛋白（secreted protein acidic and rich incysteine，SPARC）

SPARC是一種鈣結(jié)合蛋白，能分泌到細(xì)胞外基質(zhì)并被多種蛋白酶迅速降解，影響細(xì)胞的遷移、增殖以及血管生成等[48-50]。SPARC已在紫杉醇治療中作為預(yù)測(cè)胰腺癌患者預(yù)后的生物標(biāo)志物。在PDAC切除術(shù)后聯(lián)合吉西他濱與替吉奧膠囊（S-1）或單獨(dú)使用吉西他濱治療時(shí)，SPARC的高表達(dá)與患者的低生存率有關(guān)[51]。SPARC對(duì)胰腺癌的治療的研究中，Vaz等[52]發(fā)現(xiàn)在PDAC和大部分其他實(shí)體性腫瘤中SPARC表達(dá)與預(yù)后不良有關(guān)[53]。SPARC表達(dá)的位置在胰腺癌中似乎起決定性的作用。Infant等[54]發(fā)現(xiàn)過(guò)度表達(dá)SPARC的腫瘤周?chē)衫w維細(xì)胞能預(yù)測(cè)PDAC患者預(yù)后，腫瘤間質(zhì)細(xì)胞SPARC陽(yáng)性患者的平均生存期要短于陰性患者（15個(gè)月vs. 30個(gè)月，P＜0.001），因此腫瘤間質(zhì)細(xì)胞能延長(zhǎng)患者生存期。許多研究[53,55]表明存在腫瘤間質(zhì)成纖維細(xì)胞不代表預(yù)后不良，相反，它甚至可以延長(zhǎng)總體生存期。

3.3 miRNA

miRNA不僅作為PDAC的潛在診斷標(biāo)志物，還在預(yù)后評(píng)估上具有重要的作用。目前，研究證實(shí)腫瘤中高度表達(dá)miR-21能明顯縮短PDAC患者的總體生存期和無(wú)病生存期[56]；miR-155與miR-203表達(dá)升高，以及miR-34a表達(dá)降低使患者總體生存期縮短[57]；miR-221/222在PDAC中過(guò)度表達(dá)，這說(shuō)明了miR-221/222基因的表達(dá)顯著促進(jìn)生長(zhǎng)和侵襲，抑制細(xì)胞凋亡。此外，低表達(dá)水平miR-218與miR-494以及高表達(dá)水平miR-744也與預(yù)測(cè)PDAC患者的生存率低有關(guān)[49-60]。

3.4 預(yù)后指數(shù)

各種預(yù)后標(biāo)志物的結(jié)合構(gòu)成預(yù)后指數(shù)。Park等[61]應(yīng)用5個(gè)參數(shù)（PS、血紅蛋白、白細(xì)胞計(jì)數(shù)、中性粒細(xì)胞比值、CEA）將轉(zhuǎn)移性胰腺癌患者分為3個(gè)亞組，即低風(fēng)險(xiǎn)組，中風(fēng)險(xiǎn)組和高風(fēng)險(xiǎn)組，三者的平均總體生存期分別為11.7、6.2、1.3個(gè)月（P＜0.001）。對(duì)接受姑息性化療的PDAC晚期患者，Xue等[62]創(chuàng)建由3個(gè)臨床參數(shù)（美國(guó)東部腫瘤協(xié)作組體能狀態(tài)評(píng)分標(biāo)準(zhǔn)(Eastern Cooperative Oncology Group Performance Status,ECOG PS)、血清CA19-9水平與血清中C反應(yīng)蛋白水平）組成的預(yù)后指數(shù)，將胰腺癌晚期患者分為低風(fēng)險(xiǎn)和高風(fēng)險(xiǎn)兩組，低風(fēng)險(xiǎn)組與高風(fēng)險(xiǎn)組的平均總體生存期和1年生存率分別為9.9、5.3個(gè)月（P＜0.001）和40.5%、5.9%（P＜0.05）。預(yù)后指數(shù)模型的建立是聯(lián)合不利于患者預(yù)后的因素進(jìn)行統(tǒng)計(jì)學(xué)分析，這些易于從患者身上獲得的預(yù)處理參數(shù)和預(yù)后指數(shù)模型可以幫助臨床醫(yī)生識(shí)別高?；颊?，并在臨床實(shí)踐中為胰腺癌晚期患者選擇恰當(dāng)?shù)闹委煼椒?。但目前為止，沒(méi)有一個(gè)可靠的評(píng)分系統(tǒng)可用于胰腺導(dǎo)管腺癌患者的常規(guī)預(yù)后判斷[63]。

4 總結(jié)與展望

綜上所述，早期診斷、及時(shí)治療可極大的提高胰腺癌患者的總體生存率。因此各種腫瘤標(biāo)志物、血清蛋白、miRNA以及在未來(lái)可能滿足這些需求的基因標(biāo)記等，在很大程度上能提高胰腺癌的檢出率。聯(lián)合使用腫瘤標(biāo)志物能更好地提高胰腺癌的檢出率，并在指導(dǎo)治療和評(píng)估預(yù)后上具有重要意義。

近年來(lái)，基于腫瘤標(biāo)志物在早期診斷、指導(dǎo)治療和評(píng)估預(yù)后等方面具有重要作用，使PDAC患者的治療效果有所改善。但尋找敏感性高、特異性強(qiáng)、結(jié)果穩(wěn)定的腫瘤標(biāo)志物，仍是胰腺癌早期診斷中待解決的問(wèn)題。相信今后隨著技術(shù)的發(fā)展和胰腺癌分子生物學(xué)研究的深入，胰腺癌的早期診斷、預(yù)后以及總體生存率將會(huì)得到極大的改善。

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