Screening and Validation of Potential Prognostic Markers of Cervical Squamous Cell Carcinoma Based on The Cancer Genome Atlas Database
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摘要:
目的 筛选并验证宫颈鳞状细胞癌(cervical squamous cell carcinoma,CESC)潜在的miRNA预后标志物,初步探究CESC发生的分子机制。 方法 利用TCGA数据库中宫颈鳞状细胞癌组织和癌旁组织的miRNA测序信息及患者临床数据,通过生物信息学分析,构建了由4个miRNAs (miR-505-5p、miR-142-3p、miR-532-5p、miR-218-1-3p)组成的预测宫颈鳞状细胞癌患者预后的风险模型并进行诊断效果评价,同时应用逆转录-聚合酶链反应(RT-PCR)检测21对CESC组织及癌旁正常组织中该4个miRNAs的表达水平,以差异表达显著的miR-505-5p作为研究对象,分析其表达水平与CESC患者各临床病理特征间的关系。在CESC细胞中转染miR-505-5p mimics后通过细胞实验探究miR-505-5p对CESC细胞功能的影响;最后通过生物信息法预测miR-505-5p的可能靶基因,并通过RT-PCR及Western blot实验进行验证。 结果 通过对TCGA数据库中宫颈鳞状细胞癌相关数据的分析,构建了由4个miRNAs(miR-505-5p、miR-142-3p、miR-532-5p、miR-218-1-3p)组成的预后风险模型,预后风险模型能有效地将CESC患者分为预后不良的高风险组和低风险组;miR-505-5p在收集到的21对CESC组织中的表达低于癌旁组织(P < 0.05),其表达量与CESC患者的临床分期和侵袭程度负相关;过表达miR-505-5p后抑制了宫颈鳞状细胞癌SiHa细胞的增殖(P < 0.05)、迁移,促进了凋亡(P < 0.05);TBL1XR1作为miR-505-5p的最佳预测靶基因,过表达miR-505-5p后TBL1XR1的RNA水平及蛋白水平下降(P < 0.05)。 结论 miR-505-5p可作为CESC患者的潜在预后标志物,在CESC中miR-505-5p可能通过靶向TBL1XR1发挥抑癌作用。 -
关键词:
- 宫颈鳞状细胞癌 /
- 预后标记物 /
- miR-505-5p /
- TBL1XR1
Abstract:Objective To screen and verify the potential prognostic markers of miRNA in cervical squamous cell carcinoma (CESC), and to explore the molecular mechanism of CESC. Methods Using miRNA sequencing data of cervical squamous cell carcinoma tissues and adjacent tissues in the TCGA database, as well as patient clinical data, a risk model for predicting the prognosis of cervical squamous cell carcinoma patients was constructed using bioinformatics analysis. The model consists of four miRNAs (miR-505-5p, miR-142-3p, miR-532-5p, miR-218-1-3p). The diagnostic performance of the model was evaluated. Reverse transcription-polymerase chain reaction (RT-PCR) was used to detect the expression levels of these four miRNAs in 21 pairs of cervical squamous cell carcinoma tissues and adjacent normal tissues. MiR-505-5p, which showed significant differential expression, was selected for further analysis to examine its relationship with various clinical pathological features of cervical squamous cell carcinoma patients. Transfection of miR-505-5p mimics into cervical squamous cell carcinoma cells was performed to investigate the impact of miR-505-5p on the cellular functions of cervical squamous cell carcinoma. Finally, potential target genes of miR-505-5p were predicted using bioinformatics methods and validated through RT-PCR and Western blot experiments. Results By analyzing the cervical squamous cell carcinoma (CESC) related data from the TCGA database, a prognostic risk model composed of 4 miRNAs (miR-505-5p, miR-142-3p, miR-532-5p, miR-218-1-3p) was constructed. The prognostic risk model effectively stratifies CESC patients into high-risk and low-risk groups for adverse prognosis. The expression of miR-505-5p in the collected 21 pairs of CESC tissues was lower than that in adjacent tissues (P < 0.05), and its expression level was negatively correlated with the clinical stage and invasion degree of CESC patients. Overexpression of miR-505-5p inhibited the proliferation (P < 0.05) and migration of cervical squamous cell carcinoma SiHa cells, and promoted apoptosis (P < 0.05). TBL1XR1 was identified as the best predicted target gene of miR-505-5p, and overexpression of miR-505-5p decreased the RNA and protein levels of TBL1XR1 (P < 0.05). Conclusion miR-505-5p can be used as a potential prognostic marker in patients with CESC, and miR-505-5p may play a tumor suppressive role in CESC by targeting TBL1XR1. -
Key words:
- Cervical squamous cell carcinoma /
- Prognostic markers /
- miR-505-5p /
- TBL1XR1
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随着胰腺外科技术的提高及治疗模式的转变,对胰头良性占位的治疗强调更小创伤和快速康复理念的Beger手术,越来越受到临床重视[1-2]。临沧市人民医院对2014年1月至2020年1月收治的59例慢性胰腺炎、胰头良性及低度恶性肿瘤患者施行手术治疗,其中行改良Beiger手术31例,胰十二指肠切除术(PD)28例,现将治疗体会报告如下。
1. 资料与方法
1.1 一般资料
选取2014年1月至2020年1月临沧市人民医院肝胆外科收治的59例胰头肿块型慢性胰腺炎、胰头良性及低度恶性肿瘤患者作为研究对象,随机分成改良Beger手术组与PD 手术组。59例患者中 54例有不同程度的腹疼表现,5例无明显症状,为体检发现。52例有7~22 a长期酗酒史。术前均B超、CT、MRI等影像检查,以胰头肿块局限性病变为主要表现,未侵犯十二指肠及血管。59例患者均术后病理石蜡切片明确诊断。两组患者平均年龄、性别、疾病谱、酗酒史、并存疾病等情况,差异无统计学意义(P > 0.05),见表1。
表 1 两组一般资料比较($ \bar x \pm s$ )Table 1. Comparison of the general data between two groups ($\bar x \pm s $ )项目 Beger组(n = 31) PD组(n = 28) t/χ2 P 男/女(n) 23/8 21/7 210.06 0.25 年龄(岁) 43.7 ± 3.1 44.2 ± 2.7 0.843 0.20 疾病谱[n(%)] 胰头肿块型慢性胰腺炎 26(83.9) 23(82.1) 202.21 0.11 胰头囊肿合并胰管结石 2(6.5) 1(3.6) 18.34 0.19 胰头实性假乳头状瘤 1(3.2) 1(3.6) 45.54 0.33 导管内乳头状黏液瘤 1(3.2) 1(3.6) 3.19 0.46 胰头浆液性囊腺瘤 1(3.2) 1(3.6) 11.51 0.29 长期酗酒史(n) 27 25 146.04 0.27 并存疾病(n) 2.96 0.31 糖尿病 16 17 高血压病 7 9 冠心病 7 5 1.2 手术方法
改良Beger手术:取上腹部正中或右侧肋缘下斜切口,切开胃结肠韧带,显露胰头,明确胰头病变区域,排除病变广泛侵袭或致密黏连,判断胰头部病变可整块切除,术中取材冰冻病理检查明确诊断,除外胰头癌等。解剖肝十二指肠韧带,显露门静脉、胃十二指肠动脉,避免胰十二指肠前上动脉损伤,解剖肠系膜上静脉,电凝离断胰颈,显露胰管置静脉穿刺硅胶管标记引流,胰腺断面用4-0 Prolene血管缝合线缝合止血,Allis钳钳夹胰腺断面头侧向右上方向牵引,逐一显露结扎胰腺钩突段肠系膜上静脉及门静脉右壁分支,循肠系膜上动脉切除胰腺钩突,避免损伤胰十二指肠下动脉。用电刀或刀片小心分离胰头,不游离胰后筋膜,距离十二指肠内侧残留 0.5~0.7 cm胰腺组织,弧形切除胰头及病变,保护十二指肠血管弓。经胆囊管置入取石网篮至胰腺段胆管作术中标记,避免胰内胆管损伤(图1)。缝扎胰管及残余胰头组织。胰管空肠黏膜对黏膜端侧吻合重建胰肠通路。胰周置双套管引流,同时术后肠内外营养支持治疗等。
PD手术:围手术期治疗及手术切口同Beger手术,手术方式采用标准的Whipple手术操作流程完成。
1.3 术后随访
通过电话、门诊复诊的方式了解术后患者疼痛程度、镇痛药物使用频率、术后糖尿病、脂肪泻、肿瘤复发以及生活质量改善等情况。疼痛情况采用疼痛积分表评价,胰瘘分级按2016版国际胰瘘研究小组的诊断和分级标准,胆漏以穿刺或引流管可见胆汁样液体判断。
1.4 统计学处理
应用SPSS统计学软件对数据分析,两组手术相关指标比较采用t检验,术后并发症相关指标比较采用Fisher确切概率法,术后随访采用χ2 检验,P < 0.05为差异有统计学意义。
2. 结果
所有患者均完成手术,无手术死亡。两组术后住院时间、术后并发症发生率,差异有统计学差异(P < 0.05),Beger组优于PD组。56例(Beger组29例,PD组27例)患者获随访6个月~5 a,无肿瘤或结石复发,疼痛缓解率、新发糖尿病、新发脂肪泻等指标,差异无统计学意义(P > 0.05),见表2。
表 2 两组手术相关指标比较($\bar x \pm s $ )Table 2. Comparison of surgical indicators between the two groups ($ \bar x \pm s$ )指标 Beger组(n = 31) PD组(n = 28) t/χ2 P 手术时间(min) 231.4 ± 42.3 268.1 ± 52.5 2.98 0.06 术中出血量(mL) 405.5 ± 64.1 449.9 ± 61.2 13.18 0.08 术后住院时间(d) 17.1 ± 3.4 28.5 ± 4.1 −17.85 < 0.001 术后并发症[n(/%)] 4/12.9 12/42.9 5.31 0.01 术后出血 0 2 胰漏 3 2 胆漏 1 1 不全性肠梗阻 0 3 非计划再次手术 0 2 胃瘫 0 2 新发脂肪泻(n) 2 3 0.77 0.07 新发糖尿病(n) 2 2 0.85 0.92 疼痛缓解(n) 有效 26 24 1.68 0.79 无变化 3 3 0.91 0.83 3. 讨论
胰头部炎症肿块导致患者疼痛的病理基础是炎症区域淋巴细胞浸润和神经束膜崩解等病理学改变,且胰头部炎性病变较胰体尾部更重,发生时间更早,故去除胰头部炎性病变,可减轻疼痛及炎性包块对胆管、十二指肠的压迫症状,明确病灶性质,同时也阻止胰腺慢性纤维化的持续发展,避免患者内、外分泌功能的严重受损。胰头肿块型慢性胰腺炎传统的手术方式包括胰十二指肠切除术、保留幽门的胰十二指肠切除术等,对于胰头部良性病变而言创伤过大,切除了过多正常器官,患者术后生活质量受到不同程度的影响[1-3]。1985年德国乌尔姆大学外科医院 Hans G·Beger 教授[4]报道并总结了保留十二指肠胰头切除治疗慢性胰腺炎患者的10 a手术经验,此后该术式在全球逐渐推广,并被命名为 Beger手术,又称保留十二指肠的胰头切除术(duodenum-preserving pancreatic head resection,DPPHR)。目前普遍认为DPPHR适用于胰头肿块型慢性胰腺炎、胰头囊肿或良性肿瘤,以及胰头部位未侵犯十二指肠及胆总管,无需行淋巴结清扫低度恶性肿瘤[3]。DPPHR较传统术式而言,手术创伤小,不破坏消化道的正常解剖和完整性,具有更低的手术并发症和死亡率。但该手术没有绝对适应证,对手术操作技巧及经验要求很高,难度较大。有关DPPHR治疗胰头部占位的手术并发症相关Meta分析,提示胰瘘、二次手术率、病死率等严重术后并发症发生率与PD术无明显差异,但DPPHR能够更为有效地避免胰腺内、外分泌功能受损[5-6]。本治疗组发生胰漏3例(9.68 %)、新发糖尿病、脂肪泻各2例,与同期PD组比较并无优势。但因手术创伤及腹腔骚扰较小,无术后出血、肠梗阻、胃瘫及非计划再次手术发生,术后住院时间较PD组明显缩短,节约了医疗成本。尤其对胰头肿块型慢性胰腺炎,DPPHR术后疼痛症状改善明显,患者更易接受,满意度较高。本组DPPHR术后随访良性和低度恶性肿瘤患者尚未见复发。相对PD,在确保胰头病灶切除的原则,DPPHR进一步降低机体损伤以及手术并发症,术中输血更少,术后住院时间更短,术后职业康复和生活质量得到显著提高[7-8]。
对于慢性胰腺炎、胰腺良性、交界性及低度恶性肿瘤患者,切除病变组织、改善患者的腹痛症状,防止病变癌变才是手术的最终目的,无论是采用 DPPHR 或 PD,均能够彻底切除病变,达到理想的手术效果。结合文献[9-11],笔者体会,对此类患者行Beger手术的指征为:(1)胰头部慢性胰腺炎内科或内镜治疗不能解决的顽固性腹痛;(2)邻近器官出现局部并发症,如胆道梗阻、十二指肠梗阻、假性动脉瘤或门静脉受累等;(3)不排除恶变者。胰头肿块型慢性胰腺炎早期手术比晚期手术获益更大,可取得理想的长期缓解疼痛效果。早期手术后发生胰腺外分泌功能不全的风险也更低。与晚期行手术者相比,对发病 < 3 a的患者早期手术,其长期生活质量将获得改善。本组患者术后顽固性疼痛缓解率达到89.7%(26/29)。
改良Beger手术重点及难点是确保十二指肠以及胆总管血供,避免十二指肠及胆管壁坏死而导致手术失败。如何顺利完成手术,结合文献[2,12],笔者体会;(1)离断胰腺颈部是首要步骤。一般情况,解剖分离肠系膜上静脉并不困难,但慢性胰腺炎往往出现血管炎性浸润,炎症致密黏连,多数情况胰颈后隧道封闭,经验不足,强行分离可能出现难以控制的大出血。笔者的经验是,病程较长胰颈炎症致密黏连者,先解剖辨认门静脉、肠系膜上静脉在胰颈的出入点,参照血管轨迹用蚊式钳逐一钳夹结扎胰腺组织,可完整显露血管。离断胰腺颈部,向右牵拉胰头部,从容离断肠系膜上静脉右侧属支,切除胰头,特别是钩突部胰腺组织,最大限度去除炎性病变,解除对肠系膜上静脉的压迫;(2)保留少部分薄层胰头组织及十二指肠内侧血管弓的完整:切除胰头部炎性病变,需保留十二指肠内侧部分胰腺织,至少保留一侧的十二指肠内侧形成的血管弓,避免十二指肠及胆管下端缺血。有研究表明,胰十二指肠动脉缘大部分行走于胰后筋膜内,保全胰后筋膜的完整性即保证了十二指肠的血供[13]。笔者体会,显露胰头时,应重点保护胃十二指肠动脉,切除钩突时,不损伤胰后筋膜。至少保留距离十二指肠约 0.5~0.7 cm 范围内的胰头组织并确切缝扎主胰管,保证血管弓的完整性。对胰头严重黏连者,如果刻意准求胰头的彻底切除,则增加损伤前后动脉弓血管的几率,造成十二指肠缺血坏死的严重并发症。合并胆管下段炎性狭窄的处理:胰头部炎性包块常可引起胆管下段狭窄,导致梗阻性黄疸。切除胰头部组织时,可在胰头创面内行胆管下段开窗,引流胆汁于胰腺创面内,为避免开窗的胆管下段再愈合狭窄,可将切开的胆管侧壁与胰腺创面缝合,近侧的胆总管切开并置入 T 管引流,既可在围手术期保护远侧胰肠吻合口,也可术后造影观察远侧胆管通畅情况。(3)避免胰内胆管壁损伤。Beger手术由于保留了胆管周围的胰腺组织,肉眼不易确切辨别胰内胆管的走行,经验不足必然损伤胆管。有主张切除胰头时,胆总管预切开,置入金属探条引导保护胆管。也行胆总管切开,远端置入导尿管作为引导者,但有时通过较为困难。笔者的经验是于胆囊管开口置入取石网篮,容易通过十二指肠乳头,在手指触摸下辨别胆管的走行路径保留薄层胰腺组织,既不损伤胆管,又不需切开胆总管T管引流,病变胰腺组织也得到了最大限度切除,简单有效。
应用标准的Whipple 术式或保留幽门胰十二指肠切除术治疗胰腺良性疾病及低度恶性肿瘤目前仍然是经典治疗方法。改良Beger手术切除胰腺组织少、手术创伤小、手术安全、恢复更快、对缓解顽固性腹痛确切、患者术后生存质量及营养状况明显改善。但晚期胰腺炎疼痛的处理非常复杂,许多非手术和外科治疗方法及疗效仍需进一步评估,应用也需慎重。
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表 1 多因素COX回归分析
Table 1. Multivariate COX regression analysis
ID coef HR HR.95L HR.95H P hsa-miR-505-5p −0.41441 0.660731 0.400047 1.091285 0.105504 hsa-miR-142-3p −0.4848 0.615818 0.441054 0.859831 0.004417* hsa-miR-532-5p −0.81274 0.443642 0.255144 0.7714 0.003982* hsa-miR-218-1-3p −0.4772 0.620519 0.393131 0.979428 0.04044* *P < 0.05。 表 2 预后风险模型中4个miRNAs在CESC肿瘤组织及癌旁组织中的表达
Table 2. Expression of 4 miRNAs in CESC tumor tissues and adjacent tissues in the prognostic risk model
指标 实验组(n = 21) 对照组(n = 21) Z P miR-505-5p 0.2535(0.1071,0.9268) 0.6417(0.1430,5.9848) −1.987 0.047* miR-142-3p 0.2382(0.0088,0.3490) 0.0326(0.0002,0.3573) −1.220 0.222 miR-532-5p 0.5070(0.1346,1.6147) 0.3869(0.0818,6.4232) −0.604 0.546 miR-218-1-3p 0.1029(0.0094,0.3314) 0.3164 (0.0494,0.8123) −1.434 0.152 *P < 0.05。 表 3 miR-505-5p相对表达量与各临床资料相关性分析
Table 3. Correlation between the relative expression of miR-505-5p and clinical data
指标 hsa-miR-505-5p r P 年龄 −0.408 0.067 CA125 −0.09 0.698 肿瘤直径 −0.064 0.784 临床分期 −0.638 0.002* HPV 感染 −0.166 0.472 淋巴结转移 0.018 0.937 分化程度 0.136 0.568 宫颈癌侵袭程度 −0.545 0.016* 绝经状态 −0.063 0.786 *P < 0.05。 表 4 TCGA数据库CESC组织中靶基因的表达
Table 4. Expression of target genes in CESC tissues from TCGA database
基因 logFC logCPM P FDR ZFP91 0.075391 5.913616 0.92952 1 TP53RK −0.26862 4.747168 0.592504 0.869575 CDKN1A −0.68114 8.690444 0.189145 0.49348 DDX3X −0.29412 7.243068 0.37913 0.710946 HMGN2 0.641482 8.918896 0.190775 0.494806 LDHA 0.964102 8.983097 0.146179 0.430027 OCRL −0.46166 4.947949 0.255322 0.579773 TBL1XR1 1.033012 6.195864 0.09947 0.345268 KXD1 −0.38121 5.861561 0.221704 0.534162 -
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