前列腺癌早期诊断相关标志物的研究进展

2016-09-02 佚名现代泌尿外科杂志

前列腺癌是男性泌尿生殖系统中最常见的肿瘤之一，我国近年来发病率也逐渐增加。前列腺特异性抗原（PsA）的广泛应用，由于提高了前列腺癌的早期诊断率而降低了患者死亡率，但由于其特异性低，造成了大量的过度诊断与治疗。 以PSA为基础而衍生的一些指标包括[-2]proPSA、前列腺健康指数（PHI）、4Kscore@提高了前列腺癌早期诊断的特异性。此外，尿中的标志物如前列腺癌抗原3（PCA3）

前列腺癌是男性泌尿生殖系统中最常见的肿瘤之一，我国近年来发病率也逐渐增加。前列腺特异性抗原（PsA）的广泛应用，由于提高了前列腺癌的早期诊断率而降低了患者死亡率，但由于其特异性低，造成了大量的过度诊断与治疗。

以PSA为基础而衍生的一些指标包括[-2]proPSA、前列腺健康指数（PHI）、4Kscore@提高了前列腺癌早期诊断的特异性。此外，尿中的标志物如前列腺癌抗原3（PCA3）、TMPRSS2-ERG融合基因等对指导前列腺癌的早期诊断也发挥了重要作用。其中，PHI和尿PCA3检测已被美国食品药品管理局（FDA）批准用于临床。

北京大学人民医院泌尿外科的顿耀军博士和徐涛主任就前列腺癌早期诊断相关标志物的研究进展进行了综述，并发表于《现代泌尿外科杂志》2016年5月第21卷第5期。

前列腺癌是当前威胁全世界男性健康的主要恶性肿瘤之一，在欧美国家，其发病率已连续多年居男性恶性肿瘤发病率首位，死亡率居第二位。我国前列腺癌发病率虽低于欧美国家，但随着我国人口老龄化和饮食结构的改变，近年来也呈逐年上升趋势。目前前列腺癌的早期诊断主要依赖于前列腺特异性抗原（prostate specific antigen，PSA）和经直肠超声检查。PSA的广泛应用无疑会提高前列腺癌的早期诊断，但PSA特异性较低，从而导致前列腺穿刺活检结果阴性率较高，也使得重复穿刺数增加。尤其是PSA水平介于3～10 ng/mL的人群，其前列腺穿刺活检的阴性率接近60%～75%。且目前关于PSA筛查能否降低前列腺癌患者死亡率，还存在着较大的争议。因此，为了减少不必要的前列腺穿刺活检，并对前列腺癌进行更精准的早期诊断，有必要探寻敏感度更高、特异性更好的前列腺癌相关标志物。本文将对前列腺癌早期诊断相关标志物的研究进展进行论述。

1、血清标志物

前列腺癌早期诊断的血清标志物主要包括PSA和以PSA为基础的一些衍生指标。

1.1、PSA

PSA相对分子质量为34 ku，为含237个氨基酸残基的单链糖蛋白，由前列腺上皮细胞分泌产生，具有丝氨酸蛋白酶活性，在前列腺组织中以高浓度形式存在，主要起到液化精液的作用，具有很高的组织特异性。PSA是第一个被美国食品药品管理局（Food and Drug Administration，FDA）批准的用于早期诊断肿瘤的标志物，目前已广泛用于前列腺癌的筛查、早期诊断及肿瘤监测。

此外，PSAD（PSA密度）、PSAV（PSA变化速率）、fPSA/tPSA（游离PSA与总PSA的比值）也在前列腺癌的早期诊断中发挥了一定的作用，提高了前列腺癌诊断的敏感性与特异性。正常前列腺组织每增加1 g，可增加PSA 0.13 ng/mL，而肿瘤组织每增加1 g，可增加PSA 315 ng/mL，而前列腺癌患者的PSA变化速率也显著快于良性前列腺疾病患者，因此计算PSAD和PSAV有助于鉴别前列腺癌和良性前列腺增生性疾病。中国泌尿外科疾病诊断治疗指南2014版指出，当PSAD>0.15或PSAV>0.75ng/（mL·年）时，应怀疑前列腺癌的可能。此外，当PSA处于“灰区”（4～10 ng/mL）时，fPSA/tPSA对于前列腺癌的早期诊断、指导前列腺穿刺活检也具有重要意义，可大大提高前列腺癌诊断的特异性。研究表明如患者PSA处于“灰区”时，fPSA/tPSA%0.1，则该患者发生前列腺癌的可能性高达56%；相反，fPSA/tPSA>0.25，发生前列腺癌的可能性只有8%；fPSA/tPSA>0.16时前列腺穿刺阳性率为1.6%；如果fPSA/tPSA<0.16时前列腺穿刺阳性率为17.4%。因此国内推荐fPSA/tPSA>0.16为正常参考值（或临界值）。

1.2、[-2]proPSA（p2PSA）与前列腺健康指数（prostatehealth index，PHI）

最近发现，fPSA有多种亚型，包括PSA前体（proPSA）。PSA首先被翻译为无活性的pre-pro PSA，携带有一段17个氨基酸的前导序列；在PSA分泌过程中，pre-pro PSA发生裂解，除去该前导序列后形成完整的由244个氨基酸组成的PSA酶原或称为proPSA。proPSA由N端7个氨基酸的pro前导肽和237个氨基酸的成熟PSA组成，proPSA在人激肽释放酶2（hK2）的作用下，在7位精氨酸和8位异亮氨酸之间发生裂解形成有活性的成熟PSA[5]。研究发现，由于pro前导肽的不同剪接可产生多种proPSA亚型，目前已在血清和前列腺组织中鉴定出的亚型包括：[--1]，[-2]，[-4]，[-5]和[-7]proPSA；而其中[-2]proPSA（p2PSA）是最稳定的亚型。

p2PSA在外周前列腺癌组织中显著升高，且对于前列腺癌患者，血清p2PSA也会出现特异性升高。SOKOLL等曾选取123名患者（51%前列腺癌患者，49%非前列腺癌患者），结果发现p2PSA和p2PSA/tPSA（p2PSA与总PSA的比值）与前列腺癌的相关性更好：p2PSA/tPSA的AUC（areaunder curve，曲线下面积，本文中均指受试者工作曲线的曲线下面积）为0.69，p2PSA的AUC为0.63，而fPSA/tPSA的AUC为0.61，PSA的AUC只有0.52；且当PSA位于2～10 ng/mI。时，p2PSA的AUC可高达0.73，而fPSA/tPSA的AUC只有0.53。

越来越多的学者发现，当p2PSA与其他指标联合应用时，可以更好地预测前列腺癌。贝克曼库尔特公司便发展了一个新的指标：前列腺健康指数（PHI），其计算公式如下：

PHI=（p2PSA/fPSA）×√tPSA

PHI已被FDA批准用于前列腺癌的早期诊断及危险程度的分级，目前关于PHI与前列腺癌关系的研究，已多达15个[8]。CATAI。ONA等凹1曾丌展了一项多中心的前瞻性筛查试验，该研究一共人选了892名患者，结果发现当tPSA介于2～10 ng/mI.时，tPSA诊断前列腺癌的AUC为0.53，fPSA的AUC为0.65，而PHI的AUC为0.70；且PHI升高的患者患前列腺癌的风险是PHI正常患者的4.7倍。

1.3、4Kscore@

4Kscore@是由美国冷泉港实验室研发出的一项新的以PSA为基础的检测指标，它涉及到4种激肽释放酶蛋白：fPSA、iPSA（intact PSA，是fPSA的亚型之一）、tPSA和人激肽释放酶2（hK2），该指标还将患者的年龄、直肠指诊结果等信息考虑在内。VEIDER等发现PSA介于3～10ng/ml。时，4Kscore@诊断前列腺癌的敏感性高于尿PCA3评分，二者的AUC分别为0.78和0.62；另一项研究也提示4Kscore@与PHI在预测前列腺癌有相似的AUC，分别为0.69和0.70。此外，4Kscore@对于预测穿刺时Gleason评分≥7的前列腺癌，也有较高的特异性。

1.4、其他标志物

最近，尚有一些新的标志物也被初步证实可有助于前列腺癌的早期诊断，包括：survivin、前列腺癌致癌基因启动子的甲基化（GSTPl，RASSFlA，RARβ2等）、miRNA以及循环肿瘤细胞等。

2、尿液标志物

与血清标志物相比，尿液标志物有更多优势，尿液与前列腺直接接触，减少了来自其他器官的蛋白质污染，且尿检属于非侵入性操作，患者依从性更高。

2.1、前列腺癌抗原3（prostate cancerantigen 3，PCA3）

PCA3基因最早于1999年由BUSSEMAKERS等u51通过基因展示技术发现，最初命名为DD3

（differential display code 3），该基因定位于人9号染色体q21-22，在前列腺上皮细胞内表达一种非编码mRNA，无法翻译成蛋白质，该mRNA序列全长约25kb，包含4个外显子和3个内含子，其生物学功能尚不明确。PCA3在超过95%的前列腺癌组织中呈高表达，而正常前列腺及良性前列腺增生组织中PCA3表达水平较低，在非前列腺组织（良性和恶性）中则几乎检测不到PCA3表达，PCA3是目前最具特异性的前列腺癌标志物[1 8I。而且PCA3水平也不受年龄、前列腺体积以及其他前列腺疾病如前列腺炎的影响。

前列腺癌组织可产生PCA3并将其释放入尿液，因此可通过检测尿液PCA3水平来预测前列腺癌。目前应用较多的是Progensa@PCA3检测，比旧式的rtPCR技术更快速、经济。该检测可定量提供尿中PCA3与PSA水平的比值，因尿液中PSA水平与血液PSA水平无关，且在前列腺癌患者中保持稳定，通过PCA3/PSA可起到校准的作用。而PCA3评分则是PCA3与PSA的比值再乘以1000。

前列腺穿刺活检依旧是目前确诊前列腺癌的金标准，尿液PCA3检测可通过预测前列腺穿刺活检的结果来达到早期诊断的目的。来源于REDUCE研究的数据证实，尿液PCA3是比血清PSA更好的标志物，第2年的尿液PCA3水平是第4年前列腺穿刺活检结果的重要预测因子。2006年GROSKOPF等最早报道了一项研究，该研究纳入了前列腺穿刺活检人群和无前列腺癌危险因素的健康人群，结果发现前列腺穿刺活检阳性者，其平均PCA3评分明显高于前列腺穿刺活检阴性者及健康人群（P<0.01），尿液PCA3检测对于预测前列腺癌的敏感度为69%、特异度为79%；而血清PSA对于预测前列腺癌的特异度仅为60%。DERAS等的研究也发现，尿液PCA3评分<5时，前列腺穿刺活检阳性率为14%；而当PCA3评分>100时，活检阳性率为69%，表明PCA3评分与前列腺穿刺活检阳性率呈正相关；且当PSA介于4～10ng/mL时，以PCA3评分等于35作为临界值，其诊断前列腺癌的敏感性为53%，特异性为71%。

2.2、 TMPRSS2-ERG融合基因

许多前列腺癌患者的精液中可以检测到雄激素调节基因与致癌基因融合的特异性改变，尤其是TMPRSS2基因与致癌基因ETS家族的融合。TMPRSS2是一种雄激素调节基因，属于丝氨酸蛋白酶家族；而ETS基因则是一种转录因子家族（主要是ERG和ETV1），参与了细胞增殖、分化、血管生成、凋亡等多种过程。在所有基因融合中，以TMPRSS2-ERG融合基因最为常见，可在50%的前列腺癌切除标本中被检测到心。在尿液中亦可检测到TMPRSS2-ERG融合基因，因此可将其作为前列腺癌早期诊断的特异性分子标志物。

TOMLINS等开展了一项多中心的研究，共收集了1312份尿液样本，检测尿液中TMPRSS2-ERG融合基因和PCA3水平，结果发现将上述两种检测与PCPT模型联合应用时，可将前列腺癌诊断的AUC从0.64提高到0.79（P

2.3、Ⅱ-甲酰基辅酶A消旋酶

AMACR位于染色体5p13.3，在2000年被首次报道，其主要作用是参与支链脂肪酸8氧化和脂肪酸从R-异构体到s-异构体的转化。LUO等发现，在前列腺癌组织中，AMACR mRNA的水平是正常组织的9倍之多，组织微阵列分析也提示前列腺癌和癌前病变（高级别上皮内瘤变）的AMACR免疫组化评分明显高于常前列腺组织。目前AMACR也多用于前列腺穿刺组织的免疫组化检测，其在穿刺前列腺组织中诊断前列腺癌的敏感性为56%～76%，特异性为100%。由于AMACR主要存在于线粒体中，血液中通常不易检测到AMACR；而前列腺所分泌的液体可进入尿道，因此AMACR可在尿液中被检测到。ZIELIE等利用实时荧光定量PCR检测前列腺按摩后尿液中AMACR mRNA，发现其在区别有无临床意义的前列腺癌中具有重要意义。OUYANG等通过对比研究43例前列腺癌患者与49例正常患者前列腺按摩后尿液标本，联合检测尿液中AM-ACR与PCA3水平，对前列腺癌诊断的灵敏度为81%、特异度为84%。

3、小结

现阶段，前列腺癌的早期诊断主要还是依赖PSA筛查，但许多其他前列腺良性疾病也可导致PSA升高；且PSA的应用虽然一定程度上降低了前列腺癌相关死亡率，但由于其特异性低，也造成了大量的过度诊断、过度治疗。因此，众多学者对前列腺癌早期诊断的标志物做了大量的研究工作，并取得了可喜的成果，包括PHI、4Kscore@和尿PCA3评分等指标已被证实可提高前列腺癌早期诊断的敏感性与特异性，并逐步获得临床推广。相信随着研究的进一步深入，未来将会有新的更高特异性和敏感性的前列腺癌标志物被发现，将在前列腺癌的早期诊断、危险程度分级乃至监测治疗、预测复发中也发挥重要的作用。

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2016-10-06 inter158

多谢分享

104 0
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2016-09-04 hukaixun

#标志物#

40 0
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2016-09-11 李东泽

很好，不错，以后会多学习

96 0
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2016-09-04 1771ae4158m

学习了，好

0 0
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2016-09-04 flysky120

谢谢文章，学习

82 0
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2016-09-04 mashirong

#研究进展#

71 0
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2016-09-04 一叶知秋

#早期诊断#

42 0
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2016-09-02 doctorJiangchao

继续学习

66 0
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2016-09-02 doctorJiangchao

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