產(chǎn)品培訓ctdna文獻冊

ctDNA1.1分1.2種1.3ctDNACTCs1986年，來自意大利的獎得主RenatoDulbecco在談到為什么一定要測定整個人類組序列的時候說：這是打贏對的唯一途徑。對于“是基因病”這一說法，科學家們已達成共識。2015年，在國情咨文目前，食品藥品監(jiān)督管理局（FDA）已強制要求在應(yīng)用某些藥物前進行EGFR、KRAS等，國立綜合網(wǎng)絡(luò)（ ）也已將EGFRKRASHER2、ERCC1等納入治療指南中?；颊叩耐庵苎h(huán)血中含有多種與相關(guān)的突變，主要由腫瘤組織釋ctDNActDNA作為一種高度靈敏、特異性的腫瘤新型標志物，可通過對其進行，分析出腫瘤中發(fā)生突變的，從而為患者在早期診斷、中，將液體活檢技術(shù)列為腫瘤治療領(lǐng)域的下一個十年趨勢之一。ctDNA作為液體活檢技術(shù)的重要一員已逐漸從科研臨床，歐洲藥品管理局（EMA）批準將ctDNA檢測用于的伴隨診斷更是標志著ctDNA臨床應(yīng)用的大規(guī)模實現(xiàn)。CirculatingTumorDNAandDNAMayHelpGuideTreatmentMorerecently,theliquidbiopsyconcepthasextendedtodetecting,capturing,andyzingcirculatingtumorDNA(ctDNA)andtumormicroRNA,minisculepiecesofthecancercell’sgeneticmaterialthatfloatlyinthebloodstream.RecentstudiesshowthatctDNAtestingcouldbeappliedtoallstagesofpatientcare–fromdetectionanddiagnosistoselectionoftreatmentsofctDNAlevelsintheboldmayalsobeusedtoquicklyestimatehowadvancedthecancerisandthepatient’ssurvivalchances,becausehigherlevelsofctDNAarestronglyassociatedwithshortersurvival.ysisofctDNAcouldalsobeusedforreal-timemonitoringofnewmutationsthatariseduringtumorprogressionandtherapyandtoselectthemostsuitabletreatments.Approximayadecadeago,researchersdiscoveredthatabnormalitiesinmicroRNAs–moleculesthatpreventcellsfrommakingspecificproteins–areassociatedwithcancerdevelopmentandprogression.SubsequentresearchhasshownthatmicroRNAysisisapromisingandcost-effectivewaytoidentifywhattypeofcancerapatienthas,estimatehowfastacancerisgrowing,monitorresponsetotherapy,anddetectrelapse.Althoughalltheseavenuesareunderintensiveresearch,confirmationinlarge-scaleclinicaltrialsisneededbeforeliquidbiopsies eroutineandwidelyavailableinIRESSAreceivesPpositiveopiniontoincludebloodbaseddiagnostictestinginEuropeanlabelAstraZenecatodayannouncedthattheCommitteeforMedicinalProductsforHumanUse(P)oftheEuropeanMedicinesAgency(EMA)hasadoptedapositiveopiniononaType-IIvariationupdatetotheEuropeanlabelforIRESSA?(gefitinib).Thelabelupdatewillhelpdoctorstoidentifylungcancerpatients-basedonthespecificgeneticdriversoftheirtumour-whocouldbenefitfromtreatmentwithIRESSAbutareunabletoprovideasuitabletumoursample.IRESSAisanepidermalgrowthfactorreceptortyrosinekinaseinhibitor(EGFRTKI)indicatedforthefirstlinetreatmentofadultpatientswithlocallyadvancedormetastaticnon-smallcelllungcancer(NSCLC)withactivatingmutationsoftheEGFRtyrosinekinase.Therefore,onlypatientswhosetumoursareEGFRmutationpositiveareeligibletoreceivetreatment.Tumoursamplesgainedthroughbiopsyaretheprimarymethodfordeterminingapatient’sEGFRmutationstatus,withoutwhichpatientsarenoteligiblefortreatmentwithanEGFRTKIsuchasIRESSA,whichisthestandardofcareinEurope.FollowingPopinion,IRESSAwillbethefirstEGFRTKIinEuropetoalabelFollowingPopinion,IRESSAwillbethefirstEGFRTKIinEuropetoalabelallowingtheuseofcirculatingtumourDNA(ctDNA)obtainedfromasample,tobeusedfortheassessmentofEGFRmutationstatusinthosepatientswhereatumoursampleisnotanoption.Theupdatewilltakeeffectimmedia yandwillbeapplicableinall28EuropeanUnionmembercountries.BriggsMorrison,Executive,GlobalMedicinesDevelopmentandMedicalOfficeratAstraZenecasaid:“AtAstraZeneca,wearecommittedtodevelotargetedmedicinesthatimprovehealth esforpatients.Understandingthenatureofanindividual’stumourandthereforewhichmedicineismostlikelytobenefitthemisvitalifwearetotransformthewaycancerpatientsaretreated.Ifdoctorsareunabletoassessthemutationstatusofatumour,thenpatients’accesstopotentiallylife-changingmedicinessuchasIRESSA esrestricted.Today’sdecisionbythe PtoendorsealabelupdateforIRESSAisasignificantstepforward.”AstraZenecahaspioneeredtheuseofinnovativeblood-baseddiagnostictestingforsolidtumoursandrecentlyannouncedapartnershipwithQiagentodevelopactDNAtestasacompaniondiagnosticforIRESSA.ctDNActDNA在了解ctDNA之前，首先需明確另一個與之相關(guān)的概念—cfDNA（circulating DNA，血液游離DNA即血漿中游離存在的DNA，主要來源于正常細胞、血液循環(huán)腫瘤DNA則是cfDNA中來源于腫瘤細胞的那一部分DNA，由腫瘤細胞釋放入血，占cfDNA的0.01%-93%不等（Ref:NatRevClinOncol.2013Aug;10(8):472-84.。1947年，MandelcfDNA；1977年，Leon發(fā)現(xiàn)腫瘤患cfDNA1989年，StrouncfDNA中攜ctDNA的研究熱度持續(xù)上升，并開始應(yīng)用于臨床。ctDNA失（Indel、拷貝數(shù)變異（CNV）和結(jié)構(gòu)變異（SV。ctDNA并非隨機釋放至血液，而是搭載其載體—核小體，核小體再以單個、雙ctDNA166bp15分鐘至數(shù)小時不等（Ref：NatRevCancer.2011Jun;11(6):426-37。ARMSBEAMing,0.01%or通過各種技術(shù)對ctDNA進序，可分析出其中突變及其突變豐度，為腫瘤患者提供有效信息。目前應(yīng)用于ctDNA的檢測技術(shù)有Sanger（又稱一代、Pyrosequecing（焦磷酸、qPCR（tativeReal-timePCR，實時熒光PC（AmliiatinsystemNG（NeARMSBEAMing,0.01%orctDNA2015年指南提出，非小細胞肺癌患者治療前應(yīng)進行，然而1/3的患者沒有足夠的腫瘤組織樣本進行（Ref:2015ASCOAnnualMeeting：e19082.。組織樣本可直接反應(yīng)腫瘤的譜，但也的確存在著一定的局限性，當近年來，ctDNA作為一種新的腫瘤標志物，在用藥指導(dǎo)、療效監(jiān)測和復(fù)發(fā)監(jiān)測等診療過程中表現(xiàn)出很大的潛力。但ctDNA的突變能否真實反映腫瘤組織的基非小細胞KRAS,EGFR,HER2,ClinCancerRes,-Cancer-PlosOne,KRASPLoSOne.NRAS0BRAFI--KRAS,EGFR,--ClinCancerRes,VNRAS--MolOncol.2015Sep25.BRAF--BRAF,cKIT,--胃腸道間--2013ASCOAnnual4--胰--50---MolOncol,異質(zhì)性，使得所檢測的組織樣本不能完全代表患者腫瘤變異的全貌，因此可能存在組織中未檢到而血液中檢到突變的情況；2）血液中ctDNA是由的細胞釋放至血液中，若在血液中未檢測到組織中檢到的突變，可能是這部分變異未另外，ctDNA作為一個系統(tǒng)性的檢測，還可克服腫瘤異質(zhì)性的問題。有研究發(fā)現(xiàn)，同一位腎癌患者的灶和轉(zhuǎn)移灶不同部位的腫瘤組織在DNA水平上是有差異而有研究表示，ctDNA更能反映腫瘤譜的全貌，可克服腫瘤異質(zhì)性，從而Capturingintra-tumorgeneticheterogeneitybydenovomutationprofilingofcirculatingcell-tumorDNA:aproof-of-principleDeMattos-ArrudaL,WeigeltB,CortesJ,etal.AnnOncol.2014Sep;25(9):1729-BACKGROUND:sma-derivedcell-tumorDNA(ctDNA)constitutesapotentialsurrogatefortumorDNAobtainedfromtissuebiopsies.Wepositthatmassivelyparallelsequencing(MPS)ysisofctDNAmayhelpdefinetherepertoireofmutationsinbreastcancerandmonitortumorsomaticaltionsduringthecourseoftargetedtherapy.PATIENTANDMETHODS:A66-year-oldpatientpresentedwithsynchronousestrogenreceptor-positive/HER2-negative,highlyproliferative,grade2,mixedinvasiveductal-lobularcarcinomawithboneandlivermetastasesatdiagnosis.DNAextractedfromarchivaltumormaterial,smaandperipheralbloodleukocyteswassubjectedtotargetedMPSusingatformcomprising300cancergenesknowntoharboractionablemutations.MultiplesmasampleswereduringthelineoftreatmentwithanAKTCONCLUSIONS:Thisproof-of-principlestudyisoneofthefirsttodemonstratethathigh-targetedMPSof sma-derivedctDNAconstitutesCONCLUSIONS:Thisproof-of-principlestudyisoneofthefirsttodemonstratethathigh-targetedMPSof sma-derivedctDNAconstitutesapotentialtoolfordenovomutationidentificationandmonitoringofsomaticgenetic tionsduringthecourseoftargetedandmaybeemployed總的來說，ctDNA不僅與腫瘤組織的檢測結(jié)果有較高的一致性，還可在無法或ctDNA在cfDNA中的濃度為0.01%-93%不等，化差異極大。ctDNA能否在能被精準應(yīng)用于臨床，使患者獲益。1.1分研究表明，幾乎在所有中，都可檢測到ctDNA，但不同癌種和不同分期患者的檢出率差異較大。I-IV47%、55%、69%、82%，腫瘤越晚期，ctDNA的檢出率越高。1.2種

Ref:SciTranslMed.2014FebctDNA，而腦部腫瘤的檢出率不到10%——這可能和不同組織的特性，如血腦屏障有關(guān)。Ref:SciTranslMed.2014Feb者，均能檢測到ctDNA，檢出率為100%，特異度高達96%。就目前技術(shù)的靈敏度而言，ctDNA適用于肺癌、結(jié)直腸癌、、黑色素瘤、胃癌、胃腸道間質(zhì)瘤、肝癌和胰的晚期患者。1.3ctDNA水平在患者治療前和治療后疾病進展后達到9TCGA數(shù)據(jù)庫中非小NatMed.9TCGA數(shù)據(jù)庫中非小NatMed.AnnOncol.PIK3CA,NEnglJMed.7exon9,11,13,14,17,AnnOncol.4胰ctDNA是近年來科學研究的熱點，科學家們圍繞其展開的研究數(shù)不勝數(shù)，以期Ref:SciTranslMed.2014Feb性，而不會波及腫瘤周圍的正常組織細胞。早在1997年，食品藥品監(jiān)督管（FDA突變的肺癌患者的生存期，是性的變化。但靶向藥物能否獲得療效主要取決于患者有無相關(guān)突變，若在不知患者有無突變狀態(tài)情況下使用此類藥，療效EGFRmutationsdetectedinsmaareassociatedwithpatient esinerlotinibplusdocetaxel-treatednon-smallcelllungcancerMackPC,HollandWS,BurichRA,etal.JThoracOncol.2009Dec;4(12):1466-PURPOSE:Activatingmutationsintheepidermalgrowthfactorreceptor(EGFR)areassociatedwithenhancedresponsetoEGFRtyrosinekinaseinhibitorsinnon-smallcelllungcancer(NSCLC),whereasKRASmutationstranslateintopoorpatient es.WehypothesizedthatysisofsmaforEGFRandKRASmutationsfromshedtumorDNAwouldhaveclinicalutility.METHODS:Anallele-specificpolymerasechainreactionassayusingScorpion-amplificationrefractorymutationsystem(DxS,)wasusedtodetectmutationsinsmaDNAfrompatientswithadvancedstageNSCLCtreatedassecond-orthird-linetherapyonaphaseI/IItrialofdocetaxelplusintercalatedRESULTS:EGFRmutationsweredetectedin10of49patients(20%).Six(12%)hadsingleactivatingmutationsinEGFR,associatedwithimprovedprogression-survival(median,18.3months),comparedwithallotherpatients(median,3.9months;p=0.008),orthosewithwild-typeEGFR(median,4.0months;p=0.012).Fourof49patientsharboredadenovoT790M (medianprogression-survival,3.9months).EGFRmutationalstatuswasassociatedwithclinicalresponse(45assessable,p=0.0001);inthesixpatientswithactivatingmutations,allachievedcomplete(33%)orpartial(67%)response.AllCRpatientshadE19deldetectableinbothtumorandsma.KRASmutationsweredetectedintwoof49(4%)patients,bothofwhomhadrapidprogressivedisease.CONCLUSIONS:ActivatingEGFRmutationsdetectedinshedDNAinsmaaresignificantlyassociatedwithfavorable esinpatientswithadvancedNSCLCreceivingdocetaxelplusintercalatederlotinib.TheadditionofdocetaxelinthisscheduledidnotdiminishtheefficacyoferlotinibagainstpatientswithEGFRactivatingmutations.（OSACBCA：ctDNA突變與患者病情進展的關(guān)系，EGFRE19/21（EGFR-19delorEGFR-L858REGFR酪氨酸酸激酶抑制劑的耐藥突變、mtKRAS和EGFR野生型患者的療效不盡理想。B、CctDNAPFS/OS，EGFRE19/21PFSOS結(jié)論：ctDNAEGFR-19del/L858R突變的非小細胞肺癌患者，對厄洛替尼和多西他賽交替治療的療效良好，PFS和OS均高于其他型。靶向藥物對不同型患者的療效不同，在選擇靶向治療之前需進行ctDNAEvaluationofcirculatingtumorcellsandcirculatingtumorDNAinnon-smallcelllungcancer:associationwithclinicalendpointsinaphaseIIclinicaltrialofpertuzumabandPunnooseEA,AtwalS,LiuW,RajaR,etal.ClinCancerRes.2012Apr15;18(8):2391-PURPOSE:Elevatedlevelsorincreasesincirculatingtumorcells(CTC)portendpoorprognosisinpatientswithepithelialcancers.LessisknownaboutCTCsassurrogateendpointsortheiruseforpredictivebiomarkerevaluation.ThisstudyinvestigatedtheutilityofCTCenumerationandcharacterizationusingtheCellSearchtform,aswellasmutationdetectionincirculatingtumorDNA(ctDNA),inpatientswithadvancednon-smallcelllungcancer(NSCLC).EXPERIMENTALDESIGN:Forty-onepatientswereenrolledinasingle-armphaseIIclinicaltrialoferlotinibandpertuzumab.PeripheralbloodwasyzedforCTCenumeration,EGFRexpressioninCTCs,anddetectionofoncogenicmutationsinCTCsandctDNA.ChangesinCTClevelswerecorrelatedwith2[18F]fluoro-2-deoxy-D-glucose-positronemissiontomographic(FDG-PET)andcomputedtomographic(CT)imagingandsurvivalendpoints.RESULTS:CTCsweredetected(≥1CTC)atbaselinein78%ofpatients.GreatersensitivityformutationdetectionwasobservedinctDNAthaninCTCsanddetectedmutationswerestronglyconcordantwithmutationstatusinmatchedtumor.HigherbaselineCTCcountswereassociatedwithresponsetotreatmentbyResponseEvaluationCriteriainSolidTumors(RECIST,P=0.009)anddecreasedCTCcountsupontreatmentwereassociatedwithFDG-PETandRECISTresponse(P=0.014andP=0.019)andlongerprogression-survival(P=0.050).CONCLUSION:ThesedataprovideevidenceofacorrelationbetweendecreasesinCTCcountsandradiographicresponsebyeitherFDG-PETorRECISTinpatientswithadvancedNSCLC.ThesefindingsrequireprospectivevalidationbutsuggestapotentialroleforusingCTCdecreasesasanearlyindicationofresponsetotherapyandctDNAforreal-timeassessmentofmutationstatusfromblood.該研究對24位受試于帕妥珠單抗和厄洛替尼IIB患者進行ctDNA，并記錄其PFS，以評估靶向藥物對不同型患者的療BB：EGFR56FDG-PETCT結(jié)果，1EGFR突變型患者在服ctDNAEGFRIF=EGFRmutationdetectioninctDNAfromNSCLCpatientsma:Across-tformcomparisonofleadingtosupporttheclinicaldevelopmentofAZD9291ThressKS,BrantR,CarrTH,etal.LungCancer.2015Oct9.OBJECTIVES:Toassesstheabilityofdifferenttechnologytformstodetectepidermalgrowthfactorreceptor(EGFR)mutations,includingT790M,fromcirculatingtumorDNA(ctDNA)inadvancednon-smallcelllungcancer(NSCLC)patients.MATERIALSANDMETHODS:AcomparisonofmultipletformsfordetectingEGFRmutationsinsmactDNAwasundertaken.smasampleswerecollectedfrompatientsenteringtheongoingAURAtrial(NCT ),investigatingthesafety,tolerability,andefficacyofAZD9291inpatientswithEGFR-sensitizingmutation-positiveNSCLC.smawascollectedpriortoAZD9291dosingbutfollowingclinicalprogressiononapreviousEGFR-tyrosinekinaseinhibitor(TKI).ExtractedctDNAwasyzedusingtwonon-digitaltforms(cobas?EGFRMutationTestandtherascreen?EGFRamplificationrefractorymutationsystemassay)andtwodigitaltforms(DropletDigital?PCRandBEAMingdigitalPCR[dPCR]).RESULTS:Preliminaryassessment(38samples)wasconductedusingallfourtforms.ForEGFR-TKI-sensitizingmutations,highsensitivity(78-100%)andspecificity(93-100%)wereobservedusingtissueasanon-referencestandard.FortheT790Mmutation,thedigitaltformsoutperformedthenon-digitaltforms.Subsequentassessmentusing72additionalbaselinesmasampleswasconductedusingthecobas?EGFRMutationTestandBEAMingdPCR.Thetwotformsdemonstratedhighsensitivity(82-87%)andspecificity(97%)forEGFR-sensitizingmutations.FortheT790Mmutation,thesensitivityandspecificitywere73%and67%,respectively,withthecobas?EGFRMutationTest,and81%and58%,respectively,withBEAMingdPCR.Concordancebetweenthetformswas>90%,showingthatmultipletformsarecapableofsensitiveandspecificdetectionofEGFR-TKI-sensitizingmutationsfromNSCLCpatientsma.CONCLUSION:Thecobas?EGFRMutationTestandBEAMingdPCRdemonstrateahighsensitivityforT790Mmutationdetection.GenomicheterogeneityofT790M-mediatedmayexinthereducedspecificityobservedwithsma-baseddetectionofT790Mmutationsversustissue.ThesedatasupporttheuseofbothtformsintheAZD9291clinical該研究用不同檢測技術(shù)對非小細胞肺癌患者的ctDNA進行，評估第三代EGFR-TKI藥物—AZD9291對不同型患者的療效。為59%，疾病控制率為90%，均顯著高于血液EGFR-T790M野生型患者。EGFR-T790MEGFRTKI類藥物發(fā)生耐藥的主要原因，在獲得性耐藥人群中的發(fā)生頻率高達~50-65%（Ref:NatRevClinOncol.2014Aug;11(8):IF=EmergenceofKRASmutationsandacquiredtoanti-EGFRtherapyincolorectalcancerMisaleS,YaegerR,HoborS,etal.Nature.2012Jun28;486(7404):532-Amainlimitationoftherapiesthatselectivelytargetkinasesignallingpathwaysistheemergenceofsecondarydrug .Cetuximab,amonoclonalantibodythatbindstheextracellularofepidermalgrowthfactorreceptor(EGFR),iseffectiveinasubsetofKRASwild-typemetastaticcolorectalcancers.Afteraninitialresponse,secondaryinvariablyensues,therebylimitingtheclinicalbenefitofthisdrug.Themolecularbasesofsecondary tocetuximabincolorectalcancerarepoorlyunderstood.Hereweshowthatmolecularaltions(inmostinstancespointmutations)ofKRASarecausallyassociatedwiththeonsetofacquired toanti-EGFRtreatmentincolorectalcancers.ExpressionofmutantKRASunderthecontrolofitsendogenousgenepromoterwassufficienttoconfercetuximab ,butresistantcellsremainedsensitivetocombinatorialinhibitionofEGFRandmitogen-activatedprotein-kinasekinase(MEK).ysisofmetastasesfrompatientswhodeveloped tocetuximaborpanitumumabshowedtheemergenceofKRASamplificationinonesampleandacquisitionofsecondaryKRASmutationsin60%(6outof10)ofthecases.KRASmutantallelesweredetectableinthebloodofcetuximab-treatedpatientsasearlyas10monthsbeforeradiographicationofdiseaseprogression.Insummary,theresultsidentifyKRASmutationsasfrequentdriversofacquired tocetuximabincolorectalcancers,indicatethattheemergenceofKRASmutantclonescanbedetectednon-invasivelymonthsbeforeradiographicprogressionandsuggestearlyinitiationofaMEKinhibitorasarationalstrategyfordelayingorreversingdrug 服用單抗后，ctDNA中KRAS突變型患者的PFS明顯低于KRAS野生型患者，P<0.05；但對于在服用單抗后，仍維持KRAS野生型和獲得性KRAS突變的患者，二者的PFS差異無統(tǒng)計學結(jié)論：在結(jié)直腸癌中，KRAS突變可導(dǎo)致患者對EGFR單抗類藥物耐藥。單抗可有效改善ctDNAKRAS野生型的結(jié)直腸癌患者的PFS。腫瘤的治療絕不是一蹴而就的事情，即使手術(shù)完全切除了腫瘤，還有可能會復(fù)發(fā)；即使服用了靶向藥物，還會發(fā)展出耐藥性；原位腫瘤不再發(fā)展，癌細胞還有可。NoninvasivedetectionofresponseandinEGFR-mutantlungcancerusingtativenext-generationgenotyofcell-smaDNAOxnardGR,PaweletzCP,KuangY,etal.ClinCancerRes.2014Mar15;20(6):1698-PURPOSE:Tumorgenotyusingcell-smaDNA(cfDNA)hasthepotentialtoallownoninvasiveassessmentoftumorbiology,yetmanyexistingassaysarecumbersomeandvulnerabletofalse-positiveresults.WesoughttodeterminewhetherdropletdigitalPCR(ddPCR)ofcfDNAwouldallowhighlyspecificandtativeassessmentoftumorgenotype.EXPERIMENTALDESIGN:ddPCRassaysforEGFR,KRAS,andBRAFmutationsweredevelopedusingsmacollectedfrompatientswithadvancedlungcancerormelanomaofaknowntumorgenotype.Sensitivityandspecificityweredeterminedusingcancerswithnonoverlapgenotypesaspositiveandnegativecontrols.Serialassessmentofresponseand wasstudiedinpatientswithEGFR-mutantlungcanceronaprospectivetrialoferlotinib.RESULTS:WeidentifiedareferencerangeforEGFRL858Randexon19deletionsinspecimensfromKRAS-mutantlungcancer,allowingidentificationofcandidatethresholdswithhighsensitivityand100%specificity.Receivedoperativecharacteristiccurveysisoffourassaysdemonstratedanareaunderthecurveintherangeof0.80to0.94.SensitivityimprovedinspecimenswithoptimalcfDNAconcentrations.SerialsmagenotyofEGFR-mutantlungcanceronerlotinibdemonstratedpretreatmentdetectionofEGFRmutations,completesmaresponseinmostcases,andincreasinglevelsofEGFRT790Memergingbeforeobjectiveprogression.CONCLUSIONS:NoninvasivegenotyofcfDNAusingddPCRdemonstratesassayqualitiesthatcouldalloweffectivetranslationintoaclinicaldiagnostic.Serialficationofsmagenotypeallowsnoninvasiveassessmentofresponseand,includingdetectionofmutationsupto16weeksbeforeradiographicprogression.周，患者出現(xiàn)疾病進展（PD。結(jié)論：EGFR-T790MEGFRTKIctDNAIF=Liquidbiopsies:genotycirculatingtumorDiazLAJr,BardelliA.JClinOncol.2014Feb20;32(6):579-Genotytumortissueinsearchofsomaticgeneticaltionsforactionableinformationhaseroutinepracticeinclinicaloncology.Althoughthesesequenceal tionsarehighlyinformative,samplingtumortissuehassignificantinherentlimitations;tumortissueisasinglesnapshotintime,issubjecttoselectionbiasresultingfromtumorheterogeneity,andcanbedifficulttoobtain.Cell-fragmentsofDNAareshedintothebloodstreambycellsundergoingapoptosisornecrosis,andtheloadofcirculatingcell-DNA(cfDNA)correlateswithtumorstagingandprognosis.Moreover,recentadvancesinthesensitivityandaccuracyofDNAysishaveallowedforgenotyofcfDNAforsomaticgenomical tionsfoundintumors.Theabilitytodetectandfytumormutationshasproveneffectiveintrackingtumordynamicsinrealtimeaswellasservingasaliquidbiopsythatcanbeusedforavarietyofclinicalandinvestigationalapplicationsnotpreviouslypossible.轉(zhuǎn)移性結(jié)直腸癌患者的動態(tài)監(jiān)測圖：黃色實線代表APCctDNA突變水平作為基線：APC突變型、KRAS野生型?；颊吆蚇RAS突變和/或MET擴增，表明多種類型耐藥突變的產(chǎn)生。隨后出現(xiàn)臨床耐藥癥狀。中KRAS、MET等突變有關(guān)，且突變在影像學檢出前數(shù)月即可發(fā)現(xiàn)。MutationtrackingincirculatingtumorDNApredictsrelapseinearlybreastGarcia-MurillasI,SchiavonG,WeigeltB,etal.SciTranslMed.2015Aug26;7(302):Theidentificationofearly-stagebreastcancerpatientsathighriskofrelapsewouldallowtailoringofadjuvanttherapyapproaches.WeassessedwhetherysisofcirculatingtumorDNA(ctDNA)insmacanbeusedtomonitorforminimalresidualdisease(MRD)inbreastcancer.Inaprospectivecohortof55earlybreastcancerpatientsreceivingneoadjuvantchemotherapy,detectionofctDNAinsmaaftercompletionofapparentlycurativetreatment-eitheratasinglepostsurgicaltimepointorwithserialfollow-upsmasamples-predictedmetastaticrelapsewithhighaccuracy[hazardratio,25.1(confidenceinterval,4.08to130.5;log-rankP<0.0001)or12.0(confidenceinterval,3.36to43.07;log-rankP<0.0001),respectively].Mutationtrackinginserialsamplesincreasedsensitivityforthepredictionofrelapse,withamedianleadtimeof7.9monthsoverclinicalrelapse.WefurtherdemonstratedthattargetedcapturesequencingysisofctDNAcoulddefinethegeneticeventsofMRD,andthatMRDsequencingpredictedthegeneticeventsofthesubsequentmetastaticrelapsemoreaccuraythansequencingoftheprimarycancer.Mutationtrackingcanthereforeidentifyearlybreastcancerpatientsathighriskofrelapse.SubsequentadjuvanttherapeuticinterventionscouldbetailoredtothegeneticeventspresentintheMRD,atherapeuticapproachthatcouldinpartcombatthechallengeposedbyintratumorgeneticheterogeneity.A2~4ctDNA，并統(tǒng)計患者術(shù)后三年的無病生存期。ctDNA陽性患者的無病生存率低于ctDNA患者，即ctDNA陽性患者的復(fù)發(fā)率顯著高于ctDNA患者，其復(fù)發(fā)率為86%，是ctDNA患者的12倍。BctDNA，并統(tǒng)計患者的無病生存期。相較于僅在術(shù)后單次80%；ctDNA陽性患者的中位無病生存期為13.6個月。CirculatingmutantDNAtoassesstumorDiehlF,SidtK,ChotiMA,etal.NatMed.2008Sep;14(9):985-ThemeasurementofcirculatingnucleicacidshastransformedthemanagementofchronicviralinfectionssuchasHIV.Thedevelopmentofogousmarkersforindividualswithcancercouldsimilarlyenhancethemanagementoftheirdisease.DNAcontainingsomaticmutationsishighlytumorspecificandthus,intheory,canprovideoptimummarkers.However,thenumberofcirculatingmutantgenefragmentsissmallcomparedtothenumberofnormalcirculatingDNAfragments,makingitdifficulttodetectandfythemwiththesensitivityrequiredformeaningfulclinicaluse.Inthisstudy,weappliedahighlysensitiveapproachtofycirculatingtumorDNA(ctDNA)in162smasamplesfrom18subjectsundergoingmultimodalitytherapyforcolorectalcancer.WefoundthatctDNAmeasurementscouldbeusedtoreliablymonitortumordynamicsinsubjectswithcancerwhowereundergoingsurgeryorchemotherapy.Wesuggestthatthisalizedgeneticapproachcouldbegenerallyappliedtoindividualswithothertypesofcancer.18ctDNACEA對復(fù)AABB無復(fù)發(fā)生存率均高于CEA患者，即ctDNA患者的復(fù)發(fā)率顯著低于CEA患者，假率較CEA低。CEA的靈敏度僅為56%。患者的復(fù)發(fā)率顯著高于CEA陽性患者，假陽性率較CEA低。ctDNACT10個月發(fā)現(xiàn)復(fù)發(fā)征兆（Ref:Gut.2015Feb4.pii:gutjnl-2014-308859.。發(fā)現(xiàn)時大多已是晚期，這很大一部分原因是源于在的早期診斷方面尚無準確的檢測，目前主要應(yīng)用于臨床的是腫瘤標志物和影像學檢查，但其目前還沒有足夠的證實ctDNA可作為早診的金標準，一方面是因為不同癌ctDNA水平差異較大，另一方面則源于目前僅有檢測技術(shù)的靈敏度限制。但ctDNA作為腫瘤細胞分泌的特異性分子，相較傳統(tǒng)早期診斷有著明顯的情況，而不是數(shù)周甚至數(shù)月；并且有大量研究表明，ctDNA的水平可以反映腫瘤負荷，與臨床病程相關(guān)。ctDNA在早期診斷方面仍是一個頗具潛力的指標。Circulatingcell-DNAinserumasabiomarkerfordiagnosisandprognosticpredictionofcolorectalcancerHaoTB,ShiW,ShenXJ,etal.BrJCancer.2014Oct14;111(8):1482-BACKGROUND:Toverifywhethertheconcentrationsandintegrityindexofcirculatingcell-DNA(ccf-DNA)inserummaybeclinicallyusefulforthediagnosisandprogressionmonitoringofcolorectalcancer(CRC)patients.METHODS:Serumsampleswerecollectedfrom104withprimaryCRC,85withoperatedCRC,16withrecurrent/metastaticCRC,63patientswithintestinalpolypsand110normalcontrols.Long(247bp)andshort(115bp)DNAfragmentsinserumweredetectedbyreal-timetativePCRbyamplifyingtheALUrepeats(ALU-qPCR).Serumcarcinoembryonicantigen(CEA)levelwasdetectedbyARCHITECTassay.RESULTS:ThemedianabsoluteserumALU115andALU247/115inprimaryCRCgroupwassignificantlyhigherthanthoseinintestinalpolypandnormalcontrolgroups(bothP<0.0001),inrecurrent/metastaticCRCwassignificantlyhighercomparedwithprimaryCRC(P=0.0021,P=0.0018)oroperatedCRC(P<0.0001,respectively)andduringfollow-up,ALU115andALU247/115wereincreasedbeforesurgeryanddecreasedsignificantlyaftersurgery.CONCLUSIONS:CombineddetectionofALU115,ALU247/115andCEAcouldimprovethediagnosticefficiencyforCRC.SerumDNAconcentrationsandintegrityindexmaybevaluableinearlycomplementarydiagnosisandmonitoringofprogressionandprognosisofCRC.含量和ALU247/115均顯著高于腸息肉患者和健康人群。Valueofcirculatingcell-DNAindiagnosisofhepatocelluarcarcinoChenK,ZhangH,ZhangLN,etal.WorldJGastroenterol.2013May28;19(20):3143-AIM:Toinvestigatethevalueofcombineddetectionofcirculatingc