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  南方医科大学学报  2019, Vol. 39Issue (3): 364-368  DOI: 10.12122/j.issn.1673-4254.2019.03.16.
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陈晨, 许娜, 江雪杰, 吴婉儿, 周璇, 刘靓, 黄继贤, 阴常欣, 曹睿, 廖立斌, 徐丹, 张宇明, 刘启发, 刘晓力. T315I基因突变的慢性髓性白血病临床特征及泊那替尼疗效[J]. 南方医科大学学报, 2019, 39(3): 364-368. DOI: 10.12122/j.issn.1673-4254.2019.03.16.
CHEN Chen, XU Na, JIANG Xuejie, WU Waner, ZHOU Xuan, LIU Liang, HUANG Jixian, YIN Changxin, CAO Rui, LIAO Libin, XU Dan, ZHANG Yuming, LIU Qifa, LIU Xiaoli. Clinical characteristics of chronic myeloid leukemia with T315I mutation and the efficacy of ponatinib[J]. Journal of Southern Medical University, 2019, 39(3): 364-368. DOI: 10.12122/j.issn.1673-4254.2019.03.16.

基金项目

国家自然科学基金（81700104）；广东省自然科学基金（2017A030313506）；广东省科技计划项目（2014A020211019）

作者简介

陈晨，在读硕士研究生，E-mail: 1071218383@qq.com。

通信作者

通信作者：
刘晓力，主任医师，教授，博士导师，E-mail: lxl2405@126.com

文章历史

收稿日期：2018-09-11
Contents              Abstract              Full text              Figures/Tables              PDF
T315I基因突变的慢性髓性白血病临床特征及泊那替尼疗效
陈晨 1, 许娜 1, 江雪杰 1, 吴婉儿 1, 周璇 1, 刘靓 1, 黄继贤 1, 阴常欣 1, 曹睿 1, 廖立斌 1, 徐丹 1, 张宇明 2, 刘启发 1, 刘晓力 1     
1. 南方医科大学南方医院血液科，广东 广州 510515;
2. 广东医科大学附属医院血液科，广东 湛江 524000
收稿日期：2018-09-11
基金项目：国家自然科学基金（81700104）；广东省自然科学基金（2017A030313506）；广东省科技计划项目（2014A020211019）
作者简介：陈晨，在读硕士研究生，E-mail: 1071218383@qq.com。
通信作者：刘晓力，主任医师，教授，博士导师，E-mail: lxl2405@126.com。
摘要: 目的 分析伴T315I突变的慢性髓系白血病（CML）的临床特征及不同治疗方法的疗效。方法 回顾性分析19例行BCRABL KD突变检测T315I突变的CML患者的临床资料及不同治疗的预后，通过直接测序分析获得用于RTQ-PCR样品的BCRABL KD突变。用Sanger测序法对BCR-ABL KD突变进行测序。复发标准包括血液学复发、细胞遗传学复发和分子生物学复发。结果 19例CML-T315I患者，初诊时73.7%（14/19例）患者处于慢性期（CP），Sokal评分中高危患者占81.2%（13/16例）。19例患者初诊后均行酪氨酸激酶抑制剂（TKI）治疗，病程中78.9%（15/19例）患者有附加染色体畸变，52.6%（10/19例）患者存在多重突变。68.4%（13/19例）的患者在疾病进展后（加速期/急变期）检测出T315I突变，从初诊到检测出T315I突变的中位期为40 m（5~120 m）。突变后12例行泊那替尼治疗（A组），7例选择传统化疗方案（B组）。A、B两组3年总生存率分别是83.3%和14.2%（P=0.001）。结论 小样本回顾性研究发现对TKI耐药的CML患者易检出T315I突变，进展期检出率明显高于慢性期。此类患者往往合并附加染色体和多重基因突变，预后较差，即行异基因造血干细胞移植，复发率仍较高。泊纳替尼长期维持治疗，可能会改善预后，延长生存期。
关键词: 慢性髓系白血病    BCR-ABL    T315I    泊那替尼    异基因造血干细胞移植    
Clinical characteristics of chronic myeloid leukemia with T315I mutation and the efficacy of ponatinib
CHEN Chen 1, XU Na 1, JIANG Xuejie 1, WU Waner 1, ZHOU Xuan 1, LIU Liang 1, HUANG Jixian 1, YIN Changxin 1, CAO Rui 1, LIAO Libin 1, XU Dan 1, ZHANG Yuming 2, LIU Qifa 1, LIU Xiaoli 1     
1. Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China;
2. Department of Hematology, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524000, China
Supported by National Natural Science Foundation of China (81700104)
Abstract: Objective To analyze the clinical features of chronic myeloid leukemia (CML) with T315 I mutation (CML-T315I) and compare the effectiveness of different treatments. Methods We retrospectively analyzed the clinical data and outcomes of 19 patients with CML-T315I receiving different treatments. The T315 I mutations in these patients were detected by examination of BCR-ABL kinase domain (KD) mutation by RTQ-PCR and Sanger sequencing. The relapse following the treatments, defined as hematological, cytogenetic and molecular biological recurrences, were analyzed in these patients. Results Of the 19 patients with CML-T315I, 14 (73.7%) were in CML-CP stage at the initial diagnosis, and 13 (81.2%) were high-risk patients based on the Sokal scores. All the 19 patients were treated with TKI after the initial diagnosis, and during the treatment, 15 (78.9%) patients were found to have additional chromosomal aberrations, and 10 (52.6%) had multiple mutations; 13 (68.4%) of the patients experienced disease progression (accelerated phase/blast crisis) before the detection of T315I mutation, with a median time of 40 months (5-120 months) from the initial diagnosis to the mutation detection. After detection of the mutation, 12 patients were treated with ponatinib and 7 were managed with the conventional chemotherapy regimen, and their overall survival rates at 3 years were 83.3% and 14.2%, respectively (P < 0.001). Conclusions CML patients resistant to TKI are more likely to have T315I mutations, whose detection rate is significantly higher in the progressive phase than in the chronic phase. These patients often have additional chromosomal aberrations and multiple gene mutations with poor prognoses and a high recurrence rate even after hematopoietic stem cell transplantation. Long-term maintenance therapy with ponatinib may improve the prognosis and prolong the survival time of the patients.
Keywords: chronic myeloid leukemia    BCR-ABL    T315I    ponatinib    hematopoietic stem cell transplantation    

酪氨酸激酶抑制剂（TKIs）的问世，标志着慢性髓性白血病（CML）进入靶向治疗新纪元，如今CML已成为一种可控制的慢性疾病[1]。伊马替尼高效的缓解率使80%以上的CML患者在治疗后可以取得完全细胞遗传学反应（CCyR），10年总生存率（OS）82%，大大改善了CML患者的预后[2]。然而TKI耐药性的出现，使部分患者丧失了已获得的最佳反应。研究发现BCR-ABL基因突变是TKI耐药及治疗失败的主要机制[3]，ABL激酶区的点突变使得20%~30%的患者出现IM耐药并导致疾病进展[4-6]，其中大部分ABL激酶区突变类型可以通过转换二代TKI能获得覆盖[7-8]，但是T315I突变对现有的一、二代TKIs广泛耐药，成为CML耐药患者治疗难点[9]。CML-T315I+患者，疾病进展较快，预后差，往往在数月内死亡[10]，据文献报道CML-T315I+的患者从T315I的出现到死亡/期限的中位时间仅3月[11]。泊那替尼是一种多靶点酪氨酸激酶抑制剂，属于第3代TKI抑制剂，在2013年EMA和FDA先后批准用于治疗CML或Ph+ALL的BCR-ABL1 T315I突变的患者[12-13]，对CML-T315I+患者有明确疗效[14]，已在我国香港上市。目前针对CML-T315I+患者的有效治疗方法不多，为了明确不同方法之间的疗效差异，改善此类患者的预后，本研究回顾性分析19例CML-T315I+患者的临床特征及泊那替尼治疗的疗效，为临床工作提供帮助。

1 资料和方法 1.1 病例资料

南方医科大学南方医院、广东医科大学附属医院2013年3月~2018年9月，19例对TKI耐药的CML患者经BCR-ABL KD突变检测T315I突变（+），其中初诊时慢性期14、加速期2例、急变期3例。

1.2 诊断、TKI耐药前治疗及疗效标准

所有患者初诊时均行血常规、细胞形态学、细胞遗传学、分子生物学等实验室检查明确诊断，按CML诊治指南每隔3~6月进行复查。耐药前TKI应用剂量为伊马替尼300~400 mg/d，达沙替尼100~140 mg/d，尼罗替尼剂量600~800 mg/d。治疗过程中发现TKI耐药时，检测ABL激酶区突变。CML的诊断、治疗及疗效标准参考文献[15]。TKI耐药定义参照文献[15] IM治疗CML慢性期患者治疗反应评估中的"治疗失败"。

1.3 染色体分析、BCR-ABL转录本及ABL1激酶区突变的检测

染色体标本行G显带分析，核型异常识别和描述参照《人类细胞遗传学国际命名体制（ISCN2016）》；TRIzol法提取标本中总RNA，经逆转录酶逆转成cDNA，应用RTQ-PCR检测BCR-ABL1转录本，检测敏感度为10-4~10-5；利用巢式PCR对ABL1激酶区进行突变检测，扩增产物经琼脂糖凝胶电泳鉴定后，利用Sanger测序仪对PCR产物进行测序，检测BCR-ABL KD突变情况。

1.4 临床分组

A组：泊那替尼治疗组，12人；B组：达沙替尼+干扰素、羟基脲、高三尖杉酯碱、及其他化疗方案治疗组，7人。泊纳替尼，Iclusig，ARIAD，患者自购于中国香港。预处理方案：BU+CY（白消安+环磷酰胺）或者改良（阿糖胞苷+白消安+环磷酰胺）。

1.5 随访

通过门诊等方式进行随访，随访截止时间为2018年9月，随访内容包括疾病缓解状态、是否复发及存活情况等。

1.6 统计学处理

采用SPSS17.0软件进行统计学分析。生存分析采用Kaplan-Meier法。P < 0.05为差异有统计学意义。

2 结果 2.1 19例CML-T315I患者临床特征及用药

19例患者，男性15例，女性4例，中位年龄40（19~ 67）岁，初诊时CML-CP（CP）14例，CML-AP（AP）2例，CML-BP（BP）3例，73.7%（14/19例）患者处于慢性期（表 1）。Sokal评分高危组7例、中危组6例，低危组3例，中高危患者占81.2%（13/16例）。其中78.9%（15/19例）患者有附加染色体杂畸变，+der（22）、+8是最常见的染色体畸变，52.6%（10/19例）患者有多重突变，4例存在3种突变，6例存在2种突变，其中1例有CYP3A5突变。从初诊到检测出T315I突变的中位期为40 m（5~ 120 m），31.6%（6/19例）患者在慢性期检测出T315I突变，68.4%（13/19例）患者在疾病进展后（1例加速期，12例急变期）检测出T315I突变，CML-进展期的T315I检出率明显比慢性期高（表 2）。

表 1 19例CML-T315I+患者临床特征及用药 Tab.1 Clinical characteristics and medications of 18 patients with CML-T315I+
表 2 12例行Ponatinib治疗的CML-T315I+患者的临床转归 Tab.2 Clinical outcomes of 12 patients with CML-T315I+ treated with ponatinib
2.2 19例CML-T315I+患者的治疗和转归

19例CML初诊后均行TKI治疗，其中16例选择一代TKI治疗，3例选择二代TKI治疗，后因耐药或不耐受，16例一代TKI治疗的患者先后转换为二代TKI治疗。检测出T315I突变后，根据治疗方案不同分为两组：A组：63.1%（12/19例）患者选择泊那替尼治疗。B组：36.8%（7/19例）患者选择达沙替尼+干扰素、羟基脲、高三尖杉酯碱、及其他化疗方案治疗。A组患者泊那替尼治疗后，91.7%（11/12例）患者重获血液学缓解，其中包括移植后复发的6例患者，复发的中位时间是9.5 m（2~48）m。50%（6/12例）患者获得完全分子生物学缓解，25%（3/12例）患者获得主要分子生物学缓解。2例因复发死亡。B组7例患者截止随访，14.3%（1/7例）存活，余6例因疾病进展，治疗无效死亡（图 1）。截止随访，8例因复发死亡，11例存活:(包括10例A组患者，1例B组患者）。

图 1 T315I突变后两种治疗方案的3年OS生存曲线 Fig.1 3-year overall survival probability of the patients receiving two treatments after T315I mutation. Group A was treated with Ponatinib, and group B was treated with dasatinib + interferon, hydroxyurea, homoharringtonine and other chemotherapy regimens after mutation
3 讨论

CML是一种以骨髓多能造血干细胞过度克隆增殖为特征的恶性骨髓增殖性肿瘤，Ph染色体（t 9；22）（q34；q11.2）或BCR-ABL1融合基因阳性[16]。TKIs特异性抑制BCR-ABL表达，使CML进入靶向治疗新时代。BCR-ABL基因突变是导致CML对TKIs耐药和治疗失败最主要的原因。50%~90%TKI耐药是由于ABL激酶区突变导致，已被发现的BCR-ABL激酶区突变有90余种，常见的如M244V、L248V、G250E/AF、Q252H/R、Y253F/H、E255K及T315I等[17]。大部分ABL激酶突变类型可以通过现有的二代TKIs，尼罗替尼、达沙替尼、博舒替尼等得到覆盖，T315I除外[18]。T315I突变也称T315I gatekeeper突变，即ABL激酶域中315位苏氨酸突变为异亮氨酸[19]。T315I突变在ABL激酶区突变中较为常见，有研究发现T315I在CML患者耐药患者中的检出率有15% [20]。目前针对CML-T315I+患者推荐的治疗方案包括：泊那替尼、造血干细胞移植或临床研究[9]，大量研究表明泊那替尼对TKI耐药或含有T315I点突变的难治性CML有确切的疗效[21-23]，有I期临床试验表明，泊那替尼治疗CML-T315I+的患者，可获得高达75%的细胞遗传学缓解率[24]。

分析本中心这组病人临床特征发现长期TKI耐药的CML患者易发生T315I突变，疾病进展后（加速期、急变期）检出率高于疾病慢性阶段，此类患者往往具有附加染色体畸变和多重基因突变，Sokal评分中高危者居多。T315I突变对现有的一二代TKI泛耐药，意味着CML-T315I+患者预后不良和治疗选择的有限性[25]。泊那替尼的核心分子结构碳碳三键与I315的侧链高效疏水链接，其甲基苯基后侧残基、三氟甲基苯基占用DFG外构象诱导的位点、乙炔基与T315I突变之间形成范德华力，能有效地抑制T315I及其他重要激酶结构域的突变，同时也能抑制PDGFR家族、FGFR、VEGFR和SCR [26-28]。针对长期序贯治疗复发难治的CML-T315I患者，及时选择泊那替尼治疗可能改善预后，延长生存期[29]。分析我们中心数据发现，A组患者生存预后优于B组患者（P=0.001 < 0.005），提示针对长期序惯治疗难治的CML-T315I+患者，移植后复发率极高、常规化疗手段预后很差，泊那替尼治疗的疗效优于传统化疗手段。A组患者中有6例属于移植后复发应用泊那替尼补救性治疗，且均获得不同程度的缓解，100%重新获得血液学缓解，50%的获得完全分子生物学缓解。提示泊那替尼补救性治疗对于移植后复发的患者具有显著的疗效。值得一提的是，15例在移植后+94 d，髓外复发侵及中枢，造成脑疝，给予泊那替尼（45 mg/d）治疗后，38 d后获得血液及中枢系统缓解，BCR-ABL（IS）复查阴性，连续3月获得CMR后，泊那替尼减量至30 mg/d，20 d后出现分子学复发，加量至45 mg/d后，1月后再次获得MMR，目前泊那替尼（45 mg/d）维持治疗，提示泊那替尼在有效的血药浓度下可以穿过血脑屏障起到治疗作用[30-31]，以及可能诱导移植物抗白血病效应，与Petrungaro等研究结果一致[32-33]。

虽然泊那替尼作为第三代TKI，具有显著的疗效，尤其针对CML-T315I+患者。然而，泊那替尼的药物副反应，也应引起临床重视。研究指出，泊那替尼有严重致命性心肌梗死、脑卒中及血流中断或血管重度狭窄致肢体组织损伤及坏死的风险需谨慎关注[34-35]。由于本研究患者数量较少，随访期间尚未出现严重不良反应。泊那替尼作为三代TKI，对CML-T315I+患者疗效肯定，及时在TKI耐药、疾病进展时检测出T315I突变，对CML治疗方案的调整及预后判断十分重要，有待临床进一步积累研究。

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