肿瘤相关蛋白全景检测解读精选（1）

先做精准检测，而后才能精准治疗。
精准检测要测基因和蛋白。基因编码蛋白，两者互有关联，但不是一样东西。
基因检测要做大panel基因检测（至少检测五六百个基因）。
蛋白的免疫组化检测，医院在给肿瘤定性时会做；但那只检测几个十几个蛋白，指导用药远远不够。
目前国内实际可做的肿瘤相关蛋白方面的检测主要有：
一是根据一些药物的生物标志物，做特定靶点蛋白的免疫组化检测。例如想用top1抑制剂或者后端是top1抑制剂的ADC药物，去检测top1、tdp1、SLFN11等。
早在2019年自救群就组织了病友去做了top1、top2、hsp90、hdac1/2/3/6等蛋白的免疫组化。
二是HRD评分检测，这基本上已经成为联合大panel基因检测的标配。
三是肿瘤免疫微环境的检测，检测cd8+T、cd4+T、treg、mdsc、tam等。
四就是本文重点介绍的肿瘤相关蛋白全景检测，一次集中检测五六千个蛋白。
五是现在也有蛋白质谱检测可做
已经做了大panel基因检测的基础上，仍然要做肿瘤相关蛋白全景检测。因为很多时候很多蛋白，尽管对其编码的基因并无突变、扩增等异常，但其却是活性异常的，起到了促癌的作用，要对其针对用药；而这单看基因检测是看不出来的（因为基因并无异常）。
举例说明，下面是自救群一位卵巢癌患者的基因检测结果：


这是她的肿瘤相关蛋白全景检测结果：


两者比较我们可以发现，这些异常激活的蛋白其所对应的基因，并无突变扩增等异常。这个例子就最典型的说明了精准检测只做大panel基因检测还不够，还要在其基础上做肿瘤相关蛋白全景检测。

基因突变方面：
1、pik3ca突变要用pik3ca抑制剂，fbxw7突变要用mtor抑制剂，sgk1通过激活mtor造成pik3ca抑制剂耐药；综合可以用pi3k/mtor双靶点的抑制剂（具体可见我写的《pi3k/akt/mtor通路药物再整理》一文）。此类药物都还没有上市，但都有原料药，虽然有点麻烦，但也并非不可及。事实上她也确实用上了。
2、braf突变是pik3ca抑制剂耐药的一个原因，跟她之前的基因检测对比，这个braf突变确实是她用pik3ca抑制剂阿培利司耐药后出现的获得性突变。她是Braf的非V600E突变，有研究表明，阿克拉霉素这个化疗药，对Braf的非V600E突变的疗效，超过达拉非尼等braf抑制剂。她后来做了药敏测试结果也证实了这点。
3、tert突变，用dnmt抑制剂、hdac抑制剂等表观遗传机制药物敏感。考虑到耐受，可以用做过很多临床试验的肼屈嗪（dnmti）+丙戊酸（hdaci）这一表观遗传机制替代药物组合。
基因靶向治疗策略：pi3k/mtor双靶点的抑制剂如PF4691502+阿克拉霉素+肼屈嗪+丙戊酸

肿瘤相关蛋白激活方面：
一、BTK、JAK2的激活是卵巢癌耐药的一个重要原因
1、患者的BTK蛋白活性最高，根据《Bruton's tyrosine kinase (Btk) inhibitor ibrutinib suppresses stem-like traits in ovarian cancer》一文所述“According to a Prognoscan database, upregulation of Bruton's tyrosine kinase (Btk) is associated with low overall survival in ovarian cancer patients. We found that spheroids-forming ovarian cancer cell, which highly expressed cancer stem-like cell (CSC) markers and Btk, were cisplatin resistant. We next treated CSCs and non-CSCs by a combination of ibrutinib and cisplatin. We found that chemoresistance was dependent on Btk and JAK2/STAT3, which maintained CSC by inducing Sox-2 and prosurvival genes. We suggest that addition of ibrutinib to cisplatin may improve treatment outcome in ovarian cancer.”
BTK、JAK2的激活是卵巢癌耐药的一个重要原因。这也符合她之前常规化疗疗效都不理想的实际情况。

2、BTK已有阿可替尼等三代BTK抑制剂上市；JAK2也有Fedratinib等专门抑制剂上市。可尝试在基因靶向方案控制住肿瘤后，轮换使用BTKi+JAK2i，如用两疗程基因靶向方案后换用1疗程BTKi+JAK2i，以此轮换。

二、免疫治疗
1、患者的cd274即pd-l1高，但患者用K药却并无疗效。影响icb疗效和风险的因素是很多很多的，绝不是像某些人看个tmb值，看个pd-l1表达就能决定是否用icb免疫治疗，决定用什么样的icb方案这么简单的。

2、患者的CTLA4高。这表明患者在用icb免疫治疗时，不能仅用pd-1/pd-l1抑制剂，而是该用包括Y药这样的CTLA4抑制剂在内的双免方案。

3、患者的JAK2高。前不久有两项临床试验研究结果表明，jak抑制剂能给icb免疫治疗增敏增效。
（1）《JAK inhibition enhances checkpoint blockade immunotherapy in patients with Hodgkin lymphoma》
Unleashing antitumor T cell activity by checkpoint inhibitor immunotherapy is effective in cancer patients, but clinical responses are limited. Cytokine signaling through the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway correlates with checkpoint immunotherapy resistance. We report a phase I clinical trial of the JAK inhibitor ruxolitinib with anti-PD-1 antibody nivolumab in Hodgkin lymphoma patients relapsed or refractory following checkpoint inhibitor immunotherapy. The combination yielded a best overall response rate of 53% (10/19). Ruxolitinib significantly reduced neutrophil-to-lymphocyte ratios and percentages of myeloid suppressor cells but increased numbers of cytokine-producing T cells. Ruxolitinib rescued the function of exhausted T cells and enhanced the efficacy of immune checkpoint blockade in preclinical solid tumor and lymphoma models. This synergy was characterized by a switch from suppressive to immunostimulatory myeloid cells, which enhanced T cell division.
（2）《Combined JAK inhibition and PD-1 immunotherapy for non-small cell lung cancer patients》
Persistent inflammation driven by cytokines such as type-one interferon (IFN-I) can cause immunosuppression. We show that administration of the Janus kinase 1 (JAK1) inhibitor itacitinib after anti-PD-1 (programmed cell death protein 1) immunotherapy improves immune function and antitumor responses in mice and results in high response rates (67%) in a phase 2 clinical trial for metastatic non-small cell lung cancer. Patients who failed to respond to initial anti-PD-1 immunotherapy but responded after addition of itacitinib had multiple features of poor immune function to anti-PD-1 alone that improved after JAK inhibition. Itacitinib promoted CD8 T cell plasticity and therapeutic responses of exhausted and effector memory-like T cell clonotypes. Patients with persistent inflammation refractory to itacitinib showed progressive CD8 T cell terminal differentiation and progressive disease. Thus, JAK inhibition may improve the efficacy of anti-PD-1 immunotherapy by pivoting T cell differentiation dynamics.
因此患者的免疫治疗策略可以尝试 pd-1i/pd-l1i + CTLA4i + JAK2i。

另外，患者有tert突变可以用dnmti+hdaci等表观遗传机制药物，而表观遗传机制药物对于icb免疫治疗的核心关键问题 TCF1+ CD8+ T cells 的增殖、MHC-I表达提高有极大的作用（见公众号《增殖扩散TCF1+ CD8+ T cells 的可能路径》、《增加MHC-I的表达》等文章），因此icb免疫治疗时也可以把dnmti+hdaci加上去，一举两得。

三、患者PSMB8/9/10 高
1、粘液型上皮性卵巢癌(MuOC)MuOC中差异甲基化基因的遗传相互作用网络分析显示，一个占优势的网络模块是蛋白酶体亚基β(PSMB)家族，包括PSMB2/8/9/10。PSMB2/8/9/10高对蛋白酶体抑制剂卡非佐米敏感。
《Distinct methylation profile of mucinous ovarian carcinoma reveals susceptibility to proteasome inhibitors》
Mucinous type of epithelial ovarian cancer (MuOC) is a unique subtype with a poor survival outcome in recurrent and advanced stages. The role of type-specific epigenomics and its clinical significance remains uncertain. We analyzed the methylomic profiles of 6 benign mucinous adenomas, 24 MuOCs, 103 serous type of epithelial ovarian cancers (SeOCs) and 337 nonepithelial ovarian cancers. MuOC and SeOC exhibited distinct DNA methylation profiles comprising 101 genes, 81 of which exhibited low methylation in MuOC and were associated with the response to glucocorticoid, ATP hydrolysis-coupled proton transport, proteolysis involved in the cellular protein catabolic process and ion transmembrane transport. Hierarchical clustering analysis showed that the profiles of MuOC were similar to colorectal adenocarcinoma and stomach adenocarcinoma. Genetic interaction network analysis of differentially methylated genes in MuOC showed a dominant network module is the proteasome subunit beta (PSMB) family. Combined functional module and methylation analysis identified PSMB8 as a candidate marker for MuOC. Immunohistochemical staining of PSMB8 used to validate in 94 samples of ovarian tumors (mucinous adenoma, MuOC or SeOC) and 62 samples of gastrointestinal cancer. PSMB8 was commonly expressed in MuOC and gastrointestinal cancer samples, predominantly as strong cytoplasmic and occasionally weak nuclei staining, but was not expressed in SeOC samples. Carfilzomib, a second-generation proteasome inhibitor, suppressed MuOC cell growth in vitro. This study unveiled a mucinous-type-specific methylation profile and suggests the potential use of a proteasome inhibitor to treat MuOC.
“(c) The second and largest subnetwork comprised the predominant proteasome subunit beta (PSMB)-type family module, including PSMB 8, PSMB 2, PSMB 9 and PSMB 10.”
2、患者虽然是透明细胞型上皮性卵巢癌，但用卡非佐米做药敏测试一样是敏感的。可见药物疗效好坏主要还是看有无靶点，癌种分类倒是次要的。

四、患者MS4A1高
MS4A1即CD20高，可用利妥昔。

五、患者NFKB1高
1、蛋白酶体抑制剂能抑制NF-KB的激活。
（1）《Proteasome inhibitors modulate anticancer and anti-proliferative properties via NF-kB signaling, and ubiquitin-proteasome pathways in cancer cell lines of different organs》
（2）《A proteasome inhibitor prevents activation of NF‐kappa B and stabilizes a newly phosphorylated form of I kappa B‐alpha that is still bound to NF‐kappa B》
（3）《Proteasome inhibitors: structure and function》
上述患者PSMB8/9/10 高已经要用蛋白酶体抑制剂卡非佐米，这里NFKB1高一样要用蛋白酶体抑制剂，一举两得。
（4）患者的pik3ca突变是其主驱动因素之一（用了阿培利司单药有效8个月左右）；卵巢癌里的pik3ca突变，作用机制之一是通过nf-kb通路发挥促癌作用；要抑制nf-kb通路。《Transcriptional regulation of PIK3CA oncogene by NF-kappaB in ovarian cancer microenvironment》：PIK3CA upregulation, amplification and mutation have been widely reported in ovarian cancers and other tumors, which strongly suggests that PIK3CA is a promising therapeutic target. However, to date the mechanisms underlying PIK3CA regulation and activation in vivo is still unclear. During tumorigenesis, host-tumor interactions may play a critical role in editing the tumor. Here, we report a novel mechanism through which the tumor microenvironment activates the PIK3CA oncogene. We show that PIK3CA upregulation occurs in non-proliferating tumor regions in vivo. We identified and characterized the PIK3CA 5' upstream transcriptional regulatory region and confirmed that PIK3CA is transcriptionally regulated through NF-kappaB pathway. These results offer a new mechanism through which the tumor microenvironment directly activates oncogenic pathways in tumor cells.

2、沙利度胺、三氧化二砷也是抑制NF-KB激活的
《NF-kappaB in the pathogenesis and treatment of multiple myeloma》
Moreover, several drugs that are effective against multiple myeloma, including bortezomib, thalidomide, lenalidomide and arsenic trioxide, have been found to block activation of NF-kappaB.

六、患者PML高
PML高可用三氧化二砷
《Molecular mechanisms of the antileukemia activities of retinoid and arsenic》
On the other hand, arsenic trioxide (ATO), another promising agent used to treat APL, directly binds to the PML moiety of the PML-RARα protein, causing oxidation and multimerization. ATO enhances the conjugation of small ubiquitin-like modifiers to PML-RARα, followed by ubiquitination and degradation, relieving the genes associated with granulocytic differentiation from suppressive restraint by the oncoprotein.
上述患者nf-kb激活可用三氧化二砷抑制，这里PML高一样要用三氧化二砷，一举两得。