Ispitivanje kliničkih i genetičkih prediktivnih faktora efikasnosti terapije inhibitorima tirozin kinaza pacijenata sa uznapredovalim adenokarcinomom pluća

Abstract

Karcinom pluća predstavlja globalni javno zdravstveni problem. U 2020. godini je u svetu od karcinoma pluća obolelo je 2 206 771 osoba oba pola, a umrlo 1 796 144. Petogodišnje preživljavanje pacijenata obolelih od svih tipova karcinoma pluća veoma je nisko i pored uvođenja ciljane i imunoterapije u lečenje i iznosi oko 19% za pripadnike oba pola, dok je kod pacijenata koji boluju od EGFR pozitivnog nesitnoćelijskog karcinoma pluća, kao i kod onih sa ostalim mutacijama za koje postoji ciljana terapija, petogodišnje preživljavanje nešto bolje i iznosi 5% - 50%. Terapija inhibitorima tirozin kinaza (TKI) koji blokiraju receptor za epidermalni faktor rasta (EGFR) je prva linija u lečenju pacijenata sa uznapredovalim EGFR mutiranim nesitnoćelijskim karcinomom pluća (NSCLC). Iako je efikasnija od hemioterapije većina pacijenata nakon 9-11 meseci razvije rezistenciju. Mehanizmi rezistencije na EGFR TKI su različiti, a njihovo poznavanje ključno je u donošenju odluke o najboljoj specifičnoj terapiji, proceni odgovora na terapiju i u razvoju novih lekova. Cilj: Ispitivanje demografskih karakteristika pacijenata i karakteristika tumora kao prediktivnih faktora efikasnosti EGFR TKI terapije u pacijenata sa uznapredovalim EGFR mutiranim adenokarcinomom pluća (korelacija sa ukupnim preživljavanjem (overall survival - OS), preživljavanjem bez progresije bolesti (progression free survival – PFS), pojavom rezistencije, toksičnosti i kancerskog bola) kao i ispitivanje tipa i zastupljenosti mutacija u genu EGFR kao prediktivnih faktora EGFR TKI terapije u pacijenata sa uznapredovalim EGFR mutiranim adenokarcinomom pluća (korelacija sa OS, PFS, pojavom rezistencije, toksičnosti i kancerskog bola). Ispitivanje nivoa ekspresije gena IGF-1R, E-kadherina, N-kadherina i okludina kao prediktivnih faktora EGFR TKI terapije u pacijenata sa uznapredovalim EGFR mutiranim NSCLC (korelacija sa OS, PFS, pojavom rezistencije, toksičnosti i kancerskog bola). Metodologija: Istraživanje je sprovedeno u periodu od 2013. godine do2021. godine na grupi od 101 pacijenata sa uznapredovalim adenokarcinomom pluća (klinički stadijum IIIb i IV, performans status 0, 1 ili 2) kod kojih je potvrđeno prisustvo mutacija u EGFR genu i koji su bili lečeni ili su i dalje na terapiji inhibitorima tirozin kinaza na Institutu za onkologiju i radiologiju Srbije. Dijagnoza uznapredovalog adenokarcinoma pluća postavljena je u skladu sa kriterijumima osmog izdanja Internacionalne asocijacije za istraživanje karcinoma pluća (IASLC). Pacijenti su tretirani EGFR inhibitorima tirozin kinaza prve generacije u prvoj liniji do progresije ili neprihvatljive toksičnosti. Analizirani su demografski podaci (pol i starost pacijenata), kliničke manifestacije bolesti, pušački status, performans status, TNM stadijum bolesti pri postavljanju dijagnoze, gradus tumora, lokalizacija inicijalnih metastaza, komorbiditeti, hematološki parametri, prisustvo bola pri dijagnozi i tokom terapije, tip EGFR mutacije, dužina primene TKI, odgovor na terapiju (SD – stabilizacija bolesti, PR – parcijalna regresija, CR – kompletna regresija, PD – progresija bolesti), preživljavanje bez progresije bolesti (eng. Progression Free Survival, PFS), ukupno preživljavanje (eng. Overal survival, OS,) toksičnost na TKI i rezistencija na terapiju. Toksičnost na TKI se procenjivala prema kriterijumima 5.0 verzije CTCAE – Common Terminology Criteria for Adverse Events. Prisustvo bola pri dijagnozi i tokom terapije prijavljivana je korišćenjem Pain – Related Patient - Reported Outcomes. Pacijentima je uzeta krv pre otpočinjanja primene TKI, a rezultati kompletne krvne slike sa leukocitarnom formulom dobijeni su iz elektronskih medicinskih kartona pacijenata. Analizirani su hematološki parametri: odnos neutrofila i limfocita (NLR), trombocita i limfocita (PLR), trombocita i monocita (PMR), limfocita i monocita (LMR) i neutrofila i monocita (NMR). Nivo bola procenjen je primenom dve metode – numeričkom skalom za procenu bola (NRS) i verbalnom deskriptivnom skalom (VDS) pre otpočinjanja terapije inhibitorima tirozin kinaza, kao i tokom primene ovih lekova. Iz parafinskih kalupa izolovane su DNK i RNK. Iz DNK je analizirana mutacija u genu EGFR (egzoni 18-21), a iz RNK je analizirana ekspresija gena IGF-1R, N-kadherin, E-kadherin i okludin

ntroduction: Lung cancer has been a global public health problem for decades. In 2020, 2,206,771 people of both genders became were diagnosed with lung cancer in the world, and 1,796,144 died. The five-year survival of patients with all types of lung cancer is very low (19%), despite the use of targeted and immunotherapy, while in patients with EGFR-positive non-small cell lung cancer (NSCLC), five-year survival is slightly better (5% - 50%). Epidermal growth factor receptor (EGFR) tyrosine kinase (TKI) inhibitor therapy is the first line in the treatment of patients with advanced EGFR mutated NSCLC. Although it is more effective than chemotherapy, most patients develop resistance after 9-11 months. The are different mechanisms of resistance to EGFR TKI and understanding of them is crucial in deciding on the best therapy, assessing response to therapy and developing new drugs. Aim: To assess the demographic characteristics of patients and the characteristics of tumors as predictive factors for the effectiveness of EGFR TKI therapy in patients with advanced EGFR mutated adenocarcinoma of the lung (correlation with overall survival (OS), progression free survival (PFS), toxicity and cancer pain). Assessment of the type and prevalence of mutations in the EGFR gene as predictive factors of EGFR TKI therapy in patients with advanced EGFR mutated lung adenocarcinoma (correlation with OS, PFS, resistance, toxicity and cancer pain). Assessment of IGF- 1R, E-cadherin, N-cadherin and occluding gene expression levels as predictive factors of EGFR TKI therapy in patients with advanced EGFR mutated NSCLC (correlation with OS, PFS, resistance, toxicity and cancer pain). Methodology: The research was conducted in the period from 2013 to 2021. in a group of 101 patients with advanced lung adenocarcinoma (clinical stage IIIb and IV, performance status 0, 1 or 2) in whom the presence of mutations in the EGFR gene was confirmed and who were treated or are still on tyrosine kinase inhibitor therapy at the Institute for Oncology and Radiology of Serbia. The diagnosis of advanced lung adenocarcinoma was made in accordance with the criteria of the eighth edition of the International Association for Lung Cancer Research (IASLC). Patients were treated with first generation EGFR inhibitors of tyrosine kinases in first line of therapy to progression or unacceptable toxicity. Demographic data (sex and age of patients), clinical manifestations of the disease, smoking status, performance status, TNM stage of the disease at diagnosis, tumor grade, localization of initial metastases, comorbidities, hematological parameters, presence of pain at diagnosis and during therapy, EGFR type were analyzed. mutations, length of TKI use, response to therapy (SD - disease stabilization, PR - partial regression, CR - complete regression, PD - disease progression), progression-free survival (PFS), overall survival. Overal survival, OS, TKI toxicity and resistance to therapy. Toxicity on TKI was assessed according to the criteria of version 5.0 of the CTCAE - Common Terminology Criteria for Adverse Events. The presence of pain at diagnosis and during therapy was reported using Pain - Related Patient - Reported Outcomes. Patients had their blood taken before starting TKI, and the results of a complete blood count with a leukocyte formula were obtained from the patient's electronic medical records. Haematological parameters were analyzed: ratio of neutrophils and lymphocytes (NLR), platelets and lymphocytes (PLR), platelets and monocytes (PMR), lymphocytes and monocytes (LMR) and neutrophils and monocytes (NMR). The level of pain was assessed using two methods - numerical scale for pain assessment (NRS) and verbal descriptive scale (VDS) before starting therapy with tyrosine kinase inhibitors, as well as during the use of these drugs. DNA and RNA were isolated from paraffin molds. A mutation in the EGFR gene (exons 18-21) was analyzed from DNA, and the expression of the IGF-1R, N-cadherin, E-cadherin, and occludin genes was analyzed from RNA. The expression level of the mRNA of the IGF-1R, N-cadherin, E-cadherin and occludin genes was analyzed by real-time quantitative PCR (qRT-PCR).