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颅内脑膜瘤、血管内皮生长因子-A通路与瘤周脑水肿

Intracranial meningiomas, the VEGF-A pathway, and peritumoral brain oedema.

作者信息

Nassehi Damoun

机构信息

Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark.

出版信息

Dan Med J. 2013 Apr;60(4):B4626.

Abstract

Meningiomas are the second-most common intracranial tumours in adults. They are derived from the arachnoid cells, and although approximately 90% of meningiomas are benign, more than half of all meningiomas develop peritumoral brain oedema (PTBE), which increases morbidity. The PTBE can be treated with steroid therapy, but this treatment is not specific, is not always effective, and involves long-term side-effects. Meningiomas are treated with radiation therapy, stereotactic radio-surgery or surgical resection. At the moment surgical resection is the only definite treatment, and the removal of the tumour also removes the PTBE. Based on the localization of the meningioma, surgery can be complicated. Although PTBE around meningiomas is frequent, the mechanisms behind its development are not clearly understood. It is believed that due to tumour growth and local tissue hypoxia, angiogenesis is increased and leads to the formation of PTBE. The angiogenic protein vascular endothelial growth factor A (VEGF-A) is believed to be involved in the formation of PTBE around meningiomas, as several studies have found that it is increased in meningiomas with PTBE. VEGF-A is also known as vascular permeability factor due to its ability to increase the permeability of capillaries. Paper I examines the VEGF-A protein and mRNA levels in 101 intracranial meningiomas. The PTBE is quantified on MRI, and capillary length and tumour water content are measured and compared to control brain tissue. Possible co-factors to PTBE like meningioma localization and subtypes are also examined. Forty-three of the patients have primary, solitary, supratentorial meningiomas with PTBE. The correlation between PTBE or edema index with the VEGF-A protein and mRNA, capillary length, and tumour water content is investigated in these patients. A novel method is used for mRNA quantification. It involves direct amplification of the mRNA with probes and branched DNA in order to produce a chemiluminescence signal that can be measured using a luminometer. The paper shows that the oedema index is correlated to the VEGF-A protein and mRNA, and that capillary length is correlated to the PTBE. It also finds that VEGF-A protein and mRNA, capillary length and water content is increased in meningiomas compared to control tissue, suggesting that VEGF-A is produced in, and possibly secreted from the meningiomas. In addition, supratentorial meningiomas are shown to have larger PTBE compared to infratentorial meningiomas, suggesting that infratentorial meningiomas are diagnosed and removed earlier, due to earlier symptom development based on the anatomical features of the fossa posterior. Finally, a gender-specific difference in tumour water content and VEGF-A protein is revealed (higher and lower in females, respectively). Paper II is a method-comparison study pitting the chemiluminescence assay against the often used quantitative real-time reverse transcription polymerase chain reaction (RT-qPCR) assay. In RT-qPCR, RNA is isolated, measured, reverse transcribed, purified, amplified via real-time PCR, and analyzed. The method is robust and reliable, albeit laborious to some extent. The chemiluminescence assay detects RNA directly without the need for RNA purification, complement DNA synthesis or cyclic amplification. By comparing the output of the two protocols to a dilution series ranging from 1 to 128 times of the homogenized samples, the precision of the protocols is measured. Furthermore, VEGF-A/GAPDH ratios are quantified for 15 tissue samples and the results compared between the two protocols, showing significant correlation. The study finds that the chemiluminescence assay is competitive to RT-qPCR, and reflects a similar pattern in gene expression measurement with a similar precision. Whether one method or the other should be used depends on the variability of the samples, budget, and time. RT-qPCR has a much wider dynamic range, and is preferable in case of significant sample inter-variability. It is also less expensive, and gives the user more flexibility as homemade reagents can be used. On the other hand, the chemiluminescence assay is straight forward, requires less hands-on-time, and can be used on formalin-fixed and paraffin-embedded (FFPE) tissue. Paper III continues the investigations in paper I. The sample size is increased so that 22 angiomatous and secretory meningiomas are compared to 40 non-angiomatous meningiomas and 10 control brain tissue samples. Angiomatous and secretory meningiomas are chosen because they are known to have larger PTBE compared to other meningiomas. In addition to VEGF-A, capillary length, and PTBE, the VEGF-A tyrosine kinase receptor VEGFR-2 mRNA and protein levels are also examined. VEGFR-2 is a transmembrane receptor found on endothelial cells. It binds VEGF-A and thereby increases angiogenesis. VEGFR-2's co-receptor neuropilin-1 is also examined. Neuropilin-1 is an agonist of angiogenesis through complex-binding of VEGF-A, but it can also work as an inhibitor through competitive binding of semaphorin-3A. The complex binding of semaphorin-3A to neuropilin-1 can also induce endothelial cell apoptosis, thus working as an antagonist of angiogenesis. The study finds that VEGF-A mRNA, VEGF-A protein, and neuropilin-1 mRNA are higher in angiomatous and non-angiomatous meningiomas compared to controls. VEGFR-2 protein is higher, and neuropilin-1 protein lower in angiomatous meningiomas compared to controls. The mean capillary length is 3614 mm/mm3 in angiomatous, 605 mm/mm3 in non-angiomatous meningiomas, and 229 mm/mm3 in the controls. Non-angiomatous and angiomatous meningioma patients have equally sized tumours. The mean PTBE around the angiomatous meningiomas is 695 cm3, i.e. 477 cm3 larger than the non-angiomatous meningiomas (p = 0.0045), and the mean oedema index is twice the size compared to the non-angiomatous meningiomas. Further comparison between the two meningioma groups shows that mean VEGF-A mRNA, VEGFR-2 protein, and neuropilin-1 mRNA is significantly higher and neuropilin-1 protein is lower in the angiomatous meningiomas. We believe that the VEGF-A pathway participates in the formation of PTBE in meningiomas by inducing formation of "leaky" capillaries, resulting in secretion of VEGF-A and plasma to the peritumoural brain tissue. It may therefore be worth pursuing therapies targeted directly against VEGF-A and its receptors through drugs like bevacizumab, sorafenib, sunitifib, and cediranib.

摘要

脑膜瘤是成人中第二常见的颅内肿瘤。它们起源于蛛网膜细胞,尽管约90%的脑膜瘤是良性的,但超过一半的脑膜瘤会发生瘤周脑水肿(PTBE),这会增加发病率。PTBE可用类固醇疗法治疗,但这种治疗不具有特异性,并非总是有效,且会带来长期副作用。脑膜瘤的治疗方法包括放射治疗、立体定向放射外科手术或手术切除。目前,手术切除是唯一确定的治疗方法,切除肿瘤的同时也会消除PTBE。根据脑膜瘤的位置,手术可能会很复杂。尽管脑膜瘤周围的PTBE很常见,但其发生机制尚不清楚。据信,由于肿瘤生长和局部组织缺氧,血管生成增加,导致PTBE形成。血管生成蛋白血管内皮生长因子A(VEGF - A)被认为与脑膜瘤周围PTBE的形成有关,因为多项研究发现,在伴有PTBE的脑膜瘤中其水平升高。VEGF - A也因其增加毛细血管通透性的能力而被称为血管通透性因子。论文I研究了101例颅内脑膜瘤中VEGF - A蛋白和mRNA水平。通过MRI对PTBE进行定量,并测量毛细血管长度和肿瘤含水量,并与对照脑组织进行比较。还研究了PTBE的可能辅助因素,如脑膜瘤的位置和亚型。43例患者患有伴有PTBE的原发性、孤立性幕上脑膜瘤。在这些患者中研究了PTBE或水肿指数与VEGF - A蛋白和mRNA、毛细血管长度以及肿瘤含水量之间的相关性。使用了一种新的mRNA定量方法。该方法涉及用探针和分支DNA直接扩增mRNA,以产生可使用发光计测量的化学发光信号。该论文表明水肿指数与VEGF - A蛋白和mRNA相关,且毛细血管长度与PTBE相关。研究还发现,与对照组织相比,脑膜瘤中的VEGF - A蛋白和mRNA、毛细血管长度和含水量增加,这表明VEGF - A在脑膜瘤中产生,并可能从脑膜瘤中分泌。此外,与幕下脑膜瘤相比,幕上脑膜瘤的PTBE更大,这表明由于基于后颅窝解剖特征的早期症状发展,幕下脑膜瘤更早被诊断和切除。最后,揭示了肿瘤含水量和VEGF - A蛋白的性别特异性差异(女性分别更高和更低)。论文II是一项方法比较研究,将化学发光测定法与常用的定量实时逆转录聚合酶链反应(RT - qPCR)测定法进行对比。在RT - qPCR中,先分离、测量RNA,然后进行逆转录、纯化,通过实时PCR进行扩增并分析。该方法虽然在某种程度上很繁琐,但稳健可靠。化学发光测定法无需RNA纯化、互补DNA合成或循环扩增即可直接检测RNA。通过将两种方案的输出与匀浆样品1至128倍的稀释系列进行比较,测量方案的精度。此外,对15个组织样品的VEGF - A/GAPDH比率进行定量,并比较两种方案的结果,显示出显著相关性。研究发现化学发光测定法与RT - qPCR具有竞争力,并且在基因表达测量中反映出相似的模式,精度相似。应使用哪种方法取决于样品的变异性、预算和时间。RT - qPCR具有更宽的动态范围,在样品间变异性较大的情况下更可取。它也更便宜,并且由于可以使用自制试剂,给用户更多灵活性。另一方面,化学发光测定法简单直接,需要的实际操作时间更少,并且可用于福尔马林固定石蜡包埋(FFPE)组织。论文III延续了论文I中的研究。样本量增加,将22例血管瘤样和分泌性脑膜瘤与40例非血管瘤样脑膜瘤及10例对照脑组织样本进行比较。选择血管瘤样和分泌性脑膜瘤是因为已知它们与其他脑膜瘤相比具有更大面积的PTBE。除了VEGF - A、毛细血管长度和PTBE外,还检测了VEGF - A酪氨酸激酶受体VEGFR - 2的mRNA和蛋白水平。VEGFR - 2是在内皮细胞上发现的跨膜受体。它结合VEGF - A,从而增加血管生成。还检测了VEGFR - 2的共受体神经纤毛蛋白 - 1。神经纤毛蛋白 - 1通过与VEGF - A的复杂结合是血管生成的激动剂,但它也可以通过与信号素 - 3A的竞争性结合作为抑制剂起作用。信号素 - 3A与神经纤毛蛋白 - 1的复杂结合也可诱导内皮细胞凋亡,从而作为血管生成的拮抗剂起作用。研究发现,与对照相比,血管瘤样和非血管瘤样脑膜瘤中的VEGF - A mRNA、VEGF - A蛋白和神经纤毛蛋白 - 1 mRNA更高。与对照相比,血管瘤样脑膜瘤中的VEGFR - 2蛋白更高,神经纤毛蛋白 - 1蛋白更低。血管瘤样脑膜瘤的平均毛细血管长度为3614 mm/mm³,非血管瘤样脑膜瘤为605 mm/mm³,对照为229 mm/mm³。非血管瘤样和血管瘤样脑膜瘤患者的肿瘤大小相同。血管瘤样脑膜瘤周围的平均PTBE为695 cm³,即比非血管瘤样脑膜瘤大477 cm³(p = 0.0045),平均水肿指数是非血管瘤样脑膜瘤的两倍。两组脑膜瘤之间的进一步比较表明,血管瘤样脑膜瘤中的平均VEGF - A mRNA、VEGFR - 2蛋白和神经纤毛蛋白 - 1 mRNA显著更高,而神经纤毛蛋白 - 1蛋白更低。我们认为,VEGF - A通路通过诱导形成“渗漏”毛细血管参与脑膜瘤中PTBE的形成,导致VEGF - A和血浆分泌到瘤周脑组织中。因此,通过贝伐单抗、索拉非尼、舒尼替尼和西地尼布等药物直接针对VEGF - A及其受体的治疗方法可能值得探索。

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