Article(id=1209139837190403026, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1209139833285505965, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.07.10, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1610985600000, receivedDateStr=2021-01-19, revisedDate=1621785600000, revisedDateStr=2021-05-24, acceptedDate=null, acceptedDateStr=null, onlineDate=1766211001918, onlineDateStr=2025-12-20, pubDate=1627401600000, pubDateStr=2021-07-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766211001918, onlineIssueDateStr=2025-12-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766211001918, creator=13701087609, updateTime=1766211001918, updator=13701087609, issue=Issue{id=1209139833285505965, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='7', pageStart='637', pageEnd='742', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766211000986, creator=13701087609, updateTime=1766212174313, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1209144754630168707, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1209139833285505965, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1209144754630168708, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1209139833285505965, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=702, endPage=709, ext={EN=ArticleExt(id=1209139837584667616, articleId=1209139837190403026, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Research progress on the mechanism of resistance in endocrine therapy for breast cancer, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Breast cancer is the most common malignant tumor in the world. Endocrine therapy is an important treatment for HR positive breast cancer, and its drugs are mainly divided into premenopausal estrogen receptor antagonists and postmenopausal aromatase inhibitors, but drug resistance has become a major challenge in endocrine therapy for breast cancer. This article reviews the drug resistance mechanism and the latest research results of endocrine therapy in premenopausal and postmenopausal breast cancer from the aspects of gene regulation, estrogen and coregulatory cofactor, growth factor signal pathway, cell cycle regulation,autophagy and apoptosis, non-coding RNA regulation, immune surveillance, etc., in order to provide a new basis for clinical solution of endocrine therapy resistance in breast cancer.

, correspAuthors=Ying Yuan, authorNote=null, correspAuthorsNote=
*E-mail:
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乳腺癌是目前全球范围内最常见的恶性肿瘤之一。内分泌治疗是激素受体(HR)阳性乳腺癌重要的治疗方式,治疗药物主要分为绝经前使用的雌激素受体拮抗剂和绝经后使用的芳香化酶抑制剂等,但耐药问题是目前乳腺癌内分泌治疗的重大挑战。该文从基因调控、雌激素与共调辅助因子、生长因子信号通路、细胞周期调控机制、自噬与凋亡机制、非编码RNA调控、免疫监视等方面对绝经前后乳腺癌内分泌治疗的耐药机制和最新的研究结果进行综述,以期为临床解决乳腺癌内分泌治疗耐药问题提供新的依据。

, correspAuthors=袁瑛, authorNote=null, correspAuthorsNote=
袁瑛,E-mail:
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阿迪莱·艾萨,硕士研究生,主要从事肿瘤诊断与治疗方面的研究

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阿迪莱·艾萨,硕士研究生,主要从事肿瘤诊断与治疗方面的研究

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阿迪莱·艾萨,硕士研究生,主要从事肿瘤诊断与治疗方面的研究

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tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1209139837190403026, doi=null, pmid=null, pmcid=null, year=2021, volume=30, issue=3, pageStart=161, pageEnd=191, url=null, language=null, rfNumber=[1], rfOrder=0, authorNames=He J, Chen WQ, Li N, journalName=Chin Cancer, refType=null, unstructuredReference=He J, Chen WQ, Li N, et al. 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ER. 雌激素受体;ESR1. 编码雌激素受体的基因;HER2. 人类表皮生长因子受体2;EGFR. 表皮生长因子受体;IGFR. 胰岛素样生长因子受体;MAPK. 丝裂原活化蛋白激酶;PI3K. 磷脂酰肌醇3-激酶;AKT. 丝氨酸苏氨酸激酶;mTOR. 哺乳动物雷帕霉素靶蛋白;JNK. c-Jun氨基末端激酶;CDK4/6. 细胞周期蛋白依赖性激酶4/6;CCND1. 细胞周期蛋白D1;MDM2. 双微体2基因;BCL-2. 一种主要抑制凋亡的基因;Survivin蛋白. 一种抑制肿瘤细胞凋亡的蛋白质;UPR. 未折叠蛋白反应;GRP78. 葡萄糖调节蛋白78;P450. 细胞色素P450;CYP2D6. 细胞色素P450家族中的重要成员之一;lncRNA. 长链非编码核糖核酸;miRNA. 微小核糖核酸;MTA1. 肿瘤转移相关基因1;LC-3. 微管相关蛋白1轻链3;Beclin-1. 哺乳动物ATG6同源蛋白;LAMP. 溶酶体相关膜蛋白;AIB1. 乳腺癌扩增基因1

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乳腺癌内分泌治疗耐药机制的研究进展
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阿迪莱·艾萨 , 赵菁 , 袁瑛 *
解放军医学杂志 | 综述 2021,46(7): 702-709
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解放军医学杂志 | 综述 2021, 46(7): 702-709
乳腺癌内分泌治疗耐药机制的研究进展
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阿迪莱·艾萨, 赵菁, 袁瑛*
作者信息
  • 浙江大学医学院附属第二医院肿瘤内科/恶性肿瘤预警与干预教育部重点实验室,杭州 310009
  • 阿迪莱·艾萨,硕士研究生,主要从事肿瘤诊断与治疗方面的研究

通讯作者:

袁瑛,E-mail:
Research progress on the mechanism of resistance in endocrine therapy for breast cancer
Aisa Adilai, Jing Zhao, Ying Yuan*
Affiliations
  • Department of Medical Oncology, Key Laboratory of Cancer Prevention and Intervention of Ministry of Education, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
出版时间: 2021-07-28 doi: 10.11855/j.issn.0577-7402.2021.07.10
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乳腺癌是目前全球范围内最常见的恶性肿瘤之一。内分泌治疗是激素受体(HR)阳性乳腺癌重要的治疗方式,治疗药物主要分为绝经前使用的雌激素受体拮抗剂和绝经后使用的芳香化酶抑制剂等,但耐药问题是目前乳腺癌内分泌治疗的重大挑战。该文从基因调控、雌激素与共调辅助因子、生长因子信号通路、细胞周期调控机制、自噬与凋亡机制、非编码RNA调控、免疫监视等方面对绝经前后乳腺癌内分泌治疗的耐药机制和最新的研究结果进行综述,以期为临床解决乳腺癌内分泌治疗耐药问题提供新的依据。

乳腺癌  /  内分泌治疗耐药  /  雌激素受体

Breast cancer is the most common malignant tumor in the world. Endocrine therapy is an important treatment for HR positive breast cancer, and its drugs are mainly divided into premenopausal estrogen receptor antagonists and postmenopausal aromatase inhibitors, but drug resistance has become a major challenge in endocrine therapy for breast cancer. This article reviews the drug resistance mechanism and the latest research results of endocrine therapy in premenopausal and postmenopausal breast cancer from the aspects of gene regulation, estrogen and coregulatory cofactor, growth factor signal pathway, cell cycle regulation,autophagy and apoptosis, non-coding RNA regulation, immune surveillance, etc., in order to provide a new basis for clinical solution of endocrine therapy resistance in breast cancer.

breast cancer  /  endocrine therapy resistant  /  estrogen receptor
阿迪莱·艾萨, 赵菁, 袁瑛. 乳腺癌内分泌治疗耐药机制的研究进展. 解放军医学杂志, 2021 , 46 (7) : 702 -709 . DOI: 10.11855/j.issn.0577-7402.2021.07.10
Aisa Adilai, Jing Zhao, Ying Yuan. Research progress on the mechanism of resistance in endocrine therapy for breast cancer[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (7) : 702 -709 . DOI: 10.11855/j.issn.0577-7402.2021.07.10
随着全球人口老龄化加速及生活方式改变,女性乳腺癌疾病负担日益加重,全球乳腺癌发病率自20世纪70年代末开始呈上升趋势。最新数据显示,乳腺癌是女性常见的恶性肿瘤,其发病率和病死率分别位居我国女性恶性肿瘤的第1位和第4位[1]。雌激素受体(estrogen receptor,ER)激活在激素受体(hormone receptor,HR)阳性乳腺癌的发生和发展中起着重要作用[2],其信号通路由一个复杂的生物信息网络组成,包括ER和膜受体酪氨酸激酶[如表皮生长因子受体(epidermal growth factor receptor,EGFR)、人表皮生长因子受体2(human epidermal growth factor receptor 2,HER2)和胰岛素样生长因子-1受体(insulin-like growth factor 1,IGF-1R)等]。该信号通路具有调节基因表达,控制细胞的生长、增殖和存活等多种作用。
内分泌治疗是HR阳性乳腺癌重要的治疗方式[3],治疗药物主要分为绝经前使用的雌激素受体拮抗剂(如他莫昔芬、托瑞米芬)和绝经后使用的芳香化酶抑制剂等,但并非所有的HR阳性乳腺癌患者都对内分泌治疗初始有效(原发性耐药),且部分初始治疗有效的患者可逐渐出现对药物的抵抗(继发性耐药)。内分泌治疗的耐药机制非常复杂,目前尚未完全阐明。近年来越来越多的研究表明,雌激素表观遗传学改变以及雌激素相关信号通路的异常和交互作用是导致乳腺癌内分泌治疗耐药的主要原因[4-5]。目前的探索主要集中在乳腺癌异质性、ER突变或缺失、生长因子信号通路的交互作用、miRNA异常调控等方面。阐明内分泌治疗耐药的产生机制对临床提高疗效具有重要意义。近年来已经证实,小分子靶向药物,如CDK4/6抑制剂、PI3K抑制剂等可改善晚期HR阳性HER2阴性乳腺癌患者的预后[6-7]。本文就近年来绝经前和绝经后乳腺癌内分泌治疗耐药机制的研究进展以及可能的治疗策略进行综述。
ER阳性内分泌治疗耐药转移性乳腺癌患者中ESR1基因LBD(配体结合域)位点复发性突变的发现为临床研究内分泌治疗耐药机制提供了新的方向。15%~20%的乳腺癌患者发生LBD位点突变,其中大多数接受了内分泌治疗。功能和机制研究发现,LBD位点突变赋予了LBD不依赖配体的激动构象,从而增强了ER的转录活性和肿瘤的生长、迁移能力[8]。ESR1突变体对他莫昔芬表现出相对耐药,但高剂量用药可延缓耐药出现的时间,降低耐药程度。此外,LBD位点突变很少在初始治疗的原位乳腺癌患者中检测到,表明该突变可能是在内分泌治疗的压力下产生的一种新的获得性耐药机制[8]
一项对乳腺癌细胞系和患者来源的异种移植乳腺癌细胞的研究发现,ESR1、ESR1/YAP1的耐药相关易位点为t(6;11)。ESR1的断点位于螺旋12(H12)的起始位置,该融合蛋白由ER的N端结构域、DNA结合域以及YAP1的C端组成,其功能特性包括不依赖雌激素而生长、抗雌激素抵抗、转移相关转录程序的激活,以及诱导细胞运动等[9]。Hartmaier等[10]发现,ESR1融合蛋白在转移性ER阳性乳腺癌中富集,并可能导致内分泌治疗抵抗。此外,该研究还鉴定出9种新的ESR1融合蛋白,均具有ESR1外显子6和7之间的连接,且具有配体不依赖的ER活性,提示ESR1融合蛋白与内分泌治疗耐药有关。
有学者认为,组蛋白去乙酰化酶(histone deacetylase,HDAC)的增加可通过浓缩核小体的结构而限制转录,这可能是ER转录水平降低的原因之一。HDAC被抑制可以增高ER低表达乳腺癌细胞系中ER的转录水平[11]。有研究发现,在他莫昔芬治疗期间,乳腺癌细胞中Spalt样转录因子2(SALL2)的表达显著降低。SALL2可通过直接与DNA启动子结合,上调ESR1和PTEN的转录水平。相反,沉默SALL2可诱导ERα和PTEN下调并激活AKT/mTOR信号转导通路,导致ERα阳性乳腺癌的雌激素非依赖性生长和他莫昔芬耐药[12]。此外,在他莫昔芬耐药的乳腺癌中发现SALL2启动子高甲基化,而DNA甲基转移酶(DNMT)抑制剂介导的SALL2修复可使乳腺癌对他莫昔芬治疗再敏感,这些发现可用于对可能受益于他莫昔芬和DNMT抑制剂联合治疗的乳腺癌患者进行分类[12]
RTK家族成员主要包括EGFR、IGF-1R、血管内皮生长因子受体(VEGFR)、纤维母细胞生长因子受体(FGFR)等。RTKs与各自的配体结合后主要激活MAPK、JAK/STAT和PI3K/AKT信号通路,参与体内的生理病理代谢过程。
受体酪氨酸激酶(EGFR、HER2、IGF-1R)下游信号通路的过度激活和互通串扰能够激活ER信号通路,该过程被称为“配体无关的ER激活过程”。在某些情况下,由于遗传或表观遗传改变,如HER2基因扩增,PI3K催化亚单位的激活、突变,或肿瘤抑制因子的表达缺失,导致这些信号通路的互通和激活增强。值得注意的是,EGFR和HER2信号的激活被认为是内分泌治疗耐药的重要因素之一[5]
生长因子信号在原发性和继发性内分泌治疗耐药中均具有重要意义。有研究显示,HER2与ER信号通路之间的转换是肿瘤的首选信号通路,HER2靶向治疗可导致ER通路激活,反之亦然。人乳腺癌MCF7细胞系中生长因子信号的上调与接受他莫昔芬治疗的乳腺癌患者HER2的上调一致,提示抗HER2和内分泌联合治疗可能是有益的[13]。有研究证实,在他莫西芬耐药细胞中,HER1、HER2和ER-乳腺癌扩增基因1(AIB1)复合物的表达水平升高。HER1/HER2信号通路和AIB1可促进他莫昔芬耐药细胞的增殖。然而,在他莫昔芬耐药细胞中用AIB1-siRNA沉默AIB1时,HER1/HER2信号通路介导的他莫昔芬耐药细胞的增殖受到抑制,表明在HER1/HER2介导的他莫昔芬耐药细胞不依赖激素生长的过程中,AIB1蛋白可能是一个关键因子[14]。因此,AIB1可能是一个新的治疗靶点,沉默AIB1可能会减弱ER与HER1/HER2通路之间的交互作用,从而恢复他莫西芬耐药细胞的敏感性。
IGF-1R是一种跨膜酪氨酸激酶蛋白,可被刺激性激素/配体、IGF-1和IGF-2激活,并通过MAPK/ERK、PI3K/AKT和JAK/STAT信号通路促进细胞生长及抗细胞凋亡。Kruger等[15]的研究发现,刺激IGF-1R可激活ER阳性乳腺癌细胞系中的PI3K和MAPK通路,从而导致乳腺癌他莫昔芬耐药。该结果与他莫昔芬对绝经后ER阳性、IGF-1R阳性、磷酸化的胰岛素样生长因子-1受体/胰岛素受体(p-IGF-1R/InsR)阳性乳腺癌患者的疗效不足一致。有研究发现,胰岛素样生长因子抑制剂能使该类乳腺癌细胞恢复内分泌治疗敏感性[15],尽管该结果需要在ER阳性、IGF-1R阳性乳腺癌患者的独立队列中进行验证,但对于具有IGF-1R信号通路异常激活的乳腺癌患者,IGF-1R/InsR可能是一个潜在的治疗靶点。
有研究表明,超过10%的乳腺癌患者出现基因扩增(位于染色体11q12-14),包括成纤维细胞生长因子受体1(FGFR1)以及成纤维细胞生长因子(FGF)配体3、4和19[16]。Shee等[17]的研究发现,FGF2可激活FGFR信号通路,抑制细胞凋亡,解除增殖阻滞,从而降低肿瘤细胞对药物的敏感性。研究发现,FGFR1扩增的细胞系对他莫昔芬产生耐药性,而沉默FGFR1的表达可缓解这种耐药性,表明FGFR1过表达可增强内分泌治疗耐药性[18]。FGFR抑制剂为ER(+)/HER-2(–)/FGFR扩增的肿瘤提供了一种新的治疗靶点,但部分抑制剂尚处于临床试验的初始阶段。有研究对选择性FGFR抑制剂BGJ398的作用进行初步评估,结果显示其对进展期乳腺癌和向肺转移的乳腺癌疗效较好[19]
PI3K/AKT/mTOR通路对细胞生长和存活、蛋白质合成以及葡萄糖代谢至关重要。该通路在多种肿瘤中处于失调状态,研究该通路在肿瘤发生发展中的作用具有重要意义,如三阴性乳腺癌[20]。已知PI3K/AKT/mTOR通路与雌激素介导的信号传导之间存在交互作用,进一步研究并充分了解其相互作用的机制,并寻找针对该通路的靶向药物具有重要的临床意义。抑制PI3K/AKT/mTOR通路可导致细胞增殖和存活率下降,这一信号通路也能够使代偿性反馈机制被激活,即该通路中某一种分子被抑制,其他分子的表达代偿性增加,赋予细胞对单一抑制剂的耐药性[21]。有研究发现,AKT抑制剂AZD5363可恢复乳腺癌细胞对他莫昔芬的敏感性,并与氟维司群具有协同作用[22]。上述研究结果推进了内分泌治疗与PI3K/AKT/mTOR抑制剂联合应用的临床研究。
Wnt信号通路是一条重要的细胞信号通路,对细胞的迁移、侵袭、黏附和存活起重要作用,但其在人类癌症(包括乳腺癌)中常处于失调状态。有研究发现,与亲本MCF7细胞相比,他莫昔芬耐药细胞中Wnt信号通路相关基因、β-catenin相关基因以及上皮-间质转化(EMT)标志物(VIM、Twist1、SNAI2)的表达均上调。用人重组Wnt3a(RWnt3a)处理他莫昔芬耐药细胞株以增强Wnt信号通路,可进一步增强MCF7细胞对他莫昔芬的耐药性。经Wnt抑制剂IWP-2处理后,Wnt信号通路和EMT标志物的表达均受到抑制,MCF7细胞对他莫昔芬的敏感性有所增强,表明Wnt信号通路和EMT相关信号的激活有助于MCF7细胞他莫昔芬耐药性的产生[23]。有研究发现,他莫昔芬耐药细胞系中CXXC锌指蛋白4(CXXC4)的表达水平降低,敲除CXXC4基因可加速细胞增殖,使乳腺癌细胞对他莫昔芬不敏感,而CXXC4过表达则可抑制癌细胞生长,增加耐药细胞对他莫昔芬的敏感性[24]。此外该研究还发现,CXXC4可通过调节糖原合成酶激酶-3β(GSK-3β)的磷酸化,影响β-catenin降解复合物的完整性,从而抑制癌细胞中Wnt/GSK-连环蛋白信号转导。沉默CXXC4基因可上调cyclin D1和c-MYC(Wnt信号的下游靶点)的表达,促进细胞周期进程。相反,CXXC4异位表达下调了这些蛋白的表达,使细胞周期阻滞在G0/G1期。小分子抑制剂XAV939可抑制Wnt信号通路并使耐药细胞对他莫昔芬敏感[21],表明Wnt通路中对他莫昔芬早期应答的成分可能是内分泌治疗耐药转变的内在因素,抑制Wnt信号转导可能是克服他莫昔芬耐药的有效策略。另一项研究表明,他莫昔芬耐药细胞株中Wnt效应基因AXIN2和Dkk1的表达显著增加,这种Wnt信号通路的激活反应被认为是乳腺癌细胞对内分泌治疗的早期适应性反应,有助于他莫细芬耐药细胞株的生长[25]。激活的Wnt信号通路降低他莫昔芬作用的机制有待进一步研究。由于一些针对Wnt信号通路的小分子药物目前正处于临床前开发阶段,内分泌药物和Wnt信号通路抑制剂的联合应用在未来可能是一种有用的治疗方案,适用于部分乳腺癌患者。
EMT与肿瘤的进展及转移密切相关,主要表现为β-catenin与E-cadherin之间的平衡失调,细胞迁移率增高以及细胞间黏附丧失。有研究表明,他莫昔芬耐药的MCF7(TAMR)细胞呈松散集落生长,细胞间连接缺失;他莫昔芬耐药的TAMR细胞表现出β-catenin与E-cadherin之间的平衡失调,胞质和细胞核β-catenin表达增加,以及与肿瘤进展和EMT相关的β-catenin靶基因转录增加。而EGFR抑制剂能够降低β-catenin的磷酸化水平,逆转EMT进程,并在一定程度上增强肿瘤细胞对他莫昔芬的敏感性,表明他莫昔芬耐药性与EGFR信号通路及EMT密切相关[26]。MiR-200家族成员(miR-200a、miR-200b和miR-200c)可通过抑制转录抑制因子ZEB1/2的表达来调节EMT进程。研究发现,miR-200在内分泌治疗耐药的LY2间叶性乳腺癌细胞中呈低表达。随着miR-200表达降低,ZEB1 mRNA表达增加,从而促进了EMT进程。在LY2细胞中过表达miR-200b或miR-200c可改变细胞形态,抑制细胞迁移,并增强LY2细胞对他莫昔芬的敏感性,即去甲基化药物5-氮杂-2'-脱氧胞苷(5-aza-DC)与组蛋白脱乙酰化酶抑制剂曲古抑素A(TSA)联合应用可增加LY2细胞中miR-200b和miR-200c的表达,降低ZEB1的表达,抑制EMT进程,并增强LY2细胞对他莫昔芬的敏感性[27]。该结果为克服乳腺癌耐药提供了新的方向和潜在的靶点。
细胞周期蛋白cyclin D-CDK4/6-INK4-Rb通路在正常乳腺上皮细胞和癌细胞的增殖中起关键作用。周期蛋白依赖性激酶(cyclin-dependent kinases,CDKs)是细胞周期、细胞分裂和癌症发生中至关重要的细胞周期蛋白依赖性驱动因子。研究发现,c-MYC、cyclins E1和cyclins D1等细胞周期调节因子的过表达与乳腺癌内分泌治疗耐药有关。雌激素非依赖性c-MYC过表达可使ERαY537S和ERαD538G突变的乳腺癌细胞对内分泌治疗产生耐药[28]。另有研究发现,CDK7可激活Ser118处的ER-α磷酸化,从而增强ER+乳腺癌中MYC的转录[29]。因此,理论上可通过siRNA等下调CDK7以阻断ER激活和ER靶基因(包括MYC)的表达,从而克服乳腺癌内分泌治疗的耐药性。
CD1与CDK4/6结合可调节细胞周期G1期的进展,是PI3K/AKT/mTOR通路的下游靶点。CDK4/6被证实可与ER信号通路发生串扰,这为联合抑制CDK4/6和PI3K通路从而控制肿瘤进展提供了理论基础[6]。研究表明,抑制CDK4/6或PI3K/AKT通路可以延迟内分泌治疗耐药的发生。临床上,联合抑制PI3K和CDK4/6通路可下调cyclin D并阻滞细胞周期的进展,克服CDK4/6单一因子抑制引起的耐药性[30]
自噬是一个保守的过程,作为对外界刺激或营养缺乏的反应,自噬试图通过降解受损或多余的蛋白质和亚细胞器,并传递到溶酶体来维持代谢平衡。自噬对多药耐药肿瘤可能是一把双刃剑:既参与多药耐药的发展,保护癌细胞免受抗肿瘤药物的影响,也可杀死不活跃的多药耐药癌细胞[31]。目前研究发现,自噬是他莫昔芬耐药的一个重要机制,抑制自噬可实现获得性耐药乳腺癌细胞的再增敏[32]。微管相关蛋白1轻链3(LC-3)是一种与自噬反应相关的关键蛋白质,Beclin-1 B是自噬小体形成和自溶酶体融合的关键标志之一,而miR-101被认为是一种强大的自噬抑制剂。一项关于自噬与他莫昔芬耐药关系的研究发现,与MCF-7细胞系相比,他莫昔芬耐药细胞系中LC-3、Beclin-1的表达水平均较高,但miR-101在TAM-R细胞系中的表达水平低于MCF-7细胞系,表明他莫昔芬耐药细胞系的自噬水平较高[33]。另有研究发现,对他莫昔芬耐药的乳腺癌细胞系MCF7/TAM-R和T47D/TAM-R中肿瘤转移相关基因1(MTA1)的表达水平增高,而敲除MTA1可使这些细胞对4-羟基他莫昔芬(4OHT)敏感,表明MTA1高表达与乳腺癌细胞他莫昔芬耐药相关,进一步研究其机制发现,MTA1可通过诱导AMPK信号通路激活细胞自噬,从而促进乳腺癌细胞对他莫昔芬耐药[34]。Wang等[35]发现,长链非编码RNA(lncRNA)H19在他莫昔芬耐药乳腺癌细胞系和肿瘤组织中的表达显著上调,且其上调后可通过H19/SAHH/Dnmt3b轴下调Beclin-1启动子的甲基化,增强细胞自噬,从而促进ER+乳腺癌细胞他莫昔芬耐药性的产生。此外,葡萄糖转运蛋白1(GLUT1)、溶酶体相关膜蛋白3(LAMP3)等也可通过促进细胞自噬来参与乳腺癌细胞对他莫昔芬的耐药过程[36-37]。但自噬介导的他莫昔芬耐药的确切机制尚不完全清楚,需进一步深入研究。
总之,使用他莫昔芬治疗可以触发癌细胞的保护性自噬,进而促使他莫昔芬耐药。因此,揭示自噬与他莫昔芬耐药之间的关系具有重要意义。明确可积极或消极地调节自噬的蛋白质,临床上可以设计特定的治疗方法,通过调节这些蛋白质来抑制内分泌治疗耐药或使耐药细胞对治疗重新敏感。因此,自噬相关蛋白的表达可能成为他莫昔芬耐药的预测因子。
lncRNA (>200 bp)参与多种生物学过程,包括他莫昔芬耐药性的产生。有研究发现,lncRNA HOTAIR在乳腺癌中表达上调,其上调增强了配体非依赖性的ER活性,并促进了他莫昔芬耐药性的产生[38]。Liu等[39]研究发现,lncRNA UCA1的表达与乳腺癌患者的病理分级和病死率呈正相关,且他莫昔芬耐药细胞系中UCA1的表达明显高于野生型亲本细胞。UCA1的异常表达促进了细胞的存活和对他莫昔芬耐药,而抑制UCA1则增强了乳腺癌细胞对他莫昔芬的敏感性,并可诱导乳腺癌细胞凋亡。此外,与亲本MCF7和T47D细胞相比,他莫昔芬耐药细胞表现出Wnt信号的激活。同时,UCA1的缺失降低了Wnt/β-catenin通路的激活活性和他莫昔芬耐药乳腺癌细胞的致瘤性,表明lncRNA UCA1/Wnt/β-catenin通路的异常激活与他莫昔芬耐药性的产生有关[39]。另有研究发现,在他莫昔芬耐药的乳腺癌组织中,lncRNA DSCAM-AS1和表皮生长因子受体途径底物8(Eps8)的表达明显上调,而miR-137的表达明显下调[40]。DSCAM-AS1可促进乳腺癌对他莫昔芬的耐药性,并与乳腺癌组织中miR-137的表达呈负相关,与Eps8的表达呈正相关。MiR-137可通过靶向作用于Eps8,使细胞周期阻滞在G0/G1期,从而抑制肿瘤细胞的生长。作为miR-137的内源性竞争RNA,lncRNA DSCAM-AS1可阻止miR-137与Eps8的相互作用,解除细胞周期阻滞,促进他莫昔芬耐药乳腺癌细胞的增殖,抑制细胞凋亡[40]。此外,lncRNA BDNF-AS在他莫昔芬耐药乳腺癌中呈高表达,且可通过RNH1/TRIM21/mTOR级联途径减弱RNH1调节和RISC介导的mTOR mRNA衰变,从而维持mTOR信号的激活,进一步诱导乳腺癌他莫昔芬耐药和恶性进展。mTOR抑制剂可逆转BDNF-AS过表达诱导的他莫昔芬耐药性[41]。lncRNA ROR能够促进MAPK/ERK信号转导并诱导乳腺癌雌激素非依赖性生长,从而促进他莫昔芬耐药[42];lncRNA MAFG-AS1可通过海绵作用竞争性结合miR-339-5p,上调CDK2的表达。ER通路与lncRNA MAFG-AS1/miR-339-5p/CDK2轴之间的相互作用可促进ER+乳腺癌的进展并诱导他莫昔芬耐药[43]。由此可见,lncRNA可通过影响ER及其相关信号通路的表达,参与乳腺癌他莫昔芬耐药性的产生。因此,上述小分子可作为临床预测和克服他莫昔芬耐药的生物标志物。
miRNA与乳腺癌细胞的生命过程密切相关,包括细胞增殖、细胞死亡或凋亡、免疫反应、细胞周期、新陈代谢、衰老、侵袭、转移以及血管生成等[44],其中一些miRNAs被ER调节和(或)影响ER基因的表达[45]。研究发现,miRNAs可通过调控ER的表达和ER信号通路,激活生长因子信号通路,参与细胞周期调控和EMT,调控细胞凋亡,并且通过外泌体转运的方式在乳腺癌的发生发展以及对内分泌治疗产生耐药性的过程中起着重要作用[46]。Zeng等[47]发现,细胞色素C氧化酶亚单位5a(COX5A)与ER阳性乳腺癌预后不良有关。进一步研究发现,COX5A的表达与ER+乳腺癌的转移和化疗耐药呈正相关,敲除COX5A基因能增强乳腺癌细胞的化疗敏感性。miRNA-204可以靶向并抑制COX5A的表达,降低其功能,从而缓解乳腺癌内分泌治疗耐药[45]。这些新的发现可能为克服乳腺癌内分泌耐药提供潜在的靶点。
CYP2D6是细胞色素P450家族的重要成员之一,主要在肝脏和中枢神经系统中表达,在外源性生物代谢过程中发挥重要作用,参与多种药物的代谢。CYP2D6能够将他莫昔芬转化为活性和亲和力更强的4-羟基他莫昔芬和恩多昔芬,从而增强疗效。因此,CYP2D6突变、缺失或低表达的乳腺癌患者从他莫昔芬内分泌治疗中获益较少[48]。但最近一项关于乳腺癌患者他莫昔芬疗效与CYP2D6代谢活性关系的前瞻性-回顾性研究发现,接受标准剂量的他莫昔芬治疗后,CYP2D6低代谢活性组和超高代谢活性组乳腺癌患者的预后均较正常或中等CYP2D6代谢活性组患者差[49],表明他莫昔芬药效的发挥与CYP2D6代谢活性并非呈线性相关,应根据患者CYP2D6基因型或代谢活性调整他莫昔芬的剂量而非使用标准剂量治疗。但是目前关于CYP2D6对他莫昔芬药效和耐药的作用仍没有一致的结论,需要进一步研究。
肿瘤相关巨噬细胞(tumor-associated macrophages,TAMs)是肿瘤间质中数量最多的炎性细胞群,可分为M1型和M2型。M1型被认为具有杀灭细菌和肿瘤细胞,以及分泌多种促炎细胞因子的能力。M2型通过分泌多种细胞因子参与细胞生长、血管生成、免疫抑制、组织修复等过程[50]。体外研究发现,肿瘤间质中癌相关成纤维细胞(CAFs)分泌的细胞因子可与β1整合素相互作用,随后激活PI3K/AKT信号通路,从而诱导他莫昔芬耐药。此外,TAMs在微环境中表达上调与乳腺癌患者他莫昔芬耐药性和生存率降低有关[51]。基于广泛的研究,有学者提出肿瘤微环境中的TAMs主要向抗炎巨噬细胞(M2)表型极化,且具有促进肿瘤血管生成、促进肿瘤细胞生长以及分泌多种免疫抑制因子(包括IL-10和TGF-β)的能力,这可能为乳腺癌抗内分泌治疗耐药的形成提供有利的免疫微环境[52]
绝经后乳腺癌内分泌治疗的药物主要有芳香化酶抑制剂,如阿那曲唑、来曲唑、依西美坦等。这些药物可通过抑制芳香化酶的活性而抑制雌激素的生物合成,进而抑制肿瘤的发展。
绝经后芳香化酶抑制剂类内分泌药物的耐药机制与绝经前他莫昔芬耐药机制的相同点:(1)ER基因调控异常(包括ESR基因的点突变、扩增、转录异常等[53-54]);(2)生长因子受体(EGFR、IGFE、HER-2、FGFR)信号通路异常激活并与ER通路串扰互通[18,55],及其下游信号MAPK、PI3K/AKT/mTOR和JNK通路异常激活[7,56];(3)细胞周期调控蛋白CDK4/6异常[57];(4)细胞凋亡与自噬的调控失调等[21,58]
此外越来越多的研究发现,雄激素受体水平的异常升高[59]、肿瘤干细胞样特性的诱导[60]、肿瘤相关成纤维细胞(CAF)的活性增强[61-62]、未折叠蛋白反应(UPR)的过度激活[63]、葡萄糖调节蛋白78(GRP78)的异常表达[64],以及肿瘤微环境的改变[65]等在芳香化酶抑制剂耐药的形成中也具有一定的作用,但其具体机制尚不清楚。绝经前后乳腺癌内分泌治疗耐药机制的对比汇总如图1所示。
目前临床上用于解决乳腺癌内分泌治疗耐药的可行方案主要为绝经前使用的雌激素受体抑制剂(他莫昔芬、托瑞米芬),或者绝经后使用的芳香化酶抑制剂(阿那曲唑、来曲唑、依西美坦)等联合CDK4/6抑制剂、PI3K抑制剂、mTOR抑制剂的联合用药方案,且在临床实践中已取得了一定成效,但尚需要进一步探索内分泌治疗耐药的分子机制并寻找更多的靶点,以为临床克服内分泌治疗耐药提供新的方向。
乳腺癌内分泌治疗药物主要分为绝经前使用的雌激素受体拮抗剂和绝经后使用的芳香化酶抑制剂等。内分泌治疗药物的耐药机制比较复杂,主要有ER基因的异常表达、生长因子信号通路的异常激活及其下游信号的上调、细胞周期调控蛋白表达异常、细胞自噬和凋亡的调控异常等。此外,非编码RNA、细胞色素P450、Wnt信号通路、EMT等在雌激素受体拮抗剂耐药形成中也发挥一定的作用。肿瘤微环境的改变、UPR过度激活、GRP78表达异常在芳香化酶抑制剂耐药形成中也起着不可忽视的作用。临床上已用于克服内分泌治疗耐药的主要药物有CDK4/6抑制剂、PI3K抑制剂、mTOR抑制剂等。目前,药物耐药仍然是乳腺癌内分泌治疗亟需解决的主要问题之一。研究药物耐药的机制是解决内分泌治疗耐药问题、提高药物疗效的必要前提,因此,需要进行更多的耐药机制研究和相关临床试验,发现耐药的具体机制并将基础研究成果转化为安全有效的临床药物,以解决乳腺癌内分泌治疗耐药问题,提高内分泌药物的疗效,改善患者预后,为乳腺癌患者带来更多福音。
  • 国家自然科学基金(81872481)
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2021年第46卷第7期
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doi: 10.11855/j.issn.0577-7402.2021.07.10
  • 接收时间:2021-01-19
  • 首发时间:2025-12-20
  • 出版时间:2021-07-28
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  • 收稿日期:2021-01-19
  • 修回日期:2021-05-24
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National Natural Science Foundation of China(81872481)
国家自然科学基金(81872481)
作者信息
    浙江大学医学院附属第二医院肿瘤内科/恶性肿瘤预警与干预教育部重点实验室,杭州 310009

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2种不同金属材料的力学参数

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种数
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total species (%)

Genus
种数
Number of
species
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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