2017-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/658396摘要：兒童急性淋巴性白血病是精準醫學最成功以及最著名的模式，化學治療的強度根據病人發病時的臨床資料、癌細胞的特徵等來做初步化學治療強度的分類。再來根據初步化學治療的反應 minimalresidual disease (MRD)的概念，在引導期及鞏固期根據MRD 的數值來做化學治療藥物的調整，以上這些因子都可以用來預測疾病復發的風險1。兒童急性淋巴性白血病的整個染色體變異，在過去五年使用次世代定序儀 (next generation sequencing, NGS) 幾乎已經快要接近100%被確認。如許多kinasefusions, cytokine receptors2,3, DUX4 , MEF2D, ZNF384 轉位等被幾個不同的研究團隊發現 4-7。如新型急性淋巴性白血病像ETP (early T-cell precursor)、 hypodipoidy, hyperdipoidy, ETV6-RUNX1, iAMP21 等的致病機轉或是其他基因體變化被發現8-11。另外用全基因定序診斷、緩解以及復發的檢體， 也發現了relapse- specific mutations 如NT5C2、PRPS1 等12-14。 而新一代基因定序同時也增加了MRD 偵測的敏感度15。藥物代謝基因和治療預後尤其是副作用有很密切的關係16，近年來genome-wide association study(GWAS) 發現ITPA、MRP4、以及 NUDT15 的基因多型性和亞洲地區的病人mercaptopurine 的不耐受性有相當程度的關係17-19。因此宿主本身的genetic variants 和化學治療的相關性值得在不同的族群以及療程中被探討。我的前期研究發現台灣病人kinase fusions 的種類和西方世界的研究不同，最常被發現的ZC3HAV1-ABL2 而不是EBF1-PDGFRB。 有一個未被報告過的zinc finger protein 基因 在此cohort 中被發現和許多不同的基因有轉位的現象。除了和mercaptopurine 不耐受性相關的SNPs 有關係外，其他文獻報告和藥物副作用相關的SNPs 在本研究中皆不顯著。本計畫的目標是希望完成兒童急性淋巴性白血病的精準醫學。此計畫的第一年將完成台灣兒童急性淋巴性白血病的基因診斷，包括Ph-like、DUX4， MEF2D、 ZNF384 fusions。同時將設計leukemiapanel ， 並用deep sequencing 來定序relapse-specific mutations 如NT5C2、PRPS1 等基因，並完成 SNParrays 以及確認新的zinc finger protein 的基因轉位。第二年探討宿主和化學治療副作用的關係，以及完成一個新發現的 relapse-specific mutation 的functional assay。也會開始使用次世代定序來做leukemiapanels 的實驗。最後一年將準備投稿並完成novel zinc finger protein 基因轉位的功能研究以及臨床的影響。對於這三年新診斷個案我將使用NGS 來偵測其MRD。以上結果將可診斷出台灣兒童急性淋巴性白血病的染色體變化以及常見的基因突變，可以增加MRD 的敏感度，並利用relapse-specific mutations 來早期追蹤relapsed clones，。而GWAS 的研究則可以找到本土的資料，以上可以將兒童急性淋巴性白血病的risk stratification 做得更好， 最終的目的是希望未來可以進步到個人化的醫療 達到精準醫學的目的。<br> Abstract: Childhood ALL has provided the most successful model for improvement of cancer survival by stratificationof treatment intensity according to the clinical features of the patient , the characteristics of the leukemia cells ,and the early response to treatment (minimal residual disease, MRD), all of which are predictive of the risk ofrelapse1. The genetic landscape of childhood ALL is almost defined comprehensively by using next-generationsequencing in the past 5 years. There are many kinase fusions involving different kinases and cytokinereceptors in Ph-like ALL2,3. DUX4, MEF2D, and ZNF384 fusions were identified by different groups and havesignificant clinical impacts4-7. The associated genetic alterations in different subtypes of ALL, including ETP,ETV6-RUNX1, iAMP21, hypodipoidy and hyperdipoidy are also defined comprehensively8-11. Detail analysisof the relapsed samples also revealed relapse-specific mutations, such as NT5C2, PRPS1. This will help us tounderstand the clonal evolution of relapsed childhood ALL12-14. Researchers are using NGS to increase thesensitivity of MRD detection in ALL15.Pharmacogenomics also affect the chemotherapy complications and treatment outcomes of childhoodALL16. Recent genome-wide association study (GWAS) showed that the ITPA4, MRP4 and notably NUDT15polymorphisms contributed to the mercaptopurine intolerance in Asian, highlighting the racial difference ofdrug metabolism17-19. Germline variants worth further investigations in different populations and cohorts andmight affect the clinical outcomes.My pilot studies show the distributions of kinase fusions are different from that of Caucasian origin inchildhood ALL. The most frequent identified kinase fusion is ZC3HAV1-ABL2, not EBF1-PDGFRB. I alsoidentified a novel zinc finger protein gene which are fused with different partner genes. Except SNPs formercaptopurine intolerance, most reported SNPs have no associations with complications of chemotherapy inthis cohort. Several relapse-specific mutations were also identified by whole exome sequencing. Thevalidations are ongoing.The aim of this proposal is to develop precision medicine for childhood ALL in Taiwan. In the first fiscalyear, we will complete the cytogenetic classification of childhood ALL, including Ph-Like, DUX4, MEF2D,ZNF384 rearrangements. Leukemia-panel will be designed in the first year. We will profile the targetsequencings of NT5C2, PRPS1 and other relapse-specific mutations. I will confirm the novel zinc-fingerprotein gene fusions. SNP arrays for the original cohort will be complete in the first year. In the second fiscalyear, I will have the functional of one novel gene in the disease progression of ALL. We will validate therelapse-specific mutations and start to do the leukemia panels by NGS at this time. GWAS for chemotherapywill be also analyzed and validated. In the final fiscal year, we will prepare the manuscripts and do thefunctional analysis of these novel zinc finger protein fusions. I will also use NGS to detect the MRD for thenew-diagnosed patients in this three-year projects.These findings may help the risk classification system, more sensitive detection of leukemia clone, anddecrease the possible complications of chemotherapy. These will help the design of clinical trials and achievethe goals of precision medicine in the future.兒童急性淋巴性白血病類費城染色體白血病次世代定序藥物基因學急性淋巴性白血 病基因體childhood ALLPh-like ALLnext-generation sequencingpharmacogeneticsleukemia genome