腫瘤微環(huán)境中巨噬細(xì)胞及相關(guān)細(xì)胞因子對(duì)肝癌切除術(shù)后患者預(yù)后的影響

劉立國(guó) 綜述　楊志英審校中日友好醫(yī)院肝膽外科，北京100029

腫瘤微環(huán)境中巨噬細(xì)胞及相關(guān)細(xì)胞因子對(duì)肝癌切除術(shù)后患者預(yù)后的影響

劉立國(guó) 綜述楊志英#審校
中日友好醫(yī)院肝膽外科，北京100029

目前肝切除術(shù)仍是臨床治療肝癌首選的治療方式。但肝切除術(shù)后仍有一定復(fù)發(fā)率。腫瘤微環(huán)境中巨噬細(xì)胞及其相關(guān)細(xì)胞因子能夠影響肝癌細(xì)胞生物學(xué)行為，促進(jìn)肝癌的侵襲和轉(zhuǎn)移，引發(fā)腫瘤復(fù)發(fā)和影響患者預(yù)后。測(cè)定巨噬細(xì)胞及相關(guān)細(xì)胞因子水平對(duì)判斷肝癌肝切除術(shù)后患者的預(yù)后具有重要價(jià)值，同時(shí)巨噬細(xì)胞及相關(guān)細(xì)胞因子也是肝癌治療的潛在靶點(diǎn)。

肝癌；巨噬細(xì)胞；肝切除術(shù)；肝移植；復(fù)發(fā)

肝癌惡性程度高，預(yù)后差，在男性癌癥相關(guān)死因中位居第2位，在女性中位居第7位[1]，肝切除術(shù)和肝移植術(shù)仍是目前肝癌治療的首選治療方法[2]。但肝切除術(shù)后復(fù)發(fā)率較高，約達(dá)70%，肝移植術(shù)后復(fù)發(fā)率也有15%左右。多數(shù)患者腫瘤復(fù)發(fā)后缺乏有效的治療方法，從而導(dǎo)致肝癌總體生存較差。尋找肝癌治療的新靶點(diǎn)，延緩腫瘤復(fù)發(fā)，延長(zhǎng)患者生存是目前肝癌研究的熱點(diǎn)。肝癌腫瘤微環(huán)境中的炎癥和免疫細(xì)胞在腫瘤的發(fā)生發(fā)展過程中起重要作用。其中腫瘤相關(guān)巨噬細(xì)胞（tumor-associated macrophages，TAM）作為重要的炎癥細(xì)胞，能表達(dá)多種細(xì)胞因子和趨化因子介導(dǎo)免疫反應(yīng)，影響肝癌的侵襲和轉(zhuǎn)移。本文對(duì)相關(guān)文獻(xiàn)進(jìn)行綜述。

1　巨噬細(xì)胞與肝切除術(shù)后復(fù)發(fā)

1.1巨噬細(xì)胞簡(jiǎn)介

巨噬細(xì)胞是一種免疫細(xì)胞，自單核細(xì)胞分化而來，其具有多種生物學(xué)功能，如抗原呈遞、器官重塑、炎癥調(diào)節(jié)、免疫誘導(dǎo)等。腫瘤微環(huán)境中的巨噬細(xì)胞能促進(jìn)血管生成、細(xì)胞外基質(zhì)的破壞和重塑，并引發(fā)腫瘤細(xì)胞向血管內(nèi)遷移[3]。多種腫瘤中已證實(shí)，腫瘤微環(huán)境中TAM數(shù)量增加者預(yù)后不佳[4]。巨噬細(xì)胞在激活狀態(tài)時(shí)，根據(jù)細(xì)胞表面受體和功能特征不同，分為經(jīng)典激活型巨噬細(xì)胞（M1）和選擇性激活型巨噬細(xì)胞（M2）兩種亞型。巨噬細(xì)胞的分化受到不同細(xì)胞因子的調(diào)節(jié)，干擾素-γ（interferon γ，IFN-γ）能誘導(dǎo)巨噬細(xì)胞向M1方向分化，白介素4（interleukin 4，IL-4）能誘導(dǎo)巨噬細(xì)胞向M2方向分化。M2具有免疫調(diào)節(jié)作用，能促進(jìn)腫瘤侵襲[5]。

1.2TAM

TAM能促進(jìn)肝癌的侵襲和轉(zhuǎn)移，導(dǎo)致肝切除術(shù)后復(fù)發(fā)，同時(shí)TAM也具有抑制肝癌侵襲轉(zhuǎn)移的作用。

肝臟中巨噬細(xì)胞又稱為庫(kù)普弗細(xì)胞，該類型細(xì)胞激活后能促進(jìn)肝臟炎癥的發(fā)生，并進(jìn)而促進(jìn)肝癌的發(fā)展。許多研究證實(shí)TAM與肝癌患者術(shù)后預(yù)后相關(guān)。Ding等[6]報(bào)道腫瘤內(nèi)浸潤(rùn)的巨噬細(xì)胞高者術(shù)后生存率和無病生存率均低，其可能機(jī)制為腫瘤內(nèi)巨噬細(xì)胞的表型呈現(xiàn)出IL-10高表達(dá)而人白細(xì)胞抗原DR（human leukocyte antigen DR，HLA-DR）低表達(dá)的狀態(tài)，即HLA-DRlow/IL-10high狀態(tài)，而該狀態(tài)能夠抑制抗腫瘤免疫，從而促進(jìn)腫瘤進(jìn)展。2013年有研究發(fā)現(xiàn)CD68+巨噬細(xì)胞密度高與患者術(shù)后無病生存率低具有相關(guān)性，而CD163+巨噬細(xì)胞則與患者術(shù)后預(yù)后不相關(guān)，僅與肝臟的炎癥程度相關(guān)[7]。2015年Yeung等[8]報(bào)道M2型巨噬細(xì)胞具有促進(jìn)腫瘤血管生成，抑制抗腫瘤免疫等作用，癌旁組織中CD163+M2表達(dá)水平與術(shù)后復(fù)發(fā)相關(guān)，同時(shí)與腫瘤多灶和靜脈浸潤(rùn)相關(guān)，具體機(jī)制為M2能通過趨化因子CCL22通路和促進(jìn)上皮間質(zhì)轉(zhuǎn)化（epithelial-mesenchymal transition，EMT）而發(fā)揮促腫瘤作用。2014年Zhu等[9]研究發(fā)現(xiàn)癌旁組織中巨噬細(xì)胞和骨橋蛋白均表達(dá)上調(diào)時(shí)腫瘤復(fù)發(fā)時(shí)間縮短。Fan等[10]研究發(fā)現(xiàn)TAM能通過TGF-β1介導(dǎo)的EMT過程促進(jìn)肝癌細(xì)胞朝腫瘤干細(xì)胞方向分化而促進(jìn)腫瘤的遷移、浸潤(rùn)和轉(zhuǎn)移，從而影響患者肝切除術(shù)后的預(yù)后。Wan等[11]研究發(fā)現(xiàn)TAM可通過IL-6/STAT3信號(hào)通路促進(jìn)肝癌腫瘤干細(xì)胞增殖，進(jìn)而促進(jìn)腫瘤生長(zhǎng)。2015年Kang等[12]報(bào)道肝癌腫瘤組織中巨噬細(xì)胞表達(dá)增多與衛(wèi)星灶、血管侵犯、淋巴結(jié)轉(zhuǎn)移等病理指標(biāo)正相關(guān)，同時(shí)患者術(shù)后生存期短，且TAM數(shù)目增多的患者共刺激分子B7類似物3（costimulatory molecule B7 homologue 3，B7-H3）表達(dá)上調(diào)，進(jìn)一步的細(xì)胞實(shí)驗(yàn)發(fā)現(xiàn)B7-H3能通過介導(dǎo)STAT3信號(hào)通路促進(jìn)人單核細(xì)胞向M2細(xì)胞分化發(fā)揮促腫瘤作用。2014年Fujita等[13]報(bào)道腫瘤相關(guān)巨噬細(xì)胞能夠促進(jìn)腫瘤血管的生成，特別是對(duì)于高分化肝癌作用更為明顯。以上的研究顯示，TAM能夠抑制抗腫瘤免疫、促進(jìn)腫瘤血管生成和影響EMT過程，影響肝癌細(xì)胞的侵襲和轉(zhuǎn)移，進(jìn)而影響患者的預(yù)后，因此可作為肝癌的治療的潛在靶點(diǎn)[14]。TAM既能促進(jìn)肝癌侵襲轉(zhuǎn)移，同時(shí)也具有抑制肝癌侵襲轉(zhuǎn)移的作用。有學(xué)者指出巨噬細(xì)胞在受到不同激活條件影響時(shí)，會(huì)出現(xiàn)促進(jìn)腫瘤生長(zhǎng)、抑制宿主免疫和殺傷腫瘤細(xì)胞、維持腫瘤免疫這兩種不同的作用[15]。中國(guó)學(xué)者報(bào)道了高水平的瘤內(nèi)浸潤(rùn)TAM是肝切除術(shù)后無病生存率較好的獨(dú)立預(yù)后因素[16]。

2　巨噬細(xì)胞相關(guān)因子與肝切除術(shù)后復(fù)發(fā)

2014年Yan等[17]研究發(fā)現(xiàn)巨噬細(xì)胞中T細(xì)胞免疫球蛋白黏蛋白分子3（T cell immunoglobulin and mucin-domain containing protein-3，Tim-3）表達(dá)上調(diào)者肝癌細(xì)胞分化差，并且術(shù)后生存期短，進(jìn)一步的細(xì)胞實(shí)驗(yàn)顯示轉(zhuǎn)化生長(zhǎng)因子β（transforming growth factor，TGF-β）能夠通過上調(diào)Tim-3促進(jìn)TAM轉(zhuǎn)化為M2，M2產(chǎn)生IL-6等細(xì)胞因子促進(jìn)腫瘤生長(zhǎng)和侵襲。2014年Lanaya報(bào)道肝癌腫瘤細(xì)胞中巨噬細(xì)胞表皮生長(zhǎng)因子受體（epidermal growth factorReceptor，EGFR）表達(dá)陽性的患者較EGFR表達(dá)陰性的患者接受肝切除或肝移植術(shù)后總生存率和無病生存率均較低，進(jìn)一步的動(dòng)物實(shí)驗(yàn)表明巨噬細(xì)胞能通過表達(dá)EGFR而促進(jìn)IL-6的分泌來促進(jìn)腫瘤進(jìn)展[18]。巨噬細(xì)胞移動(dòng)抑制因子（macrophage migration inhibitory factor，MIF）是一種由巨噬細(xì)胞、嗜酸性粒細(xì)胞、活化的T細(xì)胞等多種炎癥和免疫相關(guān)細(xì)胞產(chǎn)生的細(xì)胞因子，在機(jī)體炎癥和免疫過程中發(fā)揮著重要作用，同時(shí)也有研究發(fā)現(xiàn)MIF在腫瘤發(fā)生中有重要作用，它能夠控制細(xì)胞增殖、分化、血管生成和腫瘤進(jìn)展[19]。Hira等[20]研究發(fā)現(xiàn)腫瘤內(nèi)MIF表達(dá)水平與腫瘤微血管密度呈正相關(guān)，MIF高水平表達(dá)是肝切除術(shù)后無病生存率低的獨(dú)立預(yù)后因素，且認(rèn)為這可能是與MIF調(diào)節(jié)腫瘤血管生成有關(guān)。我國(guó)學(xué)者趙一鳴等研究血清中的MIF水平與肝癌切除術(shù)后預(yù)后的關(guān)系時(shí)發(fā)現(xiàn)，術(shù)前高水平的血清MIF與患者術(shù)后無病生存率低顯著相關(guān)[21]。2013年Wang等[22]研究發(fā)現(xiàn)肝癌患者血清MIF水平和血管內(nèi)皮生長(zhǎng)因子（vascular endothelial growth factor，VEGF）水平正相關(guān)，活化MIF/ VEGF能夠促進(jìn)肝癌的增殖、侵襲、轉(zhuǎn)移。2009年夏金堂等[23]報(bào)道肝癌組織中MIF和Cyclin D1在肝癌組織中過表達(dá)。而后，Huang等[24]研究發(fā)現(xiàn)肝癌組織中MIF的表達(dá)與細(xì)胞周期素D1正相關(guān)，并且應(yīng)用MIF敲除的人肝癌細(xì)胞系建立小鼠移植瘤模型，結(jié)果發(fā)現(xiàn)MIF敲除后能抑制生長(zhǎng)相關(guān)因子的表達(dá)和誘導(dǎo)凋亡蛋白的表達(dá)，從而抑制腫瘤生長(zhǎng)。巨噬細(xì)胞另一相關(guān)因子是巨噬細(xì)胞集落刺激因子（macrophage colony-stimulating factors，MCSF）。腫瘤發(fā)生過程中MCSF能促進(jìn)巨噬細(xì)胞浸潤(rùn)，導(dǎo)致腫瘤血管形成。有學(xué)者報(bào)道腫瘤旁肝臟組織中MCSF高水平表達(dá)是影響患者術(shù)后無病生存率的不良預(yù)后因素[25]。此外，動(dòng)物實(shí)驗(yàn)表明MCSF-1能通過和巨噬細(xì)胞集落刺激因子受體（macrophage colony-stimulating factor-1Receptor，MCSF-1R）結(jié)合，引發(fā)巨噬細(xì)胞的促腫瘤生長(zhǎng)作用，影響患者預(yù)后[26]。Jia等[27]研究發(fā)現(xiàn)，瘤旁組織中MCSF-1R高表達(dá)水平的患者，術(shù)后復(fù)發(fā)率高，生存期短。由此可見巨噬細(xì)胞相關(guān)因子能通過調(diào)節(jié)腫瘤血管生成，參與凋亡，發(fā)揮促進(jìn)肝癌侵襲轉(zhuǎn)移，影響患者術(shù)后復(fù)發(fā)的作用。

總之，巨噬細(xì)胞和相關(guān)細(xì)胞因子能夠影響肝癌細(xì)胞生物學(xué)行為，從而促進(jìn)肝癌的侵襲和轉(zhuǎn)移。測(cè)定巨噬細(xì)胞及相關(guān)因子水平對(duì)判斷肝癌肝切除術(shù)后患者的預(yù)后具有重要價(jià)值，同時(shí)也是肝癌治療的潛在靶點(diǎn)。這也需要更多臨床和基礎(chǔ)研究來進(jìn)一步證實(shí)這些免疫指標(biāo)的有效性。

[1]Torre LA,Bray F,SiegelRL,et al.Global cancer statistics, 2012[J].CACancer J Clin,2015,65(2):87-108.

[2]徐意瑤,楊華瑜,楊曉波,等.肝癌術(shù)后復(fù)發(fā)患者96例臨床分析[J].癌癥進(jìn)展,2013,11(5):489-492.

[3]Condeelis J,Pollard JW.Macrophages:obligate partners for tumor cell migration,invasion,and metastasis[J].Cell, 2006,124(2):263-266.

[4]Siveen KS,Kuttan G.Role of macrophages in tumor progression[J].Immunol Lett,2009,123(2):97-102.

[5]Shirabe K,Mano Y,Muto J,et al.Role of tumor-associated macrophages in the progression of hepatocellular carcinoma [J].Surg Today,2012,42(1):1-7.

[6]Ding T,Xu J,Wang F,et al.High tumor-infiltrating macrophage density predicts poor prognosis in patients with primary hepatocellular carcinoma afterResection[J].Hum Pathol,2009,40(3):381-389.

[7]Kong LQ,Zhu XD,Xu HX,et al.The clinical significance of the CD163+and CD68+macrophages in patients with hepatocellular carcinoma[J].PLoS One,2013,8(3):e59771.

[8]Yeung OW,Lo CM,Ling CC,et al.Alternatively activated (M2)macrophages promote tumour growth and invasiveness in hepatocellular carcinoma[J].J Hepatol,2015,62(3): 607-616.

[9]Zhu W,Guo L,Zhang B,et al.Combination of osteopontin with peritumoral infiltrating macrophages is associated with poor prognosis of early-stage hepatocellular carcinoma after curativeResection[J].Ann Surg Oncol,2014,21 (4):1304-1313.

[10]Fan QM,Jing YY,Yu GF,et al.Tumor-associated macrophages promote cancer stem cell-like properties via trans-forming growth factor-beta1-induced epithelial-mesenchymal transition in hepatocellular carcinoma[J].Cancer Lett, 2014,352(2):160-168.

[11]Wan S,Zhao E,Kryczek I,et al.Tumor-associated macrophages produce interleukin 6 and signal via STAT3 to promote expansion of human hepatocellular carcinoma stem cells[J].Gastroenterology,2014,147(6):1393-1404.

[12]Kang FB,Wang L,Li D,et al.Hepatocellular carcinomas promote tumor-associated macrophage M2-polarization via increased B7-H3 expression[J].OncolRep,2015,33 (1):274-282.

[13]Fujita N,Nishie A,Aishima S,et al.Role of tumor-associated macrophages in the angiogenesis of well-differentiated hepatocellular carcinoma:pathological-radiological correlation[J].OncolRep,2014,31(6):2499-2505.

[14]Heindryckx F,Gerwins P.Targeting the tumor stroma in hepatocellular carcinoma[J].World J Hepatol,2015,7(2): 165-176.

[15]Heusinkveld M,van der Burg SH.Identification and manipulation of tumor associated macrophages in human cancers[J].J Transl Med,2011,9:216.

[16]Li YW,Qiu SJ,Fan J,et al.Tumor-infiltrating macrophages can predict favorable prognosis in hepatocellular carcinoma afterResection[J].J CancerRes Clin Oncol, 2009,135(3):439-49.

[17]Yan W,Liu X,Ma H,et al.Tim-3 fosters HCC development by enhancing TGF-β-mediated alternative activation of macrophages[J].Gut,2015,64(10):1593-1604.

[18]Lanaya H,Natarajan A,Komposch K,et al.EGFR has a tumour-promotingRole in liver macrophages during hepatocellular carcinoma formation[J].Nat Cell Biol,2014,16 (10):972-81,1-7.

[19]Han Y,Zhang C.Macrophage migration inhibitory factor plays a pivotalRole in hepatocellular carcinoma and may be a noninvasive imaging target[J].Med Hypotheses, 2010,75(6):530-532.

[20]Hira E,Ono T,Dhar DK,et al.Overexpression of macrophage migration inhibitory factor induces angiogenesis and deteriorates prognosis afterRadicalResection for hepatocellular carcinoma[J].Cancer,2005,103(3):588-598.

[21]Zhao YM,Wang L,Dai Z,et al.Validity of plasma macrophage migration inhibitory factor for diagnosis and prognosis of hepatocellular carcinoma[J].Int J Cancer,2011, 129(10):2463-2472.

[22]Wang D,Luo L,Chen W,et al.Significance of the vascular endothelial growth factor and the macrophage migration inhibitory factor in the progression of hepatocellular carcinoma[J].OncolRep,2014,31(3):1199-1204.

[23]夏金堂,伍兆鋒,李雯,等.MIF和Cyclin D1在肝細(xì)胞癌中的表達(dá)[J].中華普通外科雜志,2009,24(5):398-401.

[24]Huang XH,Jian WH,Wu ZF,et al.Small interferingRNA (siRNA)-mediated knockdown of macrophage migration inhibitory factor(MIF)suppressed cyclin D1 expression and hepatocellular carcinoma cell proliferation[J].Oncotarget,2014,5(14):5570-5580.

[25]Zhu XD,Zhang JB,Zhuang PY,et al.High expression of macrophage colony-stimulating factor in peritumoral liver tissue is associated with poor survival after curativeResection of hepatocellular carcinoma[J].J Clin Oncol,2008,26 (16):2707-2716.

[26]Kluger HM,Dolled-Filhart M,Rodov S,et al.Macrophage colony-stimulating factor-1Receptor expression is associated with poor outcome in breast cancer by large cohort tissue microarray analysis[J].Clin CancerRes,2004, 10(1):173-177.

[27]Jia JB,Wang WQ,Sun HC,et al.High expression of macrophage colony-stimulating factor-1Receptor in peritumoral liver tissue is associated with poor outcome in hepatocellular carcinoma after curativeResection[J].Oncologist, 2010,15(7):732-743.

R735.7

A

10.11877/j.issn.1672-1535.2016.14.01.09

（corresponding author），郵箱：yangzhy@aliyun.com

2015-07-05）