科普專欄–薯不揀單 - 深入淺出–免疫治療(Immunotherapy)手段醫治癌症

以免疫治療(Immunotherapy)手段醫治癌症，絕對是人類在醫學界踏出的「月球一小步」;2029Please respect copyright.ＰＥＮＡＮＡ8WL1hh106d
2018年的醫學諾貝爾得獎者，亦是因為對免疫治療方面作出了無比重要的貢獻因而獲獎。2029Please respect copyright.ＰＥＮＡＮＡkMrKYbPvak
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對比傳統的化療，免疫治療不但不會引起脫髮等副作用，病人的存活率更會比傳統化療的顯著為長，但略為遺憾的是並不是所有人及所有的癌症也能從免疫治療中獲益。2029Please respect copyright.ＰＥＮＡＮＡGXLtLVFrPv
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今次的深入淺出，將會為大家講解免疫治療的原理及解釋箇中的好處。2029Please respect copyright.ＰＥＮＡＮＡBuw33Z0hMS
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（圖1）正常細胞(Normal Cell)進行繁殖的時候，無可避免會出現DNA變異。我們的細胞雖有著完善的機制可即時修正錯誤，但隨著年紀歲數的增長，修正DNA錯誤的效率亦會相對減低，最終造就DNA出現變異。2029Please respect copyright.ＰＥＮＡＮＡKz1MawFRUY
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而當細胞DNA出現變異後，我們的免疫細胞T cell會將其視作為外來物，把變異細胞殲滅。2029Please respect copyright.ＰＥＮＡＮＡhV9VfHFp3L
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可是，若然變異細胞發展出躲避免疫系統的機制，而又累積一定程度的基因變異，便會獲得無驅無束般繁殖的能力，形成腫瘤。2029Please respect copyright.ＰＥＮＡＮＡ2MCe3c7LR8
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（圖2）癌細胞躲避免疫系統機制的方法有很多種，較為常見的是PD1（Programmed cell death protein1)系統。2029Please respect copyright.ＰＥＮＡＮＡIA1KqAFUGD
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我們的T cell會依靠癌細胞與別不同的蛋白質（Neoantigen)來作出辨認，並將變異細胞殲滅。2029Please respect copyright.ＰＥＮＡＮＡPHjdowcKu3
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但是若果變異細胞的表面產生名為PDL1的蛋白質，它便能夠與T Cell的PD1作出合併，因此觸發一系列的機制，大幅度銳弱T cell殺滅變異細胞的能力，導致T cell再也不能消滅自己。2029Please respect copyright.ＰＥＮＡＮＡVlefc1E2rJ
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形象化的來說，若果癌細胞穿上「我愛警察」的衣服（PDL1)後，擁有PD1警棍的黑警便會立刻手軟，放生癌細胞離開，讓癌細胞繼續任意妄為。2029Please respect copyright.ＰＥＮＡＮＡ27jmdFfJF3
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換句話說，癌細胞只要能夠產生PDL1，就能夠逃避T cell的追捕及殺滅;2029Please respect copyright.ＰＥＮＡＮＡmpOHQ6wUns
相對上，皮膚癌及肺癌的癌細胞較大機會出現PDL1。2029Please respect copyright.ＰＥＮＡＮＡJQEyJUJ1ue
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（圖3）既然了解得到PDL1/PD1的關係，那麼對付的方法顯然變得非常簡單，只要把對應的抗體送到體內，阻截PDL1及PD1合併便可。2029Please respect copyright.ＰＥＮＡＮＡjftsjzSrFD
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以下為現今運用在治療中及臨床研究中的抗體整理。2029Please respect copyright.ＰＥＮＡＮＡAeFcWR1YUA
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阻擋PD1的抗體:2029Please respect copyright.ＰＥＮＡＮＡ2sPjEwn70C
1.Nivolumab (FDA approved)2029Please respect copyright.ＰＥＮＡＮＡ1ljKoW7ESN
2.Pembrolizumab (FDA approved)2029Please respect copyright.ＰＥＮＡＮＡGhAx0pkZHw
3.Pidilizumab2029Please respect copyright.ＰＥＮＡＮＡeNncw7jOBp
4.MEDI-06802029Please respect copyright.ＰＥＮＡＮＡNsGAiFKc1S
4.PDR0012029Please respect copyright.ＰＥＮＡＮＡ6LivVsDMgF
5.REGN28102029Please respect copyright.ＰＥＮＡＮＡEfqmnVZSHV
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阻擋PDL1的抗體:2029Please respect copyright.ＰＥＮＡＮＡjaXRiSkZLv
1.Atezolimumab2029Please respect copyright.ＰＥＮＡＮＡxtdQFksA1W
2.Durvalumab2029Please respect copyright.ＰＥＮＡＮＡu87lBwkN2N
3.Avelumab2029Please respect copyright.ＰＥＮＡＮＡ3dvSXDenRj
4.MDX-11052029Please respect copyright.ＰＥＮＡＮＡL4dsaMI7G5
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簡單來說，就是利用抗體來阻截PD1/PDL1，促使癌細胞無法逃避免疫細胞的追捕，被迫接收免疫細胞的制裁。2029Please respect copyright.ＰＥＮＡＮＡepTe9kYAbM
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（圖4）為突顯Immunotherapy（免疫系統治療）的好處，我們可以找一個Chemotherapy(化療)的例子作出比較。2029Please respect copyright.ＰＥＮＡＮＡRahbE5ZeRH
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針對癌細胞出現X變異，我們便用上針對X變異的化療藥物醫治。2029Please respect copyright.ＰＥＮＡＮＡClmRjxf04Q
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在初期，此方法可能會有奇效，但是隨著時間推進，沒有死去的話癌細胞便會發展出不同抗藥機制，導致藥物失效。2029Please respect copyright.ＰＥＮＡＮＡ65qzAb8Z8b
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譬如說，X變異變成Y變異，導致只針對X變異的藥物再也沒能針對自己。2029Please respect copyright.ＰＥＮＡＮＡqjrEJgO3tS
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又或者，癌細胞會產生蛋白質將藥物帶出細胞外，現今有著不同真實例子顯示出還有各種不同的機制，在這裡不便詳列。2029Please respect copyright.ＰＥＮＡＮＡuD0SDmcxJC
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（圖5）但是，在免疫系統治療方面來說，無論癌細胞如何變異也好，它們始終亦會被T cell界定為外來之物，成為被殲滅的目標。2029Please respect copyright.ＰＥＮＡＮＡG9NdlCuka4
甚之乎，越多的變異反而會更容易令T cell被認出為外來之物，更易被成為T cell的目標。2029Please respect copyright.ＰＥＮＡＮＡ9yMt8FehmS
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在這裡，我們可以看得出免疫治療的精髓所在。2029Please respect copyright.ＰＥＮＡＮＡORDjYHVRLB
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免疫治療的方針並不是在針對癌細胞自身，而是針對癌細胞逃避免疫系統細胞的機制。2029Please respect copyright.ＰＥＮＡＮＡJ4xmMSmzHh
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在此，我們只是讓免疫系統回復正常運作，糾正它們懂得把癌細胞辨認為外來物，並把外來物消除。2029Please respect copyright.ＰＥＮＡＮＡTlaKibUKW0
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這方法根本上沒有額外改動身體的機制，有部份病人可能會出現輕微作嘔感覺，但大部份人士並不會遭受脫髮、食慾不振、手軟腳軟、血球細胞出現問題等等會在化療時候遭受得到的副作用！2029Please respect copyright.ＰＥＮＡＮＡ9jCzcpWEQy
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只不過的是，普遍來說一整個免疫治療至少需要美金150,000才能進行，而且若然癌細胞並沒有產生大量PDL1的話，這方法亦不會太過有效。2029Please respect copyright.ＰＥＮＡＮＡGctNB2ttBR
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對此，現時科學家亦研發出不同手段針對這個問題，若然大家對這話題有興趣的話，請正評以及回覆此Post，我會視乎反應寫出下集講解現時免疫治療的最新發展、成果及所面對著的問題。2029Please respect copyright.ＰＥＮＡＮＡoN6YANIZtd
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希望大家看完這篇文章後，會領略得到免疫治療的原理及與化療手段的根本性分別。2029Please respect copyright.ＰＥＮＡＮＡsdHmA39gpS
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如果想我快啲出文的話，請入去Penana網站科普專欄–薯不揀單俾一個like以及Bookmark，這對我非常之重要。2029Please respect copyright.ＰＥＮＡＮＡh2D7cC12We
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