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研究生:翁瑞宏
研究生(外文):Ruey-Hong Wong
論文名稱:氯乙烯暴露工人世代研究
論文名稱(外文):COHORT STUDY OF VINYL CHLORIDE EXPOSED WORKERS
指導教授:鄭尊仁鄭尊仁引用關係
指導教授(外文):Tsun-Jen Cheng
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:職業醫學與工業衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文出版年:2001
畢業學年度:89
語文別:中文
論文頁數:271
中文關鍵詞:氯乙烯肝癌標準化死亡比肝硬化B型肝炎病毒CYP2E1基因XRCC1基因姊妹染色分體交換
外文關鍵詞:vinyl chlorideliver cancerstandardized mortality ratioliver cirrhosishepatitis B virusCYP2E1 geneXRCC1genesister chromatid change
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台灣氯乙烯聚合工業 (polyvinyl chloride [PVC]) 已有五十年以上的歷史,過去至今約有三千五百人從事生產,並且長期暴露於氯乙烯 (vinyl chloride monomer [VCM]) 者為數不少,相信在族群中,將會有因氯乙烯暴露所引發的相關疾病病患陸續出現;所以氯乙烯暴露族群的長期追蹤是相當必要,而長期追蹤工作則有賴於完善研究世代的建立。
本研究利用回溯性世代研究法,進行台灣氯乙烯聚合工人各種死因之標準化死亡比 (standardized mortality ratio [SMR]) 分析。收集於1950年1月1日至1991年12月31日間進入工廠工作,年資在一年以上,並且於1985年1月1日仍存活的3,293名男性工人納入分析。利用衛生署死亡登記檔,追蹤世代成員自1985至1997年間之存活狀況,共有144名工人死亡;死因分析結果發現,第一次進廠年代在1970年以前的暴露工人,其肝癌標準化死亡比最具顯著相關 (SMR = 482.4,95% confidence interval [C.I.] = 240.5 - 863.2),臨床證據也指出罹患肝癌的本研究世代成員,大多為肝細胞癌 (hepatocellular carcinoma [HCC])。
氯乙烯暴露已被發現與肝硬化、肝癌具有統計相關;台灣的研究也發現,大部分罹患肝硬化或肝癌的氯乙烯暴露工人,具有B型肝炎病毒 (hepatitis B virus [HBV]) 感染。為了探討B型肝炎病毒在氯乙烯暴露工人之肝硬化或肝癌發展歷程中所扮演的角色,我們利用原先所建立的氯乙烯世代,進行病例對照研究;共收集40名肝硬化、肝癌病例與155名對照之氯乙烯暴露工人進行分析。當以B型肝炎病毒表面抗原陰性者中,從未參與清槽工作並且非1970年以前即被雇用之工人為參考組,則B型肝炎病毒表面抗原陰性者中,曾經參與清槽工作並且在1970年以前即被雇用之工人,具有3.8倍的肝硬化、肝癌相對危險性 (95% [C.I.] = 0.8 - 17.7);B型肝炎病毒表面抗原陽性者中,從未參與清槽工作並且非1970年以前即被雇用之工人,具有9.0倍的肝硬化、肝癌相對危險性 (95% C.I. = 3.3 - 25.0);而B型肝炎病毒表面抗原陽性者中,曾參與清槽工作並且在1970年以前即被雇用之工人,具有最高的相對危險性 (matched odd ratio [ORm] = 26.3;95% C.I. = 2.7 - 261.0)。因此,我們的結果證實了職業性氯乙烯暴露與B型肝炎病毒感染對於肝硬化或肝癌的發展,具有協同性交互作用存在。
雖然氯乙烯暴露與肝癌的關係已經被清楚地建立,但是氯乙烯所引起的致癌機轉,至今並不明瞭。因此,我們探討代謝及DNA修補基因多形性與氯乙烯暴露所導致的突變p53蛋白以及anti-p53抗體表現之關係。研究對象是333名男性氯乙烯暴露工人;結果顯示在調整年齡及抽菸的作用後,相較於具有X-ray repair cross-complementing group 1 (XRCC1,exon 10) Arg-Arg / Arg-Gln基因型的氯乙烯低暴露組工人,具有XRCC1 Gln-Gln基因型的氯乙烯高暴露組工人,呈現明顯的p53過度表現之危險 (odds ratio [OR] = 6.4;95% C.I. = 1.8 - 23.5);有趣的是,氯乙烯低暴露組工人中具有細胞色素P450 2E1 (cytochrome P450 2E1 [CYP2E1]) c2c2基因型者,相較於氯乙烯低暴露組工人中具有CYP2E1 c1c1 / c1c2基因型者,也呈現出p53過度表現之顯著危險 (OR = 8.2;95% C.I. = 1.0 - 69.8)。進一步的分析顯示,具有愈多易感性基因型的個人,可能具有愈高的p53過度表現之機會。因此,易感性的XRCC1和CYP2E1基因型,對於氯乙烯所導致的p53突變具有修飾作用。
氯乙烯是種致烷基化劑,容易引起姊妹染色分體交換 (sister chromatid exchange [SCE]);代謝及DNA修補基因多形性已經被認為與化學暴露所導致的致癌性有關,也與姊妹染色分體交換頻率相關;工人若具有遺傳易感性代謝與DNA修補基因型,可能呈現出較高的基因毒性之危險。因此,我們對於易感性代謝與DNA修補基因型,是否與氯乙烯暴露工人之姊妹染色分體交換 (sister chromatid exchange [SCE]) 頻率相關也加以探討。研究對象由61名男性氯乙烯暴露工人,與29名男性對照工人所組成。結果顯示抽菸狀態、年齡和氯乙烯暴露,與姊妹染色分體交換頻率的增加,呈現顯著相關。在調整年齡、抽菸狀態、與氯乙烯暴露的效應後,迴歸模式 (general liner model [GLM]) 分析也顯示姊妹染色分體交換頻率與XRCC1 (P = 0.04)、CYP2E1 (P = 0.03) 和乙醛脫氫酶 (aldehyde dehydrogenase 2 [ALDH2];P = 0.06) 具有統計顯著相關。進一步分析包括CYP2E1、ALDH2及XRCC1的基因合併效應,整體顯示在氯乙烯低暴露組 (P < 0.01) 中,當個人具有愈多的易感性基因型,對於姊妹染色分體交換頻率也具有增加的趨勢;然而相同的趨勢,在氯乙烯高暴露組 (P = 0.29) 以及對照組 (P = 0.49) 中並未發現。因此,易感性的代謝與DNA修補基因型,可能對於氯乙烯所導致的DNA傷害,具有增加的危險。
本研究建立職業暴露世代,探討氯乙烯職業暴露所引起的健康危害,歸納出氯乙烯聚合工人較一般台灣男性族群容易罹患肝癌;特別是在1970年以前暴露於氯乙烯的工人,以及同時具有B型肝炎病毒感染者。暴露工人若攜帶有愈多的易感性基因型,特別是XRCC1 Gln-Gln和CYP2E1 c2c2基因型,就愈容易增加氯乙烯所導致的p53突變與姊妹染色分體交換頻率的危險性。
Abstract
Production of polyvinyl chloride (PVC) has been developed in Taiwan since the 1950s, approximately 3,500 employees have been involved in this process. Many workers have been exposed to high concentrations of vinyl chloride monomer (VCM). Thus, we suspect that related patients caused by VCM will appear in succession in this occupational population. Long-term follow-up for this exposed population is necessary, which is depended upon the establishment of study cohort.
In our study, a retrospective cohort study was conducted, and the standardized mortality ratio (SMR) corresponding to different causes of death was determined for Taiwanese PVC workers. A total of 3,293 male workers who had been employed for at least one year during the period January 1, 1950 to December 31, 1992, and had been alive as of January 1, 1985 were included for analysis. Using data acquired from Taiwan''s National Mortality Registry, it would appear that one hundred and forty-four of these workers died during the period 1985 to 1997. The SMR due to liver cancer revealed that the association was prominent for workers who were first employed in the industry prior to 1970 (SMR = 482.4, 95% confidence interval [C.I.] = 240.5 - 863.2). Medical record also indicated that most of liver cancers in this study were hepatocellular carcinoma (HCC).
Liver cirrhosis or liver cancer have previously been associated with VCM exposure. In Taiwanese studies, the majority of VCM exposed workers with liver cirrhosis or liver cancer experienced hepatitis B virus (HBV) infection. To determine the role of HBV on the development of liver cirrhosis or liver cancer in these VCM exposed workers, we conducted a case-control study from a previously established PVC cohort. A total of 40 cases of liver cirrhosis and/or liver cancer, and 155 controls with VCM exposure were selected. When those hepatitis B virus surface antigen (HBsAg)- negative subjects with neither a history of tank-cleaning nor PVC-industry employment prior to 1970 were used as a reference, those HBsAg-negative subjects with a history of both tank-cleaning and PVC-industry employment prior to 1970, demonstrated a 3.8-fold greater risk of liver cirrhosis and/or liver cancer (95% C.I. = 0.8 - 17.7), those HBsAg carriers with neither a history of tank-cleaning nor PVC-industry employment prior to 1970 revealed a 9.0-fold greater risk of liver cirrhosis and/or liver cancer (95% C.I. = 3.3 - 25.0), whereas those HBsAg carriers with a history of both tank-cleaning and PVC-industry employment prior to 1970 revealed the greatest risk (matched odds ratio [ORm] = 26.3; 95% C.I. = 2.7 - 261.0). Thus, our results demonstrated a synergism between occupational VCM exposure and HBV infection on the development of liver cirrhosis or liver cancer.
Although the relationship between VCM exposure and liver cancer is established, the mechanism of VCM-related carcinogenesis remains indistinct. Therefore, we explored the association between polymorphisms of metabolic and DNA repair genes with mutant p53 protein and anti-p53 antibody expression induced by VCM. Study subjects consisted of 333 male workers with VCM exposure. After adjusting the effects of age and smoking, the results showed that p53 over-expression was more prominent in individuals with high VCM exposure and X-ray repair cross- complementing group 1 (XRCC1, exon 10) Gln-Gln genotype (odds ratio [OR] = 6.4; 95% C.I. = 1.8 - 23.5) as compared to those with low VCM exposure and XRCC1 Arg-Arg / Arg-Gln genotypes. Interesting, those with cytochrome P450 2E1 (CYP2E1) c2c2 genotype in low VCM exposure group had a greater risk of p53 over-expression (OR = 8.2; 95% C.I. = 1.0 - 69.8) compared to those with low VCM exposure and CYP2E1 c1c1 / c1c2 genotypes. Further analysis revealed that individuals with more susceptible genotypes were more likely to have p53 over-expression. Thus, susceptible XRCC1 and CYP2E1 genotypes may have modulate effects on VCM-induced p53 mutation.
Vinyl chloride monomer is an alkylating agent, which can readily induce the sister chromatid exchange (SCE). Metabolic and DNA repair genotypes have been implicated in the VCM related carcinogenesis, and associated with SCE. When workers with inherited susceptible metabolic and DNA repair genotypes might have an altered risk of genotoxiciy. Thus, we also investigated whether metabolic and DNA repair genotypes were associated with SCE frequency in PVC workers. Study subjects consisted of 61 male workers with VCM exposure and 29 male controls. Analysis revealed that smoking status, age and exposure to VCM were significantly associated with increased SCE frequency. After adjusting the effects of age, smoking, and VCM exposure, general liner model (GLM) analysis also revealed obvious associations for SCE frequency with XRCC1 (P = 0.04), CYP2E1 (P = 0.03), and aldehyde dehydrogenase 2 (ALDH2; P = 0.06). Further analysis of gene combinations, including CYP2E1, ALDH2 and XRCC1, together revealed an increased trend for these genotypes on SCE frequencies in the low (P < 0.01) VCM exposure group. Therefore, VCM exposed workers with susceptible metabolic and DNA repair genotypes, may have an increased risk of DNA damage caused by VCM.
We established an occupational exposure cohort, and further investigated related health effects caused by VCM. The results summarized that PVC workers had a higher risk of developing liver cancer compared to general Taiwanese male population, especially for those first exposure occurred before 1970, and those with HBV infection concurrently. When VCM exposed workers with the more susceptible genotypes, especially XRCC1 Gln-Gln and CYP2E1 c2c2 genotypes, had a higher risk on p53 mutation and the elevation of SCE frequency.
目錄
頁次
中文摘要------------------------------------------------------------------------------------------i
Abstract------------------------------------------------------------------------------------------iv
目錄------------------------------------------------------------------------------------------vii
圖表目錄------------------------------------------------------------------------------------------x
第一章前言------------------------------------------------------------------------------------1
研究目的------------------------------------------------------------------------------1
文獻探討------------------------------------------------------------------------------4
第一節氯乙烯的環境流布------------------------------------------------------------------4
第二節氯乙烯與相關癌症之流行病學研究--------------------------------------------- 5
第三節氯乙烯的代謝------------------------------------------------------------------------7
第四節氯乙烯與動物試驗------------------------------------------------------------------10
第五節氯乙烯與基因毒性研究------------------------------------------------------------11
第六節氯乙烯與腫瘤致癌基因、抑癌基因的研究------------------------------------16
第七節台灣的氯乙烯研究與未來方向---------------------------------------------------17
參考文獻------------------------------------------------------------------------------20
研究設計------------------------------------------------------------------------------50
第二章台灣氯乙烯聚合工人具有較高的肝癌標準化死亡比------------------------55
摘要------------------------------------------------------------------------------------55
前言------------------------------------------------------------------------------------56
材料與方法---------------------------------------------------------------------------57
氯乙烯聚合工人世代之建立---------------------------------------------------57
研究世代之合格條件------------------------------------------------------------57
研究世代死因追蹤---------------------------------------------------------------57
統計分析---------------------------------------------------------------------------58
結果------------------------------------------------------------------------------------58
描述性統計------------------------------------------------------------------------58
死因分析---------------------------------------------------------------------------59
不同暴露定義與潛伏期對於標準化死亡比的分析------------------------59
討論------------------------------------------------------------------------------------61
誌謝------------------------------------------------------------------------------------64
參考文獻------------------------------------------------------------------------------64
第三章氯乙烯暴露與B型肝炎病毒感染對於肝硬化和肝癌具有協同性交互作
用---------------------------------------------------------------------------------------73
摘要------------------------------------------------------------------------------------73
頁次
前言------------------------------------------------------------------------------------74
材料與方法---------------------------------------------------------------------------75
研究世代與病例確認------------------------------------------------------------75
對照之選擇------------------------------------------------------------------------76
問卷訪視---------------------------------------------------------------------------76
健康檢查與實驗室分析---------------------------------------------------------77
氯乙烯暴露之評估---------------------------------------------------------------77
統計分析---------------------------------------------------------------------------78
結果------------------------------------------------------------------------------------78
討論------------------------------------------------------------------------------------81
誌謝------------------------------------------------------------------------------------ 84
參考文獻------------------------------------------------------------------------------84
第四章XRCC1和CYP2E1基因型是氯乙烯暴露工人之血漿突變p53蛋白與
anti-p53抗體表現的決定因子----------------------------------------------------94
摘要------------------------------------------------------------------------------------94
前言------------------------------------------------------------------------------------95
材料與方法---------------------------------------------------------------------------98
研究對象與流行病學資料------------------------------------------------------98
氯乙烯暴露之評估---------------------------------------------------------------98
肝炎帶原狀態的決定------------------------------------------------------------99
血漿突變p53蛋白與anti-p53抗體分析-------------------------------------100
代謝與DNA修補基因型分析--------------------------------------------------101
CYP2E1-PstI基因型-----------------------------------------------------------101
ALDH2-MboII基因型---------------------------------------------------------101
GSTT1基因型------------------------------------------------------------------102
XRCC1 exon-10 -MspI基因型-----------------------------------------------102
統計分析---------------------------------------------------------------------------103
結果------------------------------------------------------------------------------------103
討論------------------------------------------------------------------------------------106
誌謝------------------------------------------------------------------------------------ 109
參考文獻------------------------------------------------------------------------------109
第五章XRCC1、CYP2E1和ALDH2基因型是氯乙烯暴露工人之姊妹染色分體
交換頻率的易感性因子------------------------------------------------------------ 122
摘要------------------------------------------------------------------------------------122
前言------------------------------------------------------------------------------------123
材料與方法---------------------------------------------------------------------------125
頁次
研究對象與流行病學資料------------------------------------------------------125
姊妹染色分體交換---------------------------------------------------------------126
代謝與DNA修補基因型分析--------------------------------------------------127
CYP2E1-PstI基因基因型----------------------------------------------------127
ALDH2-MboII基因基因型---------------------------------------------------128
GSTT1基因型------------------------------------------------------------------128
XRCC1 exon-10 -MspI基因型-----------------------------------------------129
統計分析---------------------------------------------------------------------------129
結果------------------------------------------------------------------------------------130
討論------------------------------------------------------------------------------------133
誌謝------------------------------------------------------------------------------------ 135
參考文獻------------------------------------------------------------------------------136
第六章結論------------------------------------------------------------------------------------147
肝血管肉瘤之有無------------------------------------------------------------------147
肝硬化的真實危險性---------------------------------------------------------------148
氯乙烯暴露對於肝癌之可能致病機轉------------------------------------------149
氯乙烯暴露與B型肝炎病毒對於肝硬化與肝癌之協同性交互作用-----151
氯乙烯暴露世代再追蹤之成效---------------------------------------------------152
本研究的成果與未來方向---------------------------------------------------------153
參考文獻------------------------------------------------------------------------------154
附錄一An increased standardized mortality ratio for liver cancer amongst
polyvinyl chloride workers in Taiwan --------------------------------------------162
附錄二Synergistic effects of vinyl chloride monomer exposure and hepatitis B
virus infection upon liver cirrhosis and liver cancer-----------------------------182
附錄三XRCC1 and CYP2E1 polymorphisms as determinants of plasma mutant
p53 protein and anti-p53 antibody expression in vinyl chloride exposed
workers --------------------------------------------------------------------------------207
附錄四XRCC1, CYP2E1 and ALDH2 genotypes are susceptibility factors for sister
chromatid exchange frequency in vinyl chloride exposed workers------------ 237
附錄五Effect on sister chromatid exchange frequency of aldehyde dehydrogenase
2 genotype and smoking in vinyl chloride exposed workers-------------------263
圖表目錄
頁次
第一章
表1歷年來台灣地區聚氯乙烯生產量與銷售量------------------------------------40
表2 氯乙烯暴露與相關癌症之流行病學研究---------------------------------------41
圖1 氯乙烯可能的代謝途徑------------------------------------------------------------44
表3 氯乙烯暴露與相關的動物研究---------------------------------------------------45
表4 氯乙烯暴露與相關基因毒性之研究文獻探討---------------------------------46
表5 氯乙烯暴露與相關易感性基因之關係------------------------------------------47
表6 氯乙烯暴露與致癌基因Ki-ras、抑癌基因p53之相關研究----------------48
表7 台灣的氯乙烯研究------------------------------------------------------------------ 49
第二章
表1氯乙烯聚合工人研究世代之暴露資料------------------------------------------68
表2 氯乙烯暴露世代之各死因別觀察值與期望值,以及其標準化死亡比---69
表3 氯乙烯暴露世代在不同暴露長度分組之各死因別觀察值,以及其標準
化死亡比------------------------------------------------------------------------------ 70
表4氯乙烯暴露世代在不同的第一次暴露年代分組之各死因別觀察值,以
及其標準化死亡比------------------------------------------------------------------71
表5罹患肝癌之男性氯乙烯聚合工人的臨床診斷與基本資料------------------ 72
第三章
表1肝硬化與肝癌之病例組與其配對對照組的特性分佈------------------------90
表2 相關危險因子對於肝硬化或肝癌之配對危險對比值------------------------91
表3 調整相關干擾因子後,氯乙烯暴露指標在HBsAg感染狀態分組中,對
於肝硬化與肝癌之配對危險對比值---------------------------------------------92
表4調整相關干擾因子後,氯乙烯暴露指標在HBsAg感染狀態分組中,對
於肝硬化或肝癌之配對危險對比值---------------------------------------------93
第四章
表1氯乙烯暴露工人的基本特徵------------------------------------------------------117
表2XRCC1、CYP2E1、ALDH2以及GSTT1基因型,在不同的氯乙烯暴露
狀況分組間的分佈------------------------------------------------------------------118
表3氯乙烯暴露工人的p53過度表現之多變項迴歸模式------------------------119
圖1p53 over-expression by VCM exposure with XRCC1 and CYP2E1
genotypes respectively, after adjusting the effects of age, smoking,
genotypes of ALDH2, GSTT1, and CYP2E1 or XRCC1, respectively---------120
圖2Interaction of p53 over-expression by VCM exposure with metabolic and
DNA repair genotypes after adjusting the effects of age and smoking--------121
頁次
第五章
表1氯乙烯暴露及對照工人在不同暴露程度分組之基本特徵------------------142
表2XRCC1、CYP2E1、ALDH2以及GSTT1基因型,在不同的氯乙烯暴露
與對照分組間的分佈---------------------------------------------------------------143
表3姊妹染色分體交換頻率在氯乙烯暴露狀態與不同影響因子分層間的分
佈---------------------------------------------------------------------------------------144
表4姊妹染色分體交換頻率之多變項迴歸模式------------------------------------145
圖1Adjusted SCE frequency by the numbers of susceptible genotype and
VCM exposure adjusted age and smoking effects-------------------------------146
第六章
圖1氯乙烯暴露與環境因子及宿主易感性因子對於肝臟疾病進展的可能關
係---------------------------------------------------------------------------------------160
圖2氯乙烯暴露與B型肝炎病毒對於肝硬化與肝癌之協同性交互作用-------161
參考文獻
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