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目的:探讨n MYCN基因、n PHOX2B基因及血浆游离DNA(cfDNA)水平用于高危神经母细胞瘤(NB)危险度分层及预后评估的作用和意义。n 方法:对2017年8月至2018年12月首都医科大学附属北京儿童医院收治的94例高危NB患儿进行前瞻性研究，分别于初诊时、化疗4个疗程和6个疗程后检测n MYCN基因、n PHOX2B基因及cfDNA水平，观察治疗过程中3项指标的变化，采用n χ2检验和Kaplan-Meier生存分析法评价其与疗效的关系。n 结果:94例患儿中n MYCN基因扩增14例(14.9%)，n PHOX2B基因阳性76例(80.8%)，cfDNA水平>100 μg/L者56例(59.6%)。n MYCN基因扩增患儿初诊高乳酸脱氢酶(LDH，≥1 500 U/L)比例(6/14例)显著高于基因正常组患儿(9/80例)(n P＝0.009)；n PHOX2B基因阳性患儿多部位转移病例(54/76例)及高神经元特异性烯醇化酶(NSE，≥370 μg/L)比例(37/76例)显著高于基因阴性组患儿(5/14例，2/14例)(n P＝0.015、0.020)；cfDNA高水平患儿初诊高LDH及高NSE比例(13/37例，28/37例)显著高于cfDNA低水平组患儿(2/48例，10/48例)(均n P<0.001)。治疗过程中，随着肿瘤负荷减小，n PHOX2B基因拷贝数和cfDNA水平较初诊时显著降低[0(0~719.6)拷贝比1 723.5(0~186 000.0)拷贝；19.0(1.1~225.5) μg/L比200.6(8.0~5 247.4) μg/L](均n P<0.001)。初诊时，n MYCN基因扩增组患儿2年无事件生存(EFS)率显著低于n MYCN基因正常组患儿[(33.3±13.1)%比(58.5±7.1)%，n P＝0.020]；n PHOX2B基因阳性组患儿2年EFS率显著低于阴性组患儿[(47.9±7.1)%比(79.1±11.1)%，n P＝0.043]；cfDNA高水平组(≥229.6 μg/L)2年EFS率显著低于cfDNA低水平组[(38.6±9.8)%比(71.7±8.2)%，n P＝0.001]。6个疗程后n PHOX2B基因阳性组患儿2年EFS率显著低于基因阴性组患儿[(16.7±14.4)%比(60.6±6.6)%，n P＝0.014]；维持治疗前间碘苄胍(MIBG)核素扫描阳性组患儿2年EFS率显著低于阴性组患儿[(35.2±11.7)%比(65.8±7.1)%，n P＝0.037]。治疗过程中，n MYCN基因和cfDNA水平与患儿预后无显著相关性。将6个疗程后的n PHOX2B基因及维持治疗前MIBG结果联合分组进行生存分析(n PHOX2B+/MIBGn +，n PHOX2B+或MIBGn +，n PHOX2B-/MIBGn -)，组间比较差异有统计学意义[0比(53.6±1.2)%比(65.5±7.4)%，n P＝0.003]。n 结论:MYCN和n PHOX2B基因及cfDNA水平在高危NB危险度分层及预后评估中具有重要作用；与n MYCN和cfDNA水平相比，n PHOX2B基因更适于治疗过程中的疗效监测，n PHOX2B与维持治疗前的MIBG结果联合分析，用于判断患儿治疗效果，评估体内残余病灶更精准。n “,”Objective:To explore the clinical significance of the n MYCN gene, n PHOX2B gene and plasma cell-free DNA (cfDNA) in risk stratification and predicting the prognosis of high-risk neuroblastoma (NB).n Methods:This was a prospective study involving 94 high-risk NB children admitted to Beijing Children′s Hospital, Capital Medical University from August 2017 to December 2018.Relative levels of n MYCN and n PHOX2B and cfDNA at diagnosis, and 4 and 6 cycles of chemotherapy were detected, and their differences were compared by the n Chi-n square test.Kaplan-Meier survival analysis was performed to explore their prognostic potential in high-risk NB.n Results:Among the 94 high-risk NB children, 14 cases (14.9%) had n MYCN amplification, 76 cases (80.8%) had positive expression of n PHOX2B and 56 cases (59.6%) had cfDNA level higher than 100 μg/L.The proportion of high lactate dehydrogenase (LDH, ≥1 500 U/L) level in the n MYCN gene amplification group (6/14 cases) was higher than that in the normal group (9/80 cases) (n P=0.009). The proportion of multi-site metastasis (54/76 cases) and high neuron specific enolase (NSE) level (NSE≥370 μg/L, 37/76 cases) in n PHOX2B positive group were significantly higher than those in the negative group (5/14 cases, 2/14 cases) (n P=0.015, 0.020). The proportion of high LDH and high NSE in high cfDNA concentration (≥229.6 μg/L)group (13/37 cases, 28/37 cases) were significantly higher than those in low cfDNA concentration group (2/48 cases, 10/48 cases) (all n P<0.001). With the decreased tumor burden during the treatment, the copy number ofn PHOX2B gene and cfDNA level were significantly lower than those at the initial diagnosis [0 (0-719.6) copies n vs.1 723.5 (0-186 000.0) copies; 19.0 (1.1-225.5) μg/L n vs.200.6 (8.0-5 247.4) μg/L, all n P<0.001]. The 2-year event-free survival (EFS) rate of then MYCN gene amplification group was significantly lower than that of the normal group[(33.3±13.1)% n vs.(58.5±7.1)%, n P=0.020]. The 2-year EFS rate of n PHOX2B positive group was significantly lower than that of the negative group[(47.9±7.1)% n vs.(79.1±11.1)%, n P=0.043]. EFS rate in high cfDNA concentration group was significantly lower than that in cfDNA low concentration group[(38.6±9.8)% n vs.( 71.7±8.2)%, n P=0.001]. After 6 cycles of chemotherapy, EFS rate in the n PHOX2B positive group was significantly lower than that in the negative group [(16.7±14.4)% n vs.( 60.6±6.6)%, n P=0.014]; which was significantly lower in the Metaiodobenzylguanidine (MIBG) positive group than that of the negative group[(35.2±11.7)% n vs.(65.8±7.1)%, n P=0.037]. The n MYCN gene and cfDNA concentration were not correlated with the prognosis of high-risk NB.Survival analysis of the combination of n PHOX2B and n MYCN gene (n PHOX2B+ /MIBGn + , n PHOX2B+ or MIBGn + , n PHOX2B-/MIBGn -) showed a significant difference in the survival among three groups[0 n vs.(53.6±1.2)% n vs.(65.5±7.4)%, n P=0.003].n Conclusions:The n MYCN and n PHOX2B gene and cfDNA concentration are of significance in risk stratification and predicting the prognosis of high-risk NB.Compared with the n MYCN gene and cfDNA concentration, the n PHOX2B gene is more suitable for monitoring the curative effect of chemotherapy on high-risk NB.A combined analysis of n PHOX2B gene and MIBG before treatment can be more accurate in evaluating the treatment effect and residual lesions.n