iindaba

Kule minyaka ilishumi idlulileyo, itekhnoloji yolandelelwano lwemfuza isetyenziswe ngokubanzi kuphando lomhlaza kunye nokuziqhelanisa nonyango, ibe sisixhobo esibalulekileyo sokutyhila iimpawu zemolekyuli zomhlaza. Inkqubela phambili yokuxilongwa kweemolekyuli kunye nonyango olujoliswe kuyo lukhuthaze uphuhliso lweengcamango zonyango oluchanekileyo lwe-tumor kwaye lwezisa utshintsho olukhulu kulo lonke icandelo lokuxilongwa kwethumba kunye nonyango. Uvavanyo lwe-Genetic lungasetyenziselwa ukulumkisa umngcipheko womhlaza, ukukhokela izigqibo zonyango kunye nokuvavanya i-prognosis, kwaye sisixhobo esibalulekileyo sokuphucula iziphumo zekliniki zesigulane. Apha, sishwankathela amanqaku amva nje apapashwe kwi-CA Cancer J Clin, JCO, Ann Oncol kunye nezinye iijenali ukuphonononga ukusetyenziswa kovavanyo lwemfuza ekuxilongweni komhlaza kunye nonyango.

Ukuguqulwa kweSomatic kunye nokuguqulwa kwentsholongwane. Ngokuqhelekileyo, umhlaza ubangelwa ukuguqulwa kwe-DNA enokuthi izuzwe kubazali (i-germline mutations) okanye ifunyenwe ngobudala (ukuguqulwa kwe-somatic). Ukuguqulwa komgca we-germ kukho ukususela ekuzalweni, kwaye i-mutor ihlala ithwala ukuguqulwa kwe-DNA yeseli nganye emzimbeni kwaye inokudluliselwa kwinzala. Ukuguqulwa kweSomatic kufunyanwa ngabantu kwiiseli ezingezona ze-gametic kwaye zihlala zingagqithiselwa kwinzala. Zombini i-germline kunye nokuguqulwa kwe-somatic kunokutshabalalisa umsebenzi oqhelekileyo wokusebenza kweeseli kwaye kukhokelela ekuguquleni okungalunganga kweeseli. Ukuguqulwa kweSomatic ngumqhubi ophambili we-malignancy kunye neyona nto ixela kwangaphambili i-biomarker kwi-oncology; kunjalo, malunga 10 ukuba 20 ekhulwini izigulane ithumba baphathe iinguqulelo zentsholongwane eyonyusa kakhulu ingozi yomhlaza wabo, kwaye ezinye zezi nguqu nazo zonyango.
Ukuguqulwa komqhubi kunye nokuguqulwa komkhweli. Ayizizo zonke iintlobo zeDNA ezichaphazela ukusebenza kweeseli; ngokwe-avareji, kuthatha ezintlanu ukuya kwezilishumi iziganeko genomic, ezaziwa ngokuba "umqhubi iinguqulelo," ukuqalisa ukuwohloka kweseli eqhelekileyo. Ukuguqulwa komqhubi kaninzi kwenzeka kwiijethi ezisondeleyo kwimisebenzi yokuphila kweeseli, ezifana nezakhi zofuzo ezibandakanyekayo ekulawuleni ukukhula kweeseli, ukulungiswa kwe-DNA, ukulawula umjikelezo weseli kunye nezinye iinkqubo zobomi, kwaye zinamandla okusetyenziswa njengeethagethi zonyango. Nangona kunjalo, inani elipheleleyo leenguqu kuwo nawuphi na umhlaza likhulu kakhulu, ukusuka kumawaka ambalwa kwezinye ii-cancer zebele ukuya ngaphezulu kwe-100,000 kwezinye ii-cancer ze-colorectal kunye ne-endometrial. Utshintsho oluninzi alunantsingiselo okanye alunamda webhayoloji, nokuba uguquko lwenzeka kwindawo yekhowudi, ezo ziganeko zingabalulekanga zoguqulo zibizwa ngokuba “zinguqu zabakhweli”. Ukuba ulwahlulo lwemfuza kuhlobo oluthile lwethumba luqikelela impendulo yalo okanye ukunganyangeki kunyango, umahluko uthathwa njengosebenza eklinikhi.
I-Oncogenes kunye ne-tumor suppressor genes. Imfuza ehlala iguqulwe kumhlaza inokwahlulwa ngokwezigaba ezimbini, i-oncogenes kunye ne-tumor suppressor genes. Kwiiseli eziqhelekileyo, iprotheyini efakwe kwi-oncogenes idlala indima enkulu yokukhuthaza ukwanda kweeseli kunye nokuthintela i-apoptosis yeeseli, ngelixa iprotheni efakwe kwi-oncosuppressor genes inoxanduva lokulawula kakubi ukwahlukana kweeseli ukugcina ukusebenza kweeseli eziqhelekileyo. Kwinkqubo yenguqu eyingozi, ukuguqulwa kwe-genomic kukhokelela ekuphuculeni umsebenzi we-oncogene kunye nokuncipha okanye ukulahlekelwa kwe-oncosuppressor gene gene.
Ukwahluka okuncinci kunye nokwahluka kwesakhiwo. Ezi zezona ntlobo ziphambili zotshintsho kwi-genome. Iintlobo ezincinci ziguqula i-DNA ngokuguqula, ukucima, okanye ukongeza inani elincinci leziseko, kubandakanywa ukufakwa kwesiseko, ukucima, ukuguqulwa kwefreyimu, ukuqala ukulahleka kwe-codon, ukuyeka ukuguqulwa kwe-codon ukulahleka, njl njl. ukuguqulwa okanye ukutshintshwa. Olu tshintsho lunokubangela ukuncitshiswa okanye ukuphuculwa komsebenzi weprotheyini. Ukongeza kwiinguqu kwinqanaba lezakhi zofuzo zomntu ngamnye, iisignesha ze-genomic nazo ziyinxalenye yeengxelo zokulandelelana kweklinikhi. Iisignesha ze-Genomic zingabonwa njengeepateni ezintsonkothileyo ezincinci kunye / okanye ulwahlulo lwesakhiwo, kubandakanywa umthwalo we-tumor mutation (TMB), ukungazinzi kwe-microsatellite (MSI), kunye neziphene zokuvuselela i-homologous.

Ukuguqulwa kweClonal kunye nokuguqulwa kwe-subclonal. Utshintsho lweClonal lukhona kuzo zonke iiseli zethumba, zikhona ekuxilongeni, kwaye zihlala zikhona emva kokuhambela phambili konyango. Ngoko ke, ukuguqulwa kwe-clonal kunamandla okusetyenziswa njengeethagethi zonyango lwe-tumor. Iinguqu ze-Subclonal zikhona kuphela kwi-subset yeeseli zomhlaza kwaye zingabonwa ekuqaleni kokuxilongwa, kodwa zinyamalale ngokuphindaphinda okulandelayo okanye zivele kuphela emva konyango. I-Cancer heterogeneity ibhekiselele kubukho beenguqu ezininzi ze-subclonal kumhlaza omnye. Ngokucacileyo, uninzi lotshintsho olubalulekileyo lweklinikhi kuzo zonke iintlobo zomhlaza eziqhelekileyo lutshintsho lwe-clonal kwaye luhlala luzinzile kulo lonke ukuqhubela phambili komhlaza. Ukuchasana, okuhlala kuxutyushwa ngama-subclones, akunakufunyanwa ngexesha lokuxilongwa kodwa kubonakala xa kuphinda kubuyele emva kwonyango.

Ubuchule bemveli I-FISH okanye i-cell karyotype isetyenziselwa ukubona utshintsho kwinqanaba le-chromosomal. I-FISH ingasetyenziselwa ukubona ukuxubana kwemfuza, ucimo, kunye nokwandiswa, kwaye ithathwa "njengomgangatho wegolide" wokufumanisa ezo ntlobo zahlukeneyo, ngokuchaneka okuphezulu kunye novakalelo kodwa ukuphumela okulinganiselweyo. Kwezinye izifo ze-hematologic, ngakumbi i-acute leukemia, i-karyotyping isasetyenziswa ukukhokela ukuxilongwa kunye nokuxilongwa, kodwa obu buchule buthatyathwa ngokuthe ngcembe buthatyathelwa indawo ngovavanyo lweemolekyuli ekujoliswe kuzo njenge-FISH, WGS, kunye ne-NGS.
Utshintsho kwimizila yomntu ngamnye inokubonwa yi-PCR, zombini i-PCR yexesha lokwenyani kunye ne-PCR yokulahla idijithali. Ezi ndlela zobuchule zinovakalelo oluphezulu, zifaneleke ngokukodwa ukukhangela kunye nokubeka iliso kwizilonda ezincinci ezishiyekileyo, kwaye zinokufumana iziphumo kwixesha elifutshane elincinane, ukungahambi kakuhle kukuba uluhlu lokufumanisa lulinganiselwe (ngokuqhelekileyo lufumanisa kuphela ukuguqulwa kwesinye okanye kwi-genes embalwa), kunye nokukwazi ukuvavanya iimvavanyo ezininzi zilinganiselwe.
I-Immunohistochemistry (IHC) sisixhobo sokubeka iliso esisekelwe kwiprotheni esisetyenziswa ngokuqhelekileyo ukufumanisa ukubonakaliswa kwee-biomarkers ezifana ne-ERBB2 (HER2) kunye ne-estrogen receptors. I-IHC ingasetyenziselwa ukufumanisa iiprotheyini ezithile eziguqukileyo (ezifana ne-BRAF V600E) kunye ne-gene fusions ethile (efana ne-ALK fusions). Inzuzo ye-IHC kukuba inokudibaniswa lula kwinkqubo yokuhlalutya izicubu zesiqhelo, ngoko inokudibaniswa nezinye iimvavanyo. Ukongeza, i-IHC inokubonelela ngolwazi malunga neprotheyini ye-subcellular. Izinto ezingeloncedo kukulinganiswa komlinganiselo kunye neemfuno eziphezulu zombutho.
Ulandelelwano lwesizukulwana sesibini (NGS) I-NGS isebenzisa iindlela eziphezulu zokulandelelana kwe-parallel ukufumanisa ukuhluka kwinqanaba le-DNA kunye / okanye i-RNA. Obu buchule bunokusetyenziswa ukulandelelanisa zombini i-genome (WGS) kunye nemimandla yemfuza enomdla. I-WGS ibonelela ngeyona nkcazelo ibanzi yokuguqula i-genomic, kodwa kukho imiqobo emininzi kwisicelo sayo seklinikhi, kuquka imfuneko yeesampulu zezicubu zethumba (i-WGS ayikakulungelanga ukuhlalutya iisampulu ze-formalin-immobilized) kunye neendleko eziphezulu.
Ulandelelwano lwe-NGS ekujoliswe kulo lubandakanya ulandelelwano olupheleleyo lwe-exon kunye nephaneli yegene ekujoliswe kuyo. Olu vavanyo lutyebisa imimandla enomdla nge-DNA probes okanye iPCR amplification, ngaloo ndlela kunciphisa ubungakanani bolandelelwano olufunekayo (i-exome iyonke yenza i-1 ukuya kwi-2 ekhulwini ye-genome, kunye neepaneli ezinkulu eziqulethe i-500 yemfuza yenza i-0.1 yepesenti ye-genome kuphela). Nangona ulandelelwano olupheleleyo lwe-exon lusebenza kakuhle kwizicubu ezisisigxina ze-formalin, iindleko zalo zihlala ziphezulu. Imidibaniso yemfuza ekujoliswe kuyo inoqoqosho kwaye ivumela ukuguquguquka ekukhetheni imizila yemfuza ukuba ivavanywe. Ukongeza, ukujikeleza i-DNA yasimahla (i-cfDNA) ivela njengokhetho olutsha lohlalutyo lwe-genomic lwabaguli abanomhlaza, olwaziwa ngokuba zii-biopsies zolwelo. Zombini iiseli zomhlaza kunye neeseli eziqhelekileyo zinokukhulula i-DNA egazini, kwaye i-DNA ephalazwe kwiiseli zomhlaza ibizwa ngokuba yi-circulating tumor DNA (ctDNA), enokuthi ihlalutywe ukuze kubonwe utshintsho olunokubakho kwiiseli zethumba.
Ukhetho lovavanyo luxhomekeke kwingxaki ethile yeklinikhi ekufuneka iqwalaselwe. Uninzi lwee-biomarkers ezinxulumene nonyango oluvunyiweyo lunokubonwa nge-FISH, i-IHC, kunye nobuchule be-PCR. Ezi ndlela zifanelekile ukufunyanwa kweemali ezincinci ze-biomarkers, kodwa aziphuculi ukusebenza kakuhle kokubona ngokunyuka kwe-throughput, kwaye ukuba zininzi ii-biomarkers zichongiwe, akunakubakho izicubu ezaneleyo zokubona. Kweminye imihlaza ethile, enjengomhlaza wemiphunga, apho iisampulu zethishu kunzima ukuzifumana kwaye kukho ii-biomarkers ezininzi zokuvavanywa, ukusebenzisa i-NGS lukhetho olungcono. Ekugqibeleni, ukhetho lokuvavanya luxhomekeke kwinani lee-biomarkers eziza kuvavanywa kwisigulane ngasinye kunye nenani lezigulane eziza kuvavanywa kwi-biomarker. Kwezinye iimeko, ukusetyenziswa kwe-IHC / FISH kwanele, ngakumbi xa kuchongiwe ekujoliswe kuyo, njengokufumanisa i-estrogen receptors, i-progesterone receptors, kunye ne-ERBB2 kwizigulane zomhlaza webele. Ukuba ukuphononongwa okubanzi ngakumbi kweenguqu ze-genomic kunye nokukhangela iithagethi ezinokubakho zonyango ziyafuneka, i-NGS ihlelwe ngakumbi kwaye ineendleko. Ukongeza, i-NGS inokuqwalaselwa kwiimeko apho iziphumo ze-IHC/FISH zingacacanga okanye zingaquki.

Izikhokelo ezahlukeneyo zinika isikhokelo malunga nokuba izigulane kufuneka zifanelekele uvavanyo lwemfuzo. Ngo-2020, i-ESMO Precision Medicine Working Group yakhupha iingcebiso zokuqala zovavanyo lwe-NGS kwizigulana ezinomhlaza ophambili, icebisa uvavanyo lwe-NGS oluphambili lwesifo somhlaza wemiphunga, umhlaza we-prostate, umhlaza we-colorectal, umhlaza we-bile duct, kunye neesampulu zomhlaza we-ovarian, kwaye ngo-2024, i-ESMO ihlaziywe kwesi siseko somhlaza webele. Ezinje ngamathumba e-stromal esiswini, i-sarcomas, umhlaza wegilo kunye nomhlaza ongaziwayo.
Ngo-2022, i-ASCO's Clinical Opinion kuvavanyo lwe-somatic genome kwizigulana ezinomhlaza we-metastatic okanye ophucukileyo uthi ukuba unyango olunxulumene ne-biomarker luvunyiwe kwizigulana ezine-metastatic okanye i-tumor eqinileyo eqinileyo, uvavanyo lwemfuzo luyacetyiswa kwezi zigulana. Umzekelo, uvavanyo lwe-genomic kufuneka lwenziwe kwizigulana ezine-metastatic melanoma ukukhangela utshintsho lwe-BRAF V600E, njengoko iRAF kunye ne-MEK inhibitors zamkelwe olu phawu. Ukongeza, uvavanyo lwemfuzo kufuneka kwakhona lwenziwe ukuba kukho uphawu olucacileyo lokuchasa ukuba ichiza linikezelwe kwisigulana. Umzekelo, i-Egfrmab ayisebenzi kumhlaza oguqukayo we-KRAS. Xa kuqwalaselwa ukufaneleka kwesigulane ngokulandelelana kofuzo, isimo somzimba wesigulane, i-comorbidities, kunye nesigaba se-tumor kufuneka sihlanganiswe, kuba uchungechunge lwamanyathelo afunekayo ekulandeleni i-genome, kubandakanywa nemvume yesigulane, ukuqhutyelwa kwebhubhoratri, kunye nohlalutyo lweziphumo zokulandelelanisa, kufuna ukuba isigulane sibe nomthamo owaneleyo womzimba kunye nexesha lokuphila.
Ukongeza kwiinguqu ze-somatic, ezinye ii-cancer kufuneka zivavanyelwe iijene ze-germline. Ukuvavanyelwa ukuguqulwa komgca wentsholongwane kunokuchaphazela izigqibo zonyango zomhlaza ezifana ne-BRCA1 kunye ne-BRCA2 utshintsho kwibele, i-ovarian, i-prostate, kunye nomhlaza we-pancreatic. Ukuguqulwa kweGermline kunokuba nefuthe ekuhlolweni komhlaza wexesha elizayo kunye nokuthintela kwizigulana. Izigulana ezinokuthi zilungele ukuvavanyelwa ukuguqulwa kwentsholongwane kufuneka zihlangabezane neemeko ezithile, ezibandakanya izinto ezifana nembali yosapho yomhlaza, ubudala bokuxilongwa, kunye nohlobo lomhlaza. Nangona kunjalo, izigulane ezininzi (ukuya kwi-50%) ezithwele iinguqu ze-pathogenic kumgca wentsholongwane azihlangabezani nemilinganiselo yendabuko yokuvavanya ukuguqulwa kwentsholongwane esekelwe kwimbali yosapho. Ke ngoko, ukukhulisa ukuchongwa kwabathwali benguqu, iNational Comprehensive Cancer Network (NCCN) icebisa ukuba zonke okanye uninzi lwezigulana ezinebele, i-ovarian, i-endometrial, i-pancreatic, i-colorectal, okanye umhlaza we-prostate zivavanyelwe ukuguqulwa komgca wentsholongwane.
Ngokubhekiselele kwixesha lovavanyo lwemfuza, ngenxa yokuba uninzi lweenguqu zeklinikhi ezibalulekileyo zomqhubi zi-clonal kwaye zizinzile ngexesha lokuqhubela phambili komhlaza, kunengqiqo ukwenza uvavanyo lwemfuzo kwizigulane ngexesha lokuxilongwa komhlaza ophezulu. Kuvavanyo olulandelayo lwemfuza, ngakumbi emva konyango olujoliswe kwimolekyuli, uvavanyo lwe-ctDNA lunenzuzo ngakumbi kune-tumor tishu ye-DNA, kuba i-DNA yegazi inokuqulatha i-DNA kuzo zonke izilonda zethumba, eziluncedo ngakumbi ekufumaneni ulwazi malunga ne-tumor heterogeneity.
Uhlalutyo lwe-ctDNA emva konyango lunokukwazi ukuqikelela impendulo yethumba kunyango kunye nokuchonga ukuqhubela phambili kwesifo ngaphambi kweendlela eziqhelekileyo zokucinga. Nangona kunjalo, iiprothokholi zokusebenzisa ezi datha ukukhokela izigqibo zonyango azikasekwa, kwaye uhlalutyo lwe-ctDNA alukhuthazwa ngaphandle kokuba kulingo lwezonyango. I-ctDNA ingasetyenziselwa ukuvavanya izilonda ezincinci ezishiyekileyo emva kotyando lwethumba olukhulu. Uvavanyo lwe-ctDNA emva kotyando luqikelelo oluqinileyo lokuqhubekela phambili kwesifo kwaye lunokunceda ukufumanisa ukuba isigulana siya kuzuza na kwi-adjuvant chemotherapy, kodwa ayikacetyiswa ukuba kusetyenziswe i-ctDNA ngaphandle kolingo lwezonyango ukukhokela izigqibo ze-adjuvant chemotherapy.

Ukusetyenzwa kwedatha Isinyathelo sokuqala sokulandelelana kwe-genome kukukhupha i-DNA kwiisampuli zesigulane, ukulungiselela amathala eencwadi, kunye nokuvelisa idatha yokulandelelana ekrwada. Idatha ekrwada ifuna ukuqhubekeka phambili, kubandakanywa ukuhluzwa kwedatha ekumgangatho ophantsi, ukuyithelekisa ne-reference genome, ukuchonga iintlobo ezahlukeneyo zokuguqulwa kweendlela ezahlukeneyo zokuhlalutya i-algorithms yokuhlalutya, ukugqiba umphumo wolu tshintsho kwi-protein translation, kunye nokucoca ukuguqulwa komgca wentsholongwane.
Inkcazo yemfuza yomqhubi yenzelwe ukwahlula iinguqu kumqhubi nabakhweli. Ukuguqulwa komqhubi kukhokelela ekulahlekeni okanye ekuphuculeni umsebenzi wemfuza we-tumor suppressor. Izahluko ezincinci ezikhokelela ekungasebenzini kwe-tumor suppressor genes zibandakanya ukuguqulwa kobuvuvu, ukuguqulwa kwe-frameshift, kunye nokuguqulwa kwesiza esitshixo, kunye nokucinywa rhoqo kwe-codon, ukucinywa kwe-codon, kunye noluhlu olubanzi lokufakelwa kwe-intron / ukucima ukuguqulwa. Ukongeza, ukuguqulwa kwe-missense kunye nokufakwa kwe-intron encinci / ukuguqulwa kokuguqulwa kunokukhokelela ekulahlekeni komsebenzi we-tumor suppressor gene xa kuchaphazela imimandla ebalulekileyo yokusebenza. Ukwahluka kolwakhiwo olukhokelela ekulahlekeni komsebenzi wemfuza we-tumor suppressor kubandakanya ukucinywa kofuzo ngokuyinxenye okanye ngokupheleleyo kunye nezinye iinguqulelo zegenomic ezikhokelela ekutshatyalalisweni kwesakhelo sokufunda somfuzo. Ukwahluka okuncinci okukhokelela ekusebenzeni okuphuculweyo kwe-oncogenes kubandakanya ukuguqulwa kwe-missense kunye nokufakwa kwe-intron ngamaxesha athile / ukususwa okujolise kwiiprotheyini ezibalulekileyo zokusebenza. Kwiimeko ezinqabileyo, i-protein truncation okanye i-splicing site mutations ingakhokelela ekusebenziseni i-oncogenes. Ukwahluka kolwakhiwo olukhokelela ekusebenzeni kwe-oncogene kubandakanya ukuxubana kofuzo, ukucinywa kwemfuza, kunye nokuphindaphinda ufuzo.
Utoliko lwezonyango lokwahluka kwe-genomic kuvavanya ukubaluleka kweklinikhi yeenguqu ezichongiweyo, oko kukuthi, ukuxilonga, ukubikezela, okanye ixabiso lonyango. Kukho iinkqubo ezininzi zokuhlela ezisekwe kubungqina ezinokusetyenziselwa ukukhokela ukutolika kweklinikhi yokwahluka kwe-genomic.
I-Memory Sloan-Kettering Cancer Centre ye-Precision Medicine Oncology Database (OncoKB) ihlela ukuhlukahluka kwemfuza kumanqanaba amane ngokusekelwe kwixabiso labo eliqikelelwayo lokusetyenziswa kweziyobisi: iNqanaba 1/2, i-FDA-evunyiweyo, okanye i-biomarkers-standard yekliniki eqikelela impendulo yesalathiso esithile kwiyeza elivunyiweyo; Inqanaba le-3, i-FDA-evunyiweyo okanye i-biomarkers engavunywanga echaza kwangaphambili impendulo kwi-novel ejoliswe kwiziyobisi eziye zabonisa isithembiso kwizilingo zeklinikhi, kunye neNqanaba lesi-4, i-biomarkers engavunywanga ye-FDA eqikelela impendulo kwi-novel ejoliswe kwiziyobisi eziye zabonisa ubungqina obukholisayo bezinto eziphilayo kwiimvavanyo zeklinikhi. Iqela elingaphantsi lesihlanu elinxulumene nokuxhathisa unyango longezwa.
I-American Society for Molecular Pathology (AMP) / American Society of Clinical Oncology (ASCO) / College of American Pathologists (CAP) izikhokelo zokutolika ukuhluka kwe-somatic ukwahlula ukuhluka kwe-somatic kwiindidi ezine: IBakala I, ngokubaluleka okunamandla kwekliniki; IBanga lesi-II, elinokubaluleka konyango; IBakala III, ukubaluleka kweklinikhi ayaziwa; IBanga lesi-IV, alaziwa njengelibalulekileyo ngokwezonyango. Kuphela ukwahluka kweBanga I no-II zibalulekile kwizigqibo zonyango.
I-ESMO's Molecular Target Clinical Operability Scale (ESCAT) ihlela ukwahluka kwemizila yemfuza ibe ngamanqanaba amathandathu: iNqanaba I, iithagethi ezifanele ukusetyenziswa kwesiqhelo; ISigaba sesi-II, ekujoliswe kuko okusafundwayo, kusenokwenzeka ukuba kusetyenziswe ukuhluza inani lezigulane ezinokuxhamla kwichiza elijoliswe kuyo, kodwa idatha eninzi iyafuneka ukuyixhasa. IBanga le-III, iinguqu zemfuza ezijoliswe kuzo eziye zabonisa inzuzo yeklinikhi kwezinye iintlobo zomhlaza; IBanga lesi-IV, kuphela ukwahluka kwemfuza ekujoliswe kuyo kuxhaswe bubungqina bangaphambili; Kwibanga le-V, kukho ubungqina bokuxhasa ukubaluleka kweklinikhi ekujoliseni ukuguqulwa, kodwa unyango lweyeza elilodwa elichasene nethagethi alinandisi ukusinda, okanye isicwangciso sonyango esidibeneyo singamkelwa; IBanga X, ukungabikho kwexabiso leklinikhi.