:ﺰﻤﻠﯾو رﻮﻣﻮﺗ ﺰﯿﻣآﺖﯿﻘﻓﻮﻣ نﺎﻣرد لﺎﺒﻧد ﻪﺑ ﻪﯾﻮﻧﺎﺛ ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ دﺎﺣ ﯽﻤﺳﻮﻟ درﻮﻣ 1 ﯽﻓﺮﻌﻣ
I ﯽﻧﺎﺠﻨﺴﻓر یﺪﻨﻤﺟرا ﻪﺠﯾﺪﺧ ﺮﺘﮐد*
II قﻮﺛو ﻪﻧاوﺮﭘ ﺮﺘﮐد
III ﯽﻠﻘﻫﺎﺷ مﺎﻬﻟا ﺮﺘﮐد
ﻪﻣﺪﻘﻣ ﯽﮔراﻮﺧﺮﯿﺷ هرود رد ﻪﯿﻠﮐ رﻮﻣﻮﺗ ﻦﯾﺮﺗﻊﯾﺎﺷ ﺰﻤﻠﯾو رﻮﻣﻮﺗ ﻪـﺑ و یرﻮﺗﺎـﻤﻫ ،ﯽﻤﮑـﺷ هدﻮـﺗ ﺎــﺑ ار دﻮﺧ ﻪﮐ ﺖﺳا ﯽﮐدﻮﮐ و نﺎـﺸﻧ ﻪـﯾر ﻪـﺑ صﻮــﺼﺧ ﻪﺑ ﺖﺳد رود زﺎﺘﺳﺎﺘﻣ ﻢﺋﻼﻋ ترﺪﻧ ﻞﻣﺎــﺷ رﻮـــﻣﻮﺗ ﻦـﯾا درﻮـﻣ رد ﯽﻧﺎـﻣرد یﺎـﻫشور .ﺪـﻫدﯽﻣ ﻪـﯿﻟوا رﻮـﻣﻮﺗ ﺮﺘـﺴﺑ ﻪــﺑ ﯽﭘاﺮﺗﻮﯾدار و ﯽﻧﺎﻣردﯽﻤﯿﺷ ،ﯽﺣاﺮﺟ ،ﺐـﺳﺎﻨﻣ نﺎـﻣرد و ﻊـﻗﻮﻣ ﻪـﺑ و ﻊﯾﺮـﺳ ﺺﯿﺨــﺸﺗ ﺎﺑ .ﺪﺷﺎﺑﯽﻣ رادرﻮـﺧﺮﺑ ﯽـﯾﻻﺎﺑ ﺮﻤﻋ لﻮﻃ زا ﺰﻤﻠﯾو رﻮﻣﻮﺗ ﻪﺑ ﻼﺘﺒﻣ نارﺎﻤﯿﺑ یﺎﻫنﺎﻃﺮـﺳ زوﺮـﺑ ﺮـﻄﺧ ﺮـﻤﻋ لﻮــﻃ ﺶﯾاﺰﻓا ﺎﺑ .دﻮﺑ ﺪﻨﻫاﻮﺧ
ﺎــﯾ ﯽﮑﯿﺘﻧژ داﺪﻌﺘﺳا ﺪﻧاﻮﺗﯽﻣ نآ ﺖﻠﻋ ﻪﮐ ﺪﺑﺎﯾﯽﻣ ﺶﯾاﺰﻓا ﻪﯾﻮﻧﺎﺛ
و1).ﺪﺷﺎﺑ ﯽﭘاﺮﺗﻮﯾدار و ﯽﻧﺎﻣردﯽﻤﯿﺷ یﺎﻫواد سرﺮﯾد ضراﻮﻋ
:زا ﺪﻨﺗرﺎــﺒﻋ ﺐــﯿﺗﺮﺗ ﻪــﺑ ﻪـــﯾﻮﻧﺎﺛ یﺎﻫنﺎﻃﺮـﺳ ﻦﯾﺮﺗﻊﯾﺎـﺷ (2 و نﺎﺘـــﺴﭘ نﺎﻃﺮـﺳ ،مﺮـﻧ ﺞـﺴﻧ یﺎﻣﻮﮐرﺎـﺳ ،ﺎﻣﻮﮐرﺎـﺳﻮﺌﺘﺳا ﻪـﯾﻮﻧﺎﺛ ﯽﻤـﺳﻮﻟ ﻦﯾﺮﺗﻊﯾﺎـﺷ ﺪـﯿﯾﻮﻠﯿﻣ دﺎـﺣ ﯽﻤــﺳﻮﻟ (1).ﯽﻤﺳﻮﻟ ﺎﻬﻨﺗ ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ دﺎﺣ ﯽﻤﺳﻮﻟ ﻪﮐ ﯽﻟﺎﺣ رد دﻮـﺷﯽﻣ بﻮﺴﺤﻣ
هﺪﯿﮑﭼ
سرﺮـﯾد تاﺮـﺛا زا ﯽـﮑﯾ (Secondary Malignant Neoplasm=SMN)ﻪﯾﻮﻧﺎﺛ یﺎﻫﯽﻤﯿﺧﺪﺑ Acute Myeloid=AML)دﺎﺣ ﺪﯿﯾﻮﻠﯿﻣ ﯽﻤﺳﻮﻟ ،ﻪﯾﻮﻧﺎﺛ یﺎﻫﯽﻤﯿﺧﺪﺑ ﻦﯿﺑ رد .ﺖﺳا نﺎﻃﺮﺳ نﺎﻣرد ﮏﯿﺘـﺳﻼﺑﻮﻔﻨﻟ ﯽﻤـﺳﻮﻟ .ﺪـﺷﺎﺑﯽﻣ ﺎﻫﻢـﺳﻼﭘﻮـﺌﻧ ﻦﯾﺮﺗرﺎـﺑگﺮــﻣ و ﻦﯾﺮﺗﻊﯾﺎﺷ زا ﯽﮑﯾ (Leukemia
%10 ﺎﻬــﻨﺗ و هدﻮـــﺑ ردﺎـﻧ رﺎﯿـﺴﺑ ﻪـﯾﻮﻧﺎﺛ (Acute Lymphoblastic Leukemia=ALL)دﺎـﺣ ﻪـﺑ ﻼـﺘﺑا ﺮـﻄﺧ رد ﺰﯿـﻧ ﺰـﻤﻠﯾو رﻮـﻣﻮﺗ ﻪـﺑ ﻼـﺘﺒﻣ نارﺎـﻤﯿﺑ .ﺪــﻫدﯽﻣ ﻞﯿﮑﺸﺗ ار ﻪﯾﻮﻧﺎﺛ یﺎﻫﯽﻤﺳﻮﻟ ﻦﯾﺮﺗﻊﯾﺎـﺷ ﺰﯿــﻧ نارﺎﻤﯿﺑ ﻦﯾا رد .ﺪﻨﺘﺴﻫ ﻪﯿﻟوا یرﺎﻤﯿﺑ ﺺﯿﺨﺸﺗ زا ﺪﻌﺑ ﺎﻫلﺎﺳ ﻪﯾﻮﻧﺎﺛ یﺎﻫﯽﻤﯿﺧﺪﺑ دﺎـﺣ ﯽﻤـﺳﻮﻟ درﻮـﻣ 1 ﻪـﻟﺎﻘﻣ ﻦـﯾا رد .ﺪــﺷﺎﺑﯽﻣ ردﺎﻧ رﺎﯿﺴﺑ ALL و هدﻮﺑ AML ﻪﯾﻮﻧﺎﺛ ﯽﻤﺳﻮﻟ عوﺮـﺷ زا ﺪـﻌﺑ هﺎـﻣ 19 ﻪـﮐ دﻮـﺷﯽﻣ ﯽــﻓﺮﻌﻣ ﺰﻤﻠﯾو رﻮﻣﻮﺗ ﺺﯿﺨﺸﺗ زا ﺪﻌﺑ لﺎﺳ 4 ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ زوﺮـﺑ لﺎـﻤﺘﺣا ﻪــﮐ ﺎﺟ نآ زا .دﺮﮐ تﻮﻓ رﺮﮑﻣ یﺎﻫدﻮﻋ و نﺎﻣرد ﻪﺑ ﺖﺒﺴﻧ ﺖﻣوﺎﻘﻣ ﺖﻠﻋ ﻪﺑ نﺎﻣرد ﻪــﯿﺻﻮﺗ و ﻪﺘﺷاد تروﺮﺿ ﻪﺘﻓﺎﯾ دﻮﺒﻬﺑ نارﺎﻤﯿﺑ رد یاهرود ﻪﻨﯾﺎﻌﻣ ،دراد دﻮﺟو ﻪﯾﻮﻧﺎﺛ یﺎﻫرﻮﻣﻮﺗ .ددﺮﮔﯽﻣ ﻪﯾﻮﻧﺎﺛ ﯽﻤﺳﻮﻟ – 2 ﻪﯾﻮﻧﺎﺛ ﯽﻤﯿﺧﺪﺑ – 1 :ﺎﻫهژاوﺪﯿﻠﮐ ﺰﻤﻠﯾو رﻮﻣﻮﺗ – 4 ﻪﯾﻮﻧﺎﺛ ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ دﺎﺣ ﯽﻤﺳﻮﻟ – 3
ـ ﯽﺘـﺷاﺪﻬﺑ تﺎـﻣﺪﺧ و ﯽﮑـﺷﺰﭘ مﻮــﻠﻋ هﺎﮕﺸﻧاد ،ﺮﻔﻇ نﺎﺑﺎﯿﺧ ،(ع)ﺮﻐﺻاﯽﻠﻋ تﺮﻀﺣ نﺎﺘﺳرﺎﻤﯿﺑ ،نﺎﮐدﻮﮐ رد ﯽﺳﺎﻨﺷنﺎﻃﺮﺳ و نﻮﺧ یﺎﻫیرﺎﻤﯿﺑ ﺺﺼﺨﺗقﻮﻓ و رﺎﯾدﺎﺘﺳا (I (لﻮﺌﺴﻣ ﻒﻟﻮﻣ*).ناﺮﯾا ﯽﻧﺎﻣرد .ناﺮﯾا ﯽﻧﺎﻣرد ـ ﯽﺘﺷاﺪﻬﺑ تﺎﻣﺪﺧ و ﯽﮑﺷﺰﭘ مﻮﻠﻋ هﺎﮕﺸﻧاد ،نﺎﮐدﻮﮐ رد ﯽﺳﺎﻨﺷنﺎﻃﺮﺳ و نﻮﺧ یﺎﻫیرﺎﻤﯿﺑ ﺺﺼﺨﺗقﻮﻓ و دﺎﺘﺳا (II
.ناﺮﻬﺗ ﯽﻧﺎﻣرد ـ ﯽﺘﺷاﺪﻬﺑ تﺎﻣﺪﺧ و ﯽﮑﺷﺰﭘ مﻮﻠﻋ هﺎﮕﺸﻧاد ،نﺎﮐدﻮﮐ رد ﯽﺳﺎﻨﺷنﺎﻃﺮﺳ و نﻮﺧ یﺎﻫیرﺎﻤﯿﺑ ﯽﺼﺼﺨﺗقﻮﻓ رﺎﯿﺘﺳد و رﺎﯾدﺎﺘﺳا (III
ﻦــﯾا رد (3).ﺪـﻫدﯽﻣ ﻞﯿﮑـﺸﺗ ار ﻪـﯾﻮﻧﺎﺛ یﺎﻫنﺎﻃﺮـﺳ زا %5-10 ﺪــﻌﺑ لﺎﺳ 4 ﻪﮐ دﺎﺣ ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ ﯽﻤﺳﻮﻟ ردﺎﻧ درﻮﻣ 1 ﻪﻌﻟﺎﻄﻣ .ددﺮﮔﯽﻣ شراﺰﮔ دﻮﺑ هدﺮﮐ زوﺮﺑ ﺰﻤﻠﯾو زﻮﻣﻮﺗ نﺎﻣرد زا
رﺎﻤﯿﺑ ﯽﻓﺮﻌﻣ ﺎـﺑ 1377 لﺎﺳ رد ﻪﮐ دﻮﺑ پ.م مﺎﻧ ﻪﺑ یاﻪﻟﺎﺳ 4 ﺮﺘﺧد رﺎﻤﯿﺑ نآ ﻪـﺟﻮﺘﻣ ﯽﻓدﺎــﺼﺗ رﻮﻃ ﻪﺑ شردﺎﻣ ﻪﮐ ﯽﻤﮑﺷ هدﻮﺗ ﺖﯾﺎﮑﺷ ﺮـﻐﺻاﯽﻠﻋ تﺮـﻀﺣ نﺎﺘـﺳرﺎﻤﯿﺑ نﻮــﺧ هﺎﮕﻧﺎﻣرد ﻪﺑ ،دﻮﺑ هﺪﺷ ﭗﭼ یﻮﻠﻬﭘ رد ﯽﮔرﺰﺑ هدﻮﺗ ﺎﻬﻨﺗ ،ﯽﮑﯾﺰﯿﻓ ﻪﻨﯾﺎﻌﻣ رد .ﺪﺷ عﺎﺟرا دﻮــﺟو هﺪﻨﻨﮐ ﺪﯿﯾﺄﺗ رﺎﻤﯿﺑ ﻢﮑﺷ ﻦﮑﺳاCT و ﺖﺷاد دﻮﺟو رﺎﻤﯿﺑ ﺎﻫﯽـﺳرﺮﺑ ﺮﯾﺎـﺳ و ﻪـﯾر ﻦﮑـﺳاCT .دﻮـﺑ ﭗـﭼ ﻪــﯿﻠﮐ رد هدﻮﺗ .ﺪﻧدﻮﺑ ﯽﻌﯿﺒﻃ سﺎـﺳاﺮﺑ ﻪـﮐ ﺖـﻓﺮﮔ راﺮــﻗ ﭗﭼ ﯽﻣﻮﺘﮐﺮﻔﻧ ﻞﻤﻋ ﺖﺤﺗ رﺎﻤﯿﺑ ﺰــﻤﻠﯾو رﻮـﻣﻮﺗ ﺺﯿﺨـﺸﺗ ،ﯽـﺣاﺮﺟ و ﯽـﺳﺎﻨﺷﺐﯿﺳآ شراﺰـﮔ ﺎـﺑ .دﻮـﺑ (Unfavorable)بﻮﻠﻄﻣﺎــﻧ یژﻮﻟﻮﺘﺴﯿﻫ ﺎﺑ III ﻪﻠﺣﺮﻣ یﺎــﻫوراد ﺎــﺑ نﺎــﻣرد ﺖــﺤﺗ رﺎـــﻤﯿﺑ ﺐـﻠﻄﻣ ﻦـﯾا ﻪـﺑ ﻪـﺟﻮﺗ هﺎــﻣ 15 تﺪﻣ ﻪﺑ ﻦﯿﺘﯿﺴﯾﺮﮐﻦﯾو و ﻦﯿﺴﯾﺎﻣﺎﯾردآ ،ﻦﯿﺴﯾﺎﻣﻮﻨﯿﺘﮐا نوﺪـﺑ نﺎـﻣرد هرود .ﺖـﻓﺮﮔ راﺮـﻗ ﻢﮑــﺷ ﯽﭘاﺮﺗﻮﯾدار ﺎﺑ هاﺮﻤﻫ .دﺮـﮑﻧ ﻪﻌﺟاﺮﻣ یﺮﯿﮔﯽﭘ ﺖﻬﺟ رﺎﻤﯿﺑ ﺎﻣا ﺪﯿﺳر نﺎﯾﺎﭘ ﻪﺑ ﻪﺿرﺎﻋ ﯽﺸﺘﭘ ،ﯽﮔﺪﯾﺮﭘﮓﻧر ،ﺐﺗ ﻢﺋﻼﻋ ﺎﺑ یو 1381 لﺎﺳ هﺎﻣ ﺪﻨﻔﺳا رد رد .ﺪـــﺷ هدروآ نﺎﺘـﺳرﺎﻤﯿﺑ ﻪـﺑ ﻦـﯾﺪﻟاو ﻂـﺳﻮﺗ ارﻮـﭘرﻮـﭘ و
رد 230000)زﻮﺘﯿـــﺳﻮﮑﻟﺮﭙﯿﻫ (CBC)نﻮــﺧ ﻞﻣﺎــﮐ ﯽــﺳرﺮﺑ
مﺮــﮔ 7/4 ﻦﯿﺑﻮﻠﮔﻮﻤﻫ و ﺖﺷاد دﻮﺟو (WBC=ﺐﻌﮑﻣ ﺮﺘﻣﯽﻠﯿﻣ
.دﻮـﺑ ﺐـﻌﮑﻣ ﺮﺘــﻣﯽﻠﯿﻣ رد 10000 ﺖﮐﻼﭘ داﺪﻌﺗ و ﺮﺘﯿﻟﯽﺳد رد یدﺎــﯾز ناﺰﯿﻣ ﻪﺑ ﺖﺳﻼﺑ یﺎﻫلﻮﻠﺳ ،ﯽﻄﯿﺤﻣ نﻮﺧ هدﺮﺘﺴﮔ رد ﺺﯿﺨــﺸﺗ هﺪﻨﻨﮐ ﺪﯿﯾﺄﺗ ناﻮﺨﺘﺳا ﺰﻐﻣ نﻮﯿﺳاﺮﯿﭙﺳآ و ﺪﺷ هﺪﯾد FAB یﺪﻨﺑﻪـــﻘﺒﻃ سﺎـــﺳاﺮﺑ L1 یژﻮــــﻟﻮﻓرﻮﻣ ﺎــﺑ ALL .دﻮﺑ (French-American-British) ﺶـﯾاﺰﻓا ﯽـﻄﯿﺤﻣ نﻮــﺧ و ناﻮﺨﺘﺳا ﺰﻐﻣ یﺮﺘﻣﻮﺘﯿﺳﻮﻠﻓ رد ﻪــﺴﻔﻗ یرﺎـــﮕﻧﻮﺗﺮﭘ .ﺖـﺷاد دﻮـﺟو TdT/CD3/CD7/CD5 ﯽـﻌﯿﺒﻃ CSF ﯽـﺳرﺮﺑ و ﻦﺘـﺳﺎﯾﺪﻣ هدﻮــﺗ دﻮﺟو ﺮﻈﻧ زا ﻪﻨﯿﺳ ﺺﯿﺨـﺸﺗ ﺎـﺑ رﺎـﻤﯿﺑ ،هﺪـﻣآ ﺖـﺳد ﻪــﺑ ﺪﻫاﻮﺷ ﻪﺑ ﻪﺟﻮﺗ ﺎﺑ .دﻮﺑ ،ﺪﯾﺎﻣﺎﻔــــﺴﻓﻮﻠﮑﯿﺳ نﺎـــﻣرد ﺖـــﺤﺗ T.Cell عﻮـــﻧ زا ALL ﯽــﺴﮐﻼﯿﻓوﺮﭘ و نوﺰﯿــﻧدﺮﭘ ،ﻦﯿـــﺴﯿﺑورﻮﻧود ،ﻦﯿﺘـﺴﯾﺮﮐﻦﯾو ﺎـﻣا ﺖـﻓﺮﮔ راﺮـﻗ LSA2-L2 ﯽﻧﺎـﻣرد ﻪــﻣﺎﻧﺮﺑ سﺎﺳاﺮﺑ CNS
ار یدﻮﺒﻬــﺑ ﻪﻧﻮﮔ ﭻﯿﻫ 28 زور رد ناﻮﺨﺘﺳا ﺰﻐﻣ نﻮﯿﺳاﺮﯿﭙﺳآ VM-26 ﺎـﺑ ﯽـﮕﺘﻔﻫ نﺎـﻣرد ﺖـﺤﺗ رﺎــﻤﯿﺑ ﻦﯾاﺮﺑﺎﻨﺑ داﺪﻧ نﺎﺸﻧ ﺮــﺛﻮﻣ ﺰﯿﻧ نﺎﻣرد ﻦﯾا ﻪﮐ ﺖﻓﺮﮔ راﺮﻗ رازﻮﺘﯿﺳ و ،ﻦﯿﺘﺴﯾﺮﮐﻦﯾو .دﻮﺒﻧ ﯽﻧﺎــﻣرد ﻪــﻣﺎﻧﺮﺑ ﺎــﺑ نﺎــﻣرد ﺖــــﺤﺗ رﺎــﻤﯿﺑ ﺖــﯾﺎﻬﻧ رد ﺰـﻐﻣ ،نﺎـﻣرد ﻦـﯾا ﺎـﺑ ﻪــﮐ ﺖﻓﺮﮔ راﺮﻗ ALL-REZ-BFM85 زا ﺪﻌﺑ هﺎﻣ 4 ﺎﻣا ﺪﺷ کﺎﭘ ﺖﺳﻼﺑ یﺎﻫلﻮﻠﺳ زا رﺎﻤﯿﺑ ناﻮﺨﺘﺳا رﺎـﭼد ﯽﻫﺎـﺗﻮﮐ ﻪـﻠﺻﺎﻓ ﻪـﺑ و CNS دﻮــﻋ رﺎﭼد نﺎﻣرد عوﺮﺷ ﺦـﺳﺎﭘ مﺪـﻋ ﺖـﻠﻋ ﻪـﺑ ،ﺪــﻌﺑ هﺎﻣ 3 و ﺪﯾدﺮﮔ ناﻮﺨﺘﺳا ﺰﻐﻣ دﻮﻋ .دﺮﮐ تﻮﻓ ﺖﻧﻮﻔﻋ و ﯽﻨﭘوﺮﺗﻮﻧ و ﯽﻧﺎﻣرد
ﺚﺤﺑ یﺎــﻫشور رد نوﺰـﻓازور یﺎـﻫﺖﻓرﺶﯿﭘ ﻪـﺑ ﯽﺑﺎﯾﺖـﺳد ﺎﺑ ﺮـﻤﻋ لﻮـﻃ ﺶـﯾاﺰﻓا تازاﻮـﻣ ﻪـﺑ ،ﯽﺘﯾﺎـﻤﺣ تﺎــﻣاﺪﻗا و ﯽﻧﺎﻣرد ﻪـﺘﻓﺎﯾ ﺶــﯾاﺰﻓا ﻪﯾﻮﻧﺎﺛ ﯽﻤﯿﺧﺪﺑ ﻪﺑ ﻼﺘﺑا ﺮﻄﺧ ،ﯽﻧﺎﻃﺮﺳ نارﺎﻤﯿﺑ
6 ضﺮـﻋ رد ﻪـﮐ دﻮـﺷﯽﻣ ﻪــﺘﻔﮔ ﯽﯾﺎﻫنﺎﻃﺮﺳ ﻪﺑ SMN .ﺖﺳا
ﻦـﯾا (3).ﺪــﻨﮐ زوﺮﺑ رﺎﻤﯿﺑ رد ﻪﯿﻟوا ﯽﻤﯿﺧﺪﺑ ﺺﯿﺨﺸﺗ زا ﺪﻌﺑ هﺎﻣ ﻢﯿﻘﺘـﺴﻣﺮﯿﻏ ﺎـﯾ ﻢﯿﻘﺘــﺴﻣ تاﺮﺛا لﺎﺒﻧد ﻪﺑ ﺪﻨﻧاﻮﺗﯽﻣ ﺎﻫﻢﺳﻼﭘﻮﺌﻧ خر ﯽـﮑﯿﺘﻧژ داﺪﻌﺘـﺳا و ﯽـﭘاﺮــﺗﻮﯾدار ،ﯽﻧﺎﻣردﯽﻤﯿﺷ یﺎﻫوراد (4).ﺪﻨﻫد رﻮـــﻣﻮﺗ ﺺﯿﺨـﺸﺗ زا ﺪـﻌﺑ لوا لﺎـﺳ 20 رد SMN عﻮـﯿﺷ SMN ﻦﯾﺮﺗﻊﯾﺎــﺷ دﺎــﺣ ﯽﻤــﺳﻮﻟ و (5)هدﻮـــﺑ %3-12 ،ﻪـﯿﻟوا زوﺮـﺑ ﺪــﯿﯾﻮﻠﯿﻣ ﯽﻤﺳﻮﻟ ترﻮﺻ ﻪﺑ دراﻮﻣ ﺐﻠﻏا رد ﻪﮐ ﺪﺷﺎﺑﯽﻣ
،نﺎﻣز ﺖﺷﺬﮔ ﺎﺑ ﺰﻤﻠﯾو رﻮﻣﻮﺗ ﻪﺑ ﻼﺘﺒﻣ نارﺎﻤﯿﺑ رد (7 و6).ﺪﻨﮐﯽﻣ 10 نارﺎـﻤﯿﺑ ﻦـﯾا رد ﻪﮐ یرﻮﻃ ﻪﺑ ﺪﺑﺎﯾﯽﻣ ﺶﯾاﺰﻓا SMN ﺮﻄﺧ ﻪـﺑ ﻼـﺘﺑا ﺮـﻄﺧ ﺰــﻤﻠﯾو رﻮﻣﻮﺗ نﺎﻣرد و ﺺﯿﺨﺸﺗ زا ﺲﭘ لﺎﺳ زا ﺪـﻌﺑ لﺎـﺳ 15 و (8)ﺪـﺷﺎﺑﯽﻣ ﯽـﻟﻮﻤﻌﻣ داﺮــﻓا ﺮﺑاﺮﺑ 5 SMN
ﻪــﺑ (Cumulative Incidence)ﯽﻌﻤﺠﺗ زوﺮﺑ ناﺰﯿﻣ ﺺﯿﺨﺸﺗ
(9).ﺪﺳرﯽﻣ %1/6 دوﺪﺣ :زا ﺖــﺳا ترﺎﺒﻋ نارﺎﻤﯿﺑ ﻦﯾا رد ﺮﻄﺧ ﺶﯾاﺰﻓا ﯽﻟﺎﻤﺘﺣا ﻞﻠﻋ یﺎــﻫوراد ،ﺎــﻫﯽﻤﯿﺧﺪﺑ عاﻮـــﻧا ﻪـﺑ ﯽـﮑﯿﺘﻧژ و ﯽـﺗاذ داﺪﻌﺘـﺳا ﻞﻣﺎـﻋ ﻦﯾﺮﺗﻢﻬـﻣ (9).ﯽــﭘاﺮﺗﻮﯾدار و هﺪﺷ فﺮﺼﻣ ﯽﻧﺎﻣردﯽﻤﯿﺷ ﺰــﻤﻠﯾو رﻮـــﻣﻮﺗ ﻪـﺑ ﻼـﺘﺒﻣ نارﺎـﻤﯿﺑ رد SMN هﺪـﻨﻨﮐ ﺪﻌﺘـﺴﻣ
ﺪﻨﻧﺎـــﻣ ﻢـﯿﺧشﻮﺧ یﺎﻫﻢـﺳﻼﭘﻮـﺌﻧ (10).ﺪـﺷﺎﺑﯽﻣ ﯽـﭘاﺮـﺗﻮﯾدار شراﺰـﮔ ﯽــﭘاﺮﺗﻮﯾدار ﻞﺤﻣ رد ﺰﯿﻧ هﺪﻧد مﻮﭙﯿﻟ و مورﺪﻨﮐﻮﺌﺘﺳا درﻮــﻣ 2 ،ﻦــﻣﺰﻣ ﺪـــﯿﯾﻮﻠﯿﻣ ﯽﻤـﺳﻮﻟ درﻮـﻣ ﮏـﯾ .ﺖـﺳا هﺪـﺷ 9 ﺐـﯿﺗﺮﺗ ﻪـﺑ نﺎﺘـﺴﭘ نﺎﻃﺮـﺳ درﻮــﻣ 1 و هﺪﻧد مﻮﮐرﺎﺳﻮﺌﺘﺳا ﻞــﺤﻣ رد ﺰﻤﻠﯾو رﻮﻣﻮﺗ دﻮﺒﻬﺑ زا ﺪﻌﺑ لﺎﺳ 25 و لﺎﺳ 11 ،لﺎﺳ (10).ﺖﺳا هﺪﺷ هﺪﻫﺎﺸﻣ ﯽﭘاﺮﺗﻮﯾدار ﯽﻧﺎﻣردﯽﻤﯿـﺷ یﺎـﻫوراد زا هدﺎﻔﺘــﺳا ،ﯽﭘاﺮﺗﻮﯾدار ﺮﺑ هوﻼﻋ رد (11).ﺪــﺷﺎﺑﯽﻣ ﺮﺛﻮﻣ SMN زوﺮﺑ رد ﻦﯿﺴﯿﺑورﻮﺴﮐود ﺪﻨﻧﺎﻣ سرﺮـﯾد ضراﻮـﻋ ﻪـﮐ ﯽـﻫوﺮﮔ یﻮــﺳ زا هﺪﺷ ﺮﺸﺘﻨﻣ تﻻﺎﻘﻣ Late Effect Study=LESG)ﺪــﻨﻨﮐﯽﻣ ﯽﺳرﺮﺑ ار نﺎﻃﺮﺳ ﺖﯿﺻﺎــــﺧ ﻪــﺑ (12 و11)تﺎــﻌﻟﺎﻄﻣ ﺮﯾﺎــﺳ رد ﺰﯿــﻧ و (Group و ﺪﯾﺎـﺳﻮﭘﻮـﺗا ﻪﺑﺎــﺸﻣ ﻪﮐ ﻦﯿﺴﯿﺑورﻮﺴﮐود یوراد ﮏﯿﻧژﻮﮐﻮﻟ هﺪـﺷ هرﺎـﺷا ﺪـﺷﺎﺑﯽﻣ II زاﺮـﻣوﺰﯾاﻮﭘﻮـﺗ نﺎــﮔﺪﻨﻨﮐرﺎﻬﻣ ﺮﯾﺎﺳ ،ﻪـﯾﻮﻧﺎﺛ یﺎــﻫALL یور ﯽﺳرﺮﺑ 1 رد نارﺎﮐﻢﻫ و Pui .ﺖﺳا هﺪـــﻨﻨﮐ ﺖﻓﺎـﯾرد نارﺎـﻤﯿﺑ رد ار t (11 و4)نﻮﯿـﺳﺎﮐﻮﻟ ﺲـﻧاﺮﺗ
(14 و13)
.ﺪﻧاهدﺮﮐ شراﺰﮔ II زاﺮﻣوﺰﯾاﻮﭘﻮﺗ ﻦﯿـﺴﯿﺑورﻮﮐود ﺎــﺑ نﺎﻣرد ﺖﺤﺗ ﺰﯿﻧ ﺮــﺿﺎﺣ ﻪﻌﻟﺎﻄﻣ رﺎﻤﯿﺑ راﺮـﻗ ،ﺪـﻨﮐﯽﻣ ﻞـﻤﻋ II زاﺮــﻣوﺰﯾاﻮﭘﻮﺗ نﺎﮔﺪﻨﻨﮐرﺎﻬﻣ ﻪﺑﺎﺸﻣ ﻪﮐ ﻪـﺑ ﻼـﺘﺒﻣ رﺎـﻤﯿﺑ 5278 ،ﻪﻟﺎـﺳ 30 ﻪـﻌﻟﺎﻄﻣ ﮏــﯾ رد .دﻮﺑ ﻪﺘﻓﺮﮔ ﯽﻧﺎــــﻣرد ﻪــﻣﺎﻧﺮﺑ ﺎــﺑ نﺎــﻣرد ﺖــﺤﺗ ﻪــﮐ ﺰــﻤﻠﯾو رﻮــﻣﻮﺗ
ﻪـﺘﻓﺮﮔ راﺮـﻗ National Wilms’ Tumor Study=NWTS
(15).ﺪﻧﺪﺷ ﯽﺳرﺮﺑ ،ﺪﻧدﻮﺑ درﻮـﻣ 7 ﻪـﮐ ﺪــﺷ هﺪﻫﺎﺸﻣ SMN درﻮﻣ 43 ،ﻪﻌﻟﺎﻄﻣ ﻦﯾا رد هدﻮـﺑ M5 یژﻮــﻟﻮﻓرﻮﻣ ﺎﺑ دﺎﺣ ﺪﯿﯾﻮﻠﯿﻣ ﯽﻤﺳﻮﻟ ترﻮﺻ ﻪﺑ نآ و ﺰـﻤﻠﯾو ﻪـﯿﻟوا ﺺﯿﺨـﺸﺗ ﻦـﯿﺑ ﯽﻧﺎـﻣز ﻪــﻠﺻﺎﻓ ﻦﯿﮕﻧﺎﯿﻣ .ﺖﺳا ﻪـﮐ دﺮـﮐ هرﺎــﺷا ﻪﺘﮑﻧ ﻦﯾا ﻪﺑ ﺪﯾﺎﺑ .ﺪﻣآ ﺖﺳد ﻪﺑ لﺎﺳ 3 AML 15 زا ،شراﺰـــﮔ 1 رد و ﺪـﺷﺎﺑﯽﻣ ردﺎـﻧ رﺎﯿـﺴﺑ ﻪـﯾﻮﻧﺎﺛ ALL خر ﺰـﻤﻠﯾو رﻮـﻣﻮﺗ لﺎـﺒﻧد ﻪــﺑ درﻮﻣ 3 ﺎﻬﻨﺗ ﻪﯾﻮﻧﺎﺛ ALL درﻮﻣ (16).دﻮﺑ هداد ﻪـﺑ ﺰــﻤﻠﯾو رﻮﻣﻮﺗ و ﻪﯾﻮﻧﺎﺛ ALL ﻪﺑ ﻼﺘﺑا ﻦﯿﺑ ﯽﻧﺎﻣز ﻪﻠﺻﺎﻓ ﺰﯿـﻧ ﻪـﻌﻟﺎﻄﻣ ﻦـﯾا رﺎــﻤﯿﺑ رد .ﺪﺷﺎﺑﯽﻣ لﺎﺳ 4-10 لﻮﻤﻌﻣ رﻮﻃ هدﻮــﺑ ﻪﯿﻟوا رﻮﻣﻮﺗ ﺺﯿﺨﺸﺗ زا ﺪﻌﺑ لﺎﺳ 4 ،ALL زوﺮﺑ نﺎﻣز 1 رد ﺰﯿـﻧ ﻪـﯾﻮﻧﺎﺛ ﮏﯿﺘـﺳﻼﺑﻮﻔﻨﻟ دﺎــﺣ ﯽﻤﺳﻮﻟ درﻮﻣ ﮏﯾ .ﺖﺳا ﻪـﮐ ﺎﻣﻮﺘـﺳﻼﺑﻮﻟوﺪﻣ ﺺﯿﺨـﺸﺗ زا ﺪــﻌﺑ لﺎﺳ 7 ،ﻪﻟﺎﺳ 13 ﺮﺴﭘ شراﺰـﮔ دﻮـﺑ ﻪـﺘﻓﺮﮔ راﺮـﻗ ﯽــﭘاﺮﺗﻮﯾدار و ﯽﻧﺎﻣردﯽﻤﯿﺷ ﺖﺤﺗ
ﻪـﺑ هﺪـﺷ شراﺰـﮔ ﻪـﯾﻮﻧﺎﺛ ALL دراﻮـﻣ مﺎـﻤﺗ (17).ﺖــﺳا هﺪﺷ تﻮــﻓ ﯽــﻧﺎﻣرد ﺖــﺴﮑﺷ ﺖـــﻠﻋ ﻪـﺑ و ﺪـﻧدﻮﺑ موﺎـﻘﻣ نﺎـﻣرد ﺰـﻤﻠﯾو رﻮـﻣﻮﺗ یژﻮﻟﻮﺘـﺴﯿﻫ ﺎـﺑ ALL زوﺮـﺑ ناﺰﯿــﻣ .ﺪﻧاهدﺮﮐ ﻪﻘﺑﺎــﺳ ﻪــﻧﻮﮔﭻــﯿﻫ درﻮــﻣ 2 رد .دراﺪـــﻧ یرادﯽـﻨﻌﻣ ﻪـﻄﺑار ﺰﯿـﻧ رﺎـﻤﯿﺑ ﻪـﺳ ﺮـﻫ و ﺖــﺳا ﻪـــﺘﺷاﺪﻧ دﻮــﺟو ﯽــﭘاﺮﺗﻮﯾدار ،ﻦﯿــﺴﯾﺎﻣﻮﻨﯿﺘﮐا ﺎــﺑ نﺎــﻣرد ﺖــﺤﺗ ﺮﺿﺎــﺣ ﻪـــﻌﻟﺎﻄﻣ ﺪﻨﻧﺎـﻣ .ﺪـــﻧدﻮﺑ ﻪـــــﺘﻓﺮﮔ راﺮـــﻗ ﻦﯿﺘﯿـﺴﯾﺮﮐﻦﯾو و ﻦﯿـﺴﯿﺑرﻮﺴﮐود هﺪـﺸﻧ مﺎـﺠﻧا ﯽـﻣوزﻮﻣوﺮﮐ ﯽـﺳرﺮﺑ یدرﻮــﻣ ﭻﯿﻫ رد نﻮﻨﮐﺎﺗ (16).ﺖﺳا AML ﻪﺑﺎﺸﻣ ﯽﻤﺳﻮﻟهﺮﭘ زﺎﻓ ،ﻪﯾﻮﻧﺎﺛ ALL ﻪﺑ نﺎﯾﻼﺘﺒﻣ رد لﻮـﻤﻌﻣ رﻮـﻃ ﻪـﺑ ﻪـﯾﻮﻧﺎﺛ ALL نﺎـﻣرد .دراﺪـﻧ دﻮــﺟو ﻪﯾﻮﻧﺎﺛ .ﺪـﺷﺎﺑﯽﻤﻧ ﺶﺨﺑﺖﯾﺎــﺿر ﺰــﯿﻧ نآ ﯽـﻬﮔآﺶﯿﭘ و هدﻮﺑ ﻖﻓﻮﻣﺎﻧ یﺎـﻫشور ﺎـﺑ نارﺎـﻤﯿﺑ ﻦـــﯾا دﻮـــﺷﯽﻣ ﻪﯿﺻﻮﺗ ﻦﯾا دﻮﺟو ﺎﺑ راﺮـﻗ نﺎـﻣرد ﺖـﺤﺗ ناﻮﺨﺘـﺳا ﺰــﻐﻣ ﺪــﻧﻮﯿﭘ و ﯽﻧﺎــﻣرد ﺪﯾﺪﺟ .ﺪﻧﺮﯿﮔ زا هدﺎﻔﺘـﺳا ﺎــﺑ ﺖـﻔﮔ ناﻮـﺗﯽﻣ ﯽـﻠﮐ یﺮــﯿﮔﻪﺠﯿﺘﻧ ناﻮﻨﻋ ﻪﺑ نارﺎـﻤﯿﺑ ،ﯽـــﭘاﺮـﺗﻮﯾدار و ﯽـــﻧﺎﻣرد ﯽﻤﯿــﺷ ﺪﯾﺪﺟ یﺎﻫشور ﺪـــﻧاهﺪﺷ رادرﻮـﺧﺮﺑ یﺮــﺗﺶﯿﺑ ﺮﻤﻋ لﻮﻃ زا نﺎﻃﺮﺳ ﻪﺑ ﻼﺘﺒﻣ یﺎﻫﻢـﺳﻼﭘﻮـﺌﻧ ﻪـﺑ ﻼـــﺘﺑا ﺮـﻄﺧ ،ﻦــﺳ ﺶﯾاﺰﻓا تازاﻮﻣ ﻪﺑ ﺎﻣا ﻦـﯾا ،نﺎـﻣز ﺖـﺷﺬﮔ ﺎـﺑ و ﺪــﻨﮐﯽﻣ ﺪﯾﺪﻬﺗ ار نارﺎﻤﯿﺑ ﻦﯾا ﻪﯾﻮﻧﺎﺛ نارﺎــﻤﯿﺑ یﺮـﯿﮔﯽﭘ ﺖـﻠﻋ ﻦـﯿﻤﻫ ﻪـﺑ ﺪــﺑﺎﯾﯽﻣ ﺶــﯾاﺰﻓا ﺮــﻄﺧ دﻮـﻋ زا ﺪـﻌﺑ ﺪـــﻧاﻮﺗﯽﻣ ﻪـــﮐ ﻪـــﯾﻮﻧﺎﺛ یﺎﻫﻢــﺳﻼﭘﻮﺌﻧ ﺮﻈﻧ زا یروﺮـــﺿ ،ﺪــــﺷﺎﺑ گﺮـــــﻣ ﺖـﻠﻋ ﻦﯾﺮﺗﻢﻬـﻣ ﻪـﯿﻟوا رﻮـﻣﻮﺗ .ﺪﺷﺎﺑﯽﻣ دﺎـﺣ ﺪـﯿﯾﻮﻠﯿﻣ ﯽﻤـﺳﻮﻟ نارﺎـﻤﯿﺑ ﻦــﯾا رد ﯽﻤﺳﻮﻟ ﻦﯾﺮﺗﻊﯾﺎﺷ ردﺎــﻧ رﺎﯿﺴﺑ نارﺎﻤﯿﺑ ﻦﯾا رد ﮏﯿﺘﺳﻼﺑﻮﻔﻨﻟ دﺎﺣ ﯽﻤﺳﻮﻟ و هدﻮﺑ ﻞﯿﮑـــﺸﺗ ار ﻪـﯾﻮﻧﺎﺛ یﺎﻫﯽﻤـﺳﻮﻟ ﻞـﮐ زا %5-10 ﺎﻬـﻨﺗ و ﺖـﺳا .ﺪﻨﻫدﯽﻣ ﯽﻤـﺳﻮﻟ ﺪــﺷ هﺪﻫﺎﺸﻣ ﻪــﻌﻟﺎﻄﻣ ﻦــﯾا رد ﻪــﮐ رﻮــﻃ نﺎﻤﻫ رﻮــﻣﻮﺗ ﺺـــﯿﺨﺸﺗ زا ﺲـــﭘ لﺎـﺳ 4 ﻪـﮐ ﮏﯿﺘــﺳﻼﺑﻮﻔﻨﻟ دﺎﺣ ﻪـﺑ نﺎـﻣرد عوﺮـﺷ زا هﺎـﻣ 19 زا ﺲـﭘ دﻮــﺑ هدﺮﮐ زوﺮﺑ ﺰﻤﻠﯾو رﺎـﻤﯿﺑ گﺮـﻣ ﺐﺒـﺳ رﺮـﮑﻣ یﺎــﻫدﻮﻋ و ﯽﻧﺎﻣرد ﺖﻣوﺎﻘﻣ ﺖــﻠﻋ .دﻮﺑ هﺪﺷ
ﻪـــﻨﯾﺎﻌﻣ ،ﻪـﯾﻮﻧﺎﺛ یﺎـﻫرﻮﻣﻮﺗ زوﺮـــﺑ لﺎـﻤﺘﺣا ﻪـﺑ ﻪـﺟﻮﺗ ﺎﺑ ﻪـﯿﺻﻮﺗ و ﻪﺘـﺷاد تروﺮـﺿ ﻪــﺘﻓﺎﯾ دﻮﺒﻬﺑ نارﺎﻤﯿﺑ رد یاهرود .ددﺮﮔﯽﻣ
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Secondary Acute Lymphoblastic Leukemia Following a Successful Treatment of Wilm’s Tumor: A Case Report
I II III
*Kh. Arjmandi Rafsanjani, MD P. Vossough, MD E. Shahgholi, MD
Abstract
Secondary Malignant Neoplasm(SMN) is one of the late effects of childhood cancer. Among secondary malignancies, acute myeloid leukemia(AML) is the most common and life-threatening neoplasm. Secondary acute lymphoblastic leukemia(ALL) is rare and only 10% of SMN is ALL.
Patients with Wilm’s tumor are not protected from the secondary cancers after the primary diagnosis.
Among patients with this tumor the most common SMN is AML and ALL is very rare. In this paper, we report a case of ALL, four years after diagnosis of Wilm’s tumor. The patient died nineteen months after the beginning of leukemia treatment due to multiple relapse and resistance to treatment. With advances in the treatment of childhood cancer, more children are surviving long periods of time; therefore, careful follow-up and other examination sequels are necessary for early diagnosis of SMN.
Key Words: 1) Secondary Malignancy 2) Secondary Leukemia 3) Secondary Acute Lymphoblastic Leukemia
4) Wilm’s Tumor
I) Assistant Professor of Pediatric Hematology and Oncology. Hazrat Ali Asghar Hospital, Zafar Ave., Iran University of Medical Sciences and Health Services. Tehran, Iran.(*Corresponding Author)
II) Professor of Pediatric Hematology and Oncology. Iran University of Medical Sciences and Health Services. Tehran, Iran.
III) Assistant Professor and Resident of Pediatric Hematology and Oncology. Tehran University of Medical Sciences and Health Services. Tehran, Iran.
