BAO CAO KET QUA 6 TRUIOmG HOP

Y HQC VigT NAM THANG 8 • S6 BAC BljT/2012

DIEU TR| BACH c A u CJiP DONG TUY T R E N D E N H N H A N L A N TUtfl:

BAO CAO KET QUA 6 TRUIOmG HOP

Nguyin NgQC Qui Anh, Nguyen H^nh Thu Hujrnh Vin Min, Ngd Nggc Ngin LinhC) T6MTAT

B^nh bach cau cSp ddng tiiy (BCCDT) l i benh ly xuat hiin d mpl Ida tudi, tuy nhiin thudng gip d binh nhin (BN) Idn tufii. Mic dii cd nhiiu Ben bp ding ke trong dISu tr| benh BCCDT trong nhiing thip nien gan day, vigc dieu hi d binh nhan Idn tudi vIn ia mdt thich thiic idn cua cac nha iam sang. Tir 4/2011, t?i Binh vien Tmyen Miu Huyit Hpc Tp.HCM, chiing tdi da va dang thut hiin 1 nghien ciiU thCr nghiem iam sang nham dinh gia hiiu qua v i dpc b'nh aia phic dd dieu trj chinh lieu, sii dung cho benh nhan BCCDT idn tuoi (s 60 tuoi). Cho den thing 2/2012 CO 6 trudng hap dii tieu chuan tham gia vao nghien ciiu. Chung tdi bio cao ket qua ghi nhan duijc d 6 trudng hdp: 6 BN deu iui benh (1 BN iui benh mot phan), 3BN t i i phat sau iui benh 4, 6 va 9 thing.

Tit khoa: Bach cau cap ddng tiiy, Idn tuoi, lui binh hoan toan, tai phit, dpc tinh.

ABSTRACT

Acute myeloid leukemia (AI4L) occurs at any age, but common in older patients. Despite considerable progress during recent decades in the therapy of AI>1L, the treatment of AML in the elderly remains a challenge for clinicians. Since April 2011, at Ho Chi Minh Blood Transfusion and Hematology Hospital, we have carried out a dinical trial to evaluate the effective and toxicity of the reduced regimen, used in elderly patients (over 60) with AI4L Until Feb 2012, 6 patients was enrolled this study. We report the results recorded in 6 cases: 5 patients had complete n Benh vien Truyen mau Huyet hoc Tp. HCM Phan bien khoa hoc: TS. Huynh NghTa

remission, 1 patient had partial remission; 3 of them had relapse after 4-month, 6-month and 9- month CRs.

Key words: Acute myeloid leukemia, elderly, complete remission, relapse, toxicity

I.

OAT VAN

of

B?ch ciu cip ddng tuy (BCCDT) li b^nh ly xuit hien d mpi lira tuii, nhung tin suit ting vpt d din si sau 55 tuii. Tuii trung binh mic BCCDT li khoing 69 mil d Hoa Ky vi khoing 60%-70% ti li bgnh xuit hiin d Ilia tuii tren 60 theo thing ke d cic nude Chau Au. Diiu trj bach ciu cip ddng tuy trin ngudi Idn tuoi rit khd khin do ti 1§ lui binh thip vi ti li tir vong lien quan vdi diiu tri cao. Nhiiu nghiin ciiu da dugc thuc hiin vdi nhiiu cdng thiic phic dd, ip dung cic thudc mdi trong diiu trj BCCDT trin ngudi Idn tuoi nhim ning cao ti le lui bpnh vi giim ti li tir vong trong diiu tri.

Tir 4/2011, BV TMHH TPHCM da xiy dung phic dd di dieu tt\ bpnh nhin BCCDT Idn tuii (> 60 tuii) ding thai cflng dua vio nghiin cuu lim sing nhim dinh gii hiiu qui vi dpc tinh cua phic do niy. Vdi phic dd niy, liiu ciia Anthracyline trong giai doan tan cdng giim cdn 30 mg/m^ vi giai doan sau tin cdng Aracytine dugc sir dung vdi liiu thip. Cho din 2/2012, cd 6 binh nhin du diiu kiin dugc diiu tri BCCDT, chiing tdi thuc hiin bii bao cio nay nham dua ra nhirng kit qui diiu tri ghi nhan d 6 BN diu tien.

CHUYSN Bg: HQI NOHI KHOA HpC HUYgl HOC •'nWJjfc MAU TOAN OUgC 8012 II. 061 TUgNO VA PHUONG PHAP NOHICN C O U

1. Dii tuvng nghiin cihi:

Tiiu chuin chpn b$nh: chin doin b^ch ciu cip ddng tdy; tuii tCr 60-70 tuii, chiic ning tim m«ich tit, ding ^ diiu trj.

Tiiu chuin lo^i b$nh: tii lofui chiic ning gan th$n, tiin sCi nhii miu co tim hay thiiu miu CO tim, nhilm trimg tiin triin.

2. Phuomg phip tiin hinh:

B$nh nhin thda tiiu chuin chpn miu si dugc khio sit vi die diim lim sing, huyit hpc, phin tich cic bit thudng nhilm sic thi.

Tiin hinh diiu trf theo phic d i : Tin cdng: Daunorubicine 30mg/m^/

ngiy X 3 ngiy; Aracytine lOOmg/mV ngiy truyin tinh m^ch liin tyc 24 gid x 7 ngiy.

Niu t f t d i vi sinh thiit tOy d N14 hay N2Uiia jm di xic djnh rS ti \i ti bio Blast

>5%, BN i | dugc diiu trj tiip Mitoxantrone 8mg/m'/ ngiy x 2 ngiy; Aracytine

lOOmg/mV ngiy truyin tTnh m^h liin tuc 24 gid X 5 ngiy

• Sau lin cdng: Aracytine 100 mg/m^/

ngiy X 5 ngiy.

Theo dSi vi dinh gii kit qui diiu trf:

• Dinh gii lui b ^ .

Theo dSi vi dinh gii biin chiing trong thdi gian diiu trj.

• Khio sit thdi gian hii phyc bach ciu, tiiu ciu, thdi gian nim v i ^ .

Khio sit thdi gian tii phit, thdi gian sing toin bd.

III. K I T Q U A VA BAN LU;;iN:

Tit 4/ 2011 din 2/2012, BV TMHH TPHCM diiu trj 6 b^nh nhan b ^ b?ch ciu cip ddng tiiy tit 60 tuii trd lin, cho kit qui nhu sau:

1. S i c dl^m lim sing vi sinh hoc liic chin doin:

Bans 1- Pic agm BN trUdc digu W

Tonq so Tuoi (tudi) Nam/nO' Hinh thai hpc F.A.B . AI4L M l . AI4L M2 Karyotype

t(8;21)

• Binh thudng -8/45XY SLBC trUdc dieu h i (xlO'/mm^)

Tonq tranq (chi sd ECOG) EC0G=1 EC0G=2

6BN 63 4/2 1 5 1/6 4/6 1/6 42.5

4/6 2/6

(60-67 tuSi)

(16.7%) (83.3%)

( 1 7 % ) ( 6 6 % ) ( 1 7 % ) (1.5 - 142)

(66%) (34%)

24

Y HQC VlgT NAM THANO » - S6 BAC BI$T/2012 B ^ nhin trong nghiin ciiu chiing tdi

chu yiu dudi 65 tuii vi cd ting tr(uig tuong dii khi (chi si ECOG 1-2). 4 b$nh nhin cd binh ly nil khoa kim theo (cao huyit ip; viy nin, dau thin kinh tpa cd chin ip rl thin kinh; tri ndi xuit huyit; viim loit d? diy kim trT ndi).

1 b^nh nhin cd biiu hifn tiiy ting sinh dugc diiu trj vdi hydrea 10 thing trudc khi chuyin thinh b^ch ciu cip. 1 b$nh nhin cd biiu hiin xim lin ngoii biy. Vi bit thudng nhiem sic thi, 4/6 binh nhin cd karyotype binh thudng, 1 BN cd yiu ti tiin lugng thuin Igi, chi 1 BN cd bit thudng karyotype tiin

lugng xiu.

Theo Y vin, bit thudng nhilm sic thi tim thiy trong 60% b$nh nhin Idn tuii BCCDT[7]. Theo y vin cic biin dii cd Igi nhu t(15;17), t(8;21) vi inv (16) giim din khi tuii ting din 17% d tuii < 55 so vdi 4%

d tuii >75; vi ngugc cic ddt biin bit Igi nhu 5q-, 7q- tit 35% ting 57%, lojm sinh tiiy chuyin b?ch ciu cip chiim khoing 30% cic trudng hgp. Ngoii ra, cic yiu ti nhu ting ttfuig kim horn vi cic binh 1^ ndi khoa kim theo si h ^ chi hda trj li^u chuin dua din giim ti li lui binh vi du hiu vi sau cho cic BN niy.

2. Kit qui diiu trj:

Bang 2. Kit qui diiu tri Dap lihq dieu tri

• Lul benh hoan toan

• Lui benh 1 phan' Bien chiinq cua dieu tri

• Nhiem trunq

• Sot nhiem triinq, chuS phat hien 6 nhiem

• Viem phoi

• Nhiem triinq huyet"

• Nhip Cham xoanq Thdi gian hoi phuc

Bach cau hat > 0.5xl0'/i

" Tieu cau > 50 X lo'/l Thdi qian nam vien

5/6 1/6 6/6 2/6 3/6 1/6 1/6

26 nqay 28 nqay 43 'Lui benh hoan toan sau bo sung phac dS l^itoxantrone 8mg/m^ x 2

C lOOmg/m' x 5 ngiy.

" Nhilm triing huyet E.coii tiet ESBL

(83%) (17%) 100%

(34%) (50%) (17%) (17%)

(17-40) (19-46) (35-60) igay va Ara-

Kit qak ghi nhdn 5/6 b^nh nhan dat lui benh hoan t o ^ . 1 benh nhSn lui b?nh mot phin. BN nay 60 tu6i, co biSu hi$n loet rang vung cing chan keo dai, kh6ng Idnh vet thucfng, CO biiu hien de dpa ho^i thu co nguy

CO doEin chi va dugrc phdt hi^n benh b^ch ciu d p tinh CO qua cdc x6t nghi?m kiem tra. BN dugc chung toi chi dinh cat Igc rat rgng 6 ton thuong mo mem vung cing chan trai va van bao t6n chi. Voi ket qua giai phau b?nh.

CHUYEN ei: HOI NOHI KHOA HPC HUVfT HOCvTwlrtlNlli*6T0AM 0U6c M12

nhudm hda md v i diu i n miln djch, chiing tdi xic djnh tin thuong do x i m lin bfwh c i u cip, BN dugc tiin hinh diiu trj sdm v i d(it lui b^nh 1 phin sau tin cdng lin 1. BN sau dd dugc tiip tyc diiu trj tin cdng dgt 2 vdi mitoxantrone 8 rag/m' x 2 ngiy v i aracytine lOOmg/m* « 5 ngiy v i d»t lui b^nh hoin toin. BN niy hi^n v5n cdn lui bfnh sau 14 thing d«t lui bf nh hoin toin.

Qui trinh theo ddi sau lui b^nh, chiing tdi ghi nhin 3 BN d i tii phit sau 9 thing, 6 thing v i 4 thing sau lui b^nh hoin toin;

trong dd 2 b^nh nhin tii phit rit sdm (< 6 thing) di bi vong vdi thdi gian sing toin bd l i 7 v i 15 thing.

Theo cic nghiin ciiu, ti 1^ lui b^nh thip hon bin so vdi nhdm tuii < 60 tuii, 33% so vdi 67%, v i ti Ip til vong trong tin cdng l i 21% so vdi 12% [4], theo EORTC CR 58%, thdi gian sing 2 nim 17%. Theo CALGB ti Ip lui binh l i 48.5%, 57% d nhdm karyotype binh thudng v i 20% - 37% d nhdm cd bit thudng 5q-, 7q- hay bit thudng phiic tap khic. [5]

Nhihig yiu t i v i bit thudng nhilm s i c thi cOng inh hudng din ti Ip lui bpnh. Theo ECOG nghiin cihi hi^u qui v i ddc tinh cda aracytine kit hgp vdi daunorubicine, mitoxantrone hay idarubicine trong diiu trj tin cdng binh nhin BCCDT trin 60 tuii cho thiy ti li lui binh cao hon 53% d bgnh nhin cd karyotype binh thudng so vdi 30% nhdm cd bat thudng nhilm thi [5] 6 bpnh nhin ciia chung tdi diu dat lui binh cd thi do hiu hit deu cd nhilm sic thi di binh thudng v i cd t (8;21).

Trong giai do^n tan cdng, thdi gian hii phuc BCH > 0.5 xlO'/L trung binh l i 26 ngiy ( 1 7 - 4 0 ngiy). Thdi gian hii phyc TC

>50 x lO'/L l i 28 ngay (19 - 46 ngiy). Thdi

gian n i n ^ i f n trung binh l i 43 ngiy. Do c i 6 bfnh nhte trong nghiin cdu cda chdng tdi khi nhSp vi^n ludn cd tinh tr«mg nhilm trung trudc khi diiu trj nin vi^c bit diu diiu trj tri, kio dii thdi gian n i m vi$n.

Biin chiing ehii y i u li nhilm triing, 3 b^nh nhin viim | ^ 1 b ^ nhin nhilm triing ning vita viim phii vira nhilm uimg huyit, tuy nhiin cic tnrdng hgp niy dip ung tit vdi khing sinh tTnh m ^ h phi idng. Mdt binh nhin ghi nhin cd biin chiing chim nhjp tim v i hii phyc khi can t h i ^ bing theophyline.

IV. K ^ LUf N

6 b^nh nhin d i u tiin cd thi dung n^p vdi phic d i diiu trj v i d«t dugc mdt kit qui khi quan vdi biin chiing d miic cd thi chip nhin dugc. Cd thi hy vpng d i y s i l i m$t phic do khi dl cd hipu qui, mang tdi 1 c i u nii tiin din viic ghip khdng d i ^ tiiy trin nhdm BCCDT d BN Idn tuii hay ching? Nghiin cihi cua chiing tdi v i n dang tiip tyc thyc h i ^ v i hy vpng s i b i o c i o nhihig so lipu cd y nghta trong thdi gian tdi.

TAI UfU THAM KHAO

1. Arnaud Pigneui, J. L. H. (2010).

"Addition of Lomustine to Idarubicin and Cytarabine Improves the outcome of Elderly Patients with de novo acute myeloid leukemia: A report from the GOELAMS." J Clin Oncol 28 (18): 3028-3034.

2. Lowenberg B, S. S., Archimband E (1998). "1998 Mitoxantrone versus daunorubicine in induction- consolidation chemotherapy — the value of low -dose cytarabine for maintenance of remission, and a assessment of prognostic factors in acute myeloid leukemia in the elderly: final

26

Y HQC VlgT NAM THANO 8 • S 6 B A C BI$T;2012

report. European Organization for Research and treatment of Cancer and the Dutch- Belgian Hemato-Oncology Cooperative Hovon Group." J Clin Oncol 16(3): 872-881.

Lowenberg B, Z. R., Kerkhofs H (1989).

"On the value of intensive remission- induction chemotherapy in the elderly patients of 65+ years with acute myeloid leukemia: a randomized phase III study of European Organization for Research and Treatment of cancer Leukemia Group." J Clin Oncol 7; 1268-1274.

M.Baudard, J. M., M Cadiou (1994).

"Acute Myelogenous leukemia in the elderly: retrospective study of 235

consecutive patients." Bristish Journal of heamatology 86 (I): 82-91.

P.Erba, H., Ed. (2007). Prognostic Factor in Elderly Patients with AML and the Implication for treatment. ASH.

Tilly H, C. S., Bordessoul D (1990). "Low- dose cytarabine versus intensive chemotherapy in the treatment of acute nonlymphocytic leukemia in elderly." J Clin Oncol 8 (272-279).

Yin, J. A. L. (1993). "Acute Myeloid Leukaemia in the elderly: Biology and treatment." Bristish Journal of heamatology 83: 1-6.

KHAO SAT DAP UMG BliU TR! XUJIT HUY^T 61AM TIEU CJU M I I N DjCH cAP ism EM Cd TIEU CAU DiJAl 20.00a/MM' TAI B I N H VIEN NHI DiiNG 2

TUri5-03-2011 DEN 15-08-2011

Phan Thi Thu Trang*, LSm Thi Mf **

TOM TAT

Muc t i i u : khio sat dip li^g dieu tri ciia xuat huyet giim tieu rau mien djch (XHGTCMD) cd tieu cau< 20.000/mm' duS vao phan dp xuat huyet lam sang tai Benh Vien Nhi Dong 2.

eSi taCffng v i phiTdng p h i p nghien a h i : Nghien dtu md ta hang loat ca b i n 52 ca XHGTCMD cap cd tieu cau < 20.000/mm^

Kel qua: nam chiem uu.the; TuSi trung v! la 28,5 (4-174) thing, tuoi <5 chiem 77%, nhu nhi 37%; 29% cd tien can nhilm sieu vi,

10% cd tien can chich ngilS 2-4 tuan trUdc dat binh. I»liic dd xuat huyet lie nhip vien: nhe 12%, trung binh 73%, ning 15%. Nhdm xuat huyet nhe luc nhap vien dap litig d tuin 1, tuan 2, tuan 4 Ian iuat 83%, 100%, 50%. Nhdm xuat huyet trung binh luc nhap vipn dap irng d tuan 1, tuan 2, tuan 4 lin iupt la 79%, 87% v i 86%.

Nhdm xuat huyet nang luc nh$p viin dip uhg tuan 1, tuan 2, tuan 4 iln iuat la 50%, 87% va 100%. Toan nhdm cho dap irng tuan 1, tuan 2, tuan 4 Ian iUpt la 75%, 88% va 85%. ChuS ghi

* Benh vien Nhl BSng 2 ** Bg mon Nhl Trudng Dal hgc y dugc TP.HCM Phin bl$n khoa hgc: TS. Hujrnh Nghia