Nghien cii'u dac diem lam sang, can lam sang va ket qua dieu tri tan cong phac do cytarabine va doxorubicine o"
benh nhan bach cau tuy cap
Clinical, paraclinical characteristics of acute myeliod leukemia and outcomes of induction therapy
Tru'o'ng Thi Thiio Hien, Nguyin Thj Minh Phiro'ng Khoa Huyit hoc lam sdng Binh vien Trung uang Qudn doi 108
Muc tieu: Md ta dac diem lam sang, can lam sang, danh gia ket qua dieu trj tan cdng va tac dung phu cua phac do "7+3"- Cytarabine + doxorubicin d benh nhan (BN) bach cau tuy cap (8CTC). Ddi tupng vdphUOngphdp nghien cdu: Hoi cud, md ta, cat ngang 40 BN BCTC dieu tri Doxorubicine 30 mg/mVngay x 3 ngay va Cytarabine 200 mg/mVngay x 7 ngSy tai khoa Huyet hpc lam sang Benh vien TL/QD 108, Ki't qud: tuoi trung binh IS 52,27 ± 15,67 tudi, ty le nam: n d 1:1,1; thieu mau chiem 92,5%, sot chiem 45%, xuat huyet da va niem mac 47,5%. Phan the benh theo FAB: the M2 -32,5%, (Vll- 22,5%, M4 -17,5%, MO-12,5%, M3-7,5%, M6- 5% va M5- 2,5%. Gia trj trung binh cac chi so mau ngoai vi va tuy xUong: BC 44,89±50,79 G/L; BC hat trung tinh 11,14± 16,61 G/L; HST 85,73+ 17,96 g/l; TC 96,39+94,25 G/L; so Idpng te bao tuy 180,18+112,20 G/L, nguyen tuy bao trong tuy 70,8±19,9 %; nguyen tuy bao mau ngoai vi 52,3± 29,68%. Ty le dap dng hoan toan (CR): 50%; mpt phan (PR) 32,5% va khdng dap dng (NR) 17,5%. Tac dyng khdng mong muon chu yeu cua phac dd "7+3" la: ndn va budn ndn mdc dp 1,2 IS 15% va 37,5%, rung tdc 100% trong dd dp 4 la 32,5%. Giam BCHTTdd 3, dp 4 la 32,5% va 62,5%; giam TC dp 3, dp 4 chiem 27,5% va 57,5%.
TUkhda: Bach cau tuy cap, Cytarabine, doxorubicin, lam sang, can lam sang
Summary:
Objectives: To describe the clinical, paraclinical characteristics of acuite myeloid leukemia (AML) and to examine the effects of induction regimens "7+3"- Cytarabine + doxorubicin for AML patients. Patients and Methods: A retrospective cross sectional study on 30 AML patients who underwent Doxorubicin 30 mg/mVday x 3 days plus Cytarabine 200 mg/mVday x 7 days from 2008 to 2013 at department of haematological diseases of 108 military central hospital. Results: The mean age of patients was 52.27 ± 15.67 years; the ratio of females to males was 1:1; 92.5% of patients had anemia, 45% had fever, 47.5%
had skin and mucosal bleeding. AML was classified (by FAB) as M2 (32.5%), M l (22.5%), M4 (17.5%), MO (12.5%), M3 (7.5%), M6 (5%) and M5 (2.5%). Results from peripheral blood examinations were 44.89+50.79 G/L for WBC, 11.14± 16.61 G/L for neutrophil, 85.73+ 17.96 g/I for HGB, and 96.39±94.25 G/L for PLT. Bone marrow cell count was 180.18+112.20 G/L. In addition, percentage of myeloblast in bone marrow was 70.8±19.9 % and in peripheral blood was 52.3± 29.68%. Complete response rate (CR) was 50%; partial response rate (PR) was 32.5% and none-response rate (NR) was 17.5%. Several sife effects of
Phan bien Idioa hpc: PGS.TS. NGUYEN VAN QUYNH
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
of "7+3" regimen were noted. The pravelance of vomiting/nausea grade 2 and 3 were 15% and 37.5%, consecutively. Alopecia occurred in 100% of the sample with 32.5% was grade 4. Prevalence of granulocytopenia grade 3 and 4 were 32.5% and 62.5%, and that of thrombocytopenia grade 3 and 4 were 27.5% and 57.5%, respectively.
Keywords: acute myeloid leukemia, clinical, paraclinical, Cytarabine, doxorubicin.
1 . Oat van de
Bach cau tdy cap (BCTC) la benh ac t i n h cua he tao mau dac trUng bdi sd tang sinh bat t h u d n g cac te bao non cua tCiy xUdng lam suy giSm kh^ nang tao mau cda cp the. 6 My t i le mic bach cau tuy cap khoang 2,5/100.000 dan, chiem khoang 1,2% cac benh ung t h d va chiem 40% t r d d n g hop bach cau cap, t r o n g dd 80% la ngUdi Idn [8]. 6 Viet Nam, theo nghien cdu cua Tran Thi Minh Huong (2000) tren 2089 BN tai vien huyet hpc truyen mau Trung uang t d nam 1997-1999, B Q C chiem 54,8% [2]. Lam sang dien hinh cda bach cau tuy cap la ba hpi chdng:
thieu mau, xuat huyet va nhiem trung [2]. Tuy do thudng thay cac te bao non ac tinh ddng tuy chiem 20- 95% tai thdi diem chan doan, cac te bao ddng hdng cau, tieu cau va bach cau hat g i i m nang. Myc dfch dieu tri bach cau tuy cap la tieu diet tdi da cac te bao ac tinh, nh^m tao ra va duy tri tinh trang lui benh hoan toan.
BCTC cd nhieu the va moi the dap dng vdi cac phddng phap dieu tri va tien lupng khac nhau. BCTC dupc dieu trj tan cdng ban dau bang hda tri nham dat dupc lui benh sau do tuy theo tdng the ma hda tri bd sung hoac ghep t e b a o goc tao mau ddng loai phu hpp HLA. Cd nhieu phac do hda chat da dupc ap dung de dieu tn BCTC giai doan tan cdng nhdng phac do "7+3"
(cytarabine va doxorubicin) van dupc danh gia la mot phac do tan cdng kha hieu qua vi dat ty le lui benh cao.
Muc tiiu cua nghiin cdu ndy Id md td dgc diem Idm sdng, can Idm sdng, ddnh gid ket qud dieu tri vd tdc dung phu cua phdc do tdn cdng "7+3" d binh nhdn bach cdu tCiy cdp tai khoa Huyet hpc Idm sdng Benh vien Trung uang Qudn dpn 08.
2.061 tupng va phuong phap nghien cdu 2.1. Doi tugng nghien cdu
40 BN BCTC dieu tri tai khoa huyet hpc lam sang t U t h a n g 1/2008 den thang 12/2013.
Tiiu chuan chpn: Tuoi t d 18 t r d len. Chan do^n xac dinh BCTC. Ho sd b e n h an ghi chep day dO cac d d l i e u can nghien cdu.
Tiiu chuan chdn dodn: DUa vao hinh thai va phtin dng te bao cua tuy do vdi hien dien >20 % te bao non vdi hinh thai va nhudm hda te bao la cua dong tuy (myeloblast)- te bao blast phan dng duong ti'nh vfi perosidase, sudan black hoac esterase)
Phdn loai bach cdu tuy cdp: theo FAB {French- American-British) gom 7 t h e t U M l d e n M 7 .
2.2. Phuang phdp nghien cdu: hoi cUu, mo t i cat ngang.
BN dupc kham lam sang va khai thac cac tri&u chdng. Cac xet n g h i e m huyet hpc, tuy do, sinh hoa mau va chan doan h i n h anh lam tai Benh vien Trung u o n g Quan dpi 108
+ Dieu t n : Doxorubicine 30 m g / m V n g a y truyen tTnh mach t r o n g 30 p h u t , t r o n g 3 ngay lien tiep.
Cytarabine 200 m g / m V n g a y truyen t i n h mach trong 24h, t r o n g 7 ngay lien tiep.
+ Danh gia dap dng (theo tieu chuan cCia Vi^n ung t h u quoc gia Hoa Ky): dda tren tdy dd va mau ngoai vj dupc tam lai vao ngay t h d 14 cua chu ky hda chat
Lui benh hoan t o a n (CR): Khdng cd blast trong mau ngoai vi. Bach cau hat t r u n g t i n h > 1,5 G/L. So lupng tieu cau m a u ngoai vi 2: 100 G/L Ti!iy do:
myeloblast < 5% t r o n g t u y va khdng cd the auer.
Khdng t h a m nhiem ngoai t u y
Lui benh m p t phan (PR): Khdng cd blast trong mau ngoai vi. Sd Idpng bach cau hat trung tinh 2 1,0 G/L. Sd lupng tieu cau m a u ngoai vi > 100 G/L Tuy d d : 5% -25% myeloblast t r o n g tiiy.
Khdng lui benh: Tuy d o : Blast > 25%
+ Theo ddi tac d u n g khdng m o n g mudn cila t h u o c tren lam sang va xet nghiem theo tieu chuan cua Vien ung t h d qudc gia Hoa Ky
P h u o n g p h a p x d IE sd lieu: t r e n phan mem SPSS 18.0.
• TAP CHi Y DUCfC L A M S A N G 10i
i S . K e t q u S
3.1. Dac diem tuoi, gidi vd thi benh cua cdc BN nghien cdu
Bang 3 . 1 . Phan bo benh nhan theo t u d i , gidi, t h e benh
Dac diem ve tuoi va giori Tuoi trung binii {tuoi)
Nhiom tudi
Gidi
Ttie benii tiieo FAB
18-30 31-55 56-65
>65 Nam Nil MO M l M2 M3 M4 M5 IV16
SoIKOng BN (n= 40) T J I e % 52,27 ±15,67 (20-88 tuoi).
4 20 10 6 21 19 5 9 13 3 7 1 2
10 50 25 15 52,5 47,5 12,5 22,5 32,5 7,5 17,5
2,5 5 Tudi t r u n g binh la 52,27 + 15,67(20-88 tudi). Op tuoi tU 3 1 - 65 t u d i chiem tdi 75%. T^ le nam: n d la 1,1:1. The M2 chiem t y le cao nhat 32,5% sau d d den t h e M l 22,5%, t h e M 4 17,5%, t h e MO 12,5%, t h e M3 chiem 7,5 %, the M6 chiem 5% va the M5 la 2,5%.
Khdng cd BN nao the M 7 .
3.2. Dgc diem Idm sdng vd can Idm sang cua BN tai thdi diem chan dodn
Bang 3.2. Cac trieu chufng lam sang cua BN tai t h d i diem chan doan Trieu chitng
Tiiieu mau Xuat huyet Sot Gan to Lach to Hach t o
So BN (n=40) 37 19 18 6 5 2
Ti le (%) 92,5 47,5 45 15 12,5
5
Bang 3.2 chp ttiay trieu chu'ng thieu mau thay 6 hau het cac BN chiem 92,5%, xuat huyet 47,5%, sot chiem 45%, cac dau hieu gan t o , lach t o , hach t o lan I a g t l a 1 5 % , 1 2 , 5 % , v a 5 % .
BSng 3.3. Gia trj trung binh cac chi so mau ngoai vi va ti!iy do cr cac BN nghien cutj Chi so xet nghiem
BC (G/L) BC hat trung tinh (G/L) HST (g/l) TC (G/L) SLTBtuy (G/L) Blast tCiy (%) Blast mau (%)
Gia trj trung binh ( X ± S D ) 44,89±50,79 11,14±16,61 85,73±17,96 96,39±94,25 180,18± 112,20
70,80± 19,92 52,30±29,68 So lupng BC ngoai vl t r u n g binh la 44,89±50,79 G/L, cua HST la 85,73±17,96 g/l va TC la 96,39±94,25 G/L. Blast t r o n g tuy va d mau ngoai vi lan lUpt la 70,80 % ±19,92 va 52,30±29,68 G/L.
3.3. Ket qud dieu tri tdn cong phdc do "7+3"
BSng 3.4. Bien doi ve cac trieu chuTng lam sang sau dieu trj t a n cong
Thieu mau Xuat huyet Sot
TrUo'cOT (n,%)
37 (92,5%)-
19 (47,5%)
18 (45%)
SauDT (n,%) 19 (47,5%)
8 (20%)
12 (30%)
P 0,171
0,272
0,151
Sau dieu trj tan cdng cS 3 trieu c h d n g thieu mau, xuat huyet va sdt deu giam t d 92,5%, 47,5%, 4 5 % x u o n g tdPng dng la 47,5%, 20% va 30% . Tuy nhien sU khac biet chUa cd y nghia t h o n g ke vdi p>0,05.
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Bang 3.5. Bien dSi cac chi so' mau ngoai vi va tuy xUt(ng trUoic va sau dilu trj
Chl so BC (G/l) BChat (G/l) HST (g/L) TC (G/l) SLTB tiiy (G/l) Myeloblast tuy (%) Myeloblast mau (%)
Trirdfc dieu trj 44,89±50,79 11,14±16,61 85,73+17,96 96,39±94,25 180±112,20 70,80 ± 19,92 52,30 ± 29,68
Sau dieu tri 9,4±34,1
1,6±3,6 81±16,3 38,5±36,8 35,01 ±45,92 16,20 ±23,21 10,13 ±20.97
P
>0,05
Gia tri trung binh cua 3 ddng te bao mau ngoai vi, so Idpng te bao tuy, myeloblast tuy va mau ngoai vi deu giam rd ret sau dieu tri so vdi trddc dieu tri. Tuy nhien do cd mau nhd nen sU khac biet nay chUa cfi)) nghTa thong ke vdi p> 0,05.
BSng 3.6. Oap dng dieu trj phac do "7+3"
IVIuTc do dap ilrng Hoan toan (CR)
Mot p h i n (PR) Khong dap ufng (NR) T(5«G
So BN n=40 20 13 7 40
T ^ l e % 50%
32,5%
17,5%
100%
Ty le benh nhan dat dap dng hoan toan (CR) chiem 50%, dap dng mdt phan (PR) chiem 32,5%, 17,5%
benh nhan khdng dap dng vdi dieu trj.
3.4. Tdc dung khong mong muon cOa phdc do 7+3
Bang 3.7. Tac dung l<hdng mong muon tren he tao mau
IVIijrc do giam BC
BChat trung tinh
HST
TC
C6 0 8 20%
0
0 0
0 6 1 2 5%
0 2 5%
2 5%
O 9 2 3 7,5%
2 5%
20 50%
4 10%
0 6 3 7 17,5%
13 32,5%
12 30%
11 27,5%
0 6 4 20 50,0%
25 62,5%
6 15%
23 57,5%
Gi5m BC va BC hat trung tinh dp 4 kha cao chiem 50% va 62,5%. Giam TC do 4 chiem 57,5%. Giam HST giam dp 4 chi CO 15%.
46
BSng 3.8. Tac dung khong mong muon tren cac ccr quan khac Tac dung khong
mong muon Non
Budn non Tieu chay Vl§m loet mieng Rung toe Tang AST Tang ALT
S p O 34 85%
25 62,5%
37 92,5%
32 80%
0 36 90%
34 85%
0 6 1 3 7,5%
8 20%
3 7,5%
3 7,5%
7 17,5%
2 5%
3 7,5%
0 6 2 3 7,5%
7 17,5%
0 5 12,5%
9 22,5%
2 5%
2 5%
0 6 3 0 0 0 0 11 27,5%
0 1 2,5%
0 6 4
0 0 0 0 13 32,5%
0 0
Trieu chu'ng non va buon deu chi nhe dp 1, 2 vffl t^ IS ta 7,5% den 20%. Rung toe gap d 100% so BN trong do dp 4 chiem 32,5%. Tang ALT chl gap d dp 1 va 2 vdi ty le 5%. Viem loet mieng chi gap dp 1 va 2 vffl ty Ig 20%.
4. Ban luan
4.1. Dgc diem Idm sdng ciia cdc benh nhdn BCTC trong nghien cdu
Tuoi trung binh trong nghien ciJu ctja chung toi la 52,27 ± 15,67 tuoi cao hon so vdi cac nghien c\iu cua cac tac gia nude ngoai nhu Joseph O. Moore va cs (2005) tren 474 BN tuoi trung binh la 43 tuoi [6], ShuichlMiyawaki vacs (2011) tren 781 BN la 46 tudi [9]. So vffl cac tac gi^ Viet Nam nhi/Truong Thi Nhii y va cs (2004) tudi trung binh la 38,28 tuoi [4], Nguyen Ha Thanh va cs (2006) la 37,1 tudi [3]. Chijng tdi thay nhdm tudi 31-55 chiem tdi 50%, trong khi dd tren 65 tudi va duffl 30 tudi chi chiem 15% va 10%. BCTC la benh cua ngadi gia, ty le m^c tang theo tudi.
Nghien ciJu cilia chung tdi gap tat c5 cac the benh tCr MO den M6 khong gap the M7. Trong dd gap nhieu nhat la the M2 chiem 32,5%, tiep theo lan li/pt la the Ml chiem 22,5%, the M4 la 17,5%, the MO - 12,5% va gap it nhat la the MS chiem 2,5%. Nhin chung ket qua phan bd the benh theo FAB trong nghien cuu cOa chung tdi khong cd si/ khac biet nhieu so vdi cCia cac t^c gi^ trong va ngoai nt/dc. d
nhiJng nghien ciiu nay, the benh M2 la the gap nhieunhatp], [6], [8].
Theo bang 3.2, trade dieu trj BN cd cac bieu hien nhu thieu mau, xuat huyet, sdt vdi ty le tiidng dng la 92,5%, 47,5% va 45%, gan to 15%, lach to 12,5%, hach to 5%). Ty le BN cd thieu mau tddng dudng vdi cac tac gia Nguyen Trung Phan va cs la 97,3%, Nguyen Hdu Thang (2008) la 95%. Dau hieu sdt do giam ve sd lUdng va chdc nang BCHTT gap d gan mdt niia sd BN 45% ti/dng diidng vdi nghien cuU cCia tac gia JF. Bishop (1996) gap d 48%.
4.2. Dgc diem can lam sang cua BN BCTC trU&c dieu tri
Bang 3.3 cung cho thay cac chi sd te bao hpc cua mau va tuy xiiong trddc dieu trj bao gdm ndng dp HST (85,73 ± 17,96 g/l), SLBC (44,89 ± 50,79 G/L), SLBCHTT (11,14 ± 16,61 G/l), SLTC (96,39 ± 93,5 G/l), ty le Blast mau la (52,30 ± 29,68 %) va tuy xddng la (70,80 ± 19,92 %), sd Idpng te bao tijy la (SLTB tuy:
180,18 ± 112,20 G/l), ket quS nay cung tddng td so vdi nghien cdu cua cac tac gia Bach Qudc Khanh (2006) va Nguyen Ha Thanh (2008) [3].
4.3. Ket qua dieu tri tdn cong bach cau tuy cdp bdngphdcdo "7+3"
Oieu trj BCTC gdm nhieu giai doan: tan cong,
cung cd va duy tri... Nghien cdu cua chung tdi chl
danh gia dap dng hda trj lieu "7-i-3"giai doan tan
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cdng qua bien doi cac trieu chdng lam sang, mau ngoai vi, tdy x u o n g va t y le lui benh sau dieu trj tan cdng ddng thdi ghi nhan cac bien chdng t h u d n g gap cda phac do hda chat "7+3".
Bien doi ve lam sang trddc va sau dieu trj dupc the hien trong bang 3.4.1^ le thieu mau, xuat huyet va sdt deu giam rd t r o n g d d rd nhat la thieu mau t d 92,5% trddc dieu trj cdn 47,5 %, sau do den xuat huyet t d 47,5% cdn 20% va sdt t d 45% cdn 30%. Tuy nhien, t r o n g qua trinh dieu tri hau het cac BN da ddpc truyen khoi hdng cau va tieu cau d d phdng do d d su cai thien cac trieu chUng thieu mau va xuat huyet khdng the khang d m h hoan toan la do tdy da phuc hdi sinh mau sau dieu tri ma cdn do tac dung cua cac san pham mau ho trp.
Ket qua mau ngoai vi va tuy xuang bang 3.5.
cdng cho thay ty le myeloblast giSm dang ke sau dieu trj so vdi trudc dieu tri. Mac d u su khac biet nay chua cd y nghia t h o n g ke vdi p> 0,05 do cd mau nhd nhung rd rang rang hda chat phac do "7+3" cd tac dung tieu diet cac te bao non ac tinh rat t o t tai thdi diem dieu tri tan cdng.
Ve mdc dp dap dng dieu tri t h e hien d bSng 3.6:
ty le CR chiem 50%, ty le PR chiem 32,5% va khdng dap dng chiem 17,5%. Ty le CR trong nghien cdu cua chung tdi tUdng d d o n g n h u cua Brono van de Holt la 4 8 % [5] va thap hdn so vdi cac tac gia khac n h d Nguyen Tan Binh t r o n g nUdc 63,3% va d ngoai nddc n h u cua nhdm CALGB 66%, IVlarshall 60% hay nhdm nghien cdu cda Australia 56% khci nang do doi t d p n g BN trong nghien cdu cua chdng tdi tuoi cao han va t h e trang kem hdn nen dap dng dieu tri vi t h e ma cung kem hon [1 ], [8].
4.4. Tdc dung khong mong muon cua phdc do
"7+3"
Ket qua bang 3.7 cho thay gi^m BC dp 3, 4 chiem t y le cao t u o n g dng la 17,5% va 50%, trong dd so lupng BC giam thap nhat la 0,3 G/l. Nghien cdu cCia Nguyen Ha Thanh (2006) tren 38 BN cho thay sd l u p n g BC gicim thap nhat la 0,98 G/l [3], t u o n g t u t a c gia Truong Thj NhU Y (2004) tren 100 BN thay sd iupng BC gi^m thap nhat la 0,74 G/l [4]. Ty le giam BC hat t r u n g t i n h dp 4 la 62,5% thap hon so vdi cua Truong Thj NhU V 90% cd the la chung tdi chda cd
ddpc khu buong benh v d t r u n g de each ly BN trong giai doan giam BC hat nang nen hau het cac BN t r o n g nghien cdu cua c h u n g t o i ddpc d u n g G- GF sdm khi sd lupng BC hat t r u n g t i n h < 0,5 G/l. So lUdng BC hat t r u n g t i n h t h a p nhat la 0,1 so vdi nghien cdu cda Nguyen Ha Thanh (2006) la 0,3 [3].
Shuichi Miyawaki (2011) n g h i e n cdu tren 392 BN co sd lupng BC hat thap nhat la 0,4 G/l. Dieu nay cho thay phac do "7+3" gay dc che tuy xUang kh^ manh [9].
Phac do "7+3" cung gay giSm m a n h TC va day lii nguy cd gay chay mau, dac biet ch^y mau nao dan den t d vong t r o n g qua t r i n h dieu trj d cac BN BCTC v d n d d n g TC da bi dc che san bdi cac te bao blast Trong nghien cdu cua chung t d i giam TC dp 3 chi^m 27,5% va dp 4 chiem 57,5%. TrUdng Thj NhU V gi3m TC dp 4 !a 73% [4] cao h o n so vdi nghien cdu ci}a chung tdi, tac gia Brono van der Holt va cs (2005) nghien cdu tren 211 BN gap giam TC dp 4 la 19%, thap hPn nhieu so vdi nghien cdu cua chiing toi.
Mat khac, so lupng TC g i a m t h a p nhat la 4 G/l thap hon so vdi cac tac gia khac la Trdong Thj NhU V (2004) - 10,5 G/l, Nguyen Hdu Thang (2008) la 10 G/l. Sd bien doi sd lUpng TC t h u d n g dien ra song hanh cung vdi sU gicim BC hat t r u n g t i n h do tac d p n g cua hda chat dieu tri va xam lan tuy xUong cOa cac te bao blast gay nen [4]. Vi vay bien doi so lUpng TC cung la m p t chl so cd gia trj de theo ddi va deinh gia t i n h trang suy t d y xUong sau dieu trj hda chat.
Giam nong dp HST sau dieu trj hda chat la tac d u n g phu hay gap nhUng mdc dp nhe hon so vcii d d n g BC va TC. Giam n o n g dp HST gap d 100% s6 Bl^ trong nghien cdu n h u n g chCi yeu dp 2, 3 tddng dng la 50% va 30%, n d n g HST giam t h a p nhat la 50 g/l thap hon cua tac gia TrUdng Thj NhU V (2004) W 78,4 g/l, cua Nguyen HUu T h ^ n g (2008) la 80 g/l.
Nong dp HST giam nang bdi ban than BN khi b^t dau dieu trj hda chat da d t r o n g t i n h trang thi^u mau nang cdng vdi hda tri lieu lai cang lam tang tinh trang thieu mau d u trUdc, t r o n g va sau khi dieu trj deu dupc truyen mau.
Budn ndn va ndn la m p t t r o n g n h d n g tac dung phu t h u d n g gap t r o n g hda trj lieu benh ung thU gay cho BN cam giac sp hai khi truyen hoa chat cung n h u khd khan t r o n g viec an u d n g anh hUdng Idn tdi viec d^m bao d i n h dUdng cho BN. Trong nghien ciJfu 4 8
TAP CHl Y DWQC LAM S A N G 108
cda chung t o i cd 15% benh nhan co bieu hien ndn d mdc dp 1,2, ty le b u d n ndn dp 1,2 la 37,5%, thap hon so vdi tac gia Trddng Thj Y Nhi (2004) la 78% [4], tac gia Hainsworth (2000) la 75%, sd d l cd ket qua nay cd t h e do BN t r o n g n h d m nghien cdu cua chung tdi dupc sd d y n g thuoc chdng ndn trudc, t r o n g va sau khi dieu trj hda c h a t .
Dpc t i n h cda hda chat t r o n g dieu trj benh ung t h u tren niem mac rudt va t i n h trang nhiem khuan d u d n g ruot la nguyen nhan chu yeu gay nen t i n h trang fa chciy d BN bach cau t u y cap sau dieu trj.
Trong nghien cdu cua chung tdi, BN cd t>' le tieu chay la 7,5% t h a p hdn nhieu so vdi tac gia Huynh Van Man (2002) la 27,3 %, Trddng Thj N h d Y (2004) la 33,3%, Nguyen Ha Thanh (2006) la 12,9% [3], [4].
Trong nghien cdu cda tac gia Buchner T (1999) tieu chay d d 3 va 4 la 10%, Vogler (1992) la 13%, cdn t r o n g nghien cdu cua chdng tdi khdng gap BN nao tieu chciy dp 3 va 4, ket qua nay tUPng t d vdi nhan xet cua tac gia Haskell C M (1995) cho rang tieu chay sau dieu trj ung t h d t h d d n g nhe va t u khdi. Mat khac, cac BN dieu tri hda chat t r o n g nghien cdu cua chung t d i deu ddpc d u n g khang sinh d u d n g rudt khi cd giam BC nen phan nao cd t h e giam ddpc t y le nhiem khuan d u d n g rudt d BN bach cau tdy cap bi giam BC sau dieu trj.
Bang 3.8 cho thay t J le BN BCTC cd men gan tang sau dieu tri hda chat khdng cao: AST tang dd 1 va 2 chiem 10 % va ALT tang dp 1,2 la 12,5%. So vdi nghien cdu cua mdt sd tac gia thi cd sU khac biet kha Idn, nghien cdu cua TrUdng Thi Nhu Y (2004) tren 100 BN dieu trj hda chat phac do "7+3" gap 2 1 % BN cd tang men gan, J.K Weick (1996) la 17% [7], trong khi do nghien cdu cua Nguyen Anh Tri tr§n 34 BN cd tdi 85%
BN cd tang men gan, cdn tac gia Amadori (1992) chi cd 6%. Ndi chung viec danh gia dpc tinh tren gan mat d BN bach cau tuy cap sau dieu tri hda chat gap nhieu khd khan vl ben canh viec d u n g hda chat dieu t n benh, BN con duoc d u n g nhieu loai thudc khac de dieu trj ho trp: khang sinh, thudc ha sot, chdng nam,...cung gay cinh hudng len te bao gan.
Bieu hien r u n g toe gap d l 00% BN t r o n g do dp 4 chiem tdi 32,5%. Day la m d t t r o n g n h d n g tac d u n g phu t h u d n g gap nhat sau hda trj lieu dieu trj ung
t h u , tuy khdng de dpa t i n h mang nhung nd gay nen sd phien m u d n cho BN, Tac gia TrUdng Thi NhU t nghien cdu tren 100 BN gap 94% BN cd bieu hien rung tdc vdi dp 2 chiem t)- le cao nhat la 88% [4]. Te bao bieu m d nang tdc rat nhay cam vdi hda chat vl vay bleu hien rung toe sau dieu trj hoa chat chong ung t h u t h u d n g gap va chiem ty le cao nhdng da so BN se mpc tdc t r d lai sau 1 den 2 thang n g d n g dieu tri hda c h a t
5. Ket luan
Qua nghien cdu 40 BN bach cau tdy cap tai khoa Huyet hoc lam sang benh vien TWQD 108 t d 1/2008 den 12/2013, chung tdi r u t r a m d t s d ket luan sau:
- Cac trieu chdng lam sang chd yeu cua benh nhan BCTC la thieu mau 92,5%, sdt chiem 45%, xuat huyet da va niem mac 47,5%.
- The M2 chiem t y le cao nhat 32,5% sau d d la M l 22,5%, M4 17,5%. Khdng gap the M7. Sd Idpng nguyen tuy bao t r u n g binh t r o n g t u y 70,8±19,9% va mau ngoai vi 52,3± 29,68%.
- Ty le dap dng hoan toan (CR): 50%; m p t phan (PR) 32,5% va khdng dap Ung (NR) 17,5%.
- Tac d u n g khdng m o n g m u o n chu yeu cua phac do "7+3" la: ndn va b u o n ndn mdc dp 1, 2 la 7,5% va 20%, rung tdc 100% va dp 4 la 32,5%. Gi^m BCHTT dp 3, dp 4 la 32,5% va 62,5%; giam TC dp 3, dp 4 chiem 27,5% va 57,5%.
Tai lieu t h a m kh^o
1. Nguyen Tan Binh (1996), "Dieu trj benh bach cau cap ddng tuy vdi da hda trj lieu lieu cao", Yhpc Viet Warn, 10,209,Tr.6-10
2. Tran Thi Minh HUPng (2000), "Nghien cdu md hinh benh mau tai vien Huyet hpc truyen mau, Benh vien Bach Mai trong 3 nam{1997-1999), Ludn vdn tdt nghiep B5CKII. Ha Ndi Tr,37-58.
3. Nguyen Ha Thanh va cs. (2008), "BUdc dau nghien cdu mpt sd thay doi lam sang va xet nghiem huyet hpc mau ngoai vi d benh nhan loxemi cap d d n g tuy sau hda trj lieu tan cdng bSng phac do '3+7'", Y hpc thuc hdnh, 545,Tr.M2-U7.
4. Truong Thj Nhu Y {2004}, "Kh^o sat mdt sd bien chdng va dpc tinh thudc thudng gap do hda trj lieu tren benh nh§n Ipxemia cap ddng tuy tai Vien
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JK Weick, KJ Kopecky., et al. (1996), "A randomized investigation of high- dose versus standard- dm cytosine arabinoslde with d a u n o r u b i c l n e l i pantients previously untreated acute myel^
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Marshall A.L, Edward S.H, (1992) "Acut myelogenous leukemia. Hematology pp 138-47.
Suichi Miyawaki, Shigeki Ohtake., et al (2011),'j randommized compare of 4 courses of standard dose mutiagent chemotherapy versus 3 course high-dose cytarabine alone in postremissior therapy for acute myeloid leukemia in adults; The JALSGAML201 study" S/ood, 117, pp.2366-2372.
