Прогресс в лечении острого лимфобластного лейкоза: 25 лет применения международных протоколов в отделении детской гематологии Западноукраинского специализированного детского медицинского центра
DOI:
https://doi.org/10.15574/SP.2018.96.22Ключевые слова:
острый лимфобластный лейкоз, дети, лечение, международные протоколыАннотация
Проанализированы результаты лечения согласно модифицированным программам химиотерапии международной группы BFM 370 больных острым лимфобластным лейкозом (ОЛЛ) в возрасте от 0 до 18 лет с февраля 1993 г. по март 2018 г. Показатель безсобытийного выживания (event-free survival – EFS) для всей выборки пациентов составляет 73,2%. 143 (38,65%) пациента получали лечение по программам ALL-BFM 90/95 (группа 1); 131 (35,41%) больной — ALL IC-BFM 2002 (группа 2); 88 (23,78%) больных — ALL IC-BFM 2009 (группа 3). Дети в возрасте до 1 года (8 человек) лечились в соответствии с программами INTERFANT 99/06 (группа 4). EFS в группе 1 составляет 68,5% при медиане наблюдения (МН) 220 месяцев, по протоколу ALL IC-BFM 2002 — 77,6% при МН 111 месяцев, в группе 3 — 85,2% при МН 39 месяцев, в группе по программам INTERFANT 99/06 — 12,5% при МН 13,5 месяцев. EFS для пациентов группы среднего риска (ГСР) в группе 1 составляет 71,0%, в группе 2 — 83,7%, а в группе 3 — 90,6% (p=0,04232). EFS для пациентов группы высокого риска (ГВР) в группе 1 составляет 50,0%, в группе 2 — 55,6%, в группе 3 — 73,9% (p=0,09653). Кумулятивное выживание (оverall survival (OS) по всей выборке составляет 78,0%. Всего умерло 73 (18,7%). У 32 (43,8%) человек смерть связана с терапией I линии ОЛЛ, из них 11 (34,37%) больных умерли от токсико-септических осложнений до достижения ремиссии ОЛЛ во время индукционной терапии; 19 (59,37%) детей — от осложнений в ремиссии I на разных этапах интенсивной химиотерапии, 1 больной ГВР — от посттрансплантационных осложнений, 1 пациент — на 160 мес. после достижения ремиссии — вследствие фульминантного течения вирусного гепатита В. У 39 (53,42%) больных смерть наступила во II остром периоде от прогрессирования лейкемии и/или инфекционных осложнений. Рецидивы ОЛЛ диагностированы у 53 (16,21%) человек. Безрецидивная выживаемость (disease-free survival (DFS) составляет 83,2%. Редким отдаленным последствием лечения ОЛЛ у детей были вторичные злокачественные заболевания, зарегистрированные у 5 (1,35%) детей. Астроцитома, менингиома и вторичная острая миелоидная лейкемия (ОМЛ) успешно пролечены. Олигодендроглиома и вторичный миелодиспластический синдром с трансформацией в ОМЛ завершились летальным исходом. Аллогенная трансплантация стволовых гемопоэтических клеток (алло!ТСГК) выполнена 15 больным. Определено статистически достоверное улучшение показателей EFS при применении программной полихимиотерапии ALL IC-BFM 2009, худшие результаты лечения наблюдались у детей до 1 года (р <0,05). Лечение больных ГВР и детей первого года жизни требует дальнейшего поиска путей повышения эффективности терапии и снижения ее токсических эффектов.
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