Efficacy of a new induction regimen in the treatment of early T-cell precursor acute lymphoblastic leukemia
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摘要: 目的 成人急性淋巴细胞白血病尚无标准诱导治疗方案，急性早前T淋巴细胞白血病(ETP-ALL)对标准的强化化疗反应差，复发风险高，预后差。拟探讨合适的诱导方案来提高其缓解率，延长患者生存期。方法 回顾性分析2017年1月—2020年12月接受不同方案诱导化疗的21例初诊ETP-ALL患者的疗效及主要不良反应。初诊ETP-ALL根据骨髓细胞学、流式细胞术免疫表型检测结果诊断。结果 21例患者中男14例，女7例；中位年龄27(16~57)岁；7例接受PCIOD方案[培门冬酶注射液：2500 IU/m2肌肉注射，第1、14天；环磷酰胺：800 mg·m－2·d-1，第1天；伊达比星：6~8 mg(总量10 mg)，第1~3天；长春地辛：4 mg，第1天；地塞米松：20 mg/d，第1~7天]治疗。14例接受VTLP样方案(吡柔比星：40 mg/m2分3 d或柔红霉素30~45 mg·m－2·d-1，第8、15、22、29天；长春地辛：3 mg/m2或长春新碱1.5 mg/m2，第8、15、22、29天；培门冬酶注射液：2500 IU /m2，第14、28天；或左旋门冬酰胺酶5000 U /m2，第8、11、14、17、20、23、26、29天；±环磷酰胺：800 mg·m－2·d-1，第1天；泼尼松1 mg·kg-1·d-1，第1~14天，后改为口服逐渐减量到第30天停用，每28 d为一个周期，共1个周期)治疗。7例接受PCIOD方案患者中，5例(71.43%)达细胞学缓解，2例(28.57%)微小残病灶(MRD)阴性。14例接受VTLP样方案患者中，7例(50.00%)达细胞学缓解，1例(7.14%)MRD阴性。主要不良反应为化疗后骨髓抑制、粒细胞缺乏伴发热、败血症。7例PCIOD方案治疗的患者中3例发生肺部感染，其中1例合并败血症(肺炎克雷伯菌)，而14例VTLP样方案治疗的患者中5例发生肺部感染，3例发生败血症，2例发生急性胰腺炎。与传统方案相比，主要不良反应发生率并未增加。所有患者均无治疗相关死亡。结论 ETP-ALL诱导缓解率低，恶性程度高，易早期复发，生存期短。PCIOD方案可以提高ETP-ALL患者的完全缓解率及MRD转阴率，且不增加治疗相关死亡率，但因病例数较少，有待开展多中心、随机对照研究进一步明确。
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关键词:
- 急性早前T淋巴细胞白血病 /
- 完全缓解 /
- 微小残留病灶
Abstract: Objective There is no standard induction chemotherapy for adult acute lymphoblastic leukemia. Early T-cell precursor acute lymphoblastic leukemia(ETP-ALL) has poor response to standard intensive chemotherapy, high risk of recurrence and poor prognosis. To explore the appropriate induction program and thus improve the remission rate and prolong the survival period.Methods A total of 21 newly diagnosed patients with ETP-ALL who received induction chemotherapy with different regimens from January 2017 to December 2020 were retrospectively analyzed for efficacy and main adverse events. The initial diagnosis of ETP-ALL was based on the results of bone marrow cytology and flow cytometry immunophenotype.Results The 21 patients included 14 males and 7 females, with a median age of 27(16-57) years. Seven patients received PCIOD regimen and 14 patients received VTLP like regimen. Among the 7 patients who received PCIOD regimen, 5 patients(71.43%) achieved cytological response, and 2 patients(28.57%) were minimal residual disease(MRD) negative. In 14 patients who received VTLP-like regimen, 7 patients(50.00%) achieved cytological remission, of which 1 patient(7.14%) was MRD negative. Bone marrow suppression, granulocytopia with fever and septicemia after chemotherapy. Among the 7 patients with PCIOD regimen, 3 patients developed pulmonary infection, including 1 patient with sepsis(klebsiella pneumoniae), while 5 patients with VTLP-like regimen developed pulmonary infection, 3 patients with sepsis, and 2 patients with acute pancreatitis. The incidence of major adverse events was not increased comparing with conventional regimens. There was no treatment-related mortality in any of the patients.Conclusion ETP-ALL has low remission rate of induction therapy and highly malignant character, patients are prone to early recurrence and have short survival. PCIOD regimen can improve the complete response rate and MRD conversion rate of ETP-ALL patients, and does not increase the treatment-related mortality. However, due to the small number of cases, our result needs to be further confirmed by multi-center, randomized controlled studies. -
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表 1 患者临床特征
例 临床特征 例数 性别 男 14 女 7 年龄/岁 16~34 13 ≥35 8 初诊时外周血WBC/(×109·L-1) ＞100 2 ≤100 19 初诊时合并中枢神经系统白血病和(或)睾丸白血病 有 1 无 20 纵隔包块 有 3 无 18 细胞遗传学 正常染色体 14 复杂染色体 3 未测 4 初始诱导治疗效果 1个疗程诱导后CR 12 1个疗程诱导后未缓解 9 2个疗程后CR 19 2个疗程后未缓解 1 失访 1 移植 是 14 否 7 
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表 2 首次诱导及2个疗程后CR率及MRD转阴率
例(%) 组别 例数 诱导后CR MRD阴性 第2个疗程后CR 第2个疗程后MRD阴性 PCIOD 7 5(71.43) 2(28.57) 6(85.71) 5(71.43) VTLP±CTX 14 7(50.00) 1(7.14) 12(85.71) 7(50.00)
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表 3 主要不良反应发生率
例(%) 主要不良反应 PCIOD方案(7例) VTLP样方案(14例) 败血症 1(14.29) 3(21.43) 粒细胞缺乏伴发热 3(42.86) 9(64.29) 肺部感染 3(42.86) 5(35.71) 急性胰腺炎 0 2(14.29) 肝功能损害 3(42.86) 3(21.43) 尿酸增高 0 3(21.43)
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表 4 HSCT可提高ETP-ALL患者长期OS率
诱导化疗 例数(21例) 移植(14例) 未移植(7例) PCIOD方案 7 5例，1例死亡(因严重感染、呼吸衰竭死亡) 2例均死亡 VTLP样方案 14 9例，1例死亡(MRD持续阳性，因复发死亡) 5例(4例死亡，1例失访)
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