白血病患者造血干细胞移植前单次全身照射的预后分析

Prognostic analysis of single fraction total body irradiation followed by hematopoietic stem cell transplantation in patients with leukemia

目的 回顾性分析单次全身照射（SFTBI）后行造血干细胞移植的白血病患者的预后及相关因素.方法 2008 年9月前7年半余共102例患者行SFrBI后移植.比较不同病理类型、移植方式及不同TBI参数组间生存率、复发率及间质性肺炎（IP）发生率差异,分析生存率、复发率和IP发生率的相关因素.结果 随访15～1482 d（中位值406 d）.随访率为95.1%,随访满1、3年者分别为86、55例.1、3年生存率分别为59.0%、44.0%,单因素分析3年生存率有差异因素包括移植前有无复发（20%：55%,χ2=6.33,P=0.012）、移植方式（异基因比自体基因移植,39%：68%,χ2=8.06,P=0.005）、急性移植物抗宿主病（aGVHD）级别（≥3级比0～2级,0%：54%,χ2=7.52,P=0.006）、移植后有无复发（19%：58%,χ2=10.13,P=0.001）、有无IP（23%：58%,χ2=8.35,P=0.004）.Cox模型多因素分析对生存有影响因素只有≥3级aGVHD（χ2=12.74,P=0.000）.1、3年复发率分别为30.0%、50.0%,移植前已有过复发比无复发的复发率明显升高（47%：16%,χ2=7.32,P=0.007）,Cox模型多因素分析显示移植前已有过复发对术后复发有影响（χ2=9.39,P=0.020）.IP发生率为35.0%,全身剂量均匀度〉3%和≤3%的分别为27%和4%（χ2=5.21,P=0.023）,急性腮腺炎有和无的分别为34%和3%（χ2=14.15,P=0.000）,异基因移植和自体移植的分别为31%和8%（χ2=7.70,P=0.006）.Logistic多因素分析显示移植方式、急性腮腺炎及全身剂量均匀度对IP发生有影响（χ2=10.08、10.08、7.69,P=0.002、0.002、0.010）.结论 ≥3级aGVHD患者3年生存率明显下降,全身剂量均匀性对IP发生有重要意义,异基因移植者更易发生IP,急性腮腺炎与IP明显相关,可能对预测IP发生有一定价值.

Objective To analyze the prognostic factors of patients with leukemia treated with single fraction total body irradiation （SFTBI） followed by hernatopoietic stem cell transplantation （HSCT）.Methods From January 2001 to September 2008, 102 patients received HSCT. The differences of the survival rate, relapse rate and incidence of interstitial pneumonia （IP） between groups regarding different genders, ages, pathological types, transplantation methods and TBI parameters were compared and the factors related with the survival rate, relapse rate and incidence of IP were analyzed. Results The followup time ranged from 15 to 1482 days （median, 406 days）. The follow-up rate was 95.1%. 86 and 55patients were followed up more than one year and three years. The 1-and 3-year survival rates were 59.0%and 44.0%. In univariate analysis, the 3-year survival rate was signifcantly different between the groups with and without relapse before transplantation （20% vs. 55%, χ2 = 6.33, P = 0. 012）, allogeneictranplantation versus autologous tranplantation （39% vs. 68%, χ2 = 8.06, P = 0.005）, grade 3 or more acute graft versus host disease （aGVHD） and grade 0 -2 aGVHD （0% vs. 54%, χ2 = 7.52, P = 0.006）,with and without relapse after transplantation （19% vs. 58%, χ2 = 10.13, P =0.001）, with and without IP （23% vs. 58%, χ2 =8.35, P=0.004）. Multivariate analysis showed that grade 3 or more aGVHD was the only statistically significant prognostic factors （χ2 = 12. 74 ,P =0. 000）. The l-and 3-year relapse rateswere 30. 0% and 50. 0%. The incidence of relapse was obviously higher in the group with relapse before transplantation than that without （47% vs. 16%, χ2 =7. 32, P=0. 007）. Multivariate analysis showed thatrelapse before transplantation was a significant factor predicting relapse after transplantation （χ2 = 9. 39,P =0. 020）. The cumulative incidence of IP was 35.0%. The incidence of IP was different between groups with dose homogeneity 〉 3% and ≤ 3% （27% vs. 4%, χ2 = 5. 21, P = 0. 023）, with and without acute parotitis （34% vs. 3%, χ2 = 14. 15, P= 0.000）, allogeneic transplantation group and autologous transplantation group （31% vs. 8%, χ2= 7.70, P= 0.006）. Multivariate analysis showed that transplantation methods, acute parotitis and dose homogeneity were statistically significant factors in predictingIP （χ2 = 10. 08 , 10. 08 and 7.69 , P = 0. 002 , 0. 002 and 0. 010 , respectively） . Conclusions Patients who develop grade 3 or higher aGVHD have poor prognosis. Dose homogeneity influences the incidence of IP. Patients undergoing allogeneic transplantation are apt to have IP. Acute parotitis is related with IP and might be a predictor.