影响弥漫大B细胞淋巴瘤预后的主要危险因素分析

Analysis of prognostic risk factors in patients with diffuse large B-cell lymphoma

目的探讨弥漫大B细胞淋巴瘤（DLBCL）的临床特点、实验室检查、治疗措施以及肿瘤细胞来源与预后的关系。方法对106例DLBCL患者进行国际标准化预后指数（IPI）评分、AnnArbor分期、ECOG评分、肿瘤细胞来源以及采用不同治疗策略的疗效进行回顾性分析，并对影响预后的独立危险因素进行分析。结果按IPI评分，低中危者61例（57．5％），中高危者45例（42．5％）；按AnnArbor分期，Ⅰ期8例（7．6％），Ⅱ期16例（15．1％），BI期54例（50．9％），Ⅳ期28例（26．4％）；25例（23．6％）患者伴骨髓受侵，其中16例诊断为淋巴肉瘤细胞白血病；38例ECOG评分≥2分、67例（63．2％）乳酸脱氢酶（LDH）值升高；伴B症状者59例（55.7％）。106例DLBCL患者完全反应（CR）63例（59．4％），部分反应13例（12．3％），病情稳定3例（2．8％），死亡29例（27．4％），治疗总有效率为71．7％，4年总生存率为72．6％；单因素分析显示：IPI评分、临床分期、ECOG分级、肿瘤细胞来源、LDH水平、有无骨髓侵犯、治疗策略的选择、是否获得CR均与预后有关。COX核型回归多因素分析发现非生发中心来源（HR=4．24，P=0．001）、骨髓侵犯（HR：2．08，P=0．012）、是否获得CR（HR=2．72，P=0．006）以及治疗策略的选择（HR=2．58，P=0．009）是影响DLBCL预后的独立危险因素。结论骨髓侵犯、不同肿瘤细胞来源是DLBCL的独立预后影响因素，用免疫组化方法检测不同肿瘤细胞的来源类型，对预后有一定的提示作用，同时利妥昔单抗联合化疗可显著提高DLBCL患者的疗效，造血干细胞移植是DLBCL的最佳治疗策略。

Objective To explore the relationship of clinical features, therapeutic measures, laboratory findings, the origin of tumor cells as well as prognosis in Chinese patients with diffuse large B-cell lym- phoma （DLBCL）. Methods One hundred and six patients with DLBCL were retrospectively assayed and followed up, the international prognostic index （IPI） score, Ann Arbor staging, ECOG score, the origin of tumor cells and different therapeutic methods were analyzed. Results According to the IPI, there were 61 cases （57.5%） with low-intermediate risk and 45 （42.5%） with intermediate-high risk. According to Ann Arbor staging, there were 8 phase Ⅰ cases （7.5%） , 16 phase Ⅱ （ 15.0% ） , 54 phase Ⅲ （51.0%） and 28 phase Ⅳ （26.5%）. Twenty-five cases （23.6%） were accompanied with bone marrow invasion, 16 of them were diagnosed as lymphosarcoma cell leukemia; 38 cases with ECOG score≥2; 67 cases （63.2%） had an increased LDH level; 59 cases （55.7%） had B symptom. The response rate （RR） for the whole group was 71.7%, the complete remission （CR） rate was 59.4% （63 cases）, the partial remission （PR） rate was 12.3% （13 cases）, the stable disease rate was 2.8% （3 cases） and the death rate was 27.4% （29 cases）. The 4-year survival rate was 72.6%. Univariate analysis indicated that eight factors were related with progno- sis （P 〈 0.05 ） , including IPI score, Ann Arbor staging, ECOG score, the origin of tumor cells, LDH level, bone marrow invasion, different therapeutic methods and whether or not CR. Multivariate analysis showed that the origin of non-germinal center （ HR = 4. 24, P = 0. 001 ）, bone marrow invasion （ HR = 2. 08 ,P = 0. 012 ） , whether or not CR （HR =2. 72,P =0.006） and therapy modality （HR =2. 58,P =0. 009） were significant factors for prognosis. Conclusion The bone marrow invasion and the origin of tumor cells are independent risk factors for prognosis. The rituximab combined with chemotherapy can significantly improve the therapeutic effect of the DLBCL, and hematopoietic stem cell transplantation is the best choice for treating patients with DLBCL.