酪氨酸激酶抑制剂在费城染色体阳性急性淋巴细胞白血病诱导治疗中的作用

Role of tyrosine kinase inhibitor in induction therapy for Philadelphia chromosome-positive acute iymphoblastic leukemia

目的探讨低剂量化疗联合酪氨酸激酶抑制剂（TKI）作为初诊费城染色体阳性急性淋巴细胞白血病（Ph＋ALL）一线诱导治疗方案的可行性。方法回顾性分析61例初诊Ph＋ALL患者接受不同诱导治疗方案的疗效与不良反应。结果全部患者初次诱导治疗的完全缓解（CR）率为73．8％（45／61），再次诱导CR率为86．7％（13／15），两程诱导治疗总的CR率为95．1％（58／61），治疗相关死亡1例（1．6％）。无论是否联用TKI，常规剂量组与低剂量组有效率差异无统计学意义[未联用组：65．5％（19／29）比60．0％（3／5），P=0．812；联用组：90．5％（19／21）比100．0％（6／6），P=0．432]；低剂量化疗联合TKI的有效率与单用常规剂量化疗比较，差异亦无统计学意义（P=0．089）。无论化疗强度如何，联合TKI均能提高初次诱导治疗有效率（常规剂量组：P=0．041；低剂量组：P=0．087）；联用TKI方案总有效率显著高于未联用TKI方案[92．6％（25／27）比64．7％（22／34），P=0．010]。对于未获CR患者，初次诱导时未联用TKI者再次诱导治疗联用TKI的有效率明显高于初次诱导曾联用TKI者[100．0％（8／8）比33．3％（1／3），P=0．011]。不同遗传学亚组问初次诱导治疗的有效率差异无统计学意义（均P〉0．05），联用TKI可在一定程度上提高有效率，但差异均无统计学意义（均P〉0．05）。全部患者初次诱导治疗的感染率为50．8％（31／61），出血发生率为4．9％（3／61）。常规剂量组总感染率[56．0％（28／50）]高于低剂量组[27．3％（3／11）]，但差异无统计学意义（P=0．084），两组总出血发生率差异亦无统计学意义[6．0％（3／50）比0（0／11），P：0．405]。低剂量化疗联合TKI组的感染率低于常规剂量化疗联合TKI组[0（0／6）比71．4％（15／21），P=0．002]，也低于单用常规剂量化疗组[0（0／6）比44．8％（13／29），P=0．039]，组间出血发生率差异均无统计学意义（均P〉0．05）。结论低剂量化疗联合TKI作为Ph’ALL一线诱导治疗方案值得进一步探索。

Objective To explore the feasibility of low-dose chemotherapy （LDCT） combined with tyrosine kinase inhibitor （TKI） （LDCT＋TKI regimen） as the first-line induction regimen for Philadelphia chromosome-positive acute lymphoblastie leukemia （Ph^-ALL）. Methods The efficacies and adverse effects of various induction regimens in 61 newly diagnosed patients with Ph＊ ALL were retrospectively analyzed. Results The complete remission （CR） rate of the first induction therapy was 73.8 % （45/61） for all 61 cases, and that of the second induction therapy was 86.7 % （13/15） for non-remission （NR） patients after the first induction. The total CR rate for two-course induction was 95.1% （58/61）. Treatment related mortality happened in one case （1.6 %） after the first induction therapy. The response rates between conventional-dose chemotherapy （CDCT）＋TKI group and LDCT-＋TKI group were not statistically different [without TKI, 65.5 % （19/29） vs 60.0 %（3/5）, P = 0.812; with TKI, 90.5 % （19/21） vs 100.0 % （6/6）, P = 0.432]. The response rate of LDCT＋TK1 group was not statistically different from that of CDCT alone group （P = 0.089）. The introduction of TKI to LDCT and CDCT could improve the response rate （CDCT＋TKI group, P = 0.041; LDCT＋TKI group, P = 0.087）. The total response rate of the induction therapy with TKI was significantly higher than that without TKI [92.6 % （25/27） vs 64.7 % （22/34）, P = 0.01]. The response rate of the TKI-based second induction therapy for non-CR eases after the first induction therapy without TKI was significantly higher than that after the first induction therapy with TKI [100.0 % （8/8） vs 33.3 % （1/3）, P = 0.011]. There were no significant differences in the effieaeies of the first induction therapy between various genetic subgroups （all P 〉 0.05）, and the introduction of TKI to the treatment of various genetic subgroups could improve the efficaeies to a certain extent without statistical significance （all P 〉 0.05）. The incidences of treatment related infections and bleeding due to the first induction therapy in all patients were 50.8 % （31/61） and 4.9 % （3/61）, respectively. Compared with LDCT ＋TKI group, the overall incidences of treatment related infections and bleeding in CDCT＋TKI group were higher, hut there were no statistical significances [infection, 56.0 % （28/50） vs 27.3 % （3/11）, P = 0.084; bleeding, 6.0 % （5/30） vs 0 （0/11）, P = 0.405]. The incidence of treatment related infections in LDCT＋TKI group was significantly lower than that in CDCT＋TKI group [0 （0/6） vs 71.4 % （15/21）, P = 0.002] or that in CDCT alone group [0 （0/6） vs 44.8 % （13/29）, P = 0.039]. The incidence of bleeding in LDCT＋TKI group was not statistically different from that in CDCT＋TKI group or that in CDCT alone group （all P 〉 0.05）. Conclusion LDCT＋TKI regimen as the first-line induction regimen in Ph＋-ALL is deserved to be investigated further.