儿童急性淋巴细胞白血病复发60例临床分析

Clinical analysis of 60 relapsed pediatric patients with acute lymphoblastic leukemia

目的探讨影响儿童急性淋巴细胞白血病（ALL）复发的因素及治疗策略。方法回顾性分析2007年1月至2015年1月在首都医科大学附属北京儿童医院血液肿瘤中心收治的60例ALL复发患儿的临床资料，分析不同复发时间、复发部位及复发后治疗方法与预后之间的关系。结果60例复发患儿中位年龄70．5个月，初诊时B淋巴细胞表型51例，中位复发时间30．5个月，骨髓复发45例，单独髓外复发15例。共56例患儿进行复发后治疗，32例无病生存，中位随访时间19个月（3—78个月）；以包含环磷酰胺、泼尼松、多柔比星、左旋门冬酰胺酶、长春地辛（CODLP）方案及包含地塞米松、多柔比星、培门冬酶、长春地辛（VDLD）的方案进行诱导的复发后缓解率分别为85．7％（12／14例）及92．9％（39／42例）；骨髓复发及单独髓外复发的总生存率分别为57．14％（24／42例）及78．57％（11／14例），以上结果差异均无统计学意义（χ2=0．073，P=0．787；χ2=2．979，P=0．084）。早期复发、中间复发及晚期复发患儿的总生存率分别为43．75％（7／16例）、46．67％（7／15例）及80．00％（20／25例），早期及中间复发的生存率分别与晚期复发生存率比较差异均有统计学意义（χ2=10．122，P=0．001；χ2=6．179，P=0．013）；患儿骨髓复发后进行化疗及造血干细胞移植治疗的总生存率分别为26．92％（7／26例）及100．00％（16／16例），差异有统计学意义（χ2=18．481，P〈0．001）。结论初诊时的准确分层治疗可以有效减少ALL的复发，VDLD方案仍可作为有效的缓解方案，异基因造血干细胞移植是高危复发患儿的有效治疗方法，单独睾丸白血病复发患儿可以通过化疗及放疗获得长期生存。

Objective To explore the factors for the relapse,prognosis and the treatment strategy for relapsed pediatric patients with acute lymphoblastic leukemia（ALL）. Methods From January 2007 to January 2015,60 pedia- tric relapsed ALL patients were recruited in Beijing Children＇s Hospital, Capital Medical University. The association be- tween prognosis and different sites of relapse, and the duration of first complete remission and the treatment strategy were analyzed. Results The median age of the 60 patients was 70.5 months,5 l patients out of 60 cases were B - cell immunophenotype, with the median diagnosis - relapse interval 30.5 months. Forty - five patients belonged to marrow relapse and 15 had isolated extramedullary relapsed. Fifty - six patients received treatment after relapse. Thirty - two out of 56 patients survived without disease ,the median follow -up was 19 months （3 -78 months）. The remission rates in- duced by Cyelophosphamide, Prednisone, Doxorubicin, L - Asparaginase, Vindecine （CODLP） induction, and Dexa- methasone, Doxorubicin, Pegaspargase, Vindecine （VDLD） regimens were 85.7% （ 12/14 cases） and 92.9% （ 39/42 cases ） , respectively. The overall survival （OS） of bone marrow relapsed patients and the isolate extramedullary relapsed patients were 57. 14% （ 24/42 cases ） and 78.57% （ 11/14 cases ）, respectively. However, there was no statistical difference （χ2 = 0. 073, P = 0.787 ; χ2 = 2. 979, P = 0.084 ）. The OS of the early, intermediate and late relapsed patients were 43.75% （7/16 cases） ,46.67% （7/15 cases） and 80.00% （20/25 cases）. The differences between early,and late relapsed patients, intermediate and late relapsed patients were statistically slgmficant, respechvely （χ2 = 10. 122, P = 0. 001 ;χ2 = 6. 179 ,P = 0.013 ）. The OS of chemotherapy group versus hematopoietic stem cell transplantation group （HSCT） in bone marrow relapsed patients were 26.92% （7/26 cases） and 100.00% （ 16/16 cases）. Statistically,the difference between the 2 groups was significant（χ2 = 18. 481 ,P 〈 0. 001 ）. Conclusions The accurate gradation treat- ment regimen on the original diagnosis could reduce relapse rate effectively, VDLD protocol was still an useful induction regimen for relapsed ALL patients, and allo - genetic HSCT was the good choice for relapsed patients at high risk, che- motherapy with local irradiation treatment strategy could assist longer survival for the relapsed patients with isolated tes- ticular leukemia.