摘要:
目的 评价高三尖杉酯碱、阿糖胞苷、柔红霉素或去甲氧柔红霉素(HAD/HAI)方案诱导治疗初治急性髓系白血病(AML)患者的长期疗效并探讨其影响因素.方法 观察HAD/HAI方案治疗1个疗程后初治143例AML患者的完全缓解(CR)、总生存(OS)及无复发生存(RFS)率,分析WHO2008标准诊断分型、遗传学预后分组及初始WBC等因素对患者OS、RFS率的影响,评估中剂量阿糖胞苷(MD-Ara-C)巩固治疗在提高AML患者长期生存中的作用.结果 143例患者中112例(78.3%)1个疗程获CR.仅1例患者在诱导化疗期早期死亡.高白细胞与非高白细胞组、FLT3-ITD突变型与野生型组患者CR率差异均无统计学意义(P值分别为0.266和0.528).遗传学预后良好、中等、不良组患者CR率分别为93.7%、71.4%和61.3%,组间差异有统计学意义(P=0.001).中位随访24(1~104)个月,中位生存时间为30(95%CI12~48)个月.所有患者的5年OS率为40.0%,5年RFS率为37.0%.1个疗程CR后接受巩固治疗的患者为96例,5年OS率为47.0%,5年RFS率为38.0%;其中序贯含MD-Ara-C方案(71例)和序贯标准剂量Ara-C(25例)巩固治疗组患者的5年OS率差异有统计学意义(58.0%对19.0%,P=0.004).在序贯含MD-Ara-C方案巩固治疗的患者中,高白细胞与非高白细胞组、FLT3-ITD突变型和野生型组患者的5年OS率差异均无统计学意义(P值分别为0.419和0.482),遗传学预后良好、中等、不良组患者5年OS率差异无统计学意义(P=0.332).结论 HAD/HAI方案诱导化疗缓解后序贯含MD-Ara-C方案巩固治疗的策略对初治AML患者,特别是高白细胞患者,可望获得满意的长期生存率.%Objective To estimate the long-term outcomes and the prognostic factors of homoharringtonine,cytarabine,daunorubicin or idarubicin (HAD/HAI) as induction chemotherapy in de novo acute myeloid leukemia (AML).Methods The CR rate,overall survival (OS) rate,relapse free survival (RFS) rate were retrospectively assayed in 143 de novo AML patients who received the HAD/ HAI induction chemotherapy.The outcomes were compared among prognostic groups according to world health organization (WHO) classification,genetic prognosis and initial white blood cell (WBC) count.The role of consolidation chemotherapy consisting of middle-dosage Ara-C (MD-Ara-C) on long term survival was evaluated.Results Of 143 patients,112 (78.3%) achieved CR after the first course of HAD/ HAI induction treatment,and early death occurred in only one case.Notably,the CR rate of patients with an initial WBC count ≥100× 109/L was not significantly different from those with an initial WBC count<100× 109/L (70.4% vs 80.2%,P=0.266).The CR rate for the patients with favorable,intermediate and unfavorable integrated genetics risk factors was 93.7%,71.4% and 61.3%,respectively,the difference between groups was statistically significant (P=0.001).Patients with FLT3-ITD mutation obtained similar CR rate (70.6%)to that of patients with FLT3 wild type (79.3%,P=0.528).The estimated 5-year OS rate and 5-year RFS rate for all patients was 40.0% and 37.0%,respectively,with a median follow-up of 24 (range 1-104) months.The median survival time was 30 [95% CI (12,48)] months.5-year OS and 5-year RFS of the 96 patients who achieved CR after first course chemotherapy without undergoing allo-HSCT in complete remission was 47.0% and 38.0%,respectively.5-year OS was significantly higher in MD-Ara-C consolidation group than in no MD-Ara-C consolidation group among CR patients without allo-HSCT (58.0%,19.0%,respectively,P=0.004).In patients who obtained CR after first course and received MD-Ara-C consolidation without allo-HSCT,the 5-year OS of patients with hyperleukocytosis was not significantly lower than that of patients without hyperleukocytosis (55.5%,58.8%,respectively,P=0.419).FLT3-ITD mutation patients showed similar 5-year OS to that of wild type FLT3 patients (51.4%,60.2%,respectively,P=0.482).And furthermore,5-year OS of favorable,intermediate and unfavorable integrated genetics groups were 59.1%,62.5%,51.9%,respectively (P=0.332) in this subgroup.Conclusion HAD/ HAI induction chemotherapy with sequential consolidation of MD-Ara-C could obtain satisfactory CR rate and long-term survival rate in de novo AML,especially for patients with hyperleukocytosis or FLT3-ITD mutation.It yet remains to be verified by large sample,prospective studies.