摘要
第一部分：儿童急性淋巴细胞性白血病的预后与MICM分型及临床表现的关系
目的：探讨儿童急性淋巴细胞性白血病的预后与MICM分型、临床表现及主要化疗药物的关系，为确定个体化治疗方案以进一步提高患者的生存质量提供理论依据。
方法：回顾分析过去10年在我科首诊且全程依从ALL-XH-99方案化疗的115例儿童急性淋巴细胞性白血病患者的临床资料，采用Kaplan-Meier方法评估患儿的EFS，组间患儿EFS差异用Log-rank检验，全部数据均通过SPSS13．0软件处理。
结果115例ALL完全缓解率(CR)为90．4％，缓解中位时间为34天。5例死于诱导缓解之后(2例死于真菌败血症，3例死于细菌性败血症继发的弥漫性血管内凝血)。总的5年EFS率为(69．0±5．0)％，低危、中危、高危组5年的EFS率分别为(82．0±6．0)％、(77．0±15．0)％和(43．0±11．0)％，14例(12．2％)复发，复发的中位时间为17个月。单纯骨髓复发11例，中枢神经系统复发1例，睾丸白血病合并第二肿瘤(急性髓细胞性白血病)1例，骨髓复发合并中枢神经系统白血病1例，异基因造血干细胞移植术后继发淋巴瘤1例。所有病例均未采取颅脑放疗，中枢神经系统复发率并未高于既往报道。独立的不利预后因素包括：危险分度、t(9；22)／bcr／abl融合基因和初诊时白细胞计数。
结论我院儿童ALL的EFS率和发达国家类似；t(9；22)／bcr／abl融合基因为最重要的不利预后因素；在强有力的系统化疗和鞘内注射条件下，对所有患儿可取消颅脑放疗以减少副作用。
第二部分：抗凋亡基因Ayen在儿童急性淋巴细胞性白血病中的表达及其临床意义
目的探讨抗凋亡基因Aven在儿童急性淋巴细胞性白血病中的表达及其与临床分型的关系。
方法应用RT-PCR检测55例儿童急性淋巴细胞性白血病患者Aven基因mRNA的表达水平，11例非恶性血液病患儿为对照组。
结果年龄大于10岁的ALL患者，Aven的表达明显高于年龄小于10岁的ALL患者，对于复发患者，Aven的表达亦明显高于未复发者。单因素和多因素分析结果均显示Aven的高表达为儿童ALL不利的预后因素。
结论Aven在儿童急性淋巴细胞性白血病中异常表达，且为不良的独立预后因素。
第三部分自体DC-CIK治疗化疗后儿童急性白血病的临床观察
目的采用体外培养的树突状细胞(DC)致敏、细胞因子诱导激活的杀伤细胞(CIK)治疗化疗后的儿童急性白血病患者，探讨该方法降低化疗后复发的作用及其临床应用的安全性。
方法将体外培养、扩增的DC-CIK细胞分两次回输给患者。随后给予胸腺肽皮下注射，10mg／天，隔日一次，连用10次。观察用药期间的不良反应，治疗结束后定期复查患者血液学及遗传学缓解情况。
结果1．安全性：5例患者(其中3例为急性髓细胞性白血病，2例为急性淋巴细胞性白血病)9例次治疗均能顺利进行。DC-CIK细胞回输过程中有6例次出现寒战、发热，经对症处理能迅速缓解。治疗过程中未见其它不适反应，心电图、肝肾功能和心肌酶谱检查结果无明显变化；2．疗效观察：1例患者在治疗前存在染色体异常t(8；21)，一个疗程后染色体检查正常。随访至今，4例患者治疗结束后处于持续血液学及遗传学缓解状态，已分别无病生存3年半、2年、2年、1年，1例未完成全程化疗的急性髓细胞性白血病患者2年后复发。
结论DC-CIK细胞治疗全程化疗后的儿童急性白血病安全性较好，不良反应轻微，短期具有一定疗效。是否能有效降低全程化疗后儿童急性白血病的复发尚需进一步观察和大规模的临床病例对照研究。
Part 1 The relationship among the prognosis and MICM subtypes,clinical features of childhood acute lymphoblastic leukemia
Objective To obtain theoretical evidence for individual therapy and further improving thequality of life of long-term survivors, we explore the relationship among the prognosis andMICM subtypes, clinical features and main chemotherapeutics.
Methods A retrospective analysis was carried out on the childhood ALL treated in ourinstitute from January 1998 to April 2007. EFS curves were calculated by using theKaplan-Meier method and were compared with the log-rank test, Statistics was done bySPSS 13.0.
Results Out of the 115 patients, 90.4% attained complete remission (CR) in a median timeof 34 days. 5 died after induction remission (2 from fungal sepsis, 3 from bacterial sepsis leading to disseminated intravascular coagulation). The overall EFS rate at 5 years was(69.0±5.0) % with median observation duration of 21 months. The EFS rates at 5 years inlow-risk (LR), median-risk (MR) and high-risk (HR) groups were (82.0±6.0) %, (77.0±15.0) % and (43.0±11.0) %, respectively (P＜0.05). Relapse occurred in 14 patients(12.2%)in a median time of 17 months, including 11 hematological relapses, 1 isolated centralnervous system (CNS) relapse, 1 testicular leukemia combined with second malignancy(acute myeloid leukemia),1 bone marrow combined with CNS relapse, 1 second lymphomaafter allogeneic transplantation. Eliminating cranial irradiation in all the patients, theoccurrence rate of CNS relapse was not higher than previously reported. Independentadverse prognostic factors included risk group, t (9; 22)/bcr-abl and leukocyte count ofdiagnosis.
Conclusions The EFS rate in our institute was similar to those in developed countries, t (9;22)/bcr/abl was the most important adverse independent prognostic factor. In the context ofeffective systemic and intrathecal chemotherapy, cranial irradiation can be eliminated in allpatients.
Part 2 Expression and clinical significance of antiapoptotic geneAven in childhood acute lymphoblastic leukemia
Objective To explore the expression of antiapoptotic gene Aven in childhood ALL and itsrelationship with clinical features of ALL.
Methods RT-PCR was used to detect the expression of Aven mRNA in 55 cases ofchildhood ALL. The control group included 11 childhood patients with no malignanthematological diseases.
Results Aven mRNA expression was found to be higher in patients =10 years old and wasalso significantly higher in relapsed patients. Univariate and multivariate analysis indicatedthat Aven overexpression was an independent poor prognostic factor.
Conclusions Aven mRNA expression is abnormal in childhood ALL and is associated withthe clinical classification of childhood ALL. It is suggested that Aven gene expression maypredict prognosis in childhood ALL.
Part 3 Autogeneic dendritic-cell-activated and cytokine induced killercells therapy for the treatment of childhood acute leukemia previouslygiven chemotherapy
Objective To investigate the effect and safety of the therapy of autogeneicdendritic-cell-activated and cytokine induced killer cells (DC-C1K) cultured in vitro for thetreatment of childhood acute leukemia previously given chemotherapy.
Methods Autogeneic DC-CIK were transfused to the patients twice after cultivation andamplification in vitro, then thymic peptide were injected subcutaneously at 10mg/d, everyother day for ten times. The side effects were observed during the treatment andhematological and genetic changes were monitored regularly after treatment.
Results 5 patients (3 AML and 2 ALL) were treated with DC-CIK therapy and 9case-times were conducted successfully. Chill and fever appeared in 6 case-times duringthe transfusion and disappeared immediately after non-specific treatment. During thetreatment, no other side effects appeared and no changes of ECG and liver-renal functiontook place. Abnormal chromosome t (8; 21) disappeared in 1 case after one course oftherapy and all of the patients remain hematological and chromosomal remission. 4 patientsremained event-free-survival for half and three years, two years, two years and one yearrespectively since last follow-up. 1 AML patient relapsed two years later who did notundergo total course of chemotherapy.
Conclusions It seems safe to treat childhood AL by autogeneic DC-CIK therapy previouslygiven chemotherapy with mild side effects and short-term therapeutic effect. Furtherlarge-scale clinical randomized comparison needs to be carried out to investigate whetherautogeneic DC-CIK could efficiently reduce the relapse risk of childhood AL after totalcourse of chemotherapy.
引文
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