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(3)鍒嗗瓙鐢熺墿瀛稿強绱拌優閬哄偝瀛革細骞句箮鎵€鏈塀L鐥呬緥鍧囧瓨鍦╟-MYC鍩哄洜鐨勬槗浣嶏紝c-MYC鏄竴绋綁(zhu菐n)閷勫洜瀛�锛屽彲浠ヤ績閫茬窗鑳炲娈栧拰绱拌優杞�(zhu菐n)鍖�锛屽苟涓旀姂鍒剁窗鑳炲垎鍖栵紝鍦ㄧ窗鑳炲娈栧拰鍒嗗寲鐨勮(di脿o)鎺т腑璧烽棞(gu膩n)閸典綔鐢�銆俢-MYC鍩哄洜浣嶄簬鏌撹壊楂�8q24涓婏紝澶氭暩(sh霉)c-MYC鏄撲綅鐐簍(8;14)(q24;q32)鐨勯噸鎺�锛岀磩鍗�80%銆�
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2.鍏朵粬
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楠ㄩ珦娴佸紡绱拌優妾㈡煡鍙〃閬擟D10銆丆D19銆丆D20銆並appa/Lambda锛岄渶瑕佹敞鎰忚垏鎬ユ€娣嬪反绱拌優鐧借鐥呯浉閼掑垾銆傜暥楠ㄩ珦鐒′镜鐘檪锛岄楂撳父瑕�(gu墨)鍚屾甯搁楂撹薄銆侱LBCL鎮e厭楠ㄩ珦渚电姱鑰呮サ鐐哄皯瑕�銆傜敱浜庢穻宸寸槫楠ㄩ珦杞�(zhu菐n)绉荤櫦(f膩)鐢熼儴浣嶅彲鑳戒笉鍚�锛屽缓璀板悓鏅傛噳(y墨ng)鑷冲皯鍋氳兏楠ㄥ強楂傞鍏╁€嬮儴浣嶇殑楠ㄧ┛锛屼互澧炲姞闄芥€х巼銆�
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15%鐨勯櫧鎬ч儴浣嶇殑妾㈠嚭銆�
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(涓�)瑷烘柗
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鈶℃垨鏈夊奖鍍忓妾㈡煡(CT/MRI)椤ず鑵︽垨鑵﹁啘鐥呰畩鎴栨鍏�(n猫i)鍗犱綅銆�
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鈶NS3锛欳SF涓璕BC:WBC≤100:1锛學BC>5鍊�/μL锛屽苟浠ョ櫧琛€鐥呯窗鑳炵偤涓�锛屾垨鐧借鐥呯窗鑳炲崰姣斾緥楂樹簬澶栧懆琛€骞肩绱拌優鐧惧垎姣旓紝鑵﹁剨娑叉祦寮忕窗鑳炲妾㈡脯闄芥€�;鎴栨湁鐒″叾浠栨槑纰虹梾鍥犵殑椤辩缍�(j墨ng)楹荤椆;鎴朇T/MRI椤ず鑵︽垨鑵﹁啘鐥呰畩锛屽苟闄ゅ鍏朵粬涓绁炵稉(j墨ng)绯荤当(t菕ng)鐤剧梾銆�
4.鐫父渚电姱鐨勮ê鏂�
BL鎮h€呭嚭鐝�(xi脿n)鐫父渚电姱鏅傚彲琛ㄧ従(xi脿n)鐐虹潽涓稿柈鍋�(c猫)鎴栭洐鍋�(c猫)鑵ぇ锛岃唱(zh矛)鍦拌畩纭垨鍛堢祼(ji茅)绡€(ji茅)鐙€缂轰箯褰堟€ф劅锛岄€忓厜瑭﹂闄版€�锛岃秴鑱叉尝妾㈡煡鍙櫦(f膩)鐝�(xi脿n)鐫父鍛堥潪鍧囪唱(zh矛)鎬ф蹈娼ょ伓锛屽垵瑷烘偅鍏掑彲涓嶄簣娲绘銆�
5.鑵槫绶╄В瑷烘柗妯欐簴
(1)瀹屽叏绶╄В(CR)锛氶€氶亷鏌ラ珨鍜屽奖鍍忓妾㈡煡璀夊鎵€鏈夌槫鐏跺叏閮ㄦ秷澶�銆侰T椤ず鍘熻叓澶х殑娣嬪反绲�(ji茅)鍜岃叓濉婂凡绺皬鑷虫甯歌寖鍦�(鏈€澶у緫绶�<1.5cm)锛屽悇鍣ㄥ畼褰卞儚瀛稿彲瑕嬪埌鐨勬墍鏈夌槫鐏跺潎宸叉秷澶�銆侾ET鎺冩弿宸茬劇闄芥€х櫦(f膩)鐝�(xi脿n)銆傞楂撴秱鐗�/娲绘姝e父銆�
(2)閮ㄥ垎绶╄В(PR)锛氱槫鐏舵渶澶у緫绶氱府灏�≥50%锛屾矑鏈夋柊鐧�(f膩)鐦ょ伓銆�
(3)鐒″弽鎳�(y墨ng)(NR)(鐤剧梾绌�(w臎n)瀹�)锛氳⿻浼伴’绀烘矑鏈夐仈鍒癙R锛屼絾涔熸矑鏈夋柊鐧�(f膩)鐦ょ伓銆�
(4)鐤剧梾閫插睍(PD)锛氫换浣曠槫鐏跺澶�≥25%鎴栧嚭鐝�(xi脿n)鏂扮櫦(f膩)鐦ょ伓鎴栭楂撳京(f霉)鐧�(f膩)銆�
(5)鐒℃硶纰哄畾鐨勫畬鍏ㄧ珐瑙o細闆栫劧鐥呯伓鏈€澶у緫>1.5cm锛屼絾绺介珨涓婄梾鐏剁府灏�>75%(鐩镐簰鍨傜洿鍏╂鏈€澶ф┇寰�)銆傚緸褰卞儚瀛镐笂鐒℃硶纰哄畾鏄惁鐐烘畼鐣欑殑鑵槫鎬х梾鐏�锛屾噳(y墨ng)琛岀梾鐞嗘椿妾㈢⒑瀹�锛岃€屾湁鐨勭梾鐏跺張鍙兘涓嶉仼浜庢墜琛�(sh霉)娲绘纰哄畾銆�
(6)鍒嗗瓙鐢熺墿瀛哥珐瑙o細鑻ョ梾鍒濆瓨鍦ㄩ楂撲镜鐘�锛岄渶閫氶亷FISH鏂规硶鐩�(ji膩n)娓楂撹瀺鍚堝熀鍥燾-MYC寰為櫧鎬ц綁(zhu菐n)鐐洪櫚鎬�銆�
(7)鍒嗗瓙鐢熺墿瀛稿京(f霉)鐧�(f膩)(鎴栭櫚杞�(zhu菐n)闄�)锛氭不鐧傚悗杞�(zhu菐n)鐐洪櫚鎬х殑c-MYC鍩哄洜鍐嶆妾㈡脯鐐洪櫧鎬с€�
鍥�銆侀憭鍒ヨê鏂�
1.鑵硅厰鍏�(n猫i)鑵槫锛氬湪鎮f湁鑵硅厰鍏�(n猫i)鑵槫鐨勫厭绔ヤ腑锛屾渶甯歌鐨勫楂旀槸鑵庢瘝绱拌優鐦ゅ拰绁炵稉(j墨ng)姣嶇窗鑳炵槫;鍏朵粬鍖呮嫭鍏锋湁寤f硾楂撳鍙楃疮鐨勭櫧琛€鐥�銆佽倽鑵槫銆佸嵉宸㈣叓鐦ゅ拰杌熺祫绻旇倝鐦ゃ€俉ilm's鐨勮叓鐦ゅ拰绁炵稉(j墨ng)姣嶇窗鑳炵槫鍦ㄥ鍏掍腑鏇村父瑕�锛岃€岃倽鑷�銆佽劸鑷熸垨鑵硅啘鍚庢穻宸寸祼(ji茅)鐨勭櫧琛€鐥呮垨娣嬪反鐦ゅ彈绱洿甯歌浜庡勾榻¤純澶х殑鍏掔銆傛垚浜虹殑閼掑垾瑷烘柗鍖呮嫭鑹€у拰鎯℃€у楂�锛屼緥濡傜祼(ji茅)鑵哥洿鑵哥檶鍜屽嵉宸㈢檶銆�
2.闈㈤儴鑵槫锛氶潰閮ㄨ叓鐦ょ殑閼掑垾瑷烘柗鍖呮嫭鑲夌槫銆佺檶銆佺缍�(j墨ng)闉樼槫銆侀粦鑹茬礌鐦�銆佸斁娑茶吅鑵槫鍜岃壇鎬у楂旂槫锛屽鍓缍�(j墨ng)绡€(ji茅)鐦ゃ€�
3.娣嬪反姣嶇窗鑳炴穻宸寸槫锛氭槸鍙︿竴绋珮搴︿镜瑗叉€х殑娣嬪反鐦�锛屽湪绲勭箶瀛镐笂鑸嘊L琛ㄩ潰鐩镐技銆傜劧鑰�锛孊L绱拌優鍦ㄥ咕鍊嬫柟闈㈣垏娣嬪反姣嶇窗鑳炴穻宸寸槫绱拌優涓嶅悓锛屽畠鍊戝叿鏈変腑绛夊ぇ灏忕殑姗㈠湏褰㈡垨鍦撳舰鏍�锛屾洿鍒嗘暎鐨勬煋鑹茶唱(zh矛)锛屽咕鍊嬩笉鍚岀殑绱拌優鏍稿拰鏇磋睈瀵岀殑绱拌唱(zh矛)銆傛澶�锛屾穻宸存瘝绱拌優娣嬪反鐦よ〃閬擳dT锛孊娣嬪反姣嶇窗鑳炴穻宸寸槫涓嶈兘琛ㄩ仈鑶滆〃闈㈢殑鍏嶇柅鐞冭泲鐧斤紝娴佸紡绱拌優琛�(sh霉)鎴栧厤鐤祫鍖栧彲浠ユ槑纰哄崁(q奴)鍒咮L鍜屾穻宸存瘝绱拌優娣嬪反鐦�銆�
浜�銆佹不鐧�
(涓€)绯荤当(t菕ng)鍖栫檪
1.鍖栫檪鍘熷墖
鐩墠鍦嬮殯涓婂厭绔ユ垚鐔烞绱拌優娣嬪反鐦ゅ閲囩敤BFM95銆丩MB89銆丩MB96绛夋柟妗堝寲鐧�锛屾柟妗堢殑鐗归粸鏄珮寮峰害銆佺煭鐧傜▼銆�
2.鍖栫檪鍓嶆簴鍌�
(1)纰鸿ê妾㈡煡锛氱洝鍙兘鍦ㄦ渶瀹规槗鍙栨潗鐨勯儴浣嶅彇寰楁鏈皨鎵捐叓鐦ょ窗鑳�锛屽寘鎷細楠ㄩ珦銆佽兏鑵规按銆佹泛琛ㄦ穻宸寸槫銆佺毊鑶氬彲鐤戠槫鐏躲€佹繁閮ㄦ穻宸寸祼(ji茅)绌垮埡鎴栨椿妾�銆佺槫鐏舵墜琛�(sh霉)鍙栨椿妾€€傜劧鍚庡畬鍠勮叓鐦ょ窗鑳炵殑MICM鍒嗗瀷锛屽畬鎴愪腑蹇冪梾鐞嗘渻瑷�(鑷冲皯2瀹朵笁鐢查啱(y墨)闄㈢梾鐞嗚€佸斧鏈冭ê)銆�
(2)寤鸿鑳搁鍙婇珎楠ㄥ叐鍊嬮儴浣嶉楂撶┛鍒烘垨娲绘锛氭噳(y墨ng)琛岄楂撶窗鑳炲舰鎱�(t脿i)瀛�銆佹祦寮忕窗鑳炲厤鐤〃鍨嬪垎鏋�銆佺窗鑳為伜鍌冲鍜屽熀鍥犳鏌�銆�
(3)甯歌(gu墨)妾㈡煡锛氬寘鎷叏琛€绱拌優鍒嗘瀽銆佺櫧绱拌優鍒嗛銆佽倽鑵庡姛鑳�銆佽娓呬钩閰歌劔姘叾銆佽兏鑵规按鍙婂叾浠栭珨娑茬殑绱拌優瀛告鏌ョ瓑銆�
(4)鑵﹁剨娑叉鏌ワ細绱拌優闆㈠績娉曟壘鐦ょ窗鑳炪€佹祦寮忔柟娉曟娓井閲忕窗鑳�銆�
(5)褰卞儚瀛告鏌ラ€茶鍒嗘湡锛氳鍙枒娣嬪反绲�(ji茅)鍙婅吂閮˙瓒�銆佸彲鐤戝彈渚甸儴浣嶇殑楠ㄩ鐗囥€丆T绛夊奖鍍忓妾㈡煡浠ヤ究浜嗚В鐥呰畩鑼冨湇銆傛嚪鐤戜腑妯炵缍�(j墨ng)绯荤当(t菕ng)鐥呰畩鏅傚彲琛岃叇鍙婅剨楂揗RI妾㈡煡銆傛湁姊濅欢鐨勮PET/CT妾㈡煡銆�
(6)鍖栫檪鍓嶆鏌ワ細浜嗚В鑷熷櫒鍔熻兘銆佸厤鐤媭娉�銆佺梾姣掓劅鏌�銆佸偝鏌撶梾绛夌媭娉�銆�
3.鎸夊嵄闅害鍒嗙祫
A绲勶細鎵€鏈夊畬鍏ㄥ垏闄ょ殑I鏈熷強鑵归儴鐨勨叀鏈熻叓鐦わ紝鏈垏闄ょ殑鈪犳湡鍜屸叀鏈熸烤娉$窗鑳炴穻宸寸槫(鏈夋不鐧傜悊鐢�);
B绲勶細鏈垏闄ょ殑鈪狅綖鈪℃湡鑵槫锛屸參锝炩叄鏈�(鐒NS娴告饯锛岄楂�<25%)锛孉绲勬棭鏈熷弽鎳�(y墨ng)涓嶅ソ锛屾烤娉$窗鑳炴穻宸寸槫鈪綖鈪f湡;
C绲勶細鏈垏闄ょ殑鈪綖鈪f湡浼存湁宸ㄥぇ鐦ゅ(鐩村緫>10cm鎴栧浜�4鍊嬪櫒瀹樹镜鐘�)锛屸叄鏈熶即CNS娴告饯(鍖呮嫭CNS2)锛屸叄鏈熶即鐫父鍙婂嵉宸镜鐘�锛岄楂撳辜绋氱窗鑳�>25%(Burkitt's鐧借鐥�)锛�
B绲勬棭鏈熸不鐧傚弽鎳�(y墨ng)涓嶅ソ锛屼腑鏈熸湁娈樼暀鐥呯伓銆�
4.鏂规娴佺▼
(1)涓€绶氭不鐧�
鈶燜AB/LMB96鏂规(閬╃敤浜嶣L锛孌LBCL锛孍BV闄芥€LBCL锛岄珮绱氬垾B绱拌優娣嬪反鐦�锛孎(xi脿n)L)
A绲勬柟妗圕OPAD—COPAD
B绲勬柟妗圕OP—COPADM31—鍒╁Ε鏄斿柈鎶�+COPADM32—鍒╁Ε鏄斿柈鎶�+CYM1—鍒╁Ε鏄斿柈鎶�+CYM²—鍒╁Ε鏄斿柈鎶�+COPDM33(鍒嗙董鎸佽垏涓嶇董鎸佺祫)
C1绲勬柟妗圕OP—COPADM51—鍒╁Ε鏄斿柈鎶�+COPADM52—鍒╁Ε鏄斿柈鎶�+CYVE1—MTX5—鍒╁Ε鏄斿柈鎶�+CYVE2—鍒╁Ε鏄斿柈鎶�+M51—M²—M3—M4
C2绲勬柟妗�(CNS+绲�)COP—COPADM51—鍒╁Ε鏄斿柈鎶�+COPADM82—鍒╁Ε鏄斿柈鎶�+CYVE1-MTX8—鍒╁Ε鏄斿柈鎶�+CYVE2—鍒╁Ε鏄斿柈鎶�+M81—M²—M3—M4
A绲勬柟妗�:COPAD—COPAD銆�
COPAD鍏烽珨濡備笅:
VCR2mg/m²(鏈€澶у姂閲�2mg)闈滆剤鎺ㄦ敞锛宒1锛宒6;Pred60mg/(m²·d)(鍒�2娆$郸)d1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;CTX250mg/(m²·娆�)Q12h×3d锛�15鍒嗛悩杓稿叆锛宒1锝瀌3(棣栧姂鎳�(y墨ng)鍦―NR鍓嶇郸);鍚屾檪姘村寲3000mL/(m²·d)[125mL/(m²·h)]锛屾寔绾�(x霉)姘村寲鑷虫渶鍚�1娆TX鍚�12灏忔檪;
DNR30mg/m²×2d(d1锝瀌2)锛�6灏忔檪杓稿叆锛屽湪棣栧姂CTX鍚庣郸銆�
B绲勬柟妗�
B1绲勬柟妗堬細
COP—COPADM3—鍒╁Ε鏄斿柈鎶�+COPADM3—鍒╁Ε鏄斿柈鎶�+CYM1—鍒╁Ε鏄斿柈鎶�+CYM²—鍒╁Ε鏄斿柈鎶�+COPDM3
B2绲勬柟妗�
COP—COPADM3—鍒╁Ε鏄斿柈鎶�+COPADM3—鍒╁Ε鏄斿柈鎶�+CYM1—鍒╁Ε鏄斿柈鎶�+CYM²—鍒╁Ε鏄斿柈鎶�+COPDM3(3)—M²—M3COP鍏烽珨濡備笅:VCR1mg/m²(鏈€澶у姂閲�2mg)锛宒1;CTX300mg/m²(15鍒嗛悩鍏�(n猫i)婊村叆)锛宒1;Pred60mg/m²鍒嗗叐娆″彛鏈�锛宒1锝瀌7;浜岃伅(li谩n)闉樻敞d1鍔戦噺濡備笅:骞撮健(姝�)MTX(mg)Dex(mg)<1821锝�1022锝�122≥3154COPADM3
(1)鍏烽珨濡備笅:VCR2mg/m²(鏈€澶у姂閲�2mg)锛岄潨鑴堟帹娉�锛宒1;Pred60mg/(m²·d)(鍒�2娆℃湇)锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;MTX3g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�3灏忔檪锛宒1;FH4Ca15mg/m²MTX鍚�24灏忔檪闁嬪鍙f湇锛屾瘡6灏忔檪1娆★紝鍏�12娆�(鍏堟湇8娆�锛屼互鍚庝緷鎿�(j霉)MTX婵冨害瀹�);CTX250mg/(m²·娆�)Q12h×3澶╋紝闈滆剤婊存敞15鍒嗛悩鍏�锛宒2锝瀌4;
棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑DNR鍓嶈几鍏�锛屽悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m².h)]锛岀洿鑷矯TX鐢ㄥ畬鍚�12灏忔檪;DNR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3锛屽湪棣栧姂CTX鍚庣郸闉樻敞锛氬叐鑱�(li谩n)闉樻敞(MTX+Dex)d2锛宒6銆�
绗簩鐧傜▼COPADM3(2)鍏烽珨濡備笅:VCR2mg/(m²·d)(鏈€澶у姂閲�2mg)闈滆剤鎺ㄦ敞锛宒1;Pred60mg/(m²·d)(鍒�2娆℃湇)锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;CTX500mg/(m²·娆�)Q12h锛岄潨鑴堟淮娉�15鍒嗛悩鍏�锛宒2锝瀌4[鍗虫瘡澶�1000mg/m²锛岀編鍙搁垑200mg/m²(CTX鐨�0h銆�4h銆�8h绲�)]棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑DNR鍓嶈几鍏ュ悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m²·h)]鎸佺簩(x霉)杓告恫鑷虫渶鍚�1娆$敤钘ュ悗12灏忔檪;DNR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3锛屽湪棣栧姂CTX鍚庣郸;MTX3g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�3灏忔檪閫插叆锛宒1锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)[125mL/(m²·h)],鐩磋嚦MTX婵冨害浣庝簬0.15μmol/L;鍥涙矮钁夐吀閳�:15mg/m²锛屽彛鏈�锛孧TX闈滆剤婊存敞闁嬪鍚�24灏忔檪闁嬪锛屾瘡6灏忔檪1娆�锛屽叡12娆�(鍏堟湇8娆�锛屼互鍚庝緷鎿�(j霉)MTX婵冨害瀹氾紝瑙f晳鑷虫績搴﹀皬浜�0.15μmol/L鍋滄瑙f晳)銆傞灅娉細鍏╄伅(li谩n)闉樻敞(MTX+Dex)d2锛宒6銆�
CYM1—CYM²CYM1闁嬪姊濅欢锛氬湪COPADM32鍚嶢NC>1.0×10⁹/L锛孭LT>100×10⁹/L;Ara-c100mg/m²婧跺叆500锝�1000mL/m²婧舵恫锛屾寔绾�(x霉)杓告敞24灏忔檪锛宒2锝瀌6(鍏�5澶�);MTX3g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�锛�>3h鍏ャ€傚悓鏅傛按鍖�3000mL/(m²·d)[鍫垮寲125mL/(m²·h)]銆傛寔绾�(x霉)杓告恫鑷虫績搴﹀皬浜�0.15μmol/L;FH4Ca15mg/m²;闉樻敞MTX+Dex绗�2澶�(鍔戦噺鍚屽墠)Ara-c+Dex绗�7澶�;CYM²鐢ㄨ棩鍚孋YM1锛屾噳(y墨ng)鍦–YM1鍚嶢NC>1.0×10⁹/L锛孭LT>100×10⁹/L闁嬪鎳�(y墨ng)鐢�銆侰OPADM3(3)鍏烽珨濡備笅VCR2mg/m²(鏈€澶у姂閲�2mg)锛岄潨鑴堟淮娉�锛宒1;Pred60mg/(m²·d)(鍒�2娆℃湇)锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;CTX500mg/(m²·娆�)Q12h锛岄潨鑴堟淮娉�30鍒嗛悩鍏�锛宒2锝瀌4[鍗虫瘡澶�1000mg/m²锛岀編鍙搁垑200mg/m²锛孋TX0h銆�4h銆�8h绲棣栧姂鎳�(y墨ng)鍦―NR鍓嶈几鍏�锛屽悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m²·h)]鎸佺簩(x霉)杓告恫鑷虫渶鍚�1娆$敤钘ュ悗12灏忔檪;E-ADR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3锛屽湪CTX鍚庣郸;MTX3g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�>3h鍏�锛宒1;FH4Ca15mg/2
24灏忔檪鍚庨枊濮�锛屽彛鏈嶏紝姣�6灏忔檪1娆★紝鍏�12娆�(鍏堟湇8娆�锛屼互鍚庝緷鎿�(j霉)MTX婵冨害瀹�);闉樻敞锛歁TX+Dex鍏╄伅(li谩n)闉樻敞锛宒2銆傛敞锛欱2绲勫湪COP绗�8澶╃槫鐏剁府灏�>25%浣�<75%;涓湡鐤戞畼鐣欑殑闈炴烤娉$窗鑳炲瀷B绱拌優娣嬪反鐦�锛屽彲绻肩簩(x霉)瀹屾垚缍寔娌荤檪M²-M3銆�
M²鍏烽珨濡備笅锛欰ra-c50mg/m²闈滆剤婊存敞Q12h锛宒1锝瀌5;VP16150mg/m²闈滆剤婊存敞90鍒嗛悩锛宒1锝瀌3;M3鍏烽珨濡備笅锛歏CR2mg/m²(鏈€澶у姂閲�2mg)锛宒1;Pred60mg/(m²·d)鍒�2娆″彛鏈�锛宒1锝瀌5锛�3澶╁収(n猫i)娓涘仠;CTX500mg/m²30鍒嗛悩鍏�(n猫i)杓稿叆锛孮d锛宒1锝瀌2锛岄鍔戝湪DNR鍓嶇郸锛岀董鎸佹恫閲忓湪3000mL/m²鑷矯TX鍚�12灏忔檪;E-ADR30mg/m²锛宒1锛宒2锛岄潨鑴堟淮娉�6灏忔檪鍏�(鍦–TX鍚庣郸)銆傛敞锛欱绲勬垚鐔烞绱拌優娣嬪反鐦ゅ湪鍖栫檪鏈熼枔鍙伅(li谩n)鍚�4鍔戝埄鏄斿柈鎶楁不鐧傦紝鍧囧湪鍖栫檪鍓�1澶�锛屽姂閲�375mg/(m²·娆�)銆�
C绲勬柟妗�
C1绲�
COP—COPADM5—鍒╁Ε鏄斿柈鎶�(2鍔�)+COPADM5—鍒╁Ε鏄斿柈鎶�(2鍔�)+CYVE1—MTX5-鍒╁Ε鏄斿柈鎶�(1鍔�)+CYVE2—鍒╁Ε鏄斿柈鎶�(1鍔�)+M51—M²—M3—M4
C2绲�
COP—COPADM5—鍒╁Ε鏄斿柈鎶�(2鍔�)+COPADM8—鍒╁Ε鏄斿柈鎶�(2鍔�)+CYVE1-MTX8—鍒╁Ε鏄斿柈鎶�(1鍔�)+CYVE2—鍒╁Ε鏄斿柈鎶�(1鍔�)+M81—M²—M3-M4
C1鏂规闋�(y霉)娌荤檪锛欳OPVCR1mg/m²(鏈€澶у姂閲�2mg)锛宒1;CTX300mg/m²(15鍒嗛悩鍏�(n猫i)婊村叆)锛宒1;Pred60mg/m²鍒嗗叐娆″彛鏈�锛宒1锝瀌7;涓夎伅(li谩n)闉樻敞d1锛宒3锛宒5;FH4Ca5mg/m²鍙f湇Q6h×2娆�锛岄灅娉ㄥ悗24灏忔檪闁嬪;COPADM51鍏烽珨濡備笅锛歏CR2mg/m²(鏈€澶у姂閲�2mg)闈滆剤鎺ㄦ敞锛宒1;Pred60mg/(m²·d)(鍒�2娆℃湇)锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;
CTX250mg/(m²·娆�)Q12h锛岄潨鑴堟淮娉�15鍒嗛悩鍏ワ紝d2锝瀌4;棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑DNR鍓嶈几鍏�锛屽悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矯TX鐢ㄥ畬鍚�12灏忔檪;DNR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3銆傚湪棣栧姂CTX鍚庣郸;MTX5g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�4h閫插叆d1锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑DNR鍓嶈几鍏ワ紝鍚屾檪姘村寲3000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矯TX鐢ㄥ畬鍚�12灏忔檪;DNR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3銆�
鍦ㄩ鍔慍TX鍚庣郸;MTX5g/m缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�4h閫插叆d1锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矼TX婵冨害浣庝簬0.15μmol/L;125mL/(m²·h)锛岀洿鑷矼TX
婵冨害浣庝簬0.15μmol/L;FH4Ca15mg/m²24灏忔檪鍚庨枊濮�锛屽彛鏈�锛屾瘡6灏忔檪1娆�锛屽叡12娆�(鍏堟湇8娆★紝浠ュ悗渚濇摎(j霉)MTX婵冨害瀹�)銆傞灅娉細涓夎伅(li谩n)闉樻敞(MTX+Dex+Ara-c)d2锛宒4锛宒6COPADM52鍏烽珨濡備笅锛歏CR2mg/m²(鏈€澶у姂閲�2mg)闈滆剤鎺ㄦ敞锛宒1;Pred60mg/(m²·d)(鍒�2娆℃湇)锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;
CTX500mg/(m²·娆�)Q12h锛岄潨鑴堟淮娉�锛�15鍒嗛悩鍏2锝瀌4(鍗虫瘡澶�1000mg/m²锛岀編鍙搁垑200mg/m²锛孋TX0h銆�4h銆�8h绲�)棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑DNR鍓嶈几鍏�锛屽悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m²·h)]鎸佺簩(x霉)杓告恫鑷虫渶鍚�1娆$敤钘ュ悗12灏忔檪;DNR30mg/m²×2d锛�6灏忔檪杓稿叆锛宒2锝瀌3鍦ㄩ鍔慍TX鍚庣郸;MTX5g/m²缃簬500mL娑�(5%绯栭菇閴€)涓潨鑴堟淮娉�4灏忔檪鍏�锛宒1锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矼TX婵冨害浣庝簬0.15μmol/L;鍥涙矮钁夐吀閳�:15mg/m²锛孧TX闈滆剤婊存敞闁嬪鍚�24灏忔檪锛岄枊濮嬪彛鏈�锛屾瘡6灏忔檪1娆�锛屽叡12娆�(鍏堟湇8娆�锛屼互鍚庝緷鎿�(j霉)MTX婵冨害瀹�)銆傞灅娉細涓夎伅(li谩n)闉樻敞(MTX+Dex+Ara-c)d2锛宒4锛宒6銆�
C1绲�—CNS闄版€х殑闉忓浐娌荤檪:CYVE1-MTX5鍜孋YVE2
CYVE1—MTX5鍏烽珨濡備笅锛�
灏忓姂閲廇ra-c50mg/m²鎸佺簩(x霉)闈滆剤婊存敞12灏忔檪(寰炴櫄20榛炶嚦娆℃棩鏅�8榛�)鍏辩敤5澶�;澶у姂閲廇ra-c3000mg/m²鍔犲叆375mL/m²娑查珨闈滆剤婊存敞灏忔檪锛屽湪灏忓姂閲忛枊濮嬪悗12灏忔檪绲�锛屽叡4娆�锛宒2锝瀌5(8榛炶嚦11榛�);鍙殑鏉炬淮鐪兼恫榛炵溂鍏�5澶╋紝姣�2灏忔檪涓€娆�;VP16200mg/m²鍔犲叆500mL/m²娑查珨涓潨鑴堟淮娉�4灏忔檪锛孮d锛宒2锝瀌5(14榛炶嚦18榛�);
MTX5g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�4灏忔檪鍏�锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矼TX婵冨害浣庝簬0.15μmol/L鏈檪绋婱TX蹇呴爤鍦–YVE1鍚�18d锝�25d锛岀暥ANC>0.5×10⁹/L鍜孭LT>50×10⁹/L;G-CSF(濡傛灉鐢�)绲�(ji茅)鏉熷悗绗�48灏忔檪;杞�(zhu菐n)姘ㄩ叾<10鍊嶆甯稿€�锛屾墠鑳戒娇鐢�;FH4Ca15mg/m²锛孧TX闈滆剤婊存敞闁嬪鍚�24灏忔檪锛岄枊濮嬪彛鏈�锛屾瘡6灏忔檪1娆�锛屽叡12娆�(鍏堟湇8娆★紝浠ュ悗渚濇摎(j霉)MTX婵冨害瀹�)銆備笁鑱�(li谩n)闉樻敞锛歁TX+Dex+Ara-c锛孌19锛屽湪鍥涙矮钁夐吀閳hВ鏁戝墠绲�銆侰YVE2鍔戦噺鍚孋YVE1
C1绲勭董鎸佹不鐧侻51—M²—M3—M4锛氭湰鐧傜▼鎳�(y墨ng)鍦–YEV2鍚庤璞℃仮寰�(f霉)ANC>1.0×10⁹/L鍜孭LT>100×10⁹/L;
M51鍏烽珨濡備笅锛歏CR2mg/m²(鏈€澶у姂閲�2mg)闈滆剤鎺ㄦ敞锛宒1;Pred60mg/(m²·d)鍒�2娆℃湇锛宒1锝瀌5锛屼互鍚�3澶╁収(n猫i)娓涘仠;MTX5g/m²缃簬500mL娑查珨(5%绯栭菇閴€)涓潨鑴堟淮娉�4灏忔檪锛宒1锛屽悓鏅傛按鍖�3000锝�4000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矼TX婵冨害浣庝簬0.15μmol/L;FH4Ca15mg/m²鍦∕TX鍚�24灏忔檪闁嬪鍙f湇锛孮6h×12(鎸夎钘ユ績搴﹀畾娆℃暩(sh霉));CTX500mg/(m²·娆�)锛屾瘡澶�1娆★紝闈滆剤婊存敞15鍒嗛悩鍏�锛宒2锝瀌3;
棣栧姂鎳�(y墨ng)鍦ㄧ2澶╃殑E-ADR鍓嶈几鍏�锛屽悓鏅傛按鍖�3000mL/(m²·d)[125mL/(m²·h)]锛岀洿鑷矯TX鐢ㄥ畬鍚�12灏忔檪;E-ADR30mg/m²Qd×2澶╅潨鑴堟淮娉�6灏忔檪锛屽湪棣栧姂CTX鍚庣郸锛宒2锝瀌3銆傞灅娉細涓夎伅(li谩n)闉樻敞(Ara-c+MTX+Dex)d2銆侻²-M4鍧囨噳(y墨ng)鍦∕1鍚庤璞℃仮寰�(f霉)ANC>1.0×10⁹/L鍜孭LT>100×10⁹/L銆�
M²鍏烽珨濡備笅锛欰ra-c50mg/m²闈滆剤婊存敞锛孮12h锛宒1锝瀌5;VP16150mg/m²闈滆剤婊存敞锛�90鍒嗛悩锛宒1锝瀌3;M3鍏烽珨濡備笅锛歏CR2mg/m²(鏈€澶у姂閲�2mg)锛宒1;Pred60mg/(m²·d)鍒�2娆″彛鏈�锛宒1锝瀌5锛�3澶╁収(n猫i)娓涘仠;CTX500mg/m²30鍒嗛悩鍏�(n猫i)杓稿叆锛宒1锝瀌2棣栧姂鍦―NR鍓嶇郸锛岀董鎸佹恫閲忓湪3000mL/m²鑷矯TX鍚�12灏忔檪;E-ADR30mg/md1锛宒2闈滆剤婊存敞6灏忔檪(鍦–TX鍚庣郸)銆�
M4鍏烽珨濡備笅锛欰ra-c50mg/m²闈滆剤婊存敞锛孮12h锛宒1锝瀌5;VP16150mg/m²锛岄潨鑴堟淮娉�90鍒嗛悩锛宒1锝瀌3;
C2绲�
COP鏂规鍙婇枊濮嬫浠跺悓C1绲�;COPADM51鏂规鍚孋1绲�;COPADM82鏂规鍚孋1绲�(MTX鏀圭偤8g/m²);C2—CNS+鐨勯瀼鍥烘不鐧�:CYVE1-MTX8鍜孋YVE2(鏈祫鐢ㄨ棩闄TX鍔戦噺鏈夎畩鍖栧锛屽叾瀹冪敤钘ュ姂閲忓悓C1绲�锛孧TX鐐�5g/m²)銆�
C2绲勭董鎸佹不鐧侻81—M²—M3—M4(闄1涓璏TX鏀圭偤8g/m²锛屼綑鍧囧悓C1绲�)娉細C绲勬垚鐔烞绱拌優娣嬪反鐦ゅ湪鍖栫檪鏈熼枔鍙伅(li谩n)鍚�6鍔戝埄濡ユ様鍠姉娌荤檪锛屽潎鍦ㄥ寲鐧傚墠1锝�2澶�锛屽姂閲�375mg/(m²·娆�)銆�
鈶HL-BFM90鏂规(閬╃敤浜嶣L锛孌LBCL锛孍B鐥呮瘨闄芥€LBCL锛岄珮绱氬垾B绱拌優娣嬪反鐦�锛屾烤娉℃穻宸寸槫)
娌荤檪鍒嗙祫锛�
R1:瀹氱京鐐鸿叓鐦ゅ畬鍏ㄥ垏闄�銆傞爯(y霉)娌荤檪V-A-B
R2锛氳叓鐦ゆ湭瀹屽叏鍒囬櫎锛孡DH<500U/L鎴栬€呰叓鐦ょ梾鐏朵笉渚电姱鑵归儴闋�(y霉)娌荤檪V-AA-BB-瑭曚及瀹屽叏绶╄В-AA-BB闋�(y霉)娌荤檪V-AA-BB-瑭曚及鏈畬鍏ㄧ珐瑙�-铏曠悊鍚孯3绲�
R3锛氳吂鑵旂槫鐏朵笖LDH>500U/L锛屾垨楠ㄩ珦渚电姱锛屾垨涓渚电姱锛屾垨澶氱櫦(f膩)楠ㄩ渚电姱銆傞爯(y霉)娌荤檪锛�
鈶燰-AA-BB-瑭曚及瀹屽叏绶╄В-AA-BB-AA-BB
鈶-AA-BB-瑭曚及鏈畬鍏ㄧ珐瑙�-CC-鍐嶈⿻浼板畬鍏ㄧ珐瑙�-AA-BB-CC
鈶-AA-BB-瑭曚及鏈畬鍏ㄧ珐瑙�-CC-鍐嶈⿻浼版湁娈樼暀鐥呯伓-浜屾娲绘锛岃嫢(-)-AA-BB-CC
鈶-AA-BB-瑭曚及鏈畬鍏ㄧ珐瑙�-CC-鍐嶈⿻浼版湁娈樼暀鐥呯伓-浜屾娲绘锛岃嫢(+)-鑷珨閫犺骞茬窗鑳炵Щ妞嶅叿楂旀柟妗堝涓嬶細
R1锛氶爯(y霉)娌荤檪V-A-B闋�(y霉)娌荤檪锛歅red30mg/m²锛宒1锝瀌5;CTX200mg/m²锛宒1锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆侰ourseA:Dex10mg/m²锛宒1锝瀌5;IFO800mg/m²锛宒1锝瀌5;MTX(24h杓告敞)500mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;VP-16100mg/(m²·娆�)锛宒4d5;MTX+Dex+Arac(闉樻敞)d1銆侰ourseB:Dex10mg/m²锛宒1锝瀌5;CTX200mg/m²锛宒1锝瀌5;MTX(24h杓告敞)1000mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;Adr25mg/(m²·娆�)锛宒4锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆�
R2锛氶爯(y霉)娌荤檪V-AA-BB---閬擟R-AA-BBCourseAA:Dex10mg/m²锛宒1锝瀌5;IFO800mg/m²锛宒1锝瀌5;MTX(24灏忔檪杓告敞)5000mg/m²锛宒1;VCR1.5mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;VP-16100mg/(m²·娆�)锛宒4锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆侰ourseBB:Dex10mg/m²锛宒1锝瀌5;CTX200mg/m²锛宒1锝瀌5;MTX(24灏忔檪杓告敞)5000mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;Adr25mg/(m²·娆�)锛宒4锝瀌5;MTX+Dex+Arac(闉樻敞)d1;
R3锛氶爯(y霉)娌荤檪V-AA-BB---CR-AA-BB-AA-BB,鏈仈CR-CC--閬擟R-AA-BB-CC銆侰ourseAA:Dex10mg/m²锛宒1锝瀌5;IFO800mg/m²锛宒1锝瀌5;MTX(24h杓告敞)5000mg/m²锛宒1;VCR1.5mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;VP-16100mg/(m²·娆�)锛宒4锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆侰ourseBB:Dex10mg/m²锛宒1锝瀌5;CTX200mg/m²锛宒1锝瀌5;MTX(24灏忔檪杓告敞)5000mg/m²锛宒1;Ara-c150mg/(m²·娆�)锛孮12h锛宒4锝瀌5;Adr25mg/(m²·娆�)锛宒4锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆侰ourseCC锛欴ex10mg/m²锛宒1锝瀌5;VDS3mg/m²锛宒1;CTX200mg/m²锛宒1锝瀌5;Ara-c2000mg/(m²·娆�)锛孮12h锛宒1锝瀌2;VP-160150mg/(m²·娆�)锛宒3锝瀌5;MTX+Dex+Arac(闉樻敞)d1銆�
鈶A-EPOCH+R鏈柟妗堝儏閬╃敤浜嶱MBL锛屾湰鐥呭湅闅涗笂鍏獚鐨勬柟妗堢偤DA-EPOCH-R锛�3骞寸殑OS閬�90%浠ヤ笂锛岃€岄噰鐢‵AB/LMB96鍙奛HL-BFM95鏂规鐢熷瓨鐜囧儏60%宸﹀彸銆傛敞锛氭湰鏂规闈滆剤婊存敞鍒╁Ε鏄斿柈鎶楀悗闁嬪鎸佺簩(x霉)涓夊€嬭棩鐗�(VP-16+ADR+VCR)娣峰悎闈滆剤婊存敞锛屾瘡鐧傜▼鍖栫檪闋嗗簭R-VP16+ADR+VCR娣峰悎-CTX锛屾瘡涓夊懆涓€鍊嬪惊鐠�(hu谩n)锛屽叡6寰挵(hu谩n)锛屾瘡涓€寰挵(hu谩n)鏍规摎(j霉)鍓嶄竴寰挵(hu谩n)琛€璞℃儏娉侊細
a.鏈€浣嶢NC>0.5×10⁹/L锛屽墖鍔戦噺澧炲姞20%(VP16锛孉DR锛孋TX);
b.鑻ュ墠涓€鐧傜▼鏈€浣嶢NC<0.5×10⁹/L锛屽墖鍔戦噺涓嶈畩;c.鑻ヨ灏忔澘<25×10⁹/L锛屽墖闄嶄綆20%IT锛歁TX12mg锛岀1锝�2寰挵(hu谩n)锛岀5锝�6寰挵(hu谩n)鍚勪竴娆�锛宒1锛岀3锝�4寰挵(hu谩n)鍚�2娆�锛宒1锛宒5EPOCH
鏂规鍏烽珨濡備笅锛歏P-1650mg/(m²·d)锛宒1锝瀌4;VCR0.4mg/(m²·d)锛宒1锝瀌4;ADR10mg/(m²·d)锛宒1锝瀌4;Pred120mg/(m²·d)锛宒1锝瀌5;CTX750mg/(m²·d)锛宒5;缇庣緟鑿�375mg/(m²·娆�)锛宒1銆�
(2)鍒嗗瓙闈跺悜钘ョ墿娌荤檪锛欳D20琚獚鐐烘槸鍏嶇柅瀛告不鐧侼HL鐨勭悊鎯抽澏榛�锛孋D20鏃笉鏁e竷鍦ㄧ窗鑳炶〃闈�锛屼篃涓嶉尐瀹氬湪鎶楅珨涓�锛屽洜姝ゅ湪娣嬪反鐦ょ殑娌荤檪涓�锛屾噳(y墨ng)鐢ㄦ姉CD20鍠厠闅嗘姉楂�(鍒╁Ε鏄斿柈鎶�)娌荤檪鎴愮偤鐩墠鏈€閲嶈鐨勪竴绋墜娈碉紝鍏舵不鐧侼HL鐨勪富瑕佹鍒跺寘鎷姉楂斾緷璩存€х窗鑳炴瘨浣滅敤(ADCC)鍜岃楂斾緷璩存€х窗鑳炴瘨浣滅敤(CDC)锛屽苟鍦ㄨ繎20骞翠腑鍙栧緱閲嶅ぇ閫插睍銆�
鍒╁Ε鏄斿柈鎶楄绋辩偤绗竴浠f姉楂旓紝鏄汉榧犲祵鍚堟姉楂�锛屾姉楂斾腑鐨勯紶婧愮祼(ji茅)妲�(g貌u)鏈冨皫鑷磋純闀锋檪闁撶殑鐏屾敞鍜屽毚閲嶇殑姣掑壇浣滅敤銆傜2浠f姉CD20鍠厠闅嗘姉楂旇垏浜虹殑鍚屾簮鎬ч珮閬�90%锝�100%锛屾槸浜烘簮鍖栨姉楂旀垨鍏ㄤ汉婧愭姉楂�銆侭linatumomab锛欳D19銆丆D3闆欐鎶楅珨锛屽叾浣滅敤姗熷埗鐐篢娣嬪反绱拌優鎵€浠嬪皫鐨勫厤鐤洠(ji膩n)瑕栦綔鐢ㄥ湪鑵槫鐨勭櫦(f膩)鐢�銆佺櫦(f膩)灞曞強鐧傛晥涓櫦(f膩)鎻憲閲嶈浣滅敤銆�
鐮旂┒琛ㄦ槑锛屽皪浜嶯HL銆丄LL鍙婁竴浜涘楂旂槫鎮h€咃紝CD8+T绱拌優鐨勬暩(sh霉)閲忚垏鎮h€呯殑闋�(y霉)鍚庡憟姝g浉闂�(gu膩n)銆俆绱拌優鐐哄熀绀�(ch菙)鐨勬不鐧備富瑕佸寘鎷細鐤嫍銆侀珨澶朤绱拌優鐨勬摯澧炲拰涓€浜涙椿鍖朤绱拌優鐨勮棩鐗�銆備絾鏄敱浜庤叓鐦ら€冮€告鍒剁殑瀛樺湪锛屼娇寰椾笂杩版不鐧傛柟娉曞湪鑷ㄥ簥鎳�(y墨ng)鐢ㄩ亷绋嬩腑鐧傛晥娆犱匠銆�
(3)绱拌優鍏嶇柅娌荤檪锛欳AR-T绱拌優鏄寚宓屽悎鎶楀師鍙楅珨(chimericantigenreceptor锛孋AR)鐨凾绱拌優锛岄€氶亷鍩哄洜杞�(zhu菐n)灏庝娇T娣嬪反绱拌優琛ㄩ仈鐗瑰畾鐨勬姉鍘熷彈楂�锛岄€氶亷瑭插彈楂旂壒鐣版€ц瓨鍒ラ澏鎶楀師锛岄€茶€岄仈鍒癟绱拌優娈哄偡闈剁窗鑳�(鑵槫绱拌優)鐨勭洰鐨勩€�
鑳炲収(n猫i)娈电偤淇¤櫉杞�(zhu菐n)灏庢锛岄€氶亷CD3(绗�1浠AR-T)浣滅偤鑳炲収(n猫i)淇¤櫉杞�(zhu菐n)灏庡煙婵€娲诲厤鐤彈楂旈叒姘ㄩ吀娲诲寲鍩哄簭妯¢珨鎴朏ceRly;鎴栬€呴€f帴1鍊�(绗�2浠AR-T)鎴�2鍊嬪強浠ヤ笂(绗�3浠AR-T)鍏卞埡婵€淇¤櫉锛屼緥濡侰D28锛岃獦灏庢€у叡鍒烘縺鍒嗗瓙銆傜2浠f垨绗�3浠AR-T鍙績閫睺娣嬪反绱拌優澧炴畺锛屽寮峰叾娈哄偡鏁堟噳(y墨ng)锛屽欢闀稵娣嬪反绱拌優鍦∟HL鎮h€呴珨鍏�(n猫i)浣滅敤鐨勬寔绾�(x霉)鏅傞枔銆�
CAR閫氶亷杓夐珨绯荤当(t菕ng)琛ㄩ仈浜嶵娣嬪反绱拌優琛ㄩ潰锛岀稉(j墨ng)OKT3銆丆D3/CD8纾佺彔绛夋縺娲绘墜娈典娇T娣嬪反绱拌優鍦ㄩ珨澶栧ぇ閲忓娈�銆佹椿鍖�锛岄€茶€屽彲浠ヨ几娉ㄨ嚦NHL鎮h€呴珨鍏�(n猫i)鐧�(f膩)鎻姉鑵槫鏁堟噳(y墨ng)銆傜洰鍓嶅凡鏈塁D19銆丆D20銆丆D22鐨凜AR-T鐢ㄤ簬娌荤檪闆f不寰�(f霉)鐧�(f膩)鎴愮啛B绱拌優娣嬪反鐦ょ殑鑷ㄥ簥瑭﹂鍦ㄩ€茶涓�锛屽苟涓旂檪鏁堝崄鍒嗚偗瀹�銆�
鍏€佸苟鐧�(f膩)鐧ュ強杓斿姪娌荤檪
(涓€)鎬ユ€ц叓鐦ゆ憾瑙g稖鍚堝緛
灏嶅寲鐧傛晱鎰熺殑鑵槫鍦ㄥ垵濮嬫不鐧傛檪锛屽ぇ閲忚叓鐦ょ窗鑳炴憾瑙e姝伙紝寮曡捣楂樺翱閰歌鐧�銆侀珮纾疯鐧ャ€佷綆閳h鐧�銆佷綆閹傝鐧ュ強灏块吀绲�(ji茅)鏅跺牭濉炶厧灏忕锛屽毚閲嶆檪灏庤嚧鎬ユ€ц厧鍔熻兘琛扮銆傛穻宸寸郴鑵槫灏嶅寲鐧傛晱鎰�锛屽湪鑵槫楂樿矤鑽锋檪鏇村鏄撳悎骞惰叓鐦ょ窗鑳炴憾瑙g稖鍚堝緛銆傞渶绌嶆サ闋�(y霉)闃插拰铏曠悊銆�
1.鑵槫婧惰В缍滃悎寰侀爯(y霉)闃�
(1)鍒ュ槍鍛ら唶:50-100mg/(m²·娆�)锛�2锝�3娆�/鏃�锛岀洿鍒扮⒑瑾嶈叓鐦よ矤鑽锋槑椤笅闄�;
(2)姘村寲:2000锝�3000mL/m²鎸佺簩(x霉)闈滆剤鍧囧嫽婊存敞锛屾厧鐢ㄥ惈閴€娑�;
(3)涓嶄富寮靛父瑕�(gu墨)鍫垮寲琛€娑插強灏挎恫锛屼互閬垮厤鍫挎€ф浠朵笅鑵庡皬绠¢垼楣芥矇绌�锛屽湪楂樺翱閰�銆侀珮閴€鏅傞仼鐣舵噳(y墨ng)鐢�;
(4)涓嶄富寮靛父瑕�(gu墨)闈滆剤瑁滃厖閳e姂锛屽儏鍦ㄤ綆閳e苟鏈夎嚚搴婄櫏鐙€鏅傝閳o紝浠ラ伩鍏嶅鍔犺厧灏忕閳i菇娌夌⿳;
(5)灏嶉珮鑵槫璨犺嵎鑰呮湁姊濅欢鑰呮噳(y墨ng)鑰冩叜鎳�(y墨ng)鐢ㄥ翱閰告哀鍖栭叾锛�0.15mg/(kg·娆�)+鐢熺悊楣芥按50mL锛岄潨鑴堟淮娉�30鍒嗛悩銆備絾闇€娉ㄦ剰妾㈡煡G6PD锛屽鏋滄湁閰剁己闄�锛屼笉鑳界敤灏块吀姘у寲閰�;涓嶈兘鍚屾檪浣跨敤鍒ュ槍鍛ら唶銆佺7閰歌倢閰镐繚蹇冭棩鐗�(闃叉纾烽吀楣界祼(ji茅)鏅�);灏块吀姘у寲閰跺彲浠ユ湁鏁堢殑闄嶄綆琛€灏块吀锛屾笡灏戣厧琛帮紝浣嗘槸骞朵笉鑳芥笡灏戝毚閲嶈叓鐦ょ窗鑳炴憾瑙g稖鍚堝緛鐨勭櫦(f膩)鐢�锛屼笉鑳戒唬鏇块€g簩(x霉)琛€娑插噲鍖栥€�
2.鑵槫婧惰В缍滃悎寰佹不鐧�
闄や簡闋�(y霉)闃叉€ф帾鏂藉锛岀暥鐧�(f膩)鐢熸憾瑙g稖鍚堝緛鏅�锛屾噳(y墨ng)鏍规摎(j霉)鑷ㄥ簥瀵﹂殯鎯呮硜铏曠悊锛�
(1)绻肩簩(x霉)闋�(y霉)闃叉€ф不鐧傘€�
(2)楂橀墍琛€鐧ワ細
鈶犻潨鑴堟敞灏勮憽钀勭硸閰搁垼锛屽儏鑳藉皪鎶楅珮閴€寮曡捣鐨勫績鑷熸瘨鎬э紝鑰屼笖浣滅敤鏅傞枔鐭毇鍍呮暩(sh霉)鍒嗛悩銆傚皪浜庢湁鏄庨’蹇冭嚐姣掓€х殑鎮e厭鎳�(y墨ng)闈滆剤绶╂參鎺ㄦ敞10%鐨勮憽钀勭硸閰搁垼1mL/(kg·娆�)锛屽姞绛夐噺5%鎴�10%钁¤悇绯栫█閲�锛屾帹娉ㄦ檪闁撳ぇ浜�20鍒嗛悩;
鈶¢潨鑴堟敞灏勭⒊閰告矮閳夛細灏嶄簬閰镐腑姣掓偅鍏掓晥鏋滆純濂�锛屼絾鐧傛晥鎸佺簩(x霉)1灏忔檪宸﹀彸锛屽彧鑳戒綔鐐烘噳(y墨ng)鎬ヤ娇鐢�锛屼笖涓嶅疁鐢ㄤ簬琛€瀹归噺閬庡鐨勬偅鍏�銆傚姂閲忕偤1锝�2mmol/kg锛�5%鐨勭⒊閰告矮閳夌敤5%钁¤悇绯栫█閲�2鍊嶏紝20锝�30鍒嗛悩杓稿叆銆�
鈶㈤潨鑴堢郸浜堣憽钀勭硸鍜岃儼宄剁礌锛�10%钁¤悇绯�5锝�10mL/kg锛屾瘡4锝�5g绯栧彲鍔犲叆1U鑳板扯绱狅紝闈滆剤婊存敞30閻�锛屽咕灏忔檪鍏�(n猫i)鍙娇琛€閴€闄嶄綆1锝�2mmol/L銆傜檪鏁堟寔绾�(x霉)鏁�(sh霉)灏忔檪銆�
鈶i洟瀛愪氦鎻涙ü鑴傦細鍙檷浣庨墍闆㈠瓙鐨勫惛鏀�锛�1g/kg(鏈€澶ч噺50g)锛屽父鐢ㄧ殑鏄仛纾鸿嫰涔欑儻鎴栬仛鑻箼鐑:閰搁垑鑸囩敓鐞嗛菇姘�1mL/g娣峰悎鍚庝繚鐣欑亴鑵�?锛�?q奴)鈶�?5%鐨勫北姊ㄩ唶娣峰悎鍙f湇銆傝┎鏂规硶骞惧皬鏅傚収(n猫i)鍙檷琛€閴€0.5锝�2mmol/L銆�
鈶ら€忔瀽:閫氶亷涓婅堪鏂规硶娌荤檪琛€閴€浠嶉€茶鎬у崌楂樻垨闋�(y霉)鏈熶笉鑳介€氶亷涓婅堪杈︽硶绯炬鐨勯珮琛€閴€鎳�(y墨ng)鑰冩叜閫忔瀽娌荤檪銆�
(3)浣庨垼銆侀珮纾疯鐧ワ細鍥犻垼楣藉彲澧炲姞鑵庡皬绠¢垼楣芥矇绌嶏紝鑷ㄥ簥鐒$櫏鐙€鏅備笉鎳�(y墨ng)甯歌(gu墨)浣跨敤闈滆剤閳e姂銆傚彲浠ュ彛鏈嶇⒊閰搁垼鍙互闃绘纾烽吀楣藉惛鏀�锛岄檷浣庤纾锋彁楂樻父闆㈤垼銆備竴鏃︾櫦(f膩)鐢熶綆閳f€ф墜瓒虫娊鎼愭噳(y墨ng)10%钁¤悇绯栭吀閳�1锝�2mL/(kg·娆�)锛屽姞绛夐噺5%钁¤悇绯栨敞灏勬恫闈滆剤鎺ㄦ敞銆�
(4)鑵庡姛鑳戒笉鍏細杓曞害鑵庡姛鑳戒笉鍏ㄥ彲閫氶亷姘村寲銆佸埄灏跨瓑铏曠悊锛岄毃钁楄叓鐦よ矤鑽锋笡杓曘€佽厧鑷熸蹈娼ょ珐瑙h€岄€愭濂借綁(zhu菐n)銆備笉鎳�(y墨ng)鍥犺厧鍔熻兘涓嶅叏鑰岄檺鍒惰几娑查噺锛屽毚閲嶈厧鍔熻兘涓嶅叏浼村皯灏裤€佺劇灏�銆佹按鑵檪鎳�(y墨ng)鑰冩叜鍙婃檪鍋氶€忔瀽娌荤檪銆�
(浜�)蹇冭嚐姣掓€�
涓昏鎸囪捊鐠�(hu谩n)椤炶棩鐗╃殑蹇冭嚐姣掓€�锛屽寘鎷€ユ€у績鑲屾悕鍌峰拰鎱㈡€у績鍔熻兘鎼嶅銆傚墠鑰呯偤鐭毇鑰屽彲閫嗙殑蹇冭倢灞€閮ㄧ己琛€锛屽彲琛ㄧ従(xi脿n)鐐哄績鎱�銆佹埃鐭�銆佽兏鎮躲€佸績鍓嶅崁(q奴)涓嶉仼绛�;鍚庤€呯偤涓嶅彲閫嗙殑鍏呰鎬у績鍔涜“绔�锛岃垏钘ョ墿绱⿳鍔戦噺鐩搁棞(gu膩n)銆�
涓€鏃﹀績鍔熻兘妾㈡脯鎻愮ず蹇冭嚐灏勮鍒嗘暩(sh霉)<55%鎴栬桓绺煭鍒嗘暩(sh霉)<28%锛岃嫢鑳借瓑鏄庡乏蹇冨姛鑳界暟甯稿拰绱拌弻鎰熸煋鏈夐棞(gu膩n)锛屽彲浠ョ辜绾�(x霉)浣跨敤钂界挵(hu谩n)椤炴姉鐢熺礌锛屽惁鍓囨噳(y墨ng)瑭叉毇鍋滐紝鐩村埌灏勮鍒嗘暩(sh霉)≥55%鎴栬桓绺煭鍒嗘暩(sh霉)≥28%銆傛牴鎿�(j霉)钂界挵(hu谩n)椤炶棩鐗╀娇鐢ㄥ姂閲忔垨蹇冭倢鎼嶅偡绋嬪害閬告搰鍙充笝浜炶兒(Zinecard)锛屽乏鏃嬭倝鍫裤€佽兘閲忓悎鍔戠瓑钘ョ墿銆�
(涓�)鑵庤嚐姣掓€�
HD-MTX锛氳厧姣掓€ц棩鐗�(濡傞樋鏄旀礇闊�)鍙皫鑷磋娓呰倢閰愭甯窯FR闄嶄綆鐨勪簽鑷ㄥ簥鎬ц厧鍔熻兘鐣板父锛屽鏈夊彲鑳介€欓钘ョ墿鎳�(y墨ng)瑭插欢閬插埌HD-MTX鍚�20灏忔檪浠ュ悗鎴朚TX宸茬稉(j墨ng)鍏呭垎鎺掓硠鍚庣郸浜�銆傚鏋滆倢閰愬€兼彁绀鸿厧鍔熻兘鐣板父锛孧TX鐢ㄩ噺闇€瑕佽(di脿o)鏁�锛孧TX琛€钘ユ績搴﹀強鍥涙矮钁夐吀閳hВ鏁�(瑭宠闄勮〃3)銆�
(鍥�)涓€х矑绱拌優缂轰箯浼寸櫦(f膩)鐔�
绮掔窗鑳炵己涔忓悎骞舵劅鏌擄紝渚嗗嫝鍏囩寷锛岄€插睍杩呴€�锛屽洜姝ゅ強鏅傚皪鎰熸煋閫茶鎭扮暥铏曠悊鑷抽棞(gu膩n)閲嶈銆傚湪鍙栭€佸悇绋煿椁�(y菐ng)鍚�锛岄爤绔嬪嵆绲︿簣鍒濆缍�(j墨ng)椹楁€ф不鐧�锛屽緟鐥呭師楂旀槑纰哄悗锛屽啀閫茶閲濆皪鎬ф不鐧�銆�
(浜�)SMZco闋�(y霉)闃插崱姘忚偤鍥婅煵鎰熸煋
寤鸿闀锋湡鏈嶇敤SMZco闋�(y霉)闃插崱姘忚偤鍥婅煵鎰熸煋锛�25mg/(kg·澶�)锛屽垎鍏╂锛屾渶澶у姂閲忔瘡娆�0.5g锛孊id锛屾瘡鍛�3澶�锛岀洿鑷冲寲鐧傜祼(ji茅)鏉熷悗3鏈�銆侶D-MTX鐢ㄥ墠24灏忔檪鍒扮敤MTX鍚庤嚦灏�72灏忔檪鍋滅敤寰�(f霉)鏂圭:鑳虹暟鍣佸攽銆�
涓�銆佽嚚搴婃不鐧傚弽鎳�(y墨ng)瑭曚及鏅傞枔榛炲強鏂规硶
(涓€)d7瑭曚及
涓昏鍋氭娓箣鐦ょ伓鐨凚瓒呭拰(鎴�)CT锛屾脯閲忕槫鐏跺ぇ灏�锛岃▓绠楃府灏忕殑鐧惧垎姣�銆�
瑭曚及妯欐簴锛�
鐦ょ伓绺皬鈮�75%鐐烘サ鍏舵晱鎰�;
鐦ょ伓绺皬>25%<75%鐐烘晱鎰�;
鐦ょ伓绺皬鈮�25%锛岀偤涓嶆晱鎰�銆�
(浜�)涓湡瑭曚及
绗�4鐧傜▼鍚庤⿻浼�锛屽寘鎷叏韬槫鐏剁殑绡╂煡锛氭牴鎿�(j霉)鐥呭垵鐨勭槫鐏舵儏娉佹焙瀹氭鏌ュ収(n猫i)瀹�锛屼富瑕佺湅鏈夌劇娈樼暀鐥呯伓锛屼腑妯炰镜鐘繀闋堝瀷闋”鎴栬剨楂揗R锛岀洝鍙兘鍋歅ET/CT鐩搁棞(gu膩n)鐢熻娑叉鏌ワ細鑲濊厧鍔熻兘銆佸績鑲岄叾妾㈡脯銆佽叓鐦NA銆丩DH銆佸翱閰�銆丆RP銆侀惖铔嬬櫧;楠ㄩ珦鍜岃叇姘寸殑褰㈡厠(t脿i)鍙婃畼鐣欑梾妾㈡煡(涓嶇鏄惁鏈夐楂撳拰CNS渚电姱鐨勭梾浜�)銆傝⿻浼版婧栵細鏈変换浣曟畼鐣欑梾鐏惰€咃紝鐩¢噺鍋氫簩娆℃椿妾㈡垨PET/CT鏄庣⒑鍚庡崌绱氭柟妗�锛屽彲鐤戞垨涓嶅仛娲绘鑰呭彲浠ョ辜鍘熸柟妗堟不鐧�锛屽瘑鍒囪瀵�銆�
(涓�)鍚庢湡瑭曚及
COPADM3鎴朚1鍚庡叏閮ㄥぇ鍖栫檪鍚庣殑妾㈡煡锛氳垏涓湡妾㈡煡椤炰技锛屼腑鏈熻⿻浼版湁鍟忛鐨勯爡鐩噸榛炴煡銆�
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鍖呮嫭鑷熷櫒鍔熻兘銆佺槫鐏跺強鍌虫煋鐥呮簮鐨勬鏌�銆�
1.澶х敓鍖�銆佽几琛€鍓嶆鏌�;
2.鐥呮瘨绡╂煡锛氱敳涔欎笝涓佹垔鑲濇姉楂�銆丆MV绛�;
3.蹇冭嚐锛氬績闆诲湒銆佸績鑷熷僵瓒�;
4.鑵归儴锛氳倽鑵庡姛銆佹穩绮夐叾銆佽吂閮˙瓒�;
5.CNS锛氶牠椤盋T锛屽師鏈塁NS2鍜�3鐨勭梾浜哄姞鍋歁RI锛岃剨楂撳崰浣嶆噳(y墨ng)鍋氱浉鎳�(y墨ng)閮ㄤ綅MRI;
6.鐪肩潧锛氳鍔涖€佺溂搴�;
7.鍏嶇柅鍔熻兘锛欳D绯诲垪銆両g绯诲垪;
8.楠ㄩ珦甯歌(gu墨)銆佽瀺鍚堝熀鍥�(鎴朤CR/IgH)銆丮RD(ALK銆丆-myc锛屽鏋滄湁姊濅欢鍋�);
9.鑵﹁剨娑叉鏌�;
10.鐦ょ伓瑭曚及锛氱浉闂�(gu膩n)閮ㄤ綅B瓒�銆丆T妾㈡煡銆丮R妾㈡煡銆�
(浜�)鍋滆棩鍚庢鏌ユ檪闁撳強闋呯洰
1.鍋滆棩3鍊嬫湀棣栨妾㈡煡锛氱槫鐏舵鏌ユ渶濂藉仛PET/CT銆�
2.鍋滆棩绗竴銆佷簩骞达細姣�3鍊嬫湀涓€娆$啊鍠⿻浼�锛屼富瑕佹槸姣忔鍋氱槫鐏剁殑褰卞儚(B瓒呭拰CT骞虫巸)鍙婅倽鍔熷拰LDH銆傛瘡6鍊嬫湀涓€娆″ぇ瑭曚及锛屽寘鎷槫鐏惰⿻浼帮細鐩搁棞(gu膩n)B瓒呫€佸寮稢T妾㈡煡鎴朚R銆佸厤鐤姛鑳�銆佽倽鍔熷拰LDH銆侀绌�(濡傛灉鏈夐楂撲镜鐘�)绛�銆�
3.绗笁骞翠互鍚庯細姣忓崐骞磋⿻浼颁竴娆�锛屼富瑕佸仛鐦ょ伓鐨勫奖鍍�(B瓒呫€丆T骞虫巸)鍙婅倽鍔熷拰LDH瑕栨儏娉佸姞鍋氬収(n猫i)鍒嗘硨婵€绱犲強鏅哄晢绛夋鏌�銆�
鍏�銆佽綁(zhu菐n)瑷烘浠跺強鍘熷墖
(涓€)鐣�?sh霉)钂痶(y墨)闄㈡矑鏈夎(gu墨)鑼冪殑鐥呯悊瑷烘柗姘村钩锛屾矑鏈夊寲鐧傚強鍏跺悎骞剁櫏瑷虹檪姊濅欢鐨勩€佹矑鏈夋不鐧傜稉(j墨ng)椹楃殑銆侀噸鐧ュ強楂樺嵄鐦よ矤鑽蜂互鍙婇洠娌诲京(f霉)鐧�(f膩)鐨勫缓璀拌綁(zhu菐n)瑷鸿嚦鏈夎ê鐧傛浠跺強娌荤檪鍩虹(ch菙)鐨勫厭绉戣娑茶叓鐦ゅ皥绉戦€蹭竴姝ヨê娌�銆�
(浜�)缍�(j墨ng)涓婄礆閱�(y墨)闄㈡不鐧傚悗绌�(w臎n)瀹�銆侀仈鍒板畬鍏ㄧ珐瑙g殑鐥呬汉鍙綁(zhu菐n)瑷鸿嚦鏈夋不鐧傛浠剁殑涓嬩竴绱氶啱(y墨)闄㈢辜绾�(x霉)娌荤檪锛屼緥濡傜董鎸佹不鐧傜殑鐥呬汉銆傛湡闁撳缓璀板畾鏈熷洖涓婄礆閱�(y墨)闄㈤€茶鐦ょ伓瑭曚及銆傚缍寔鏈熼枔鐧�(f膩)鐢熷毚閲嶇殑鍚堝苟鐧�锛屽鍤撮噸鎰熸煋锛屽彲杞�(zhu菐n)鍥炰笂绱氶啱(y墨)闄㈤€茶鎼舵晳銆�





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