胃部瀰漫性大B型淋巴瘤於R-CHOP的治療年代：單一醫學中心之經驗

Gastric Diffuse Large B Cell Lymphoma in the Era of R-CHOP: A Single Institution Experience in Southern Taiwan

陳苓萍(Ling-Ping Chen) ； 蔡碧桐(Bih-Trong Tsai) ； 余明生(Ming-Sun Yu) ； 林世哲(Shyh-Jer Lin)

《中華民國癌症醫學會雜誌》 25卷6期 (2009/12) Pp. 421-429

https://doi.org/10.6588/JCOS.2009.25.6.4

摘要

目的：Rituximab（作用在CD20的單株抗體）顯著改善瀰漫性大B型淋巴瘤的治療反應率及存活率，因此R-CHOP處方（含rituximab、cyclophosphamide、anthracycline、vincristine及prednisolone）已成為瀰漫性大B型淋巴瘤的治療首選。因rituximab對於胃部瀰漫性大B型淋巴瘤的影響尚不明確，因而本研究目的在於釐清不同治療方式對於胃部瀰漫性大B型淋巴瘤的影響。
方法及結果：回溯性分析2000年1月至2009年11月間43位新診斷胃部瀰漫性大B型淋巴瘤病患，其年齡中位數為67.8歲，依據國際預後指標(International Prognostic Index)，共有9.3%（4位）、34.9%（15位）、20.9%（9位）及34.9%（15位）病患列為低、中低、中高及高危險群。其中，27.9%（12位）病患僅接受化學治療，18.6%（8位）僅接受手術，44.2%（19位）接受多重治療，而9.3%（4位）接受支持性療法。第一線治療接受化療及使用單株抗體rituximab顯著延長病患總存活時間（p值分別為＜0.0001及0.0015），但胃切除手術並未明顯影響病人存活（p值為0.7567）。而化療處方中，併用R-CHOP總存活率較單用CHOP為佳（p值為0.0340）。治療併發症依次包含嗜中性白血球低下發燒(18.6%)，腸胃道穿孔(7%)，腸胃道出血(4.7%)，鬱血性心臟衰竭(2.3%)，慢性B型肝炎急性惡化(2.3%)及傾倒症候群(2.3%)，所有併發症與單一治療方式均未呈現顯著統計相關，而總存活的多變項分析中，國際預後指標是唯一有意義的獨立預後因子（危險比9.859；95%信賴區間1.864-52.139；p值為0.007）。
結論：Rituximab合併anthracycline為主的化療處方取代了治癒性手術，已成為未出現合併症胃部瀰漫性大B型淋巴瘤的治療首選，同時並未顯著增加併發症，但未來仍需更大型研究證實上述結論。

關鍵字

瀰漫性大B型淋巴瘤 ； 胃部淋巴瘤 ； rituximab ； 單株抗體 ； 國際預後指標

並列摘要

Rituximab, an anti-CD20 monoclonal antibody, significantly improves the response and survival rates of diffuse large B cell lymphoma (DLBCL). Therefore, the recommended frontline chemotherapy in DLBCL is the R-CHOP regimen containing rituximab, cyclophosphamide, anthracycline, vincristine and prednisolone. The first line treatment of gastric lymphoma has in the last decade evolved from surgical resection to conservative chemotherapy with or without involved field radiation. However, the impact of rituximab on gastric DLBCL is still unclear. The purpose of this study was to investigate the treatment modalities and survival outcomes of patients with gastric DLBCL. We also evaluated the associated complications and prognostic factors. This retrospective analysis of patients from a single institution in southern Taiwan revealed that, between January 2000 and November 2009, 43 of the 589 newly diagnosed lymphoma patients had gastric DLBCL. The median age of these 43 patients was 67.8 years. The patients were classified according to the International Prognostic Index (IPI) into low (9.3%), low-intermediate (34.9%), high-intermediate (20.9%) and high-risk groups (34.9%). Of these patients, 27.9% received chemotherapy alone, 18.6% underwent surgery only, 44.2% received multi-modality treatment, and 9.3% received palliative care. Chemotherapy and rituximab both significantly prolonged the overall survival (p＜0.0001 and 0.0015, respectively) but surgery did not (p=0.7567). Patients receiving the R-CHOP regimen had a better overall survival rate than those receiving the CHOP regimen (p=0.0340). The major adverse events of treatment included neutropenic fever (18.6%), gastrointestinal perforation (7%), bleeding (4.7%), congestive heart failure (2.3%), chronic hepatitis B with acute exacerbation (2.3%), and dumping syndrome (2.3%). No statistical correlation was noted between the treatment modalities and adverse events. Multivariate analysis showed that IPI was the only significant prognostic factor of overall survival (Hazard ratio=9.859; 95% CI, 1.864-52.139; p=0.007). In conclusion, rituximab plus anthracycline-containing chemotherapy is not associated with an obvious increase in major complications, and could replace surgical intervention as the standard treatment of uncomplicated gastric DLBCL.

並列關鍵字

diffuse large B cell lymphoma ； gastric lymphoma ； rituximab ； monoclonal antibody ； International Prognostic Index