確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件

癌癥病患常見問題的處理血液暨腫瘤科R5林煥超癌癥病患常見問題的處理血液暨腫瘤科1MultidisciplineTreatmentofCancerClinicaloncologistSurgeonRadiationoncologistPathologistRadiologistMultidisciplineTreatmentofC2TheDescriptionofCancerPatients1.Thepatternofpresentingsymptomsandsigns.2.Theevidenceofdiagnosis.3.Thediseaseextent.4.Thetreatmentplan.5.Theeffectsandsideeffectsoftreatments.6.Theongoingproblems.TheDescriptionofCancerPati3PathophysiologyofCancerLocaleffects:1.Tumornecrosis,infection,bleeding.2.Tumorinvasionofadjacentstructure.PathophysiologyofCancerLocal4PathophysiologyofCancerRemoteeffects:1.Tumorproduction:hormones,growthfactors,cytokines,otherpeptides.2.Tumor-evokedproduction:a.Immunecells:antibodies,immunecomplex.b.Non-immunecells:otherpeptides.PathophysiologyofCancerRemot5如何給予化學(xué)治療藥物如何給予化學(xué)治療藥物6DNAsynthesisAntimetabolitesDNADNAtranscriptionDNAduplicationMitosisAlkylatingagentsSpindlepoisonsIntercalatingagentsCellularlevelActionsitesofcytotoxicagentsDNAsynthesisAntimetabolitesDN76-MERCAPTOPURINE6-THIOGUANINEMETHOTREXATE5-FLUOROURACILHYDROXYUREACYTARABINEPURINESYNTHESISPYRIMIDINESYNTHESISRIBONUCLEOTIDESDEOXYRIBONUCLEOTIDESDNARNAPROTEINSMICROTUBULESENZYMESL-ASPARAGINASEVINCAALKALOIDSTAXOIDSALKYLATINGAGENTSANTIBIOTICSETOPOSIDEActionsitesofcytotoxicagents6-MERCAPTOPURINEPURINESYNTHES8化學(xué)治療可以

延長(zhǎng)轉(zhuǎn)移患者的存活期

@Primarychemotherapy

減輕癌癥引起的不適

@Palliativechemotherapy

增加手術(shù)或放射治療的療效

@Neoadjuvant&adjuvant@Concommitentradiosensitizer

改善臨床的治療方式化學(xué)治療可以延長(zhǎng)轉(zhuǎn)移患者的存活期9化學(xué)藥物的給藥?kù)o脈注射:大多數(shù)藥物長(zhǎng)期低劑量灌注短期靜脈輸注靜脈推注口服藥物:VP-16,UFT,Xeloda,Hydroxyurea,6-MP,6-TG化學(xué)藥物的給藥?kù)o脈注射:大多數(shù)藥物10化學(xué)藥物的給藥局部化學(xué)治療動(dòng)脈內(nèi)注射:肝臟腫瘤腹腔內(nèi)注射:卵巢癌,腸胃道癌肋膜腔/心包膜腔內(nèi)注射:癌性積液脊髓腔內(nèi)注射:腦膜侵犯腦室內(nèi)注射:腦膜侵犯

經(jīng)皮給藥:皮膚癌

化學(xué)藥物的給藥局部化學(xué)治療11化學(xué)藥物的靜脈給藥依藥物,腫瘤的種類而有不同不同的注射方式有不同的治療結(jié)果不同的注射方式有不同的毒性反應(yīng)Adriamycin,Epirubicin不同的注射方式有不同的殺死癌細(xì)胞的機(jī)制5-FU化學(xué)藥物的靜脈給藥依藥物,腫瘤的種類而有不同12化學(xué)藥物給藥前應(yīng)注意確定病人姓名,診斷及化療醫(yī)囑包括藥名清楚,劑量,給藥方式及時(shí)間Mitoxantrone,Mitomycin-CFluorouracil,FluconazoleVincristine,Vinblastine化學(xué)藥物給藥前應(yīng)注意確定病人姓名,診斷及化療醫(yī)囑13化學(xué)藥物給藥前選定適當(dāng)?shù)淖⑸湮恢貌豢墒褂密浗M織少又有重要構(gòu)造的部位手背,腹股溝等部位不可使用血液流通不佳的部位不可使用關(guān)節(jié)部位最佳位置為前臂手掌側(cè)Port-A為最佳輸注管道給藥前要確定靜脈管道通暢化學(xué)藥物給藥前選定適當(dāng)?shù)淖⑸湮恢?4化學(xué)藥物的給藥給藥前再確定患者姓名,藥物名稱,劑量,給藥方式及灌注時(shí)間長(zhǎng)短.依醫(yī)囑所述方式給藥,包括給藥的順序,若有困難應(yīng)立即聯(lián)絡(luò)醫(yī)師.

Ara-C:push,subcutaneous,slowinfusion,longterminfusion.etc.Cisplatin+Taxol.CDDP+MTX化學(xué)藥物的給藥給藥前再確定患者姓名,藥物名稱,劑量,給藥15化學(xué)藥物的給藥後不同的藥物的給藥後注意事項(xiàng)根據(jù)其常見毒性反應(yīng)可能不同注意嚴(yán)重的立即性毒性反應(yīng)Cisplatin:hydration&urineoutputAdriamycin/Epirubicin:heartfailureHighdoseMethotrexate:renalfailureCyclophosphamide:hemorrhagiccystitis化學(xué)藥物的給藥後不同的藥物的給藥後注意事項(xiàng)根據(jù)其常見毒性反應(yīng)16MucositisNausea/vomitingDiarrheaCystitisSterilityMyalgiaNeuropathyAlopeciaPulmonaryfibrosisCardiotoxicityLocalreactionRenalfailureMyelosuppressionPhlebitisSideeffectsofchemotherapyMucositisAlopeciaSideeffects17INCREASEDEFFICACYDifferentmechanismsofaction CompatiblesideeffectsDifferentmechanismsofresistanceACTIVITYSAFETYAimofcombinationtherapyINCREASEDEFFICACYDif18會(huì)引起組織壞死的藥物Vinkaalkaloids:Vincristine(Oncovin),Vinblastine,Vinorelbine(Navelbine)Anthracyclines:Epirubicin,IdarubicinMitomycin-C,BCNU,DTICTaxoids,TopotecanMithramycin,NitrogenMustardVP-16,CisplatinFludarabine,Gemcitabine,Irinotecan

會(huì)引起組織壞死的藥物Vinkaalkaloids:Vin19化學(xué)藥物外滲的處置及早發(fā)現(xiàn),立即停止輸注局部冷敷ColdCompressionfor30min.Q6H抬高患處,減少水腫治療可能之局部感染保持壞死皮膚所形成的水泡的完整及消毒開與止痛藥物,甚至morphine若有皮膚表面壞死,請(qǐng)教整形外科共同評(píng)估,甚至需要植皮.化學(xué)藥物外滲的處置及早發(fā)現(xiàn),立即停止輸注20Chemotherapy-associatedEmesisChemotherapy-associatedEmesis21TypeofTreatment-relatedEmesis1.Acute-phasesymptoms:Correlatedwithserotonin(5-HT)releasefromenterochromaffincells.Emeticsignalsarepropagatedatlocal5-HT3receptors.TypeofTreatment-relatedEmes22TypeofTreatment-relatedEmesis2.Delayed-phasesymptoms:Nottoberelatedtoserotonin.Severityanddurationoftencorrelatewithdrugdosage.Nauseaseverityreportedlyissimilarduringbothphases.TypeofTreatment-relatedEmes23TypeofTreatment-relatedEmesis3.Anticipatoryemeticsymptoms:AnaversiveconditionedresponseDevelopsafterrepeatedantineoplastictreatmentsthatarecharacterizedbypooremeticcontrol.Completecontrolthroughoutantineoplastictreatmentremainsthebestpreventivestrategy.TypeofTreatment-relatedEmes24確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件25AntiemeticOptions1.

Serotonin(5-HT3)receptorantagonists:Granisetron(Kytril)

Ondansetron(Zofran)Moreeffectiveandsafertousethenothertypesofantiemetics.AntiemeticOptions1.

Serotonin26SerotoninAntagonistsOndansetron,Granisetron.健保給付規(guī)定1.骨髓移植患者接受高劑量化學(xué)治療時(shí)。2.惡性腫瘤患者使用cisplatin劑量超過50mg/m2可預(yù)防性使用一日劑量。Delayvomiting每療程使用以不得超過五日為原則SerotoninAntagonistsOndansetr27SerotoninAntagonists3.惡性腫瘤患者使用中性致吐劑cisplatin劑量>30，<50mg/m2可預(yù)防性使用一日劑量且發(fā)生嚴(yán)重延遲性嘔吐，使用dexamethasone及metoclopramide無效之病例，每療程使用以不得超過五日為原則。須檢附病歷摘要及使用dexamethasone及metoclopramide無效之記錄。

SerotoninAntagonists3.惡性腫瘤患者使28SerotoninAntagonists4.接受腹部放射照射之癌癥病人，得依下列規(guī)範(fàn)使用ondansetron及granisetron：

(1)totalbodyorhalfbodyirradiation

(2)pelvisorupperabdominalregionofsingleirradiationdose>6Gy

(3)腹部放射治療中產(chǎn)生嘔吐，經(jīng)使用dexamethasone、metoclopramide或prochlorperazine等傳統(tǒng)止吐劑無效，仍發(fā)生嚴(yán)重嘔吐之患者。

SerotoninAntagonists4.接受腹部放射照29AntiemeticOptions2.

Steroids:

Acute-phasesymptoms:

effectiveagainstmildlytomoderatelysymptoms.Delayed-phasesymptoms:mostactiveagents.Dexamethasone(2-20mg)&methylprednisolone+5-HT3-andD2-receptorantagonists.AntiemeticOptions2.

Steroids:30AntiemeticOptions3.

Metoclopramide:Aweakcompetitive5-HT3-receptorantagonistathighdosages.4.

Benzodiazepines:Lorazepam(Ativan).

5.Dopaminergic(D2)-receptorantagonists:Phenothiazines—Prochlorperazine.Butyrophenones—Haloperidol.AntiemeticOptions3.

Metoclop31NeutropenicFeverNeutropenicFever32NeutropenicFeverFever:1oraltemperature>38.3oC.2oraltemperatures>38oC,anhourapart.Neutropenia:ANC(Band+Neutrophil)<500/mm3.ANC500/mm3~1,000/mm3,withapredicteddeclineto<500/mm3within48hours.NeutropenicFeverFever:33NeutropenicFeverIntheabsenceofwhitecells:1.Signsandsymptomsofinvasiveinfectionsmaybeabsent.2.Infectionscaninvadeandspreadquickly.3.Fevermaybetheonlymanifestationofapotentiallylife-threateninginfection.NeutropenicFeverIntheabsenc34NeutropenicFeverBacteremia:10%to20%Gram-positivebacteremia:70%Coagulase-negativestaphylococcusS.aureus.Gram-negativebacteremia:30%Escherichiacoli,Klebsiellasp.,Enterobactersp.,andrarely,Pseudomonasaeruginosa.NeutropenicFeverBacteremia:135NeutropenicFeverCommonsitesoflocalinfection:Therespiratorytract.Sinuses.Skin,softtissue.Venouscatheterentry/exitsites.Urinarytract.Gastrointestinaltract:oralcavity,anus.NeutropenicFeverCommonsites36NeutropenicFeverLaboratoryevaluation:CBC/DC,Platelet.Chemistries(hepaticandrenalfunction).

Bloodcultures.

U/AandU/C.CXR.

Anyaccessiblesitesofpossibleinfection.NeutropenicFeverLaboratoryev37IDSA2002GuidelinesCID2002;730-51IDSA2002GuidelinesCID2002;38VancomycinIninitialempiricaltherapy:1.Clinicallysuspectedseriouscatheter-relatedinfections.2.Knowncolonizationwithpenicillin-andcephalosporin-resistantpneumococciorMRSA.3.B/Cgram-(+)bacteriabeforefinalidentificationandsusceptibilitytesting.4.HypotensionorotherevidenceofCVimpairment.VancomycinIninitialempirical39G-CSFFilgrastim,Lenograstim.健保給付規(guī)定(1)造血幹細(xì)胞骨髓移植(2)血液惡性疾病接受靜注化學(xué)治療後(3)先天性或循環(huán)性中性白血球低下癥者

(當(dāng)白血球數(shù)量少於1000/mm3，或中性白血球(ANC)少於500/mm3)。G-CSFFilgrastim,Lenograstim.40G-CSF

(4)其他惡性疾病患者在接受化學(xué)治療後，曾經(jīng)發(fā)生白血球少於1000/mm3，或中性白血球(ANC)少於500/mm3者，在下一療程即可使用。(5)重度再生不良性貧血病人嚴(yán)重感染時(shí)使用，惟不得作為此類病人之預(yù)防性使用。(6)化學(xué)治療，併中性白血球小於100/mm3癌癥不受控制、肺炎、低血壓、多器官衰竭或侵犯性微菌感染等危機(jī)程度高之感染。使用本品之患者應(yīng)檢附治療記錄，其內(nèi)容需包括診斷、白血球數(shù)量變化、所使用之化學(xué)治療藥物名稱、劑量及使用本品劑量，如白血球超過4000/mm3時(shí)或中性白血球超過2000/mm3時(shí)，應(yīng)即停藥。G-CSF(4)其他惡性疾病患者在接受化學(xué)治療後，曾經(jīng)41癌癥疼痛

CancerPain

癌癥疼痛

CancerPain42晚期癌癥患者常見癥狀Pain89%Fatigue69%Weakness66%Lackofenergy61%Drymouth57%Constipation51%Dyspnea50%SleepDis.49%Depression41%Cough38%Nausea36%Edema28%Taste28%Hoarseness24%Anxiety24%Vomiting23%晚期癌癥患者常見癥狀Pain43癌癥疼痛可由一些簡(jiǎn)單的治療方式在90%的患者得到有效的處置

Cancerpaincanbemanagedeffectivelythroughrelativelysimplemeansinupto90%ofPatients.

Unfortunately,painassociatedwithcancerisfrequentlyundertreated.

癌癥疼痛可由一些簡(jiǎn)單的治療方式在90%的患者得到有效的處置

44疼痛評(píng)估的基本原則相信病人的疼痛抱怨仔細(xì)詢問癌癥及疼痛相關(guān)病史評(píng)估心理狀態(tài)、可請(qǐng)精神科協(xié)助進(jìn)行理學(xué)、神經(jīng)學(xué)檢查開立診斷方式：如CT，bonescan，MRI開始治療疼痛以便利適當(dāng)檢驗(yàn)重新評(píng)估治療的反應(yīng)再設(shè)計(jì)、討論進(jìn)一步治療方式疼痛評(píng)估的基本原則相信病人的疼痛抱怨45治療的基本原則1.Dose"bymouth"wheneverpossible.2.Aroundtheclock(ATC):Basalanalgesicadministrationshouldnotbebasedonan"asneeded"(prn)basis.3.DosebytheWHOthree-stepladder.治療的基本原則1.Dose"bymouth"whene46WHOAnalgesicLadder

StrongOpioids±Non-Opioids

Morphine,Oxycodone,Hydromorphone,TTS-Fentanyl,Methadon

,Step3

WeakOpioids±Non-Opioids

Codein,Dihydrocodein,Tramadol,

Tilidin/NaloxonStep2

Non-Opioids

Ibuprofen,Diclofenac,?Cox2“

Paracetamol,Metamizol,FlupirtinStep1Co-analgesics47WHOAnalgesicLadder StrongOpStrongOpioidsMorphineOxycodoneHydromorphoneFentanyl-TTSRelation127.5100Duration8-128-128-1248-72StrongOpioidsMorphineRelation48StrongOpioidsMorphine10mgIV,IM=20mgSC=30mgPOStrongOpioidsMorphine10mgIV49MorphineSRFentanyl-TTSDosageIfpaincontinues:2x30mgA.2x60mgB.3x30mgnever<8hrs12hrs12hrs8hrs25mg/hA.50mg/hB.25mg/hnever<2daysEvery3.dayEvery3.dayEvery2.dayDosageIfpaincontinues:MorphineSRFentanyl-TTSDosage50確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件51RapidCalculationofDuragesicforCancerPain

Dividemorphineequivalentdose(mg/day)POby2,roundofftoclosestDuragesicpatchinmcg/hr

EXAMPLE:Ptisonmorphine(PO)180mg/day->180/2=90,roundofftoDuragesic100mcg/hrRapidCalculationofDuragesic52癌病代謝性急癥

(MetabolicEmergenciesinOncology)

癌病代謝性急癥

(MetabolicEmergencie53高血鈣癥:病程之變化Earlysigns:fatique,lethargy,constipation,nauseaandpolyuria.Polyuriaandnocturiasecondarytorenaltubulardefectinwaterconservation.==>DehydrationStuporandcomaaresignsofseverehypercalcemia高血鈣癥:病程之變化Earlysigns:fatiqu54高血鈣癥的鑑別診斷Endocrine/metabolicdisordersCancerInfectiousdiseaseRenalinsufficiencyGranulomatousdiseasesDietary/drugrelatedMilk_alkalisyndrome高血鈣癥最常見原因?yàn)榘┌Y及副甲狀腺功能亢進(jìn)高血鈣癥的鑑別診斷Endocrine/metabolicd55高血鈣癥的治療SalinehydrationanddiureticsSteroids:inhibitboneresorptionanddecreaseGItractcalciumabsorption.mosthelpfulinmyeloma,leukemiaandbreastcancerCalcitonin:increaserenalexcretionandreduceboneresorption

高血鈣癥的治療Salinehydrationanddi56高血鈣癥的治療(II)Diphosphonates:reducecalciumfluxfrombone.osteoclastinhibitor.Galliumnitrate:inhibitboneresorptionMithramycin:killosteoclasts.高血鈣癥的治療(II)Diphosphonates:re57腫瘤融解癥候群TumorLysisSyndrome腫瘤融解癥候群TumorLysisSyndrome58腫瘤細(xì)胞內(nèi)含物及其代謝產(chǎn)物大量釋出於血液中所引發(fā)的全身性反應(yīng)

Rapidreleaseofintracellularcontentsintothebloodstream腫瘤細(xì)胞內(nèi)含物及其代謝產(chǎn)物大量釋出於血液中所引發(fā)的全身性反應(yīng)59

主要代謝異常及其引致之病變Hyperuricemia:acuteuratenephropahy-->obstructionandrenalfailureHyperkalemia:cardiacarrhythmiasHyperphosphatemia:acuterenalfailureHypocalcemia:musclecramp,cardiacarrhythmiasandtetany主要代謝異常及其引致之病變Hyperuricemia:a60TumorLysis常見於下列腫瘤Largetumorburdens,rapidproliferativefractionandsensitivetochemotherapy.Highgradelymphoma,suchasBurkit'slymphoma.Leukemiawithhighleucocytecounts,CMLinblasticcrisisRarelyseeninsolidtumors:smallcelllungca,breastcancerFewhourstofewdaysafterinitiationoftreatmentTumorLysis常見於下列腫瘤Largetumor61TumorLysis臨床癥狀Oliguria-azotemiaHyperkalemia,hyperphosphatemia,hyperuricemiaTetanyCardiacarrhythmiaHypotension-shockCardiacarrestTumorLysis臨床癥狀Oliguria-azotem62如何早期發(fā)現(xiàn)

TumorLysis密切檢測(cè)Chemistryscreen:K+,Ca++,uricacid,PO4,LDH,BUN,creatinine如何早期發(fā)現(xiàn)TumorLysis密切檢測(cè)63TumorLysis的治療方式PreventionforhighriskpatientsHydration2500-3000ml/sqm/daySodiumbicarbonateforalkalinizationtourinePH>7(50-100meq/L)Allopurinol10mg/kg/day,,300mg/day(12hrsbeforeC/T),

reducesto100mg/dayifcreatinine>2mg%TumorLysis的治療方式Preventionfor64TumorLysis的治療方式Monitorelctrolytes,uricacid,phosphorus,calciumandcreatininedailyfor1weekoncetumorlysisdeveloped,monitorthelyteseveryfewhours.Hypocalcemia:calciumgluconateHyperkalemia:Kayexalate(15gmq6h),20%dextrosewith10-20Uofinsulin/liter.Hyperphosphatemia:aluminumgel30ccq3-4hrsTumorLysis的治療方式Monitorelctro65TumorLysis的治療方式早期使用血液透析potassium>6mEq/luricacid>10mg/dlphospharus>10mg/dl,symptomatichypocalcemiaandfluidoverload.TumorLysis的治療方式早期使用血液透析66脊索壓迫癥候群

SpinalCordCompression

脊索壓迫癥候群

SpinalCordCompressio67脊索Spinalcord壓迫癥候群硬腦膜外extradural的脊索壓迫癥候是惡性腫瘤常見的神經(jīng)學(xué)併發(fā)癥.不論是硬腦膜外的腫瘤或是較罕見的由脊髓內(nèi)腫瘤所引起者,如未有立即的診斷及迅速的治療,皆可引起永久性的神經(jīng)系統(tǒng)傷害.脊索Spinalcord壓迫癥候群硬腦膜外extradur68部位分布硬腦膜外轉(zhuǎn)移頸椎10%胸椎70%腰椎及薦椎20%部位分布硬腦膜外轉(zhuǎn)移69可能的腫瘤任何可轉(zhuǎn)移的腫瘤皆可發(fā)生肺癌約佔(zhàn)了15%乳癌,攝護(hù)腺癌,淋巴瘤,骨髓瘤及原發(fā)布為不明的轉(zhuǎn)移癌則各約佔(zhàn)了10%.可能的腫瘤任何可轉(zhuǎn)移的腫瘤皆可發(fā)生70臨床徵候被壓迫脊髓相對(duì)神經(jīng)分布部位的疼痛,腸道及膀胱自主神經(jīng)控制的異常(autonomicdysfunction),肢體無力及被壓迫脊髓相對(duì)神經(jīng)節(jié)以下部位的感覺喪失.疼痛可以是局部的也可以是神經(jīng)根壓迫式(radicularpain).受侵犯部位的脊椎可有壓痛(pointtenderness).臨床徵候被壓迫脊髓相對(duì)神經(jīng)分布部位的疼痛,71放射線及實(shí)驗(yàn)室的診斷要做可能侵犯部位的脊椎X光檢查,也?？梢娪屑棺倒堑钠茐?傳統(tǒng)上是用脊髓腔攝影(myelography)來確定病灶的範(fàn)圍,阻斷的部位及嚴(yán)重程度及是否有其他部位尚未有癥狀的脊髓壓迫.核磁共振攝影成為這類病患最佳的檢查方式放射線及實(shí)驗(yàn)室的診斷要做可能侵犯部位的脊椎X光檢查,也?？梢?2臨床癥狀90%以上的患者會(huì)有脊椎中線或脊柱旁區(qū)域的疼痛.通常再躺下時(shí)會(huì)加劇,而在站著或坐著時(shí)會(huì)減輕神經(jīng)根的壓迫性疼痛(Radicularpain)是一常見的早期癥狀,疼痛與脊椎間盤疾病,肋膜發(fā)炎,膽囊炎及胰臟炎的疼痛類似.下肢的無力及麻木感但無感覺異常(paresthesias)便秘或是大解失禁臨床癥狀90%以上的患者會(huì)有脊椎中線或脊柱旁區(qū)域的疼痛.73理學(xué)檢查脊椎部位的壓痛.若加上脊髓病變的徵候則極有可能有硬腦膜上的轉(zhuǎn)移腫瘤.被壓迫的脊椎部位以下可出現(xiàn)DTR增加(hyperactive)Babinski徵候陽(yáng)性運(yùn)動(dòng)無力感覺異常(hypesthesia)肛門括約肌張力減低理學(xué)檢查脊椎部位的壓痛.若加上脊髓病變的徵候則極有可能有硬74脊椎X光檢查癌癥患者有背痛者皆應(yīng)做脊椎X光檢查脊椎X光檢查在80%的患者可判斷有無硬腦膜外的轉(zhuǎn)移.最常見的有pedicles的喪失,脊椎體的破壞及脊椎體的崩解(collapse)脊椎X光檢查癌癥患者有背痛者皆應(yīng)做脊椎X光檢查75臨床處置及治療懷疑有這類併發(fā)癥的患者需立即住院並會(huì)診神經(jīng)外科醫(yī)師及放射腫瘤?？漆t(yī)師.需要立即且積極的使用類固醇(例如dexamethasone,4-10mgIVq6h)緊急的放射治療或是神經(jīng)外科手術(shù)減壓來治療.臨床處置及治療懷疑有這類併發(fā)癥的患者需立即住院並會(huì)診神經(jīng)外科76HighlightofLeukemiaManagementBleedingdiasthesisRisksoflife-threateninghemorrhage--ICH,DIC,pulmonaryhemorrhageFever,neutropenicfeverHyperleucocytosisSevereanemiaOrganomegalyHighlightofLeukemiaManageme77CytochemicalstainingMyeloperoxidase(MPO):AMLM1,2,3,4,5Chloroacetateesterase(CAE):M1,2,3,4Alpha-naphthylbutyrate(ANBE):M4,M5PAS:ALL,AML(15%)Tdt:ALLLAPscore:leukocyteALKPstain(80-100) LAP<20inCML,PNHCytochemicalstainingMyelopero78確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件79ApproachofAcuteLeukemiaBlasts≧30%PeroxidasestainPositiveNegativeCAEPASPositiveNegativePOSNegAMLM1-M4CD13,14,33,65ANBEALLAMLM6,7CD41,61GlycophyrinAMLMoCD13,33,65ALLCD2,7,10,19M4,M5ApproachofAcuteLeukemiaBlas80確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件81確定病人姓名診斷及化療醫(yī)囑包括藥名清楚劑量給藥方式及時(shí)間課件82CHROMOSOMEANALYSISFordiagnosis t(9,22) :CML t(2,5) :Ki-1lymphomaALCL t(4,11) :biphenotypicleukemiaForprognosis

Favorable :t(8,21),t(15,17),inv(16) Unfavorable :-5/del,-7/del,+8FordetectionofminimalresidualdiseaseCHROMOSOMEANALYSISFordiagnos83AML-TreatmentRemissioninduction:Ara-c100mg/m2/dX7,Idarubicin12mg/m2/dX3Consolidation:StandardAra-c100mg/m2X5,IdaX2 HighdoseAra-c1-3gm/m2BidX4daysMaintenance:nothelpfulStemcelltransplant

—Allo-BMT,Allo-PBSCT

—ABMT,autologousPBSCT —MUD,nobetterthanHiDAC —Allo-minitransplant(mixedchimerism)AcuteGVHD,VOD,interstitialpneumonia,TRM30%AML-TreatmentRemissioninducti84COMMONCHEMOTHERAPYREGIMENAMLA)7+3Ara-C100mg/m2+N/SorD5W 500mlCIVqdorbidIdarubicin10-12mg/m2×d+N/S100ml IVinfusionfor1hr(MitoxantronesameasIdarubicin)B)HDACAra-C1gm-3gm/m2×bid+N/S500ml IVinfusionfor3-4hoursCOMMONCHEMOTHERAPYREGIMENAML85AcutePromyelocyticLeukemia(M3)Remissioninduction:ATRA45/m2/dWBC>3000/cumm:ATRA+Idarubicin12mg/m2WBC>10000/cumm:ATRA+Ida×3+Ara–CConsolidation:7+3thenHIDAC+DNRorIDAMaintenance:1yrATRAorobservation(APL93trial)5yrDFS=70%Retinoidacidsyndrome:weightgain,hyperleucocytosis,interstitialpulmonaryinfiltrate,pleuralorpericardialeffusion,hypoxemia,hypotension

Treatment:dexamethasone10mgbid×3dayAcutePromyelocyticLeukemia(86TreatmentofALL

Remissioninduction:-standardrisk:vincristin,prednisolone-highrisk:vincristin,PDN,doxorubicinEarlyintensification:L–asparaginase,MTXCNSprophylaxi