Aara - hojkinis limfoma (NHD)
Aara - hojkinis limfoma (NHD) Aara - hojkinis limfoma (NHD)
Aara - hojkinis limfoma (NHD) saqarTvelos pediatr-hematologTa da onko hematologTa kavSiri Tbilisi 2007 - 1 -
- Page 2 and 3: ara- hojkinis limfoma (NHD) 1. daav
- Page 4 and 5: • simsivnuri masis subkutaneuri b
- Page 6 and 7: • yvela pirveladi gulmkerdSiga si
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- Page 10 and 11: 10. eTikur-samarTlebrivi rekomendac
- Page 12 and 13: 1. daavadebis definicia: ara-hojkin
- Page 14 and 15: 4. ara-hojkinis mkurnalobis algoriT
- Page 16 and 17: 5.1.Terapiuli elementebi dReebi 1 2
- Page 18 and 19: 5.5. kursi AAZ1 inicialuri centralu
- Page 20 and 21: 5.9. kursi BB 24 dReebi 1 2 3 4 5 d
- Page 22 and 23: damxmare Terapia, romelic moicavs i
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<strong>Aara</strong> - <strong>hojkinis</strong> <strong>limfoma</strong> (<strong>NHD</strong>)<br />
saqarTvelos pediatr-hematologTa<br />
da<br />
onko hematologTa kavSiri<br />
Tbilisi<br />
2007<br />
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ara- <strong>hojkinis</strong> <strong>limfoma</strong> (<strong>NHD</strong>)<br />
1. daavadebis definicia:<br />
ara-<strong>hojkinis</strong> <strong>limfoma</strong> aris imunuri sistemis avTbisebiani simsivne,<br />
romlis substrats warmoadgens araZvlistvinovani limfoiduri qsovilis<br />
ujredebi.<br />
2. daavadebis etiopaTogenezi:<br />
ara-<strong>hojkinis</strong> <strong>limfoma</strong> warmoiSveba limfoiduri qsovilis<br />
winamoredisagan, romlebsac Tvis mxriv gaaCniaT sxvadasxva<br />
histologiuri Seneba, diferenciaciis done. simsivnuri procesi aris<br />
Sedegi mutaciisa, romlis drosac irRveva proliferaciisa da<br />
diferenciaciis kontrolis meqanizmi. aqtiurdebebian dnm-is onkogenebi<br />
da/an xdeba simsivnuri supresiis genebis inaqtivacia.<br />
3. epidemiologia:<br />
ara-<strong>hojkinis</strong> limfomis raodenobrivi piki aris 7-10 wlamde asakis<br />
bavSvebiSi, iSviaTad gvxvdeba 2 wlamde asakis bavSvTa populaciaSi da<br />
biWebi avaddebian ufro xSirad vidre gogonebi ( Tanafardoba 3;1). wliur<br />
SemTxvevaTa ricxvi Seadgens 9 pirvelad SemTxvevas erT milion bavSvze.<br />
<strong>Aara</strong><strong>hojkinis</strong> limfomebi mesame adgilzea bavSvTa asakis avTvisebian<br />
simsivneebs Soris.<br />
m.iaSvilis bavSvTa centraluri saavadmyofos onko-hematologur centrSi<br />
arahojkiis limfomebis mkunaloba BFM programis mixedviT tardeba 1994<br />
wlidan, saSualod yovel wiliurad 5-7 SemTxveva aRiniSneba, Tumca<br />
saqarTveloSi realuri statistika ar arsebobs, vinaidan avTvisebiani<br />
limfomebis diagnoziT mkurnaloba tardeba sxvadasxva klinikebSi da<br />
Catarebuli Terapia ar Seesabameba BFM Pprogramis moTxovnebs.<br />
4. ara-<strong>hojkinis</strong> limfomis klinika:<br />
klinikur gamovlinebas gansazrvravs simsivnuri procesis lokalizacia:<br />
1. abdominaluri (30%-45%) –<br />
mwvave muceli, asciti, sisxldena kuWnawlavis traqtidan,<br />
hepatosplenomegalia, Tirkmlos mwvave ukmarisoba (simsivnis swrafi<br />
lizisi);<br />
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2. medistinaluri (25% -35%) –<br />
mediastinaluri kompresia, cervikaluri an aqsilaruli limfadenopaTia,<br />
xvela, disfagia, tkivili mkerdis Zvlis ukan, saxis SeSupeba, cinozi,<br />
kisris venebis gafarToeba (zeda Rru venis sindromi);<br />
3. Tavis da kisris are (10%-20%) –<br />
valdeieris rgolis dazianeba, nuSurebis dazianeba (calmxrivi), cxviriT<br />
sunTqvis gaZneleba, smenis daqveiTeba dazianebul mxares, ybisqveSa da<br />
kisris limfuri kvanZebis gadideba<br />
4. sxvadasxva lokalizaciebi (5%-10%) (Zvlovani sistema, kani, filtvi,<br />
farisebri jirkvali, sanerwyve jirkvali, Tvalis orbita, Tvisa da<br />
zurgis tvini, Tirkmelebi) -<br />
osalgia, brtyeli da lulovani Zvlebis dazianeba, mkvrivi konsistenciis<br />
papulozuri gamonayari – mowiTalo-cianozuri an moruxo-moyavisfro,<br />
SesaZlebelia erozirebuli an dawylulebuli, Tavis tkivili,<br />
mxedvelobisa da smenis darRveva, parezi, dambla – gansakuTrebiT<br />
qalasSida da epidularuli simsivneebis dros.<br />
5. ara- <strong>hojkinis</strong> <strong>limfoma</strong>ze saeWvo SemTxvevaSi saWiro kvlevebi :<br />
5.1. aucilebeli diagnosikuri gamokvlevebi<br />
(mtkicebuleba1 rekomendaciis xarisxi A):<br />
• sruli fizikaluri gamokvleva (ix. Kkisris limfadenopaTiis<br />
algoriTmi);<br />
• sisxlis saerTo analizi;<br />
• sisxlis bioqimiuri analizi(laqtatdehidrogenaza, SardmJava,<br />
kreatinini, tute fosfataza);<br />
• eleqtrolitebis gansazRvra;<br />
• gulmkerdisada nazo-faringialuri aris rendgenografia or<br />
proeqciaSi;<br />
• muclis Rrus organoebis eqoskopia;<br />
• Zvlis tvinis punqtatis Seswavla 3 wertilidan (normogramis<br />
semTxvevaSi bilateraluri trepanobiofsia);<br />
• Tav-zurg-tvinis punqtatis Seswavla;<br />
• ascituri masis an plevraluri eqsudatis amoReba da gamokvleva;<br />
• lokaluri an mTliani tanis CT,MRI (saWiroebisSemTxvevaSi),<br />
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• simsivnuri masis subkutaneuri biofsia (saW.SemTxvevaSi);<br />
• gamouval SemTxvevaSi laparatomia;<br />
• virusologiuri gamokvleva;<br />
konsultacia: otolaringologis, nevropaTologis, oftalmologis<br />
5.2. gamokvlevebi Sesabamisi klinikuri simptomebis arsebobisas<br />
(mtkicebuleba 1 rekomendaciis xarisxi A):<br />
• centraluri nervuli sistemis dazianebis SemTxvevaSi eeg, CT da<br />
MRI;<br />
• Zvlovani sistemis dazianebaze eWvis SemTxvevaSi – Zvlebis<br />
skanireba; magnitur-birTvuli-rezonansi;<br />
• saWmlis momnelebeli traqtis zeda nawilis dazianebis dros; ezofago-gastro-duodenoskopia<br />
biofsiiT;<br />
• saTesle jirkvlis dazianebis SemTxvevaSi - saTesle jirkvlis<br />
eqoskenireba da punqcia<br />
6.1 bavSvTa asakis ara-<strong>hojkinis</strong> limfomebis klasifikacia :<br />
maCvenebeli<br />
tipiuri<br />
lokalizacia<br />
Citomorfologia:<br />
FAB* klasifikacia<br />
histologia<br />
ara-<strong>hojkinis</strong> limfomis saxeoba:<br />
Ara-B ujredovani B ujredovani msxvili<br />
anaplazirebuli<br />
Timusi, Suasayari, mezenterialuri nebismieri<br />
limfuri kvanZebi limfuri kvanZebi lokalizacia<br />
L 1 ; L 2 L 3 FAB –iT<br />
araklasificireb<br />
uli<br />
limfoiduri;<br />
imunoblasturi;<br />
aradiferencirebuli<br />
berkiti msgavsi;<br />
imunoblasturi;<br />
didi ujredebi<br />
folikuluri<br />
centrebiT<br />
Msxvili,<br />
anaplazirebuli<br />
ujredebi<br />
imunologia<br />
T-ujredovani: CD-1; CD-2;<br />
CD-2; CD-3;CD-4; CD-5; CD-6;<br />
CD-7; CD-8.<br />
sIg+ CD-19; CD- 20; CD-<br />
21;CALLA+; CD-10.<br />
Ki-1+(CD3) B-/T<br />
ujredovani<br />
markerebi<br />
citogenetika<br />
t(8;14); (q24;q11);<br />
t(11;14);t(1;14) (p32;q11);<br />
t(10;14);(p24; q-11);<br />
t(7;14)(q-35;p-11)<br />
t(8;14); (q24;q32);<br />
t(2;8);t(8;22)(q24;q11)<br />
t(2;5)(p23;q35)<br />
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6.2. ara –hojkiniis limfomis klinikuri stadireba: optimaluri<br />
mkurnalobis<br />
gansazRvrisaTvis mniSvnelovania moxdes daavadebis<br />
stadirebis gansazRvra da SeirCes individualuri poliqimioTerapia.<br />
(mtkicebuleba 1 rekomendaciis xarisxi A)<br />
6.3.1.rogor xdeba stadirebis gansazRvra bavSvebSi :<br />
• Sreobrivi kompiuteruli tomografia: kisris, valdeieris rgolis,<br />
subklavikularuli, aqsilaruli, medistinaluri paratraqealuri,<br />
traqeobronqialuri, abdominaluri da sazardulis limfuri<br />
kvanZebis;<br />
• gulmkerdis kompiuteruli tomografia;<br />
• Zvlis tvinis aspiracia da biofsia;<br />
• Zvlis scintigrafia (Zvlis dazianeba SemTxvevaSi).<br />
D<br />
6.3.2. daavadebis stadiebi:<br />
I stadia:<br />
• erTi nodaluri an eqstranodaluri zonis simsivnuri dazianeba;<br />
• (Mmediastinaluri, abdominaluti, epiduraluri – ara)<br />
II stadia :<br />
• erTi eqtranodaluri simsivne regionaluri limfuri kvanZebis<br />
dazianebiT ;<br />
• ori an meti zonis limfuri kvanZebis dazianeba diafragmis orive<br />
mxares;<br />
• ori eqstranodaluri zonis dazianeba regionalur limfur<br />
kvanZebTan erTad an mis gareSe, diafragmis erT mxares;<br />
• kuW-nawlavis traqtis pirveladi dazianeba, lokalizebuli<br />
III stadia:<br />
iliocekalur zonaSi, mezenterialuri limfuri KkvanZebis<br />
dazianebiT an mis gareSe, mTlianad (2R) an nawilobriv (2NR)<br />
rezecirebuli;<br />
• ori gancalkavebuli eqstranodaluri simsivne diafragmis<br />
sxvadasxva mxares;<br />
• ori an meti limfuri kvanZebi diafragmis orive mxares;<br />
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• yvela pirveladi gulmkerdSiga simsivne (mediastinaluri,<br />
plevraluri, Timusis);<br />
• yvela farTo lokalizaciis abdominaluri simsivne<br />
ararezecirebuli;<br />
• yvela paraspinaluri da epidularuli simsvne.<br />
IV.<br />
• nebismieri zemoT CamoTvlili lokalizacia c.n.s. –is da /an<br />
Zvlis tvinis pirveladi dazianebiT da /an ConCxis<br />
multifokaluri dazianeba (liqvorSi L 1 Aan L 2 >2-3%, xolo L 3<br />
nebismieri raodenoba) Zvli tvinSi blasturi ujredi >5%; < 25%<br />
L 3 morfologiis –B-ALL<br />
7. ara<strong>hojkinis</strong> limfomis mkurnaloba<br />
(mtkicebuleba 1 rekomendaciis xarisxi A):<br />
7.1. mkurnalobis taqtikas gansazRvravs pacientebis ganawileba riskis<br />
jgufebSi, rac Semdeg parametrebs efuZneba :<br />
• ara-<strong>hojkinis</strong> limfomis stadiis gansazRvra;<br />
• mTlianad an nawilobriv rezecirebuli simsivne;<br />
• operaciis Semdeg narCeni simsivnuri masis Sefaseba qimioTerapiis<br />
dawyebamde (laqtatdehidrogenazis gasazRvriT, CT,MRI;<br />
• Zvlis tvinis, centraluri nervuli sistemis da Zvlebis dazianeba.<br />
7.2. ara-<strong>hojkinis</strong> limfomebis mkurnalobis ZiriTadi principebi :<br />
7.2.1. ara-B ujredovani <strong>limfoma</strong> :<br />
• qimioTerapiis xangrZlivi, uwyveti kursi;<br />
• uwyveti dacviTi Terapia 1,2- 2 wlis ganmavlobaSi;<br />
• samkurnalo taqtikis SerCevisTvis mniSvneloovania riskis jgufi;<br />
• centraluri nervuli sistemis dazianebis mkurnalobis da/an<br />
profolaqtikisTvis gamoiyeneba radioTerapia da i/l–ad<br />
qimioprepartaebis Seyvana<br />
(ix. Mmwvave limfoiduri leikemiis samkurnalo protokoli):<br />
(mtkicebuleba 1 rekomendaciis xarisxi A)<br />
.7.2.2. B ujredovani limfomაA(ix. Pprotokoli):<br />
• maRaldozirebuli poliqimioTerapiis mokle kursebi-blokebi;<br />
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• ar saWiroebs dacviT Terapias;<br />
• mkurnalobis taqtikis SerCeva xdeba ara marto daavadebis stadiis<br />
aramed simsivnuri masis moculobis, qirurgiuli Carevis<br />
moculobisa da laqtatdehidogenazis donis safuZvelze;<br />
• centraluri nervuli sistemis dazianebis mkurnaloba da<br />
profilaqtika mxolod i/l Seyvanili qimiopreparatebiT.<br />
(mtkicebuleba 1 rekomendaciis xarisxi A)<br />
8. davadebis gamosavali:<br />
saerTaSoriso monacemebiT sruli remisiis miRweva xdeba SemTxvevaTa 85-<br />
95%-Si, ukanasknel wlebsi gadarCenis maCvenebeli gaumjobesda, Tumca<br />
Seadgens 30-50%-s. miuxedavad c.n.s.is dazianebis aqtiuri mkurnalobisa<br />
centraluri sistemis recidivi aRiniSneba SemTxvevaTa 10 20%-Si.<br />
daavadebis recidivis samkurnalod mowodebulia ganmeorebiTi, maRal<br />
dozirebuli qimiTerapia da Zvlis tvinis transplantacia.<br />
9. garTulebebi:<br />
9.1. qimioTerapiis dros mosalodneli garTulebebi:<br />
• simsivnis mwvave lizisis sindromi;<br />
• qimiuri preparatebis toqsiuri zemoqmedebiT ganviTarebuli<br />
garTulebebi (toqsiuri hepatiti, neirotoqsikozi, kardiomiopatia<br />
da a.S);<br />
• mielosupresia, pancitopenia;<br />
• neitropeniuri cxeleba (mikrobuli, fungaluri, virusuli)<br />
• tkivili<br />
(mtkicebuleba I rekomendaciis xarisxi A)<br />
9.2. mogvianebiTi garTulebebi:<br />
• meoradi simsivne;<br />
• zrdis hormonis deficiti;<br />
• osteopenia<br />
TiToeuli garTulebis mაrTvis detaluri strategia mowodebulia<br />
danarTis saxiT (mtkicebuleba I rekomendaciis xarisxi A)<br />
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diagnostikuri algoriTmi kisris limfadenopaTiis<br />
SemTxvevaSi<br />
Kkisris limfadenopaთia<br />
sistemuri mwvave simptomebi cxeleba<br />
asimptomuri<br />
kvanZi3 sm<br />
Aაrasimetriuli<br />
sიmsivne<br />
Oოrmxrivi,mr<br />
avlobiTi<br />
ki<br />
ara<br />
A<br />
C<br />
1.limf. kvanZebis<br />
xarisxi:<br />
2.xaxis nacxis<br />
baqteriologia<br />
A<br />
Ppunqcia/cit<br />
omorfologi<br />
iuri kvleva<br />
B<br />
1.sisxlis saerTo<br />
analizi;<br />
2.serologiuri<br />
testistreptokokze;<br />
3.testi EBV<br />
Aantisxeulebze;<br />
4.virusologiuri<br />
gamokvleva,<br />
kanisalergiuli<br />
sinji;<br />
5.sinji katis<br />
nakawris daavadebaze<br />
limf. kvanZis<br />
punqciacitomorfologia<br />
Tu yvela testi<br />
uaryofiTi;<br />
limf.kvanZi – zoma<br />
ucvleli an moimata<br />
6 kviraSi<br />
1.farTospeqtris<br />
antibiotikebi, gamokvleva 2-3<br />
kviris Semde;<br />
2.zomebi ar Semcirda an<br />
gaizarda<br />
C<br />
limfuri kvanZis bio<br />
fsia<br />
gamoiricxos<br />
sistemuri<br />
dazianeba:<br />
1.gulmkerdis R-<br />
grafia;<br />
2.sisxlis<br />
saerToanalizi<br />
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10. eTikur-samarTlebrivi rekomendaciebi:<br />
avTvisebiani limfomebiT daavadebuli bavSvebis ojaxebi<br />
uzrunvelyofilni unda iyvnen damakmayofilebeli socialuri pirobebiT,<br />
ris gamoc maT esWiroebaT materialuri daxmareba pensiis saxiT, rac<br />
xels Seuwyobs gankurnebuli bavSvebis socialur garemoSi adaptaciis<br />
sakiTxis mogvarebasa da Sesabamisad maTi cxovrebis xarisxis<br />
gaumjobesebas.<br />
11. praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi*<br />
m. iaSvilis sax. bavSvTa centraluri saavadmyofos onko-hematologiuri<br />
centris aTwliani muSaobis Sedegebis<br />
Sefasebis safuZvelze,<br />
rekomendirebulia bavSvTa asakSi ara<strong>hojkinis</strong> limfomebis mkurnaloba<br />
Catardes arahjkinis limfomis mkurnalobis optimizirebuli oqmebiT,<br />
mogvianebiTi garTulebebis Sesamcireblad, rogoricaa hormonaluri<br />
ukmarisoba, farisebri jirkvlisa da mkerdis simsivneebi. limfomiT<br />
daavadebuli yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes<br />
pediatriuli protokolis mixedviT, mesame donis bavSvTa saavadmyofoS i.<br />
Rekomendacia efuZneba damoukidebeli eqspertis, q.fraiburgis<br />
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri<br />
ganyofilebis xelmZRvanelis prof. Nimaeris Sefasebas. (Tbilisi, 2003w.<br />
13-20 ianvari).<br />
12. gaidlainis gadasinjvis da ganaxlebis vada:<br />
B-NHL BFM 2004 programa (mtkicebuleba 1 rekomendaciis xarisxi A)<br />
– iTvaliswinebs arahოjkinis limfomis mkurnalobaს optimizirebuli<br />
oqmebiT, romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi<br />
garTulebebis Semcireba da gadarCenis sixSiris gazrda. aRniSnulidan<br />
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros<br />
5 wliT.<br />
13. gaidlainis miRebis xerxi/wyaro:<br />
B-NHL BFM 2004<br />
– programa, romelic Targmnilia qarTul enaze da<br />
adaptirebulia saqarTveloSi gamoyenebisaTvis, aRniSnuli programis<br />
gamoiyeneba saqarTveloSi m. iaSvilis sax. bavSvTa centraluri<br />
saavadmyofo–s onko-hematologiur ganyofilebaSi da eqspertirdeba q.<br />
fraiburgis sauniversiteto klinikis profesor nimaieris mier.<br />
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avSvTa asakSi ara-<strong>hojkinis</strong> limfomebis<br />
mkurnalobis protokoli<br />
multicentruli Terapiuli oqmi: B-NHL BFM 2004<br />
(mtkicebuleba 1 rekomendaciis xarisxi A)<br />
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1. daavadebis definicia:<br />
ara-<strong>hojkinis</strong> <strong>limfoma</strong> aris imunuri sistemis avTbisebiani simsivne,<br />
romlis substrats warmoadgens araZvlitvinovani limfoiduri qsovilis<br />
ujredebi.<br />
2. inicialuri stadirebisTvis saWiro kvlevebi<br />
• dawvrilebiTi anamnezi da fizikaluri gasinjva<br />
• gul-mkerdis rentgenografia or proeqciaSi; pozitiuri<br />
pasuxis SemTxvevaSi keTdeba gulmkerdis kompiuteruli<br />
tomografia<br />
• muclis Rrus eqoskopia; pozitiurobis SemTxvevaSi muclis<br />
Rrus kompiuteruli tomografia (CT) an magnitur-rezonansuli<br />
tomografia (MRI)<br />
• Zvlis tvinis punqcia ori wertilidan;<br />
• lumbaluri punqcia<br />
• plevris an ascituri siTxis citomorfologia (saWiroebis<br />
SemTxvevaSi)<br />
• Zvlis tvinis plevris an asceturi siTxis imunologiuri da<br />
citogenetikuri kvlevebi<br />
• cetraluri nervuli sistemis dazianebis SemTxvevaSi Tavis<br />
tvinis magnitur-rezonansuli an kompiuteruli tomografia<br />
• Zvlovani sistemis dainteresebis SemTxvevaSi ConCxis Zvlebis<br />
rendgenografia<br />
• sisxlis saerTo analizi<br />
• sruli bioqoimiuri analizi<br />
• eleqtrolituri balansis Seswavla<br />
• laqtatdehidrogenazas (l.d.h.) gansazrvra<br />
• eleqtrokardiografia<br />
• eqokardiografia<br />
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yvela sxva damatebiTi kvlevebi individualuria da saWiro xdeba<br />
gansakuTrebuli klinikuri niSnebis gamovlenis SemTxevvaSi<br />
3. Terapiuli jgufebis gansazrvris kriteriumebi:<br />
• daavadebis stadia;<br />
• laqtatdehidrogenazis inicialuri done;<br />
• qirurgiuli Carevis Sedegad simsivnuri substrates<br />
rezeqcirebis moculoba.<br />
R1 - simsivnuri substrati srulad rezecirebuli;<br />
R2 - stadia I/II; stadia III l.d.h 500 da < 1000, stadia IV/B-ALL , l.d.h 1000, stadia IV/B-ALL l.d.h >1000, centraluri<br />
sistemis dazianeba +/_, simsivnuri substrati arasrulad rezeqcirebuli.<br />
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4. ara-<strong>hojkinis</strong> mkurnalobis algoriTmi:<br />
standartuli Terapiuli gegma<br />
B-NHL BFM 2004<br />
modificirebuli Terapiuli gegma pirveladi mediastinaluri ara<strong>hojkinis</strong> limfomebisTvis<br />
l.d.h. < 500 erT<br />
MTX 1 gr/m 2<br />
l.d.h. > 500 erT<br />
MTX 5 gr/m 2<br />
modificirebuli Terapiuli gegma cns inicialuri dazianebis SemTxvevaSi<br />
lumbaluri punqcia<br />
3 medik. reparatiT<br />
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4.1.qimioTerapiuli gegma<br />
cxrili 1:<br />
standartuli Terapia B-NHL da B-ALL-Tvis<br />
4.2.cxrili 2:<br />
pirveladi mediastinaluri B-NHL-Tvis<br />
l.d.h. < 500 erT<br />
MTX 1 gr/m 2<br />
l.d.h. > 500 erT<br />
MTX 5 gr/m 2<br />
4.3. cxrili 3:<br />
lumbaluri punqcia<br />
3 medik.<br />
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5.1.Terapiuli elementebi<br />
dReebi 1 2 3 4 5<br />
deqsametazoni ○ ○ ○ ○ ○ ○ ● ● ● ● ● ● ● ● ●<br />
ciklofosfamidi ● ●<br />
●<br />
5.2.kursi A 4<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
citozari ●● ●●<br />
etopozidi ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
Ifosfamidi<br />
2<br />
● ● ● ● ●<br />
42<br />
48 54<br />
lumbaluri punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
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5.3.kursi A 24 mxolod pirveladi mediastinaluri B-NHL pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
citozari ●● ●●<br />
etopozidi ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
ifosfamidi<br />
lumbaluri<br />
punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
42<br />
2<br />
● ● ● ●<br />
●<br />
48 54<br />
5.4.kursi AA 24<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
citozari ●● ●●<br />
etopozidi ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
ifosfamidi<br />
2<br />
● ● ● ● ●<br />
42<br />
48 54<br />
lumbaluri punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
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5.5. kursi AAZ1 inicialuri centraluri nervuli sistemis mqone<br />
pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5 6<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini ●<br />
citozari ●● ●●<br />
etopozidi ● ●<br />
metotreqsati ●<br />
leikovorini<br />
42 48 54<br />
ifosfamidi ●<br />
2<br />
● ● ● ●<br />
lumbaluri<br />
punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
●<br />
●<br />
5.6. kursi AAZ2 inicialuri centraluri nervuli sistemis mqone<br />
pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5 6<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
citozari ●● ●●<br />
etopozidi ● ●<br />
metotreqsati ●<br />
leikovorini<br />
42<br />
ifosfamidi<br />
2<br />
● ● ● ● ●<br />
●<br />
48 54<br />
●<br />
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5.7. kursi B 4<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
doqsorubicini ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
ciklofosfamidi ● ●<br />
2<br />
● ● ●<br />
42<br />
48 54<br />
●<br />
5.8. kursi B 24 mxolod pirveladi mediastinaluri B-NHL<br />
pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
doqsorubicini ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
2<br />
ciklofosfamidi ● ● ● ● ●<br />
42<br />
48 54<br />
●<br />
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5.9. kursi BB 24<br />
dReebi<br />
1 2 3 4 5<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●<br />
vinkristini<br />
●<br />
doqsorubicini ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
2<br />
ciklofosfamidi ● ● ● ● ●<br />
42<br />
48 54<br />
●<br />
5.10. kursi BBZ1 pirveladi centraluri nervuli sistemis dazianebis<br />
mqone pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5 6<br />
deqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●●●<br />
vinkristini<br />
●<br />
doqsorubicini ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
48 42 54<br />
ciklofosfamidi ● ●<br />
2<br />
● ● ●<br />
●<br />
●<br />
●<br />
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5.11. kursi BBZ2 pirveladi centraluri nervuli sistemis dazianebis<br />
mqone pacientebisaTvis<br />
dReebi<br />
1 2 3 4 5 6<br />
dqsametazoni ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●●●<br />
●<br />
vinkristini<br />
●<br />
doqsorubicini ● ●<br />
metotreqsati<br />
●<br />
leikovorini<br />
ciklofosfamidi ●<br />
2<br />
● ● ● ●<br />
lumbaluri<br />
punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
42<br />
48 54<br />
●<br />
5.12. kursi CC<br />
dRe 1 2 3 4 5<br />
eqsametazoni ●●● ●●● ●●● ●●● ●●●<br />
vindezini<br />
●<br />
citozari ●● ●●<br />
etopozidi ●● ●● ●<br />
lumbaluri<br />
punqcia*<br />
MTX/ARA-C/PRED<br />
●<br />
5.13. lumbaluri punqcia*:<br />
asaki<br />
wlebi<br />
MTX<br />
(mg)<br />
ARA – C<br />
(mg)<br />
PRED<br />
(mg)<br />
0.9% natri-qlori<br />
(ml)<br />
damxmare Terapia, romelic moicavs infeqciebis profilaqtikas,<br />
neitropeniul cxelebas, dadasturebuli infeqciebis marTvas, Rebinebisa<br />
da tkivilis menejments, identuria mwvave limfoiduri leikemiis damxmare<br />
Terapiisa. ixileT mwvave limfoiduri leikemiis samkurnalo protokoli.<br />
Reabilitacia da dakvirveba:<br />
protokoli dafuZნebulia bavSvTa asakშ i ara<strong>hojkinis</strong> limfomis<br />
multicentrul Terapiul oqmze - B-NHL BFM 2004<br />
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literatura:<br />
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