急性早幼粒细胞白血病合并DIC患者的护理

目的:探讨急性早幼粒细胞白血病(APL)治疗期间合并DIC护理方法。方法:对2010年1月~2012年11月我科收治的16例APL患者进行密切观察,采取及时有效的护理措施。结果:实施相关护理后,16例患者中眼底出血致双眼失明1例,单眼失明1例,无死亡病例发生。结论:密切观察及早发现APL治疗期间DIC的发生,及时提供临床资料非常重要;采取正确护理,能够提高患者生活质量,降低死亡率。     

长期培养人急性髓系白血病骨髓基质上清液对早幼粒白血病细胞的影响

目的:通过观察长期培养的白血病骨髓基质上清液对早幼粒白血病细胞体外的作用,寻求一种体外净化辅助方法。方法:实验于2002-04/2003-12在大连医科大学附属第二医院血液内科实验室完成。20例急性髓细胞白血病为初诊或复发病例。男11例,女9例,19～55岁,平均36.8岁,由大连医科大学附属第二医院血液内科、大连市友谊医院血液内科、铁路医院血液科、大连大学附属医院血液科提供。患者知情同意并签署知情同意书。诊断均符合张之南主编的“血液病诊断及疗效标准”,其中M12例,M28例,M34例,M42例,M54例。常规分离培养人骨髓基质细胞,收集14,28,35d的上清分别与早幼粒白血病细胞共孵育,以不加入急性髓细胞白血病基质上清液的早幼粒白血病细胞的培养体系作为阴性对照,通过形态、流式细胞术、DNA电泳来观察早幼粒白血病细胞有无分化及凋亡表现。结果:20例患者均进入结果分析。①急性髓细胞白血病骨髓基质细胞是由网状细胞、成纤维细胞、巨噬细胞、脂肪细胞组成。②Wright-Giemsa染色可见阴性对照早幼粒白血病细胞为悬浮生长,胞体内含颗粒,增殖旺盛,镜下常见核分裂、增殖状态的早幼粒白血病细胞;14d及28d培养的急性髓细胞白血病基质上清液作用的早幼粒白血病细胞,形态未见明显变化,35d培养的急性髓细胞白血病基质上清液作用的早幼粒白血病细胞出现细胞变形,细胞核出现改变,部分细胞核仁减少或消失。NBT还原实验发现部分早幼粒白血病细胞胞奖内出现紫蓝色颗粒,并见到核碎解成染色质小体(凋亡小体)。③35d时相上清液孵育的早幼粒白血病细胞部分出现分化现象,部分出现凋亡小体,DNA电泳见梯形带,流式细胞术检测出凋亡峰。④培养35d的急性髓细胞白血病基质上清液对早幼粒白血病细胞的诱导分化及促凋亡作用明显强于培养14,28d的急性髓细胞白血病基质上清液及阴性对照组[分化细胞数:1.5±1.8,2.1±1.5,17.3±3.0,41.0±11.1;凋亡细胞数:5.2±1.7,7.3±1.9,10.1±2.2,35.2±13.9,P<0.05],其他组间差异不显著。结论:培养35d的白血病骨髓基质上清液对早幼粒白血病细胞具有诱导分化、促进凋亡的作用。可能为白血病体外净化提供一种辅助方法。     

急性早幼粒细胞白血病的治疗

急性早幼粒细胞白血病(APL)是急性髓细胞白血病的一种特殊亚型.全反式维甲酸(ATRA)的应用使其从一种高度凶险的疾病转变成为一种高度可治愈的疾病.三氧化二砷(ATO)在治疗复发难治性APL取得成功后,也逐渐被引入APL的一线诱导治疗.危险度分层治疗的提出、口服砷剂的使用进一步提高了APL的疗效.本文就APL的治疗现状及其最新进展进行简要综述.     

Cell-SELEX技术筛选急性早幼粒细胞白血病NB4细胞适配体

目的用以细胞为靶标的指数富集配体的系统进化(Cell-SELEX)技术获得与急性早幼粒细胞白血病(APL)细胞株NB4高亲和力、高特异性的适配体。方法以NB4细胞为靶标,用Cell-SELEX技术从随机单链DNA(ssDNA)文库中筛选出一组适配体,将筛选得到的适配体群进行克隆、测序及结合力测定,用流式细胞仪和荧光显微镜对结合率最高的适配体进行亲和力和特异性分析。结果第1,4,7,10,13,16,19轮筛选获得的次级文库与NB4细胞的结合率分别为(1.6%,3.8%,6.3%,11.4%,15.4%,19.9%,16.7%);第16轮筛选的21个阳性克隆菌测序结果表明,存在有3种高度富集的适配体,分别为CX1序列2个,CX5序列3个,CX9序列16个;流式细胞仪检测3种序列的结合率分别为9.7%,12.6%,17.2%;CX9的解离常数(Kd)为16.2 nmol/L;荧光显微镜下发现,CX9与NB4细胞结合的荧光强度高于K562细胞。结论用Cell-SELEX技术成功筛选到针对NB4细胞的适配体CX9,为荧光标记适配体快速鉴定APL提供实验依据。     

Treatment of acute promyelocytic leukemia with gemtuzumab ozogamicin

Acute promyelocytic leukemia (APL) is a form of acute myeloid leukemia characterized by peculiar biologic features and a unique sensitivity to differentiation therapy with all-trans retinoic acid (ATRA). Modern treatment approaches to APL include simultaneous combination of ATRA and anthracycline-based chemotherapy. Gemtuzumab ozogamicin is a calicheamicin-conjugated monoclonal antibody directed against CD33, a cell surface antigen highly expressed on APL cells. Engagement of CD33 by gemtuzumab results in immunoconjugate internalization and hydrolytic release of calicheamicin, which, in turn, causes irreversible DNA damage and cell death. A number of preliminary reports have highlighted the sensitivity of APL to gemtuzumab given alone or in combination with other agents. Several reasons may account for the efficacy of gemtuzumab in APL, including: (1) CD33 is detectable in virtually 100% of APL cases; (2) calicheamicin belongs to the anthracycline family, a group of chemotherapeutic agents known to be highly effective in APL; and (3) the APL blast cells lack the multidrug resistance glycoprotein 170. Due to the availability of other highly effective agents (ATRA, arsenic trioxide), relatively few APL patients have been treated thus far with gemtuzumab, and their follow-up is still short. However, it is conceivable that the use of this agent in APL will increase in the near future in light of its capability to induce molecular remission even in advanced disease. Furthermore, the use of low doses of gemtuzumab in high-risk patients might be relevant in order to reduce treatment toxicity due to conventional anthracyclines. This review summarizes the mechanism of action and toxicity profile of gemtuzumab as well as the published experience with this compound in patients with newly diagnosed and relapsed APL.     

毫米波辐射对人急性早幼粒白血病细胞诱导凋亡的作用

目的 探讨毫米波对人急性早幼粒白血病细胞增殖和凋亡的影响。方法 以波长7.1mm,频率42.2GHz的毫米波辐射体外培养的NB4细胞,光镜及电镜观察细胞形态改变,生长曲线测定细胞生长及增殖情况。流式细胞仪（FCM）检测细胞周期分布。细胞凋亡指数及凋亡相关基因表达的改变。结果 1mW/cm^2的毫米波辐射,每日1次,30min,可明显抑制NB4细胞的生长,辐射第3天细胞生长抑制率为44.1%;光镜及电镜下可见凋亡细胞形态,FCM示G0/G1期细胞及凋亡百分比增加;p21、p53、Bax和Fas表达增加,c-Myc、Bcl-2表达下降,5mW/cm^2的毫米波对细胞增殖及凋亡的影响却不明显,虽然p53、Bax和Fax表达增加,Bcl-2表达下降,但c-Myc和p21的表达却无改变。结论 1mW/cm^2毫米波辐射适当时间后能显著抑制NB4细胞增殖、诱导细胞凋亡;其凋亡诱导机制可能与调控细胞凋亡相关基因的表达有关,其中对c-Myc蛋白表达的下调可能具有关键作用。     

71例急性早幼粒细胞白血病患者白血病细胞免疫表型分析

本研究通过回顾性分析急性早幼粒细胞白血病(APL)患者骨髓异常早幼粒细胞的免疫表型及患者初诊资料,探讨其免疫表型特点及其意义。利用常规6色免疫分型方法对71例APL患者的白血病细胞进行免疫表型分析。结果发现:MPO、CD33和CD13在所有患者的APL细胞中都有较强表达,其平均阳性细胞比例达到88%以上。CD117的阳性表达率为50.7%,其平均阳性细胞比例为52.5%。约10%患者的白血病细胞表达CD15,但大部分病例的阳性细胞率都集中在20%-40%的弱表达范围内,其平均阳性细胞比例为42.5%。少数患者的异常细胞表达CD34和HLA-DR,且表达强度较弱。约25%患者的APL细胞跨系表达了CD2、CD56,大部分也都集中于20%-60%的低表达范围内,其平均阳性细胞比例分别为39.3%和42.3%。由此认为,APL的典型免疫表型为MPO+CD13+CD33+CD117±CD15±CD34-HLA-DR-。CD2和CD56在CD34+或HLA-DR+组(包括CD34+HLA-DR+、CD34+HLA-DR-和CD34-HLA-DR+)的阳性比例明显高于CD34-和HLA-DR-组。初诊患者外周血白细胞计数、血小板计数、外周血中异常早幼粒细胞比例及CD13的阳性比例在CD15<10%、10%20%3组均出现显著的统计学差异。结论:APL患者的异常早幼粒细胞的免疫表型具有独特的特征,多色流式细胞术检测可辅助APL的快速诊断,对分析白血病细胞的来源和判断患者预后亦可能有着重要意义。     

急性早幼粒细胞白血病细胞亚型的形态学特征研究

目的探讨各亚型急性早幼粒细胞白血病（APL）的细胞形态学指标对诊断的意义。方法按照粗颗粒细胞百分比,以粗颗粒≥50％为粗颗粒型（M3a）,粗颗粒〈50％为细颗粒型（n3b）,微小颗粒为变异型（M3v）对66例APL患者进行分组。观察各亚型异常早幼粒细胞形态学特征,并结合骨髓象特征进行比较分析。染色用瑞氏染料、刘氏染料。结果三种亚型早幼粒细胞百分比：M3a〉M3b〉M3v,而且M3v与M3a和M3b间差异有统计学意义,并且M3v型原始细胞数明显增高。内外浆、柴捆细胞及火焰状瘤样突起异常早幼粒细胞是APL最显著的形态学特征。结论细胞形态学特征对APL亚型有诊断价值。     

Histamine H2 receptor desensitization in HL-60 human promyelocytic leukemia cells

Recent studies have suggested that cyclic AMP (cAMP) may be involved in regulation of cell growth and differentiation of cancer cells. Incubating HL-60 cells in the presence of the specific H2 agonist dimaprit resulted in 30-fold increases in cAMP levels (EC50 = 5.7 X 10(-6) M) and morphological changes suggestive of cell maturation along the granulocyte pathway. However, cells cultured with 10(-5) M dimaprit showed more than an 80% decrease in their cAMP response to subsequent addition of H2 agonists, whereas the cAMP response to prostaglandin E2 was unaltered. Desensitization was time-dependent (halftime approximately 2.5 hr with 10(-5) M dimaprit), dose-dependent (dimaprit EC50 = 1.4 X 10(-6) M) and completely prevented by 10(-3) M cimetidine. Desensitization of HL-60 cells for 4 hr with 10(-5) M dimaprit followed by the addition of 10(-3) M cimetidine resulted in total recovery of the cAMP response in less than 24 hr. The pharmacologically inactive analog N-methyldimaprit (SK&F 92054) did not increase cAMP production or cause desensitization to H2 stimulation. Desensitization was observed in the presence or absence of a phosphodiesterase inhibitor, indicating that induction of cAMP-phosphodiesterase was not involved in this process. No difference in the number of [3H]tiotidine binding sites was observed between control and dimaprit-desensitized HL-60 cells. Based on these results, we suggest that H2 receptor agonists caused an agonist-dependent desensitization, presumably due to an uncoupling of receptors from adenylate cyclase.(ABSTRACT TRUNCATED AT 250 WORDS)     

高三尖杉酯碱联合全反式维甲酸治疗急性早幼粒细胞白血病的临床研究

目的 观察高三尖杉酯碱(HHT)联合全反式维甲酸(ATRA)治疗初诊急性早幼粒细胞白血病(APL)患者的疗效及诱导治疗期间的不良事件发生情况,并与柔红霉素(DNR)联合ATRA治疗方案进行对比分析.方法 对2004年10月至2010年10月收治的115例APL患者的资料进行总结分析,其中HHT组54例、DNR组61例,对比分析两组患者的完全缓解(CR)率、总生存(0S)及无事件生存(EFS)情况.结果 115例APL患者CR率100％,达CR的中位时间32(22～43)d,109例进入巩固治疗的患者PML-RARα融合基因全部转为阴性,中位生存期未达(0.23～77.34个月),中位EFS期未达(0.23 ～ 77.34个月).3年OS率93％,5年OS率93％;3年EFS率85％,5年EFS率75％.诱导治疗后HHT组和DNR组PML-RARα融合基因转阴率分别为31.3％和15.5％;巩固治疗1个疗程后两组PML-RARα融合基因转阴率分别为68.6％和77.6％;DNR组有4例患者在巩固治疗＞1个疗程后转为阴性,但两组分子生物学复发率差异无统计学意义(9.8％和8.6％,P＞0.05).生存分析显示:HHT组与DNR组的OS、EFS相似(P值分别为0.206、0.506).两组5年OS率分别为87％和98％;5年EFS率分别为80％和71％.HHT组与DNR组的低/中危患者、高危患者OS、EFS亦相似(P值均＞0.05).诱导治疗期间HHT组合并2级以上发热患者比例显著低于DNR组,而肝、肾、心功能损伤及血液学不良反应发生率两组相似.结论 HHT和DNR为基础的方案治疗初诊APL疗效相似,同时在诱导治疗期间两者的耐受性无明显差异.     

高白细胞急性早幼粒细胞白血病的临床研究

目的探讨能有效降低高危急性早幼粒细胞白血病（APL）早期病死率、减少血液和髓外复发的合理治疗方法。方法对APL初诊时高白细胞与非高白细胞患者的临床生物学特征及治疗转归进行回顾性分析和比较。结果29例初诊高白细胞的APL患者占131例初治APL的22．0％。其细颗粒型和CD34^＋表达显著增多，早期病死率和复发率亦高于初治白细胞不高的患者。结论初诊高白细胞的APL为高危患者，治疗应个体化，尽早化疗。     

急性早幼粒细胞白血病治疗的远期疗效观察

目的观察急性早幼粒细胞白血病（APL）治疗的远期疗效。方法对初诊APL患者用全反式维甲酸（ATRA）诱导缓解治疗，完全缓解（CR）后给予3～4个疗程巩固联合化疗，达分子生物学缓解后用ATRA和巯嘌呤（6-MP）＋甲氨蝶呤（MTX）交替维持治疗2年，在完成巩固治疗后及随后的4～5年用筑巢式RT—PCR检测PML—RARα融合基因定期监测微量残留病。结果共81例APL患者，75例（92．6％）达到CR，早期死亡（ED）率6．6％，ED患者确诊时外周血白细胞计数及早幼粒细胞比例明显高于CR者（P〈0．05）。65例（80．2％）患者接受了诱导缓解后巩固化疗，60例（92．3％）患者在3个疗程化疗后PML—RARα融合基因转阴，3例（4．6％）患者第4疗程结束后PML—RARα融合基因转阴。中位随访21．2（8．0～64．0）个月，血液学复发6例，复发率9．2％。Kaplan—Meier分析5年总生存（OS）率（86．6±4．6）％。65例接受了诱导缓解后巩固化疗的患者，5年无复发生存（RFS）率为82．7％。COX回归分析表明白细胞增高（〉10×10^9／L）为影响患者OS的惟一不利因素。结论经系统治疗80％以上的APL可望获得长期无复发生存。     

Minimal residual disease in acute promyelocytic leukemia

In the last decade our understanding of acute promyelocytic leukemia (APL) has advanced tremendously. The recognition of all-trans retinoic acid (ATRA) as a powerful therapeutic agent paralleled the cloning of the t(15;17) breakpoint. RtPCR for the PML-RARA hybrid mRNA has become the hallmark of molecular diagnosis and molecular monitoring in APL. Current techniques are useful in predicting complete remission and a possible cure in many patients who repeatedly test negative by PCR. Standardizing techniques and improving the sensitivity of the assay are important. Doing this in a way so that clinically relevant minimal residual disease can be distinguished from "indolent disease" remains among the future challenges in APL.     

两种早幼粒细胞白血病融合维甲酸受体α的比较研究

目的：就配基－受体、受体－ＤＮＡ和蛋白质－蛋白质相互作用，以及蛋白质的亚细胞定位等方面，对早幼粒细胞白血病－维甲酸受体α（ＰＭＬ－ＲＡＲα）与早幼粒细胞白血病锌指－维甲酸受体α（ＰＬＺＦ－ＲＡＲα）融合蛋白的生物学功能进行比较。方法：采用受体放射配基结合分析、受体－ＤＮＡ结合分析及免疫荧光技术。结果和结论：ＰＭＬ－ＲＡＲα与ＰＬＺＦ－ＲＡＲα融合蛋白有相似的配基结合亲和力；两者都能以同二聚体形式结合维甲酸反应元件（ＲＡＲＥｓ）；都能与维甲类Ｘ受体（ＲＸＲ）结合，提示ＰＭＬ－ＲＡＲα和ＰＬＺＦ－ＲＡＲα在急性早幼粒细胞白血病（ＡＰＬ）的发病中有共同的分子基础。但是，两者在某些特性方面又有所不同，如：ＰＭＬ－ＲＡＲα和ＰＬＺＦ－ＲＡＲα结合ＲＡＲＥｓ的相对强度有所差异；两者在与ＲＸＲ形成复合物的行为以及亚细胞定位方面亦不尽相同；尤为重要的是，两者可分别通过与ＰＭＬ和ＰＬＺＦ形成异源复合物而阻断ＰＭＬ和ＰＬＺＦ蛋白质所介导的不同调节途径。因此，ＰＭＬ－ＲＡＲα与ＰＬＺＦ－ＲＡＲα之间的这些差异，可能部分解释伴ｔ（１１；１７）的ＡＰＬ患者对全反式维甲酸诱导分化治疗耐药的原因。     

急性早幼粒细胞白血病治疗的研究进展

急性早幼粒细胞白血病(APL)为急性髓细胞白血病的特殊亚型,其主要临床特征为严重的凝血功能障碍、出血倾向,并且患者早期病死率高.随着对APL研究的不断深入,该疾病成为目前治愈率最高的白血病.为了更好地指导APL的临床治疗,进一步提高APL患者的生存质量,笔者拟就APL治疗研究进展进行综述.     

THP-ADM in the treatment of acute promyelocytic leukemia

Three patients, diagnosed as acute promyelocytic leukemia and disseminated intravascular coagulation (DIC), were treated with THP-ADM in combination with heparin and intensive platelet transfusion. Two of the three patients achieved complete remission. The remaining one patient also responded favorably to the therapy and achieved marrow aplasia, and significant improvement of coagulopathy was observed after chemotherapy. However, he suddenly died of intractable congestive cardiac disturbance ten days after the completion of THP-ADM induction therapy. The mechanism of this unique delayed anthracycline-associated cardiotoxicity was discussed.     

Therapeutic targeting of the MEK/MAPK signal transduction module in acute myeloid leukemia

The mitogen-activated protein kinase (MAPK) pathway regulates growth and survival of many cell types, and its constitutive activation has been implicated in the pathogenesis of a variety of malignancies. In this study we demonstrate that small-molecule MEK inhibitors (PD98059 and PD184352) profoundly impair cell growth and survival of acute myeloid leukemia (AML) cell lines and primary samples with constitutive MAPK activation. These agents abrogate the clonogenicity of leukemic cells but have minimal effects on normal hematopoietic progenitors. MEK blockade also results in sensitization to spontaneous and drug-induced apoptosis. At a molecular level, these effects correlate with modulation of the expression of cyclin-dependent kinase inhibitors (p27(Kip1) and p21(Waf1/CIP1)) and antiapoptotic proteins of the inhibitor of apoptosis proteins (IAP) and Bcl-2 families. Interruption of constitutive MEK/MAPK signaling therefore represents a promising therapeutic strategy in AML.     

亚砷酸治疗急性早幼粒细胞白血病的研究进展

急性早幼粒细胞白血病(APL)曾经是各型白血病中病情最为凶险的一型,患者常因严重出血等原因在治疗前或治疗早期死亡,必须早期诊断、紧急治疗.我国学者在世界上最早应用亚砷酸(ATO)治疗APL,取得了非凡的效果,使APL已经成为目前治疗效果最好的一型白血病.早期合理的应用ATO,对于抢救初治危重APL患者以及提高治愈率具有重要意义.近年来,在应用ATO治疗APL过程中也逐步扩大了其应用范围,从复发难治APL到应用于初治APL,尝试将其作为一线治疗用药,并且对ATO治疗机制及临床应用的研究有很大的进展.     

Monitoring of minimal residual disease in patients with acute promyelocytic leukemia

AIM: To study efficacy of different programs of maintenance therapy, to create the program of differential therapy of minimal residual disease (MRD) and molecular recurrences at all stages of acute promyelocytic leukemia (APL) basing on the results of monitoring. MATERIAL AND METHODS: A total of 76 APL patients entered the trial. They received therapy by the protocols APL-97/98, APL-01, AIDA, 5D. Expression of chymeric oncogen PML/RARa in the disease onset was estimated by bone marrow and/or peripheral blood examination with RT-PCR. The study of chymeric oncogen PML/RARa was made once in two months. RESULTS: The program of differential therapy of APL is proposed on the basis of molecular-biological monitoring of expression of chymeric oncogen PML/RARa. The results of molecular monitoring of MRD correlated with development of molecular and hematological recurrences. Therapeutic policy is determined after diagnosis of molecular recurrence. Further therapy of APL is determined which allows a rise in overall and recurrence-free survival of the patients. CONCLUSION: The efficacy of maintenance therapy only with cytostatic drugs or their combination with ATRA is similar. The response to biological therapy with ATRA plus interferon-alpha is not sufficient. Molecular recurrences--probable or documented--are detected in maintenance therapy 2 months earlier, on the average, than hematological ones. Changes in the treatment policy in registration of molecular recurrence significantly diminish probability of hematological recurrence (from 36 to 0%, p = 0.001.