患者,男,33岁,因全身多处游走性疼痛于2012-11行X线片及CT检查,提示颈椎、肱骨、髂骨、股骨骨质破坏,股骨头见小囊状骨质破坏( 图1)。以多发性骨髓瘤(multiple myeloma,MM)收入我科。骨髓穿刺涂片检查考虑为急性淋巴细胞性白血病(acute lymphoblastic leukemia, ALL)。组织化学染色提示:过氧化物酶阴性,糖原染色阳性,糖原原始细胞积分高,醋酸萘酚酯酶染色阴性。流式细胞学检查:主要可见原始细胞群、成熟淋巴细胞群和粒系细胞群,原始细胞约占有核细胞32%,表达CD34、HLA-DR、CD19、CD10和CD13(部分阳性),少数细胞表达CD20、CD38,不表达cIgM、cCG79a,不表达cCD3、CD5、CD33和cMP0。骨髓活检:有核细胞核脂肪比值为2∶1,部分为中等偏小幼稚细胞。基因检测提示BCR-ABL融合基因阳性。综合诊断为B淋巴细胞系急性淋巴细胞性白血病L2(B-ALL-L2)。给予长春新碱、柔红霉素、环磷酰胺和泼尼松联合进行诱导缓解治疗,化疗方案6周期,预防性鞘内注射甲氨喋呤6次,最后一次化疗完成于2013-05。转入维持治疗(甲氨喋呤和巯嘌呤与泼尼松和长春新碱交替治疗)。期间于2013-01骨髓穿刺检查仅见3%幼稚淋巴细胞,评估为缓解。2013-05骨髓穿刺检查仅见1%幼稚淋巴细胞,评估为缓解。治疗过程中患者游走性疼痛症状减轻,PTH 2610 ng/L ,血钙 2121 mmol/L。2013-05 CT检查仍示胸椎多个椎体融骨性骨质破坏。2013-07患者双侧髋关节疼痛,逐渐加重,给予膦酸盐类药物治疗。患者开始口服伊马替尼。2013-08再次复查CT仍示双侧髂骨及股骨骨质破坏(图2)。继续止痛及膦酸盐类药物治疗,患者疼痛症状减轻。2014-04患者骨髓检查呈示缓解。
关键词
急性淋巴细胞白血病 /
骨骼病变
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] 秘营昌.中国成人急性淋巴细胞白血病诊断与治疗专家共识——诊断和预后分组解读[J].中华血液学杂志,2013,34(11):994-996.
[2] Swerdlow S H, Campo E, Harris N L, et al. WHO classification of tumours of haematopoietic and lymphoid tissues [M]. Lyon: Iarc Press, 2008:167-178.
[3] 袁 田,秘营昌.成年人急性淋巴细胞白血病基因组学研究进展[J].国际输血及血液学杂志,2012,35(6): 521-524.
[4] 中国医师协会血液科医师分会,中华医学会血液学分会,中国多发性骨髓瘤工作组.中国多发性骨髓瘤诊治指南(2013年修订)[J].中华内科杂志, 2013,52(9): 791-795.
[5] Riccio I, Marcarelli M, Del Regno N, et al. Musculoskeletal problems in pediatric acute leukemia[J]. J Pediatr Orthop B, 2013, 22(3): 264-269.
[6] Ganesan P, Thulkar S, Gupta R, et al. Childhood aleukemic leukemia with hypercalcemia and bone lesions mimicking metabolic bone disease [J]. J Pediatr Endocrinol Metab, 2009, 22(5): 463-467.
[7] Kawedia J D, Kaste S C, Pei D, et al. Pharmacokinetic, pharmacodynamic, and pharmacogenetic determinants of osteonecrosis in children with acute lymphoblastic leukemia [J]. Blood, 2011, 117(8): 2340-2347.
[8] Te Winkel M L, Pieters R, Hop W C, et al. Prospective study on incidence, risk factors, and long-term outcome of osteonecrosis in pediatric acute lymphoblastic leukemia[J].J Clin Oncol,2011,29(31):4143-4150.
[9] Fleisch H. Bisphosphonates: mechanisms of action [J]. Endocr Rev, 1998, 19 (1): 80-100.
[10] Padhye B, Dalla-Pozza L, Little DG, et al. Use of zoledronic acid for treatment of chemotherapy related osteonecrosis in children and adolescents: a retrospective analysis [J]. Pediatr Blood Cancer, 2013, 60(9): 1539-1545.
[11] Leblicq C, Laverdière C, Décarie J C, et al. Effectiveness of pamidronate as treatment of symptomatic osteonecrosis occurring in children treated for acute lymphoblastic leukemia [J]. Pediatr Blood Cancer, 2013, 60(5):741-747.
PDF(753 KB)
