医学课件淋巴瘤教案

淋巴瘤教案 高雄榮民總醫院 藥劑部 Speaker ：方柔壹 藥師 100.11.26 1 OutlineOutline 教案學習目標 教案設計的注意事項 在設計教案之前 疾病治療-建議參考資料 教案設計與問題討論 (SOAP) 2 教案學習目標教案學習目標 了解淋巴瘤的藥物治療 了解藥物相關問題：適當的藥物治療、治療中的注意事項 及藥物不良反應 治療目標的達成：設立治療目標、確保病患依順性 學習以SOAP格式建立完整的合理用藥評估 了解病患案例報告(case presentation)之結構及順序 說明SOAP之格式組成及擷取治療準則所需資訊 3 教案設計的注意事項教案設計的注意事項 在設計教案之前 依對象設計教案難易 Burkitts Lymphoma的表現、診斷 確定教案的問題發生在疾病初期還是治療中 疾病治療-建議參考資料 臨床指引 (clinical practical guideline) NCCN practice guideline American Society of Clinical Oncology /ASCO - Journal of clinical oncology European Society for Medical Oncology / ESMO Annals of Oncology 4 教案設計與問題討論教案設計與問題討論 (SOAP)(SOAP) 什麼是淋巴瘤 ? 5 Textbook 14)(q24;q32) or one of its variants t(8;22) or t(2;8). 13 HARRISONS_Hematology and Oncology textbook, 17th ed Three distinct clinical forms of Burkitts lymphoma are recognized; endemic, sporadic, and immunodeficiency associated. Endemic and sporadic Burkitts lymphomas occur frequently in children in Africa, and the sporadic form in Western countries. Immunodeficiency-associated Burkitts lymphoma is seen in patients with HIV infection. BL present with peripheral lymphadenopathy or an intraabdominal mass. The disease is rapidly progressive and has a propensity to metastasize to the CNS. Initial evaluation should always include an examination of cerebral spinal fluid to rule out metastasis. Characteristics of Burkitts Lymphoma 14 HARRISONS_Hematology and Oncology textbook, 17th ed 案例討論 (Non-Hodgkins Lymphoma) Burkitts lymphoma 15 Case Presentation Name ：蔡Age ：38y/o Sex ：Occupation ：military personnel Marital Status ：Married Ht / Wt ：156cm / 51kg Chief Complaint ： Progressive left upper neck mass for 2 months 16 Present illness One month prior to admission, she noticed there was an enlarging mass at left upper neck area. The mass was about 44 cm, fixed, firm, non-tender, and slightly movable. Fine needle biopsy was done but showed no malignancy at 802 Hospital. Then she sought help at our ENT OPD, admission for biopsy was done and showed unclassified lymphoma. Whole bone scan and sonogram of upper abdomen showed no malignancy. Past History No diabetes, No HTN, No asthma, no liver disease, No CV Dz, No renal Dz Case Presentation 17 Personal History Gravida：2 Drug/Food allergy：Nil Cigarette smoking：Nil Para：2 Alcohol drinking：Nil Betel nut：Nil Review of Systems General condition：no body weight loss, no fatigue, no fever Skin：no rash, no pruritus, no nodule Head：no dizziness/ Eyes：no blurred vision, diplopia Ears：no hearing impairment/ Nose：no smell disturbance Throat：no oral ulcer, no sore throat Respiratory system：no dyspnea, no cough Case Presentation 18 Physical Examination Ht / Wt：156cm / 51kg Vital sign：BP_105/64mmHg，PR_62/min，RR_18/min， BT_36.3 General appearance：conscious level：GCS E:4 V:5 M:6 Total:15 HEENT：Head_no tenderness，Ears_no vertigo， Eyes_noraml corneal reflex，Nose_no epitaxis， Throat_no exudates Neck：mass lesion over Lt upper neck Heart：No murmur / Extremities：freely movable Case Presentation 19 20 Case Presentation Case Presentation Labs and Diagnostic Tests 6/16 CT face + neck Presence of a large confluent nodal mass with central necrosis, measured about 4.2cm in maximal diameter, in left carotid space of upper neck. Nodal metastasis should be first considered. Suggest biopsy. 6/17 Surgical pathology Nasopharynx, biopsy- - Nasopharyngeal tissue with prominent lymphoid follicles and inflammatory cell infiltration. There is no evidence of malignancy in the sections examined. Tongue base, biopsy- - Tongue tissue with dense chronic inflammatory cell infiltration. Esophagus, panendoscopic biopsy- - Normal esophageal mucosa with mild acute inflammatory cell infiltration. Pyriform sinus, left, biopsy Normal squamous mucosa with acute inflammatory cell infiltration. Soft tissue, neck, left, punch biopsy Dense small lymphoid cells aggregate in soft tissue. The immunostains show mixed CD10(+) and CD20(+) in lymphoid cells Tonsil, left, biopsy Tonsillar tissue with increased cellularity of lymphoid tissue and formation of many follicles. 21 Labs and Diagnostic Tests 6/17 Frozen section- soft tissue, neck, left Pathological diagnosis：1) B cell lymphoma, classifiable with features Burkitts lymphoma. 2) Favor malignant The normal architecture is effected by diffuse infiltration of small lymphoid cells with starry-sky background. The tumor cells are positive for the CD20 and CD10, and negative for Bcl 2. The Ki-67 proliferation index is 95%. Case Presentation 22 2011/07/03 Admitted for staging and possible re-biopsy of lymphoma 7/6 Surgical pathology Soft tissue, neck, left upper, incisional biopsy B-cell lymphoma, classifiable, with features Burkitts lymphoma. The normal architecture is effaced infiltration of small lymphoid cells with starry-sky background. Case Presentation Diagnosis Burkitts lymphoma 23 24 Problem list Current medical problem Goal of therapyMeasureable endpoint Burkitts Lymphoma Symptom control- Response rate Prophylaxis metastasis to CNS Nodular size decreased No CNS involement Current Drug-Related Problem Subjective and Objective Problem (subjective and objective)Current medication S: She complains of progressive left upper neck mass for 2 months No diabetes, No HTN, No asthma, no liver disease, No CV Dz, No renal Dz No medical record Review of Systems : General condition：no body weight loss, no fatigue, no fever, no rash, no pruritus, no nodule, no dizziness, no blurred vision, diplopia, no hearing impairment, no smell disturbance, no oral ulcer, no sore throat, no dyspnea, no cough Personal History : Married with 2 children. She is a military personnel No Tobacco, Betel nut or alcohol smoking Drug/Food allergy : NKDA 25 Current Drug-Related Problem Subjective and Objective Problem (subjective and objective)Current medication O: 156cm / 51kg, BSA 1.49, BP_105/64mmHg，PR_62/min，RR_18/min， BT_36.3 General appearance：conscious level：GCS E:4 V:5 M:6, Total:15 HEENT：Head_no tenderness, Ears_no vertigo, Eyes_normal corneal reflex, Nose_no epitaxis, Throat_no exudates Neck：mass lesion over Lt upper neck Heart：No murmur / Extremities：freely movable 26 Current Drug-Related Problem Subjective and Objective (Continued) Problem (subjective and objective)Current medication O: 27 Current Drug-Related Problem Assessment Etiology (/risk factors) Evidence need for therapy evaluation (current/ recommended therapy) Burkitts Lymphoma Risk Factor : Infectious agents (-) Chemical exposure (-) Medical treatment (-) Treatment for Burkitts lymphoma- The best drug therapy option for this patient is： 28 29 Treatment for Burkitts Lymphoma 30 Those patients with all of the following features were regarded as low risk : (i) normal LDH level; (ii) WHO performance status of 0 or 1; (iii) Ann Arbor stage III; and (iv) no tumor mass 10cm. All remaining patients were considered high risk. LDH 191 U/L PS 1 Stage Ia The mass was about 44 cm Low risk Burkitts Lymphoma 31 Treatment for Burkitts Lymphoma 32 Original CODOX-M regimen- Cyclophosphamide, vincristine, doxorubicin, high-dose methotrexate Epirubicin 60mg/m2 33 CNS prophylaxis Intrathecal Ara-C 28: 5356 2. Annals of Oncology 21 (Supplement 5): v172v174, 2010 3. Blood. 2010; 116(12):2040-2045 4. American Society of Hematology, 2009, The 4th edition of the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissue 5. J Clin Oncol 29:1835-1843 6. 衛生署健康局癌症組 7. Uptodate 8. Micromedex 9. NCCN Clinical Practice Guidelines in Oncology 10. HARRISONS_Hematology and Oncology textbook, 17th ed 43 44 Rituximab 需經事前審查查核准後使用 限用於 復發或對化學療效有抗性之低惡度B細胞非何杰金氏淋巴瘤。 併用CHOP或其他化學療法，用於CD20抗原陽性之B瀰漫性大細胞非何杰 金氏淋巴瘤之病患。 併用CVP化學療法，用於未經治療之和緩性（組織型態為濾泡型）B細胞 非何杰金氏淋巴瘤的病人。 用於做為濾泡性淋巴瘤患者對誘導療法產生反應之後的維持治療用藥。 限用八劑，每三個月使用一劑，最多不超過二年。 In the current issue of Haematologica, as well as in other series, the outcome of these patients is dismal irrespective of standard R-CHOP or intensified treatment including bone marrow transplantation. 17 While in elderly patients, who actually form the majority of this group, this may be sufficient grounds to refrain from aggressive treatment, this policy may not be acceptable for younger and fit patients. In these patients, treatment with BL regimens may therefore be preferred over standard R-CHOP, which will certainly not be sufficient to control the disease. Haematologica, 2009; 94(7), p894 Lymphomas fall into one of two major categories: Hodgkins lymphoma (HL, previously called Hodgkins disease) and all other lymphomas (non- Hodgkins lymphomas or NHLs). These tw