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Вопросы гематологии/онкологии и иммунопатологии в педиатрии. 2024; 23: 116-127

Осложнения высокодозной полихимиотерапии с последующей аутологичной трансплантацией гемопоэтических стволовых клеток у детей с солидными злокачественными новообразованиями: опыт одного Центра

Алиев Т. З., Киргизов К. И., Мачнева Е. Б., Костарева И. О., Сергеенко К. А., Смирнова Д. С., Бурлака Н. А., Лозован Ю. В., Трушкова И. Ю., Елфимова А. Ю., Митраков К. В., Потемкина Т. И., Малова М. Д., Фатхуллин Р. Р., Степанян Н. Г., Капкова О. А., Сагоян Г. Б., Сулейманова А. М., Матинян Н. В., Муфтахова Г. М., Казанцев А. П., Романцова О. М., Рубанская М. В., Ушакова Т. Л., Родина А. Д., Жогов В. В., Ванесян В. Ш., Скворцова Ю. В., Казанцев И. В., Слинин А. С., Горбунова Т. В., Валиев Т. Т., Поляков В. Г., Варфоломеева С. Р.

https://doi.org/10.24287/1726-1708-2024-23-2-116-127

Аннотация

Высокодозная полихимиотерапия (ВДПХТ) с последующей аутологической трансплантацией гемопоэтических стволовых клеток (ауто-ТГСК) является терапевтической опцией, которая позволяет потенцировать противоопухолевый эффект у пациентов со злокачественными новообразованиями (ЗНО), относящихся к группе высокого риска. Однако, несмотря на эффективность данного метода, более высокие по сравнению со стандартными протоколами лечения риски развития инфекционных и токсических осложнений в раннем и позднем посттрансплантационных периодах способны значимо ухудшить результаты трансплантации. Нами проведен ретроспективный анализ результатов ауто-ТГСК в когорте из 156 пациентов с солидными ЗНО группы высокого риска, получавших лечение в НИИ детской онкологии и гематологии им. акад. РАМН Л.А. Дурнова ФГБУ «НМИЦ онкологии им. Н.Н. Блохина» Минздрава России в 2020–2023 гг. Исследование одобрено независимым этическим комитетом и утверждено решением ученого совета НМИЦ онкологии им. Н.Н. Блохина. В исследование были включены 78 (50%) мальчиков и 78 (50%) девочек, медиана возраста пациентов составила 8 лет 7 месяцев (9 месяцев – 17 лет 8 месяцев). Ауто-ТГСК была проведена 90 (57,7%) пациентам с нейробластомой, 25 (16,0%) – с саркомой Юинга, 16 (10,3%) – с герминогенноклеточными опухолями, 13 (8,4%) –с нефробластомой, 7 (4,5%) – с ретинобластомой, 3 (1,9%) – с медуллобластомой, 1 (0,6%) – с плевропульмональной бластомой и 1 (0,6%) – с сиалобластомой. Использовались режимы кондиционирования в составе: треосульфан + мелфалан (n = 116), карбоплатин + тиотепа + этопозид (n = 17), мелфалан (n = 13), карбоплатин + тиотепа + этопозид + циклофосфамид (n = 10). В зависимости от клинических показаний и используемого протокола лечения у 136 (87,2%) пациентов был проведен 1 курс ВДПХТ, а в 20 (12,8%) случаях выполнена тандемная ВДПХТ. У большинства пациентов медиана времени восстановления количества гранулоцитов и тромбоцитов составила 11 (8–19) дней и 14 (12–21) дней соответственно. Наиболее частыми инфекционными осложнениями у пациентов после ауто-ТГСК были мукозит (89,1%), нейтропенический энтероколит (76,9%), фебрильная нейтропения (71,2%), реже катетер-ассоциированная инфекция кровотока (9%), пневмония (14,1%), острый респираторный дистресс-синдром (0,6%). Среди токсических осложнений у всех пациентов отмечался эметический синдром, у 98 (62,8%) – дерматологическая токсичность, у 9 (5,8%) – геморрагический цистит, у 116 (74,3%) – печеночная токсичность, у 14 (9%) – нейротоксичность, у 102 (65,4%) – нутритивная недостаточность средней тяжести. Эпизоды геморрагического синдрома на фоне тромбоцитопении развивались у 44,2% пациентов. В большинстве случаев после ауто-ТГСК развиваются химиоиндуцированные (в том числе инфекционные) осложнения, которые могут не только значимо нарушать самочувствие и качество жизни пациента, но и в зависимости от степени выраженности представлять опасность для жизни. Правильный выбор режима кондиционирования, эффективный сбор гемопоэтических стволовых клеток, комплексная сопроводительная терапия, своевременная диагностика и лечение осложнений позволяют значимо улучшить результаты ауто-ТГСК у детей с солидными ЗНО высокого риска.

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Pediatric Hematology/Oncology and Immunopathology. 2024; 23: 116-127

Complications of high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation in children with solid malignant neoplasms: a single-center experience

Aliev T. Z., Kirgizov K. I., Machneva E. B., Kostareva I. O., Sergeenko K. A., Smirnova D. S., Burlaka N. A., Lozovan Yu. V., Trushkova I. Yu., Elfimova A. Yu., Mitrakov K. V., Potemkina T. I., Malova M. D., Fatkhullin R. R., Stepanyan N. G., Kapkova D. A., Sagoyan G. B., Suleymanova A. M., Matinyan N. V., Muftakhova G. M., Kazantsev A. P., Romantsova O. M., Rubanskaya M. V., Ushakova T. L., Rodina A. D., Zhogov V. V., Vanesyan V. Sh., Skvortsova Yu. V., Kazantsev I. V., Slinin A. S., Gorbunova T. V., Valiev T. T., Polyakov V. G., Varfolomeeva S. R.

https://doi.org/10.24287/1726-1708-2024-23-2-116-127

Abstract

High-dose chemotherapy (HDCT) followed by autologous hematopoietic stem cell transplantation (auto-HSCT) is a therapeutic option that allows potentiating the antitumor effect in patients with malignant neoplasms (MNs) belonging to the high-risk group. However, despite the effectiveness of this method, the risks of developing infectious and toxic complications in the early and late post-transplantation period are higher than the risks associated with treatment according to standard protocols and can significantly worsen the results of transplantation. We carried out a retrospective analysis of the results of auto-HSCT in a cohort of 156 patients with high-risk solid MNs treated at the L.A. Durnov Research Institute of Pediatric Oncology and Hematology, the N.N. Blokhin National Medical Research Center of Oncology of Ministry of Healthcare of the Russian Federation in 2020–2023. The study was approved by the Independent Ethics Committee and the Scientific Council of the N.N. Blokhin National Medical Research Center of Oncology. The study included 78 (50%) boys and 78 (50%) girls, the median age of the patients was 8 years 7 months (9 months – 17 years 8 months). Auto-HSCT was performed in 90 (57.7%) patients with neuroblastoma, 25 (16.0%) – with Ewing's sarcoma, 16 (10.3%) – with germ cell tumors, 13 (8.4%) – with nephroblastoma, 7 (4.5%) – with retinoblastoma, 3 (1.9%) – with medulloblastoma, 1 (0.6%) patient with pleuropulmonary blastoma and 1 (0.6%) patient with sialoblastoma. We used the following conditioning regimens: treosulfan + melphalan (n = 116), carboplatin + thiotepa + etoposide (n = 17), melphalan (n = 13), carboplatin + thiotepa + etoposide + cyclophosphamide (n = 10). Depending on the clinical indications and the treatment protocol used, 136 (87.2%) patients underwent one course of HDCT, and 20 (12.8%) patients underwent tandem HDCT. In most patients, the median recovery time for granulocytes and platelets was 11 (8–19) days and 14 (12–21) days, respectively. The most common infectious complications in patients after auto-HSCT were mucositis (89.1%), neutropenic enterocolitis (76.9%), febrile neutropenia (71.2%), less often: catheter-associated bloodstream infection (9%), pneumonia (14.1%), acute respiratory distress syndrome (0.6%). As regards toxic complications, all patients had emetic syndrome, 98 (62.8%) had dermatological toxicity, 9 (5.8%) had hemorrhagic cystitis, 116 (74.3%) had hepatic toxicity, 14 (9%) had neurotoxicity, 102 (65.4%) had moderate nutritional insufficiency. Episodes of hemorrhagic syndrome due to thrombocytopenia were observed in 44.2% of patients. After auto-HSCT, most patients develop chemotherapy-induced (including infectious) complications, which can not only significantly disrupt the patients’ well-being and quality of life, but also, depending on the severity, pose a threat to their life. The correct choice of conditioning regimen, effective collection of hematopoietic stem cells, complex accompanying therapy, timely diagnosis and treatment of complications can significantly improve the results of auto-HSCT in children with high-risk solid MNs.

References

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3. Galgano L., Hutt D. HSCT: How Does It Work? In: Kenyon M., Babic A. (eds.). The European Blood and Marrow Transplantation Textbook for Nurses. Springer, Cham; 2018. DOI: 10.1007/978-3-319-50026-3_2

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7. To L.B., Haylock D.N., Simmons P.J. The biology and clinical use of blood stem cells. Blood 1997; 89: 2233– 58.

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