41 一位55 歲病人，因為呼吸急促、牙齦出血來到急診處。理學檢查顯示體溫為39℃，意識清楚，身上

有多處瘀青。抽血檢查結果如下：血紅素7.8 gm/dL，白血球215,000/μL，其中blast 88.5%，band 1.5%，

segmented neutrophil 2.5%，monocyte 2.5%，lymphocyte 5%，血小板5,000/μL；芽細胞中15%為

peroxidase 陽性，胸部X 光及尿液檢查無異常。下列何者不正確？

 白血球過高可能有白血球鬱積症（leukostasis），需要做白血球分離術

 血小板數目太低且有出血傾向，需要輸注血小板濃縮液

 發燒可能是有感染，須做微生物培養，並開始抗生素治療

 為急性骨髓性白血病，需儘早做化學治療HOP（adriamycin, vincristine, prednisolone）

C

THIS IS A CASE OF ACUTE MYELOID LEUKEMIA

HIGH WBC: ANEMIA: THROMBOCYTOPENIA

ABC ARE RIGHT

D: THE TREATMENT PLAN IS WRONG!:

AML: INDUCTION PHASE AND THE CONSOLIDATION THERAPY PHASE

usually given induction chemotherapy with cytarabine (ara-C) and an anthracycline (such as daunorubicin or idarubicin).^[32]This induction chemotherapy regimen is known as "7+3" (or "3+7"), because the cytarabine is given as a continuous IV infusion for seven consecutive days while the anthracycline is given for three consecutive days as an IV push.

B 細胞瀰漫型大細胞淋巴瘤 DIFFUSE LARGE B CELL LYMPHOMA

42 一位43 歲病人，偶然間摸到頸部淋巴結腫大，但無其他不適。經淋巴結切片及病理檢查證實為B 細

胞瀰漫型大細胞淋巴瘤，CD20 抗原陽性。電腦斷層攝影顯示腹部大動脈旁及鼠蹊部淋巴結腫大。對

這位病人最適當的治療為何？

 密切觀察待有症狀時再治療

 給予化學治療COP（cyclophosphamide, vincristine 及prednisolone）

 給予化學治療CHOP（COP 加adriamycin）

 給予化學治療CHOP 加rituximab

D

CD20 抗原陽性 TAKE NOTE!!!!

Staging

The Ann Arbor staging system, originally designed for Hodgkin disease, traditionally is used to assess extent of disease involvement by NHL.

• Stage I is disease involvement of a single lymph node region or of a single extranodal organ or site (I E).
• Stage II is involvement of 2 or more lymph node regions on the same side of the diaphragm or localized involvement of an extranodal site or organ (II E) and involvement of 1 or more lymph node region on the same side of the diaphragm.
• Stage III is involvement of lymph node regions on both sides of the diaphragm, which may be accompanied by localized involvement of an extranodal organ or site (III E), the spleen (III S), or both (III SE).
• Stage IV is diffuse or disseminated involvement of 1 or more distant extranodal organ, with or without associated lymph node involvement.
• The presence of systemic symptoms, including fever higher than 38°C, night sweats, and/or weight loss of more than 10% of body weight in the 6 months preceding diagnosis, are denoted by the suffix B. Staging of asymptomatic patients is denoted by the suffix A.

The cyclophosphamide, Adriamycin, vincristine, prednisone (CHOP) regimen

Because CHOP cures less then 50% of patients with DLCL, new treatments are needed. Current investigations to improve treatment outcome include the following 3 goals:

• Identification of new active therapies: Rituximab (Rituxan), a chimeric antibody that targets CD20⁺ B cells, produces a 48% response rate in patients with low-grade lymphomas.⁷ It also has activity in DLCL. A phase II pilot study of rituximab in combination with CHOP in patients with previously untreated DLCL or high-grade NHL was reported. The overall response rate was 97% (32 of 33 patients), with a 61% complete remission rate, a 36% partial remission rate, and a 3% progressive disease rate. Severe adverse events were similar to those observed with CHOP alone. These results are encouraging, and randomized studies currently are underway to determine if the addition of rituximab to standard chemotherapy should be considered the standard of care.