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GPOH-HD 2002
hojkinis limfomis
optimizirebuli
Terapiis oqmi bavSvTa asakSi
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oqmis saxeli
hojkinis limfomis mkurnalobis optimizirebuli sqema bavSvTa asakSi
Semoklebuli saxeli
GPOH-HD 2002
Cveneba
hojkinis limfoma bavSvTa asakSi ( 0 – 18w)
oqmis mizani
maRali dozis qimioTerapiis da misgan gamomdinare mogvianebiTi garTulebebis Tavidan acileba pirveladi daavadebis da recidivis mkurnalobis dros.
oqmis pirveladi kiTxvebi
1.SesaZlebelia Tu ara Terapiis pirveli jgufis pacientebs, romlebic kompleqsur remisiaSi arian, qimioTerapiis dasrulebis Semdeg, sxivuri Terapiis ar Catarebis SemTxvevaSi ar gauaresdeT EFS?
2. SesaZlebelia Tu ara Terapiis meore da mesame jgufis pacientebSi COPP-ciklSi prokarbazini Seicvalos dakarbaciniT, ise rom ar gauaresdes EFS?
3.riskTan da Terapiis pasuxze adaptirebuli samkurnalo oqmis Sedegebis aRwera recidivis mkurnalobisas.
oqmis meoradi kiTxvebi
1. SesaZlebelia Tu ara OEPA-ciklSi etopozidis dozis 20%-iT gazrda da amiT adre arsebuli gansxvavebis gauqmeba biWebis da gogonebis samkurnalo sqemebSi?
2. SesaZlebelia Tu ara COPP-ciklSi prokarbazinis Secvla dakarbaziniT arsebuli toqsikuri gverdiTi movlenebis pirobebSi?
3.rogori zemoqmedeba aqvs DHAP-s recidivis mkurnalobis dros IEP-ABVD-sTan SedarebiT?
4.mosalodnelia Tu ara pozitiuri Sedegi arasasurveli prognozis maCvenebeli maRali dozis qimioTerapiis Catarebis win, autologiuri Rerovani ujredebis gadanergviT.
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mkurnaloba
meore da mesame jgufSi randomizirebuli mkurnaloba; recidivis optimizirebuli mkurnaloba
samkurnalo populaciebi
• Aaranamkurnalebi 18-wlamde asakis pacientebi klasikuri hojkinis limfomiT
• pacientebi asakiT SezRudvis gareSe, romlebsac ganuviTardaT pirveladi an meoradi recidivi hojkinis limfomis mkurnalobis Semdeg
pacientebis raodenoba
1200 pacienti ,Semdegi TanafardobiT jgufebis mixedviT: 36:28:36
Terapia
• yvela pacients diagnozis dasmis Semdeg utardeba ori cikli OEPA(biWebSi) an ori cikli OPPA(gogonebSi). Amis Semdeg Terapiis pirvel jgufSi mkurnalobis Sedegebis mixedviT mkurnaloba an mTavrdeba an grZeldeba sxivuri TerapiiT.
• Terapiis meore da mesame jgufis pacientebi ki iReben COPP-is an COPDIC-is 2 an 4 kurss, Semdeg ki sxivur Terapias.
• recidivis mqone pacientebis mkurnaloba xdeba riskTan da Terapiis pasuxze adaptirebuli sqemis mixedviT.
samkurnalo oqmis pirveladi mizani
Terapiis ZiriTadi ganmsazRvreli kriteriumia daavadebisagan uSemTxvevo gadarCena (EFS- Event Free Survival)
samkurnalo oqmis saboloo mizani
1.mTliani gamojamrTeleba (OS) 2.daavadebis progresisagan Tavisufali periodi (PFS) 3.Terapiis elementebis toqsiurobis xarisxi (CTC) 4.mogvianebiTi Sedegebi
drois monakveTi
dasawyisi: 2002, xangrZlivoba 2010 wlamde. weliwadSi 180-dan 200 pacientamde. mkurnalobis damTavrebidan minimaluri meTvalyureobis dro 5 welia gansazRvruli. SeZlebisdagvarad yoveli pacienti mTeli sicocxlis manZilze unda iqnes meTvalyureobis qveS
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protokolis dizaini gogonebisTvis
TG 1IA/B,IIA
TG 2IEA/B,IIEA
IIB,IIIA
TG 3IIEB,IIIEA/BIIIB,IVA/B
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
TG – Terapiuli Gjgufi; B - B simptomebi; A - B simptomebis ar arseboba.
protokolis dizaini biWebisaTvis4
1 5 9 13 17 21 kvira
TG 1IA/B,IIA
TG 2IEA/B,IIEA
IIB,IIIA
TG 3IIEB,IIIEA/BIIIB,IVA/B
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
TG – Terapiuli Gjgufi; B - B simptomebi; A - B simptomebis ar arseboba.
3. cvlilebebi GPOH-HD95-Tan SedarebiT
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1 5 9 13 17 21 kvira
I. yvela pacientisTvis: 1.limfocitebiT predominanturi hojkinis limfomis mkurnaloba am sqemiT ar xdeba.
2.reducirebuli radioTerapia 50-100ml simsivnuri masis dros, 2 kursi qimioTerapiis Semdeg(20 Gy-nacvlad 35 Gy)
3.paraaortaluri limfuri jirkvlebis dazianebis SemTxvevaSi elenTis dasxiveba ar xdeba.
4.radioTerapiis maqsimaluri Semcireba (30Gy-nacvlad 35 Gy-sa)
5.standartizebuli, riskTan da Terapiis efeqturobasTan adaptirebuli recidivis Terapis yvela im pacientisaTvis, romelTac ganuviTardaT pirveladi an meoradi recidivi.
6. CT-bazirebuli 3 D konformaluri sxivuri Terapia.
II. yvela biWisaTvis etopozidis 5-micema nacvlad 4-sa OEPA-s ciklSi.
III. pirveli Terapiuli jg pacientebi kompleqsuri remisiiT ar iReben radioTerapias.
IV. II da III Terapiuli jg 1.randomizacia yvela pacientisaTvis, COPDIC- COPP-is winaaRmdeg.
2.pirveli ori qimioTerapiuli ciklis Semdeg radioTerapiis dozis myari gansazRvra.
3. radioTerapia yvepacientisTvis, romlebic kompleqsur rearian.
Tu ra cvlilebebi ganicada hojkinis limfomis samkurnalo gegmam HD-78-dan HD2002-mde mocemulia tabula 1(a,b,g.)-Si
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tabula 1. Terapiuli oqmis modifikacia HD 78 –dan GPOH-HD 2003-mde.
a) Terapiuli jgufi 1.
oqmi stadia qimioTeraia radioTerapia
HD-78 Ι,ΙΙ A 2xOPPA 36-40GGy vrceli velis
DAL-HD 82
Ι,ΙΙ A 2xOPPA 35GGy pirveladi dazianebis velis
DAL-HD 85
Ι,ΙΙ A 2xOPA 35GGy
DAL-HD 87
Ι,ΙΙ A 2xOPA 30GGy
narCeni simsivnis dros:35Gy
DAL-HD 90
Ι,ΙΙ A gogonebi; 2xOPPAbiWebi:2x OEPA
25GGy
narCeni simsivnis dros:30/35Gy
GPOH-HD95
Ι,ΙΙ A gogonebi; 2xOPPAbiWebi: 2x OEPA
remisia: radioTerapia ar tardeba
remisi ara- 20GGy
narCeni simsivnis dros:30/35Gy
GPOH-HD 2002
Ι,ΙΙ A gogonebi; 2xOPPAbiWebi: 2x OE*PA
remisia: radioTerapia ar tardeba
remisi ara 20GGy narCeni simsivnis dros:30/35Gy
∗Etoposidi-s gadidebuli doza.
b) Terapiuli jgufi 27
oqmi Stadia qimioTeraia radioTerapia
HD-78 >ΙΙA 2xOPPA,4xCOPP
36-40GGy
DAL-HD 82
ΙIB,IIIA 2xOPPA, 2xCOPP
30GGy
narCeni simsivnis dros:35Gy
DAL-HD 85
ΙIB,IIIA 2xOPA,2xCOMP
30GGy
narCeni simsivnis dros:35Gy
DAL-HD 87
ΙIB,IIIA 2xOPA, 2xCOPP
25 Gy
narCeni simsivnis dros:35Gy
DAL-HD 90
I∋,IIB, II∋A,IIIA
gogonebi; 2xOPPA, 2xCOPPbiWebi: 2x OEPA, 2xCOPP
25 Gy GnarCeni simsivnis dros:30/35Gy
GPOH-HD95
Ι∋,IIB,ΙΙ∋A,IIIA
gogonebi; 2xOPPA,2xCOPPbiWebi: 2xOEPA,2xCOPP
remisia- radioTerapia ar tardeba
arasruli remisia-20 Gy
narCeni simsivnis dros:30/35Gy
GPOH-HD 2002 Pilot
Ι∋,IIB,ΙΙ∋A,IIIA
gogonebi; 2xOPPA,2xCOPP biWebi: 2xOE*PPA,2xCOPDIC
yvela: 20Gy
narCeni simsivnis dros:30/35Gy
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g) Terapiuli jgufi 3oqmi Stadia qimioTeraia radioTerapia
HD-78 rogorc jg.-2
2xOPPA,4xCOPP
36-40GGy
DAL-HD 82
ΙIIB,IV 2xOPPA, 2xCOPP
25GGy
narCeni simsivnis dros:30Gy
DAL-HD 85
ΙIIB,IV 2xOPA,2xCOMP
25GGy
narCeni simsivnis dros:30Gy
DAL-HD 87
ΙIIB,IV 2xOPA, 2xCOPP
25GGy
narCeni simsivnis dros:30Gy
DAL-HD 90
II∋B,IIIBIII∋A,IV
gogonebi; 2xOPPA, 2xCOPPbiWebi:2x OEPA, 2xCOPP
20GGy
narCeni simsivnis dros:30/35Gy
GPOH-HD95
II∋B,IIIBIII∋A,IV
gogonebi; 2xOPPA,2xCOPPbiWebi:2xOEPA, 2xCOPP
20Gy
narCeni simsivnis dros: max.30Gy
GPOH-HD 2002
II∋B,IIIBIII∋A,IV
gogonebi; 2xOPPA,2xCOPP biWebi: 2xOE∗PA,2xCOPDIC
yvela: 20Gy
narCeni simsivnis dros: max.30Gy
cvlilebebi radioTerapiaSi
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wina samkurnalo sqemebTan SedarebiT GPOH-HD 2002-Si radioTerapiam ganicada Semdegi cvlilebebi; GPOH-HD95-is monacemebma aCvenes,rom Mmeore da mesame Terapiuli jgufis pacientebSi,romlebsac radioTerapia ar miuRiaT,sakmaod maRalia recidivis ganviTarebis riski. bolo 2003wlis gamoTvlebze dayrdnobiT: DSF-i Mmeore da mesame Terapiuli jgufis pacientebSi radioTerapiiT 92%-s aRwevs, maSin roca igive monacemebiT pacientebSi-komleqsuri remisiiT, magram radioTerapiis gareSe DSF-78%.(Dörffel et al.,2003)aqedan gamomdinare, aucilebelia Mmeore da mesame Terapiuli jgufis pacientebs- kompleqsuri remisiiT CautardeT radioTerapia.
cvlilebebi invaziur diagnostikaSi:
uari eTqva laparatomiasa da spleneqtomias. invaziur diagnostikis aucileblobas saWiroa mxolod erTeul sadao SemTxvevaSi, roca sonografiuli, kompiuteruli, magnitur-rezonansuli tomografiis gamokvlevis Sedegebis axsna gaZnelebulia, dasaSvebia laparaskopia. laparatomia ki mTlianad iqna uaryofili
specifiuri cvlilebebi meore da mesame biWebisTvis - prokarbazinis eliminaciaadre arsebulma gamokvlevebma aCvenes rom prokarbazini biWebSi unayofobis gamowvevia. prokarbazinis kumulaciur dozasa da hormonalur darRvevas Soris arsebobs garkveuli urTierTdamokidebuleba. ase magaliTad, ori cikli OPPA-s Semdeg unayofoba SeiniSneboda 28,9% pacientebSi, ori cikli OPPA-sa da ori cikli COPP-is Semdeg 43,8%-Si, ori cikli OPPA-sa da 4COPP-is Semdeg 62,5%-Si, maSasadame dozaze damokidebuli hormonuli darRvevebi asocirdeba permanentul unayofobasTan. rac Seexeba qalebs, qimioTerapia maT unayofobaze naklebad moqmedebs. axalgazrda qalebSi arsebobs sakvercxis ukmarisobis da prematuruli menopauzis ganviTarebis garkveuli riski. yovelive aqedan gamomdinare, am samkurnalo sqemaSi aris mcdeloba prokarbazini Seicvalos sxva moqmedi substanciiT, romelic ar gamoiwvevs unayofobisa da adreuli menopauzas. hojkinis limfomis dros prokarbazini aris ara marto Zlier efeqturi preparati, romelic pacientTa 38%-Si kompleqsur remisias iwvevs, aramed ixmareba rogorc monoTerapiuli saSualeba da agreTve kombinaciaSi. TumcaRa samedicino gamocemebSi arsebuli informaciaze dayrdnobiT, dakarbacini( DTIC) SeiZleba prokarbazinis Semcvleli iyos.dakarbacinis moqmemedebis meqanizmi prokarbazinis msgavsia, igi inhibirebas ukeTebs rogorc dnm-s ise rnm-sinTezs. dakarbacini aris hojkinis limfomis dros aprobirebuli da daSvebuli preparati. 6ABVD-ciklis Semdegac ar uviTardebaT mamrobiTi sqesis pacientebs rogorc wesi azospermia. Pprokarbazinisgan gansxvavebiT DTIC-is aplikacia xdeba intravenurad. 1972 wels dakarbacini aprobirebuli iqna rogorc moniTerapiuli saSualeba-250mg/m²²² doziT, yovel dRe 5dRis manZilze samkviriani SualedebiT. 56%-Si miiRweoda „obieqturi“ remisia. Kleineri da doneri (1977w) mkurnalobdnen 10 pacients DTIC-is 300mg/m²²doziT 5 erTmaneTze
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miyolebuli dRe 4 kviriani SualediT. 2 pacients ganuviTarda kompleqsuri remisia,xolo 7-s parcialuri. maTi namuSevrebidan dadginda is faqti, rom DTIC-s minimalur mielosupresiul zemoqmedeba axasiaTebs. am da sxva monacemebze dayrdnobiT gamoangariSebul iqna eqvivalent-faqtori DTIC-Tvis, daaxloebiT 2,4. ABVD-ciklSi gamoyenebuli 750mg/m² dakarbacini 1800mg/m²²prokarbacins Seesabameba da mas SeuZlia COPP-ciklSi 1400mg/m²²prokarbazini Secvalos. am samkurnalo sqemaSi dakarbacini miiReba 250mg/m²²doziT sami dRis manZilze 30 wuTis ganmavlobaSi intravenurad, raTa SeZlebisdagvarad miRweul iqnas moqmedi maRali doza.rac Seexeba qimioTerapiis toqsiur zemoqmedebis xarisxs, GPOH-HD2002 Pilot-is monacemebze dayrdnobiT, COPDIC-Terapiis dros maRali ar aris. aRniSnuli gamosaxulia tab.3.
toqsiuroba
Sedegebis raodenoba cru Sedegi
0 Iº IIº IIIº Vº
zogadi mdgomareoba 4 11 44 3 0 0Hhemoglobini 0 15 31 14 2 0leikocitebi 0 37 19 5 1 0neitrofilebi 17 33 3 6 2 1Trombocitebi 0 58 4 0 0 0infeqcia 8 46 3 4 1 0temperatura 2 47 9 4 0 0gulisreva 4 47 11 0 0 0Rebineba 1 55 3 2 0 0stomatiti 1 54 6 1 0 0obstipacia 0 56 2 4 0 0diarea 0 60 1 1 0 0alergia 2 60 0 0 3 0tkivilebi 2 44 7 5 0 1sensoruli neirotoqsiuroba
5 42 14 1 0 0
motoruli neirotoqsiuroba
6 44 12 0 0 0
centraluri neirotoqsiuroba
3 59 0 0 0 0
kardiotoqsiuroba 49 13 0 0 0 0kreatinini 1 56 2 3 0 0proteinuria 14 45 3 0 0 0hematuria 12 50 0 0 0 0kreatininis klirensi 34 26 2 0 0 0
es monacemebi naTlad cxadyofs, rom COPDIC- bloki da DTIC pacientebSi naklebad toqsiur gverdiT movlenebs iwveven.samkurnalo sqemaSi miRebis kriteriumebi da pirveladi Terapia
miRebis kriteriumebi:11
yvela pacientebi 18 wlamde asakis hojkinis limfomis diagnoziT, yvela isini unda akmayofilebdnen Semdeg pirobebs:1.hojkinis limfomis diagnozi
2.asaki diagnozis dasmisas <18 welze
3.klinikis axsna-ganmarteba unda axldes Tan
4.mSoblis/pacientis werilobiTi dasturi am samkurnalo sqemaSi monawileobaze.
am samkurnalo sqemaSi ar CaerTvebian,roca pacients aqvs:
1.zemgrZnobeloba an ukuCveneba medikamentebis mimarT
2.nodularuli paragranulomis diagnozi
3.sxva Terapiul sqemaSi ukve gawevrianebulia
4.qimio- an radioTerapia Catarebuli aqvs
5.aReniSneba sxva simsivnuri daavadeba
6.orsuloba an ZuZuTi wovis periodi
7.mZime TandarTuli daavadeba (mag.imunodefeqti)
8.cnobili aiv-infeqcia
9.pacientis an mSoblebis Tanxmobis ar arseboba
Ddiagnostika
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1. histologiuri diagnozi
hojkinis limfomaze daeWvebis dros rac SeiZleba swrafad unda Catardes biopsia. histologiuri diagnozis dasma xdeba limfuri jirkvlis biopsiis an pirveladad dazianebuli organos biopsiis Sedegad. am dros unda iqnes mTliani limfuri jirkvali an didi nawili qsovilisa amoRebuli.adgilze paTologebis mier diagnozis dadasturebis SeTxvevaSi, gamokvleuli masala srulad igzavneba referens -laboratoriaSi.
2.klinikuri da laboratoriuli diagnostika
Aanamnezis Segroveba: -adre arsebulian Tanmxlebi daavadebis Sesaxeb(nefrozuli sindromi da sxva autoimunuri daavadebebi.) -zogadi simptomatika (B-simptomebi; bolo 6Tvis manZilze wonis dakleba 10%-ze meti; persistirebadi ucnobi etiologiis temperatura, Tanmxlebi oflianobiT Rame.) - Catarebuli mkurnaloba.
klinikuri gamokvleva: - yvela im limfuri kvanZebis registrireba, romelic isinjeba da regionis miTiTeba - RviZlis da elenTis palpacia (ramdeni santimetriT scildeba nekTa rkals.) - yel-yur-cxviris eqimTan gamokvleva
laboratoriuli kvlevebi: -sisxlis klinikuri suraTi sruli, eds, alati, asati, gamaglutamattransferaza, tute fosfataza, kreatinini, albumini. LDH -serologiuri kvleva Semdeg antisxeulebze: VZV, EBV, CMV, HSV, HIV, toqsoplazma da A,B,C hepatitebi. instrumentuli gamokvlevebi:
-gulmkerdis rendgenografia-muclis Rrus sonografia -eleqtrokardiografia -exokardiografia -encefalografia
danarCeni diagnostikuri zomebi(iseTi rogoricaa: ekg, filtvebis funqciis kvleva da a.S.) tardeba individualurad pacientis mdgomareobis mixedviT.
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inicialuri stadirebisaTvis gansazRvruli radiologiuri kvlevebi
kisris, valdeieris rgolis, laviwzeda da laviwqeda, iRliis, sazardulis, muxlqveSa limfuri kvanZebis Sreobrivi kompiuteruli tomografia an magnitur resonansuli tomografia.
muclis da mcire menjis Rrus Sreobrivi kompiuteruli tomografia an magnitur resonansuli tomografia.
gulmkerdis kompiuteruli tomografia.
ConCxis scintigrafia. es ukanaskneli aucilebeli Catardes maSinac, roca klinikurad pacients aReniSneba Zvlis tkivili.
Zvlis biopsiaZvlis biopsia ori adgilidan ukeTdeba yvela im pacients, romelTac aqvT >IIA stadia.
seleqtiuri laparaskopiawina samkurnalo oqmis-GPOH-HD95 monacemebze dayrdnobiT, laparatomia winamdebare sqemaSi aRar gamoiyeneba. Zalzed iSviaT SemTxvevebSi, roca yvela arsebuli gamokvlevebi ar iZleva axsnas, tardeba seleqtiuri laparaskopia, igi gamoiyeneba gansakuTrebiT maSin, roca saeWvoa gogonebSi iliakaluri limfuri jirkvlebis dazianebaovaropeqsiamaSin roca eWvgareSea iliakaluri limfuri jirkvlebis dazianeba tardeba operacia: ovaropexsia. erTi sakvercxis fiqsireba ureTrusis ukan kaudalurad, roca erT mxarezea limfuri jirkvlebi CaTreuli da orive sakvercxis, roca dazianeba ormxrivia.Aaucilebelia es operacia Catardes infradiafragmaluri dasxivebamde.
fakultaturi gamokvlevebi.mamrobiTi sqesis pacientebSi aucilebelia nayofierebaze gamokvlevis Catareba da spermis konservireba qimioTerapiis dawyebamde.
miRebuli Sedegebis Sefaseba.
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limfuri jirkvlebis Sefaseba
rogorc damoukidebeli limfuri jirkvlebis regionebi iTvlebian:
1. sasis rkalis limfuri qsovilebi (marjvena da marcxena cal-calke)
2. cervikalurad (marjvena da marcxena cal-calke) • kisris zeda • kisris qveda
3. supraklavikularulad (marjvena da marcxena cal-calke)4. infraklavikularulad (marjvena da marcxena cal-calke)5. aqsilarulad (marjvena da marcxena cal-calke)6. filtvebis hilusi (marjvena da marcxena cal-calke) ,bronqo-
pulmonaluri limfuri jirkvlebi.7. mediastinumis limf.jirkvlebi
• zeda nawili bifurkaciamde• SuaSi ,hilusi subkarinalur regionamde.• qveda nawili diafragmamde
8. supradiafragmalurad9. elenTa10.elenTis hilusi11.RviZlis hilusi12.mezenterialurad: mezenteriumi da mezokoloni13.paraaortalurad14.iliakalurad (marjvena da marcxena cal-calke)15.inguinalurad (marjvena da marcxena cal-calke)
Tu limfuri jirkvalis diametri 1sm-ze naklebia, igi ar CaiTvleba simsivnurad dazianebulad.
Tu limfuri jirkvalis diametri 2sm-ze metia, igi CaiTvleba rogorc simsivnurad dazianebuli.
Tu limfuri jirkvalis diametri 1sm-dan 2sm-mdea erTerT regionSi, aseTi regioni CaiTvleba
eqstranodaluri dazianebebis Sefaseba.
plevra da perikardiplevris simsivnuri dazianeba CaiTvleba Semdeg SemTxvevebSi, roca:. limfoma aramkveTrad, cximovani firfitis gareSe plevris pirdapir SemoisazRvreba an. limfoma gulmkerdis kedelzea gamozneqili an. limfoma gulmkerdis kedelSia infiltrirebuli an. aris plevraluri eqsudati, romelic ar aixsneba venuri SegubebiT.
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perikardiumis simsivnuri dazianeba CaiTvleba Semdeg SemTxvevebSi, roca:. limfoma kontaqtSia gulis zedapirTan, sarqvelebis sibrtyeze an. aris perikaris eqsudati
organoTa dazianeba
organoTa dazianebaze maSin saubroben, roca simsivnuri limfuri jirkvlebi romelime organoSi arian infiltrirebuli.
filtvebidiseminirebul filtvebis dazianebaze da meoTxe stadiaze saubroben, roca:. samze meti simsivnuri qsovilebis grovaa an . intrapulmonaluri grovis diametri 8mm-s aRemateba.
RviZli da elenTa. RviZlis dazianeba yovelTvis meoTxe stadiaa.. marto elenTis dazianeba periferiuli limfuri kvanZebis dazianebis gareSe niSnavs pirvel stadias.. elenTisa da RviZlis mxolod zomebSi momateba ar miuTiTebs maT simsivnur procesSi CaTrevaze.. RviZlsa da elenTaSi grovis formis msgavsi,simsivneze saeWvo struqturuli cvlileba, iTvleba rogorc organos dazianeba.
Zvlisa da Zvlis tvinis dazianebaZvlisa da Zvlis tvinis dazianebazea saubari maSin, roca scintigrafiis Sedegad iqna naxuli erTidaigive Zvalze/Zvlis tvinze simsivnuri grovebi, es raTqmaunda CaiTvleba Zvlisa da Zvlis tvinis dazianebad da ganisazRvreba rogorc meoTxe stadia. Uufro dawvrilebiTi lokalizaciis dasadgenad gamoiyeneba kompiuteruli da magnitur-rezonansuli tomografi. Tu Zvlis biopsiis Sedegad naxuli iqna simsivnuri ujredebi, es ueWvel dazianebasa da meoTxe stadiaze miuTiTebs.
stadiis gansazRvra
16
I stadia roca dazianebuli erTaderTi limfuri jirkvlis regioni (I) an dazianebulia erTaderTi eqstra limfaturi organo an regioni ( IE).
II stadia roca dazianebulia 2 an meti limfuri jirkvlebis regionebi diafragmis erTidaigive mxareze (II) an lokalurad dazianebulia eqstralimfaturi organo Tavisi regionaluri limfuri jirkvlebiT diafragmis erTidaigive mxareze (II E).
III stadia roca dazianebulia limfuri jirkvlebi diafragmis orive mxares (III), romelsac SeiZleba Tan axldes elenTis dazianebac(III S) da/an lokalurad eqstralimfaturi organoebis an qsovilebis (III E) an orTave erTdroulad ( IIIES).
IV stadia roca adgili aqvs disseminirebul eqstralimfaturi organoTa dazianebas, romelsac SeiZleba Tan axldes an ar axldes limfuri jirkvlebis dazianebac; an izolirebulad erTi eqstralimfaturi organos dazianeba araregionaluri limfuri jirkvlebis procesSi CaTreviT.
Y yoveli stadia A da B kategoriad aris dayofili
A. zogadi simptomebis ar arseboba
B. araumcires erT-erTi qvemoT moyvanili zogadi simptomebidan:
a) bolo 6Tvis manZilze umizezod wonaSi kleba 10%-ze metad
b) auxsneli persistirebadi temperatura 38 ºC
g) Zlieri oflianoba RamiT
Terapiul jgufebad dayofa
17
pacientebi onkokonferenciaze studiencentralSi Semdeg Terapiul jgufebad iyofian:
pirveli Terapiuli jgufi ( TG-1)
pacientebi, romlebsac aqvT stadia I A/B da IIA
meore Terapiuli jgufi ( TG-2)
pacientebi, romlebsac aqvT stadia I EA/B, IIEA, IIB an IIIA
mesame Terapiuli jgufi (TG-3)
pacientebi, romlebsac aqvT stadia IIEB, IIIEA/B, IIIB an IVA/B
Terapiis stratificireba da dawyeba.
18
Terapiis droulad Catareba Zalzed mniSvnelovania. iSviaT SemTxvevebSi-laparaskopiis aucileblobis dros, operaciidan me-5 dRes unda iqnes dawyebuli qimioTerapia.yoveli qimioTerapiis ciklebi daiwyeba im SemTxvevaSi, Tu pacienti akmayofilebs Semdeg kriteriumebs:
a. zogadi mdgomareoba damakmayofilebelib. leikocitebis raodenoba >2.000/mm³c. granulocitebis raodenoba >500/mm ³d. Trombocitebis raodenoba >80.000/mm³e. medikamentebis mimarT ukuCvenebis ar arseboba.
raime gansakuTrebuloba OEPA-s, OPPA-s, COPP-sa da COPDIC-is dawyebis win saWiro ar aris, vinaidan rogorc gamocdilebam aCvena mkveTrad gamoxatuli toqsiuri gverdiTi movlenebi ar aris mosalodneli. iseTi interkurentuli daavadebebis arsebobisas, rogoricaa sicxe 38,5º C-ze meti, pnevmonia, sepsisze eWvi, varicela zosteri da sxva msgavsi, qimioTerapiia unda Sewydes.
TG-1yvela pacienti TG-1_dan: gogonebi-2blok OPPA-s da biWebi-2 blok OEPA –s iReben. qimioTerapiis Semdeg maT uterdebaT restadireba postTerapiul kompiuterul tomografiasa da magnitur rezonansul tomografiiT. Tu progresi ar SeiniSneba, maSin es pacientebi iyofian or samkurnalo qvejgufad.
- pirveli qvejgufi moicavs yvela im pacients ,romelTac qimioTerapiis damTavrebis Semdeg pirveladad dazianebul regionebSi CT/MRT-kriteriumebiT ganuviTardaT kompleqsuri remisia, isini ar iReben radioTerapias.
- qvejgufi B moicavs yvela im pacients ,romelTac qimioTerapiis damTavrebis Semdeg CT/MRT-kriteriumebiT kompleqsur remisiaSi ar arian Rebuloben radioTerapias.
pirveli jgufis pacientebisTvis dasxiveba qimioTerapiis damTavrebidan araugvianes 35-e dRes unda Catardes, misi dasrulebas mosdevs Follow-up
TG-2 da TG-3
meore da mesame Terapiuli jgufis yvela pacienti, gogonebi kvlav -2blok OPPA-s da biWebi-2 blok OEPA –s iReben. Semdeg ki Staging-onkikonferenciaze isini gadian randomizacias COPP-sa da COPDIC-s Soris. meore Terapiuli jgufis pacientebi iReben or cikls, xolo mesame jgufis oTx cikls.yvela pacienti iRebs radioTerapias. Mmanmade ki tardeba Restaging, radioTerapia unda qimioTerapiis meoTxe an meeqvse ciklis Semdeg 25-e dRes daiwyos.
9.4.1. OEPA / OPPA
19
citostatikuri medikamentebis aplikaciis saxe da dozireba mocemulia sqemebSi. ix.qvemoT.pirveli ciklis Semdeg modis me-16 dRidan 28-e dRemde Sesveneba. rasac mohyveba Semdgomi cikli.
OEPA-sqemaPrednisoloni 60mg/m2 p.o. gayofili sam miRebazedRe1 - 15 Etoposid 125mg/m2 i.v. 2saaTSidRe 3-7
+ + + + +
Vincristin 1,5mg/m2 i.v. maqs. 2mgdRe 1+8=15
+ + +
Adriamicyn 100mg/m2infuzia 4saaTSidRe 1+15
+ +
dReebi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
OPPA-sqemaPrednisoloni 60mg/m2 p.o.gayofili sam miRebazedRe1 - 15 Procarbazin 100mg/m2p.o. 2-3 miRebaze dRe 1 – 15 Vincristin 1,5mg/m2 i.v. maqs. 2mgdRe 1+8 +15
+ + +
Adriamicyn 100mg/m2infuzia 4saaTSidRe 1+15
+ +
dReebi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
6.4.2. COPP / COPDIC
20
meore Terapiul jgufis mkurnalobis sqemaSi OEPA / OPPA-ciklebs emateba ori COPP an COPDIC-cikli, xolo mesame Terapiul jgufis pacientebs utardebaT oTxi COPP an COPDIC-cikli. yoveli ciklis Semdeg me-16 dRidan 28-e dRis CaTvliT aris Sesveneba.citostatikuri medikamentebis aplikaciis saxe da dozireba mocemulia Sesabamis sqemebSiciklofosfamidis yoveli micemisas aucilebelia uroproteqtor-mesnas micema. dakarbacinis emetogenuri efeqtis Sesamcireblad ki naCvenebia 5-HT3-antagonistis, an deqsametazonis an romelime neuroleptikis daniSvna.
COPP-sqema Prednisoloni 40mg/m2 p.o.gayofili sam miRebazedRe 1 - 15 Procarbazin 100mg/m2 p.o. 2-3 miRebazedRe 1 - 15Vincristin 1,5mg/m2 i.v. maqs. 2mgdRe 1+8
+ +
Cyclofosfamidi 500mg/m2,i.v.infuzia 60wTmesna 150mg/m2 0saaTzemesna 500mg/m2 24 sTSi+1500ml/m2 NaCl0,9%+1500ml/m2 Gluc5%1+8 dRe
+
+
+
+
dReebi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
21
COPDIC-sqemaPrednisoloni 40mg/m2 p.o.gayofili sam miRebaze1 - 15 dReDcarbazin 250mg/kg/ i.v.infuzia 30wTdRe 1 - 3
+ + +
Vincristin 1,5mg/m2 i.v. maqs. 2mgdRe 1+8
+ +
Cyclofosfamidi 500mg/m2,i.v. infuzia 60wTmesna 150mg/m2 0saaTzemesna 500mg/m2 24 sTSi+1500ml/m2 NaCl0,9%+1500ml/m2 Gluc5%1+8 dRe
+
+
+
+
dReebi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
dozis modifikacia da kontracefcia
am samkurnalo sqemaSi mocemuli qimioTerapiuli saSualebebs kargad itanen pacientebi da amdenad dozis modificireba ar aris saWiro. im erTeul SemTxvevebSi, roca saxezea medikamentebis gamo gamowveuli mkveTrad gamoxatuli arasasurveli gverdiTi movlenebi, unda moxdes alternatiuli saSualebis gamoZebna studiis xelmZRvanelobasTan erTad.Qqimio an radioTerapiis dros da maT Semdeg erTi wlis manZilze pacientebma unda moeridon bavSvis Casaxvas, vinaidan drois am monakveTSi mavnebeli zemoqmedeba qimio da radioTerapiisa jer kidev mosalodnelia. Kkontracefciuli saSualebebis Sesaxeb gadawyvetilebas eqimi iRebs individualurad TiToeul SemTxvevaSi.
qimioTerapiis gverdiTi movlenebi
22
qimioTerapiis zogadi gverdiTi movlenebia: gulisreva,Rebineba, wonaSi kleba, Tmis cvena da meoradi simsivnis ganviTarebis riski.
etopozidietopozidis mwvave gverdiTi movlenebi SeiZleba iyos: alergiuli reaqciebi, mukoziti, periferiuli neiropaTiebi, cns-toqsiuroba, msubuqi Zvlis tvinis depresia. etopozidiT inducirebuli meoradi leikozis ganviTarebis vada SeiZleba iyos ramodenime Tvidan wlamde. FAB-klasifikaciiT M4/M5 morfologiiT da 11 q23-translokaciiT, Tumca leikozis es forma dRemde ar dafiqsirebula.
dakarbacinidakarbacini iwvevs Zlier gulisrevas da Rebinebas. iSviaTad diareas, gripis msgavs simptomebs, alergiul egzanTemas kanze, sicxes da fotosensibilizacias. SesaZlebelia adgilobrivad ineqciis adgilze venebis gaRizianeba gamoiwvios. misi Zvlis tvinze toqsiuri zemoqmedeba sustia, iSviaTia aseve RviZlze, Tirkmelebze da cns-ze misi mavne gavlena. gansakuTrebiT mniSvnelovania aRiniSnos, rom is A BVD-TerapiiT ar iwvevs permanentul azospermias aseve iSviaTia meoradi leikozis ganviTarebis SemTxvevebic.
vinkristinivinkristinis mwvave gverdiTi movlenebia: periferiuli neiropaTia, obstipacia, iSviaTad e.w.araadeqvaturi ADH-sekreciis sindromi. mkveTrad gamoxatuli periferiuli neiropaTiis dros, romelsac axlavs siarulis darRvevac vinkristini SeiZleba Seicvalos vinblastinis 6mg/m ²–doziT.
ciklofosfamidiciklofosfamidis Sedegad SeiZleba ganviTardes: Zvlis tvinis depresia, hemoragiuli cistiti da maRalia infeqciebisadmi midrekileba.
adriamiciniadriamicinis zemoqmedebiT SesaZlebelia ganviTardes gulis kunTis funqciis darRveva. gulze mogvianebiTi garTulebebis Sesaxeb qimioTerapiis dasrulebis Semdeg informacia jerjerobiT ar aris. qimioTerapiis dawyebamde aucilebelia eqokardiografiis Catareba. gulis dazianebis SemTxvevaSi saWiroa alternatiuli Terapiuli saSualebis moZebna studiis xelmZRvanelobasTan erTad.
prednizoloni rogorc leikoziani pacientebze dakvirvebebma aCvena, rom prednizoloni iwvevs osteonekrozebs da SesaZlebelia xelovnuri saxsris aucileblobac Seiqnes. garda aRniSnulisa SeiZleba ganviTardes Sesupeba, wonaSi momateba, maRalia infeqciebisadmi midrekileba da fsiqiuri cvlilebebis ganviTareba.
23
prokarbazini prokarbazinis Sedegad SeiZleba ganviTardes: gulisreva, interstinaluri pnevmonia, c.n.s garTulebebi(neirotoqsiuri), alergiuli reaqciebi, gonadebis dazianeba da Seuqcevadi azospermia.
24
Terapiis warmatebis gansazRvra restadirebiT.
Restadireba
pirveli restadireba yvela pacientisaTvis tardeba 2cikli qimioTerapiis Semdeg Restaging-i2cikli qimioTerapiis Semdeg yvela dazianebuli adgili xelaxla unda daTvalierdes.CT/MRT gamokvlevebi-qimioTerapiis damTavrebidan me-10 dRidan me14-dRis ganmavlobaSi unda Catardes. yvela pacients me-14dRes utardeba FDG-PET gamokvleva. pirveli Terapiuli jgufis pacientebis monacemebi igzavneba centrSi, raTa ganisazRvros Semdgomi moqmedebani. meore da mesame Terapiuli jgufis pacientebis agrZeleben Terapias. is pacientebi, romlebsac SeeniSnebaT daavadebis progresi gadian srul kompleqsur xelaxal gamokvlevas da Sedegebis mixedviT gadawydeba mkurnalobis Semdegi taqtika. meore restadireba4cikli qimioTerapiis Semdeg meore meore Terapiuli jgufis pacientebSi Yyvela dazianebuli adgilebi eqvemdebarebian kvlevas. CT/MRT da eqografia unda Catardes bolo qimioTerapiuli ciklis miRebidan me-10 me-14 dRis vadebSi. am jgufis pacientebs ewyebaT agreTve radioTerapia. progresis SemTxvevaSi ki aucilebelia yvela limfuri jirkvlisa.komleqsuri gamokvleva.mesame restadireba6cikli qimioTerapiis Semdeg mesame Terapiuli jgufis pacientebSi Yyvela dazianebuli adgilebi eqvemdebarebian kvlevas . CT/MRT da eqografia unda Catardes bolo qimioTerapiuli ciklis miRebidan me-10 me-14 dRis vadebSi. am jgufis pacientebs ewyebaT agreTve radioTerapia. progresis SemTxvevaSi ki aucilebelia komleqsuri gamokvleva yvela limfuri jirkvlisa
nebismieri restadirebis dros Terapiis warmatebis gansazRvra Semdegi kriteriumebis mixedviT xorcieldeba:
kompleqsuri remisia(CR)
Terapiis Sedegi rogorc kompleqsuri remisia fasdeba im SemTxvevaSi, roca• daavadebis yvela simptomi gamqralia da • ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli da• yvela nacnobi limfomregionebisTvis:
- pirveladi simsivnuri masis 95%-ze meti ukuganviTarebulia- narCeni masa naklebia 2ml-ze
25
daudgeneli kompleqsuri remisia
Terapiis Sedegi rogorc kompleqsuri remisia-daudgeneli fasdeba im SemTxvevaSi, roca• ar aris kompleqsuri remisia da • daavadebis yvela simptomi gamqralia da • ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli da• yvela nacnobi limfomregionebisTvis:
- pirveladi simsivnuri masis 75%-ze meti, magram 95% naklebi ukuganviTarebulia an
- narCeni masa naklebia 2ml-ze
parcialuri remisia
Terapiis Sedegi rogorc parcialuri remisia fasdeba im SemTxvevaSi, roca• ar aris kompleqsuri remisia an daudgeneli kompleqsuri remisia• ar SeiniSneba daavadebis progresirecidivTerapiis Cveneba aris mxolod imSemTxvevaSi, roca damtkicebuli progresi an recidivia saxeze.
progresi /recidivi
daavadebis progresia roca:• daavadebis simptomebis xelaxali an sruliad axali ,auxsneli gamoCena an• axali limfuri an eqstarlimfaturi regionebis gaCena an • araumcires erTi limfomregionis simsivnuri masis mateba 25%-ze metad da (!) • vitaluri limfomujredebis aRmoCena zrdaSi myof an axlad aRmocenebul regionebSi
daavadebis progresi / recidivi qvia:•Terapiis dasrulebidan (qimioTerapiis bolo dRe , prednizolonis CaTvliT, an sxivuri Terapiis bolo dRe) sam TveSi ganviTarebuli procesi- progresi.• Terapiis dasrulebidan sami Tvidan Tormet Tvemde ganviTarebuli- adreuli recidivi.• Terapiis dasrulebidan Tormet Tvis Semdeg ganviTarebuli- mogvianebiTi recidivi.
26
sxivuri Terapia
Cvenebebi da dozireba
1. pacientebs romlenic ganekuTvnebian pirvel Terapiul jgufs sruli remissiis SemTxvevaSi ar sxivdebian.
2. pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs arasruli remissiis SemTxvevaSi sxivdebian doziT 20 grei.
3. pacientebs romlenic ganekuTvnebian meore da mesame Terapiul jgufs sruli remissiis SemTxvevaSi sxivdebian doziT 20 grei.
4. yvela pacienti romelTa narCeni masa, sawyisTan SedarebiT 25% metia, anu 75% isev rCeba sxivdebian doziT 30 grei.
5. yvela pacienti, romelTa narCeni masa 100 ml ia sxivdebian dosiT35 grei.
6. eqstralimfuri organoebi, Zvlis tvinis gamoklebiT, eqvemdebarebian sxivur Terapias,doziT 12 – 15 grei.
7. sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 1,8 grei, gaminaklis warmoadgens filtvebi da am SemTxvevaSi dRiuri doza ar und aRematebodes 1-1,2 greis.
8. recidivis SemTxvevaSi sayuradReboa pirveladi doza da ganmeorebiTi Terapiis sumaruli doza ar unda aRematebodes 40 greis.
sxivuri Terapiis dawyeba
bolo qimioterapiuli reJimis damTavrebidan 3 kviris Semdeg.
sxivuri Terapiis principebi.
sxivuri Terapia pirveladi dagegmarebiT, kompiuteruli simulaciiT da sxivuri aqseleratoris gamoyenebiT aris SesaZlebeli. esYyovelive emsaxureba janmrTeli qsovilebis maqcimalur dacvas sxivebis mavne moqmedebisgan da samizne qsovilebis efeqtur dasxivebas.Teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti.
velebi
mkacrad aris gansazRvruli protokolis mixedviT da maqsimalurad moicavs mxolod inicialurad dazianebul limfur kvanZebs da eqstralimfur organoebs. velebis SerCeva, dagegmareba da pirobiTi sqemis Semoxazva xdeba radiologTa, onkologTa da ratioTerapevTa erToblivi gadawyvetilebiT.
27
………………
28
valdeieris rgoli
kisris, laviwzeda
laviwqveSaaqsilaruli,peqtoruli
mediastinaluri
paraaortaluri,elenTis kari,RviZlis kari
iliakaluri
sazardulis,barZayis
elenTa
limfuri kvanZebis regionebi
karis
mezenterialuri
Terapia im pacientebisTvis visTanac standartulma mkurnalobam ar uCvena efeqturoba da gamoixata daavadebis progresireba. ( Salvage Therapy)
mkurnaloba iwyeba kvlav qimioTerapiiT. Ggamoiyeneba IEP/ABVD kursebi COPP da ChICEP reJimebTan erTad. Pacientebis am jgufisTvis blokebis raodenoba winacwar ar aris mkacrad gansaxRvruli da damokidebulia pasuxze : Tu pacients aReniSneba kargi pasuxi pirvel IEP/ABVD Terapiaze , qimioTerapia sruldeba sxivuri TerapiiT. cudi pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT.
recidivis sawinaaRmdego Terapia
gamoiyofon recidivis or Tearapiul jgufs, romlebic Tavis mxriv iyofa sam-sam qvejgufebad:
1.pirveli recidivi im pacientebSi vinc inicialurad miekuTvnebodnen pirvel Terapiul jgufs.
• pacientebi romelTac inicialurad ar Cautardad sxivuri Terapia unda miiRon: IEP- ABVD- COPP-(IEP?) + dazianebuli velebis dasxiveba doziT 25-30 grei.
• pacientebi romelbmac inicialurad miiRes dazianebuli velebis radioTerapia 20greiT da ganuviTrdad recidivi ukve dasxivebuli an axali velebis kombinaciiT: IEP- ABVD- COPP-IEP + dasxiveba 20-25 grei dasxivebuli da 25-30 axali velebisaTvis.
• pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT dasxivebuli an dausxivebeli regionebiT utrdebaT: IEP- ABVD- COPP-IEP –ABVD – COPP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30 greiT dausxivebeli velebis.
2.pirveladi recidivi im pacientebSi vinc inicialurad miekuTvnebodnen meore da mesame Terapiul jgufebs.
• pacientebi romelTac ganuvitardad recidivi axali aradausxivebel regionebSi utardebaT: IEP - ABVD - IEP –ABVD – (IEP?) + radioTerapia doziT 25-30grei.
• pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an dausxivebeli regionebiT utrdebaT: IEP- ABVD- IEP- ABVD - IEP + sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT dausxivebeli velebis.
• pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT dasxivebuli an dausxivebeli regionebiT utrdebaT: IEP- ABVD- -IEP –ABVD – IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30 greiT dausxivebeli velebis.
recidivian pacientebs romelTac Terapiaze aReniSnebaT simsivnis neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri Terapiisdoza an Tu igi ar aris SeZlo ( sumaruli doza ar unda aRematebides 45
29
greis) sxivuri Terapiis Semdeg pacients eZleva ori damatebiTi qimioTerapiuli kursi: ChICEP
antirecidiuli qimoTerapiis sqemebi
1.Ifosfamidi 2000mg/m2 24 saaTis ganmavlobaSi+mesna 1–5 dRe
2..Etoposidi 125mg/m2 i.v. 2 saaTis ganmavlobasi 1-5 dRe
3.Prednisone 100mg/m2Pp.o. sam miRebaze. 1-5 dRe
1.Adriamycin 25mg/m2 i.v. 2saaTis ganmavlobasi 1+15 dRe
2.Dacarbazin 375mg/m2 i.v. . 2saaTis ganmavlobasi 1+15 dRe
3.bleomocyni 10mg/m2 i.v. neli nakadiT 1+15 dRe
4.Vinblastini 6mg/m2 i.v. neli nkadiT 1+15 dRe
1.CCNU 80mg/m2 p.o. 1 dRe
2.Etoposid 100mg/m2 p.o. 1-5 dRe
3.Prednison 40mg/m2 p.o. 1-5 dRe
4.Chlorambuzil 6mg/m2 p.o. 1-5 dRe
30
IEP=Ifosfamid/Etoposid/Prednison
ABVD=Adriamicyn/Dacarbazin/Bleomycin/Vinblastin
ChICEP=CCNU/Etoposid/Prednison/Chlorambuzil
pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
gamokvleva qimiodan 1kv-sSemdeg
Ddasxiv.-dan 4kv-s Semdeg
1 welSi 2welSi 3welSi 4welSi
Aanamnezi × × Y yovel 6kviraSi yovel 3TveSi
yovel 6TveSi
sisxlis kl.analizi × × Y yovel 3 TveSi yovel 6TveSi
×
muclis sonografia × × Y yovel 3 TveSi Yyovel 6 TveSiCT / MRT × × yovel3 TveSi yovel
3 TveSi
yovel 6TveSi
individualurad
CT-gulmkerdis × Yyovel3TveSi Yyovel 6TveSi
individualurad
Yyelis dasxivebis Semdeg faris..jirk.sono da fT4, TSH,TG
× 1 x weliwadSi
sakvercxis karcinomos skriningi(sono, MRT)
25-wlidan qalebSi 1 x weliwadSi, supra/infraklavikularuli regionis, aqilaruli ,mediastinumis an filtvis dasxivebis Semdegs
Eekg /eqokardiograf. × ×LH-RH, FSH, prolaqtini, testosteroni estradioli,spermiograma
18wlis zemoT biWebSi, 15 wlis zemoT gogonebSi
Llufu filtvebis an mediastinumis dasxivebis Semdeg
Terapiis dasrulebidan 1wlis Semdeg
× individua-lurad
×
radioTerapiis specialisti
× Terapiis dasrulebidan 1wlis Semdeg
1 x weliwadSi ×
sicocxlis xarisxi Terapiis dasrulebidan 1wlis Semdeg
×
31
dokumentacia romelic unda warmoebdes da mkacrad unda iqnes daculi yvelaSemTxvevisaTvis:
1. paTologis saboloo da oficialuri daskvnis originali.2. yvela radiologiuri kvlevis daskvnis originali.3. Terapiuli gegmis dizaini konkretuli pacientisTvis.4. Terapiuli gegmebi TiToeuli qimioTerapiuli reJimisaTvis.5. sxivuri Terapiis pirobiTi sqema pirveladi velebis moniSvniT.6. dignozis, stadirebis, mkurnalobis da Semdgomi dakvirvebis midinareobisa
eqimis mier dawerili etapuri epikrizebi.7. pacientis da misi meurvis Tanxmobis damadasturebeli specialuri werili
32
Terapiuli gegmis dizaini konkretuli gogona pacientisTvis.
TG 1IA/B,IIA
TG 2IEA/B,IIEA
IIB,IIIA
TG 3IIEB,IIIEA/BIIIB,IVA/B
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
33
1 5 9 13 17 21 kvira
pacientis gvari saxeli ------------------------------------------------------------------------------------------
dabadebis TariRi ----------------------------------------------------------------------------------------------------
histologiuri diagnozi ----------------------------------------------------------------------------------------
stadia ----------------------------------------------------------------------------------------------------------------------
Terapiuli jgufi ---------------------------------------------------------------------------------------------------
dasxivebis doza ------------------------------------------------------------------------------------------------------
Terapiuli gegmis dizaini konkretuli biWi pacientisTvis.
TG 1IA/B,IIA
TG 2IEA/B,IIEA
IIB,IIIA
TG 3IIEB,IIIEA/BIIIB,IVA/B
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
34
1 5 9 13 17 21 kvira
pacientis gvari saxeli……__________________________________________
dabadebis TariRi -------------------------------------------------------------------------------------------
histologiuri diagnozi --------------------------------------------------------------------------------
stadia --------------------------------------------------------------------------------------------------------------
Terapiuli jgufi ________________________________________________
dasxivebis doza ----------------------------------------------------------------------------------------------
saxeli ---------------------------- gvari ----------------------------------------------dabad.TariRi -------------
wona -----------------------------kg simaRle -------------------------sm sxeulis farTi ---------------m2
prednizoloni 60mg/m2 p.o. gay. 3 miRebaze
prokarbazini 100mg/m2 p.o. gay.2-3 miRebaze
vinkristini 1,5mg/m2 i.v. maqs.2mg
adriamicini 40mg/m2 i.v. infuzia 4sT.
K kursi OPPA
35
Mmg=
Mmg=
Mmg=
Mmg=
MdReM1 M15M8
saxeli ---------------------------- gvari ----------------------------------------------dabad.TariRi ------------------
wona -----------------------------kg simaRle -------------------------sm sxeulis farTi ---------------m2
prednizoloni 60mg/m2 p.o. gay. 3 miRebaze
vinkristini 1,5mg/m2 i.v. maqs.2mg
adriamicini 40mg/m2 i.v. infuzia 4sT.
etopozidi 125mg/m2 i.v infuzia 2sT
36
Mmg=
Mmg=
Mmg=
Mmg=
MdRe
M1 M15M8M2 M5
K kursi OEPA
saxeli ---------------------------- gvari ----------------------------------------------dabad.TariRi --------
wona ----------------------kg simaRle -------------------------sm sxeulis farTi --------------- m2
prednizoloni 40mg/m2 p.o.gay. 3 miRebaze
prokarbazini100mg/m2 p.o.gay.2-3 miRebaze
vinkristini1,5mg/m2 i.v. maqs.2mg
ciclofosfamidi500mg/m2 i.v.infuzia 1 sT
mesna 150mg/m2 0sTmesna500mg/m2/24 sT+1500ml/m2 NaCl0,9%+1500ml/m2 Gluc5%
K kursi COPP
37
Mmg=
Mmg=
Mmg=
Mmg=
MdReM1 M15M8
Mmg=
Mmg=ml =
saxeli ---------------------------- gvari ----------------------------------------------dabad.TariRi ---------------
wona -----------------------------kg simaRle -------------------------sm sxeulis farTi ---------------m2
prednizoloni 40mg/m2 p.o.gay. 3 miRebaze
dakarbazini250mg/m2 i.vInfusia 30wT1,2,3 dRe
vinkristini1,5mg/m2 i.v. maqs.2mg
ciclofosfamidi500mg/m2 i.v.infuzia 1 sT
mesna 150mg/m2 0sTmesna500mg/m2/24sT+1500ml/m2 NaCl0,9%+1500ml/m2 Gluc5%
K kursi COPDIC
38
Mmg=
Mmg=
Mmg=
Mmg=
MdRe
M1 M15M8
Mmg=
Mmg=Mml=
saxeli ---------------------------- gvari ----------------------------------------------dabad.TariRi ----------
wona -----------------------kg simaRle -------------------------sm sxeulis farTi --------------- m2
prednizoloni 100mg/m2 p.o.gay. 3 miRebaze
ifosfamidi2000mg/m2 i.v.messna 700mg/m2 0sTmesna 2000mg/m2 24sT-Si2500ml siTxe 24sT-SiNaCl 0,9%/Cluc 5% +KCl 7,5% 10ml/500ml+laziqsi 10mg/100ml
etopozidi125mg/m2 i.v.infuzia 2sTetopozidi iwyeba ifosfamidis dawyebi-dan 4sT is Semdeg.am dros ifosfamidi wydeba
K kursi IEP
39
Mmg=
mg=
mg=
MdReM1 M3M2 M4 M5 M6 M7
mg=
ml
M mg=
saxeli ------------------------ gvari ------------------------------------------dabad.TariRi ------------------
wona -----------------------kg simaRle -------------------------sm sxeulis farTi --------------- m2
adriamicini25mg/m2 i.v.Infuzia 2sT
dacarbazini375mg/m2 i.v. Infuzia 2sT
bleomicini10mg/m2 i.v.infuzia nelinakadiT
vinblastini6mg/m2 i.vInfusia nelinakadiT
40
K kursi ABVD
Mmg=
Mmg=
Mmg=
Mmg=
MdReM1 M15
M
saxeli ------------------------ gvari ------------------------------------------dabad.TariRi ------------------
wona ------------------------kg simaRle -------------------------sm sxeulis farTi --------------- m2
ccnu 40mg/m2 p.o.
etapozidi100mg/m2 p.o.
prednizoloni40mg/m2 .p.ogay. 3 miRebaze
qlorambucili6mg/m2 p.o.gay. 3 miRebaze
41
M mg=
mg=
MdRe
M1 M3M2 M4 M5
Mmg=
Mmg=
K kursi ChICEP
saxeli ------------------------ gvari ---------------------------------------dabad.TariRi ------------------
Catarebuli qimioTerapia-----------------------------------------------------------
sxivuri Terapiis doza---------------------------------------------------------------
42
K sxivuri Terapiis sqema
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